Koro and Dhat Syndrome in A Rural Indian Male: A Case Report on Cultural Stigma and Its Psychiatric Impact

Abstract

Culture specific syndromes are disorders of behaviour that occur within or are limited to a specific culture. These syndromes are a mixture of psychiatric and somatic manifestations of cultural beliefs. In India, where sexual health is a taboo topic, disorders like Dhat and Koro often remain poorly understood and untreated. This case highlights how cultural beliefs and societal stigma surrounding sexual health complaints can exacerbate psychiatric symptoms and impair social functioning. The patient, a 29-year-old male from a rural background, presented with longstanding anxiety over semen loss and penile shrinkage. Diagnosis of Dhat and Koro syndrome was made along with dysthymia and generalized anxiety. Treatment included pharmacotherapy and psychoeducation. This report emphasizes the importance of culturally competent psychiatric care and the need for greater awareness of culture-bound syndromes..

Keywords

Introduction

Culture specific syndromes are disorders of behaviour that occur within or are limited to a specific culture. These syndromes are a mixture of psychiatric and somatic manifestations of cultural beliefs. They are considered as a disease in that specific culture with widespread recognition and usually treated by faith healers. [1] Dhat disorder is a clinical condition in which there is severe anxiety and hypochondriacal symptoms associated to excessive semen loss believed to cause loss in strength and sexual potency, frequently related with sexual ineptitude. The belief finds its way from ancient scriptures depicting semen as an elixir of life which should be preserved for health and longevity, as well as reinforced by lay experts. [2] Koro is related with anxiety associated to genitalia shrinkage and withdrawing into abdomen driving eventually to death. [1] P.M. Yap portrayed Koro patients as dependent, immature and lacking confidence in their virility and being in steady sexual conflicts. Koro is believed to have originated from Malay which means “shrink.” An alternative source is from the word kura which means a tortoise,“head of the tortoise” is often used as an expression for the penis by the Malays and the Chinese.[3]

Dhat syndrome has a prevalence of 12.5% in India[4], while Koro has been either been associated with epidemic or sporadic cases, common in population of north-eastern India.[1] In India, conversations around sexual health or disorders is considered a taboo due to the social beliefs, constructs and lack of sexual education. This case depicts stigma associated with any symptom of sexual nature can affect how individual is perceived and treated by the society.

CASE PRESENTATION

A 29-year old male patient, educated up to B.Com., single, from a rural background presented with complaints of losing of semen during defaecation 2-3 times/day. Patient reported that, since 10 years he had been losing his semen in this manner and was gradually getting physically weaker day by day. Along with this, patient also complained that his penis was gradually being pulled into his body and has gradually shrunk over the past years. He reported that it had shrunk and gotten darker. To relieve his worries, he would pull at his genitals to prevent it from retracting further into his body. The patient had expressed his problems to his family as it was causing him a lot of distress. The father, concerned about his son’s issues, trying to help him for his “problem”, started asking people in his friends and neighbours if they knew any possible doctor or treatment for his son’s condition. Gradually, the word of the patient’s “problem” spread over the entire village, as the news spread, people started approaching every time they would see him or his family members on the street, and would try to enquire about it, and if he had had any relief. However, not everyone who approached him was helpful, or curious about his recovery, and some would mock him whenever he would try to step out of the house. These constant reminders and ridicule by people around him added to his misery. He was constantly worried because of his symptoms, but now even had to face it everywhere he would go, whether it was for work in his field, or to meet his friends. He gradually started losing interest in these activities that would give him some respite from his worries, and would stay at home by himself, avoid meeting his friends, watching TV, going for work, etc. He would be constantly worried about his genitals shrinking and losing his vitality. He started experiencing sadness whenever he would think about it or was reminded by others. Over time, his irritability towards others increased, specifically his father, and he would get angry often, frequently pick up fights with him, and accuse him of ruining his life. He also lost interest in masturbatory practices, would not be aroused even on watching pornographic content, and felt disgusted by it. He had visited multiple doctors for his complaints but never reported any improvement on treatment. A diagnosis of Koro and Dhat was made along with generalised anxiety and dysthymia. The patient was started on Vilazodone 40mg for symptoms of depression and anxiety and Clonazepam 0.5mg for sleep disturbances. Psychoeducation regarding the illness was given, the patient was explained about the impossibility of him losing his strength through his semen and his penis retracting into his body. Family members were counselled about the impact of sharing certain sensitive details about personal life with others. He reported improvement in symptoms of anxiety and dysthymia in the 2 weeks of IPD treatment. However, had failed to follow up after.

DISCUSSION

Cultural beliefs play a major role in colouring psychopathology in a number of illnesses. Many culture-bound syndromes have combined acute anxiety and dissociative and psychotic presentations. In this case, the presentation was primarily anxiety related with secondary depressive symptoms due to anxiety worsened by stigma and discrimination. Patients with such disorders also experience a lot of guilt and shame while discussing their issues with family, friends, as well as with health professionals making it difficult to ask for help or support due to the fear of being judged or mocked. This can make them withdraw from social life and can worsen the distress associated with these syndromes, further impairing quality of life and worsening the psychological impact on the individual. The patient in this case after sharing his issues with his family members had to face a lot of shame in his village as his father would frequently discuss his son’s problems with the villagers leading to constant questioning and mocking by his neighbours and friends. Mental health professionals should be prepared to handle these sensitive issues with care, providing counselling and support to individuals and families.

PATIENT CONSENT

Written informed consent was obtained from the patient for publication of this case report. Efforts have been made to ensure anonymity.

CONFLICT OF INTEREST

The authors declare no conflict of interest

REFERENCE

1. Kapoor A, Juneja R, Chand Singh D. Culturally Specific Syndromes in India – An Overview. International Journal of Current Research and Review. 2018;10(11):2–6.
2. Akhtar S. Four Culture-Bound Psychiatric Syndromes in India. International Journal of Social Psychiatry. 1988 Mar;34(1):70–4.
3. Strong YN, Cao DY, Zhou J, Guenther MA, Anderson DJ, Kaye AD, et al. Koro Syndrome: Epidemiology, Psychiatric and Physical Risk Factors, Clinical Presentation, Diagnosis, and Treatment Options. Koro Syndrome: Epidemiology, Psychiatric and Physical Risk Factors, Clinical Presentation, Diagnosis, and Treatment Options [Internet]. 2023 Feb 21;11.
4. Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities. PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017.