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VIVIAN AFI DZOKOTO AND GLENN ADAMS

UNDERSTANDING GENITAL-SHRINKING EPIDEMICS IN WEST AFRICA: KORO, JUJU, OR MASS PSYCHOGENIC ILLNESS?

ABSTRACT. A small-scale epidemic of genital shrinking occurred in six West African nations between January 1997 and October 2003. This article presents a summary and analysis of 56 media reports of these cases. A clinical formulation of these cases considers a variety of explanations from theory and research in social and cultural psychology, psychopathology, and anthropology. Of particular interest is a comparison of genital-shrinking distress in West African settings with koro, a culture-bound syndrome involving fears of genital retraction that is prominent in Southeast Asian settings. The paper concludes with a brief discussion of the role of culture in both the experience of genital-shrinking distress and conceptions of psychopathology. KEY WORDS: culture-bound syndrome, West African, somatization

Panic has gripped residents of the Plateau State capital following reported cases of disappearing organs ostensibly for ritual purposes. No fewer than six of such cases have been reported in the last one week in different parts of the state capital, involving males and females whose organs allegedly “disappeared” upon contact with organ snatchers. A middle-aged man was almost lynched yesterday along Rwang Pam Street, after he allegedly “stole” a man’s private part through ‘remote control’. The victim allegedly felt this organ shrink after speaking to the suspect, who reportedly asked for directions, following which he raised an alarm. Passers-by who had become alert following reported similar incidents in the past few days, immediately pounced on the suspect inflicting serious injuries on him. The timely arrival of the Police who fired tear gas cannisters to disperse the irate crowd saved him from being lynched. The Police later took him and his alleged victim to the station for further investigation. However, Police officers contacted said they were still collating details of the various incidents when contacted. The situation is sending jitters down the spine of most residents with people now refusing to respond to enquiries from strangers for direction or for time. Some residents have resorted to superstitious measures such as clipping a pin to their mid-region or putting on antidotes to the charms of the organ-snatchers. —Panic as suspected organ snatchers invade plateau. The Nigerian Vanguard Online, 7th September, 2001 In recent years, news media in several West African countries have reported periodic episodes of “panic” in which men and women are beaten, sometimes to death, after being accused of causing penises, breasts, and vaginas to shrink Culture, Medicine and Psychiatry 29: 53–78, 2005. C 2005 Springer Science+Business Media, Inc. DOI: 10.1007/s11013-005-4623-8

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VIVIAN A. DZOKOTO AND GLENN ADAMS

or disappear. The above report from a Nigerian newspaper describes one such episode. Although it is clear that these outbreaks have a pathological aspect—related to both the anxiety suffered by people who report symptoms and the violence done to those accused of causing the symptoms—the exact nature of this pathology remains unclear. Are these incidents the product of regular psychological functioning in undisturbed individuals, or do they reflect psychopathology? Do they represent a sort of culture-bound syndrome or a more universal phenomenon? To better understand these incidents, we reviewed available reports of what became known as the “genital-shrinking” episodes. In the discussion that follows, we first summarize the results of this review. We then consider different explanations for the genital-shrinking episodes. Finally, we consider the implications of these episodes for prevailing conceptions of psychopathology. GENITAL-SHRINKING DISTRESS IN WEST AFRICAN SETTINGS

At least 56 separate cases of genital shrinking, disappearance, and snatching have been reported in the last seven years by news media of seven West African countries. To our knowledge, there have been no thorough, clinical studies of these cases. In lieu of such studies, we based our review on reports of genital-shrinking episodes in local and electronic news media.1 Incidence Our review begins with events that we personally witnessed: an outbreak of genitalshrinking episodes in several locations in Ghana.2 News reports suggested that the outbreak began in Nigeria or Cameroon in late 1996. It arrived in Ghana during January, 1997, moved to Cote D’Ivoire, and eventually reached Senegal in August. Content analyses of reports in Ghanaian newspapers revealed a total of 40 separate cases in both coastal locations (e.g., Accra, Cape Coast, Takoradi, and Tema) and inland locations (e.g., Ahenkro, Anyinasou, Asamankama-Sakam, Kokpti, Kumasi, Obuasi, Offinso, Samproso, Sunyani, and Tetrem). However, this is likely to be a gross underestimate of the actual number of cases. For instance, media reports did not include two cases in Tamale and two in a suburb of Accra that occurred while the authors were conducting research in those locations. Furthermore, most cases that received media coverage involved mob violence. It is possible that many more cases occurred but did not result in mob violence and therefore did not receive media coverage. Finally, reports of the phenomenon stopped abruptly once authorities began arresting people for making accusations of genital shrinking. Responses of interview participants suggest that some people may have experienced symptoms, but chose not to report to authorities (Adams and Dzokoto, 2002).

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Of the 33 Ghanaian cases that mention gender, 30 of the affected individuals were male. Age of affected individuals (in the 10 reports that mentioned this information) ranged from 12 to 31 years. Most of the reports contained no information about marital status, psychiatric history, or sexual activity of affected individuals. Subsequent to the 1997 outbreak, news media have reported more genitalshrinking episodes. The most recent outbreak reported in the media occurred in Banjul, Gambia in October, 2003 (CNN 2003). Between 1998 and 2001, genitalshrinking episodes were reported in several Nigerian cities, including the coastal city of Lagos as well as the inland cities of Ilorin, Jos, Osogbo and Oyo (Abah 2000). Media reports covered cases in Cotonou, Benin in November 2001 (BBC 2001a, 2001b; Djiwan et al. 2001). Sporadic cases have also been observed in Cameroon. Presentation Although news media in Ghana labeled the phenomenon a “genital-shrinking” epidemic, reports of specific incidents suggest a variety of gender-specific presentations. The most common symptom was the experience of a shrinking penis (20 cases). For example, a Ghanaian newspaper reported the case of a 17-year-old who claimed that, “He had gone to fetch water for his father and was returning when [the perpetrator] came behind him, touched him and immediately he felt his penis shrink until it was no longer visible.” Other reports (15 cases) described a vanishing or disappearing penis. Unfortunately, newspaper reports sometimes used these two terms interchangeably, making it unclear whether references to shrinking versus vanishing represent different ways of describing the same experience or represent qualitatively distinct forms of subjective experience (see Chowdhury 1996). In the three female cases reported in the Ghanaian media, affected women reported experiencing shrinking breasts, changes to their genitalia, or both. One report described a woman whose “private parts sealed.” Another report described a woman who reported that her genital organ (unspecified) was vanishing. Again, it is unclear whether references to sealing and vanishing of female genitalia represent different ways of describing the same experience or represent qualitatively distinct forms of subjective experience. In all reported cases, experience of symptoms tended to be brief and acute. There were no reported cases of recurrence. Assessment When assessment of affected people occurred, it typically involved visual inspection of affected areas by police or medical personnel. News media mentioned no cases in which these assessments confirmed claims of shrinking or disappearance. Instead, investigations into allegations of genital shrinking typically revealed

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an intact organ (Nyinah 1997). Confronted with this disconfirming evidence, affected persons typically expressed surprise and claimed that the organ had only recently returned, had not returned to its previous size, or no longer functioned properly (cf. Ilechukwu 1992). None of these claims could be independently confirmed. One issue that complicates assessment is temporal stability. None of the visual assessments occurred when the symptoms were experienced. Instead, a considerable amount of time elapsed between the experience of symptoms and the journey to the hospital or police station. It is possible that changes in size or function did occur but had reversed by the time of assessment.

Treatment Some people who reported genital-shrinking symptoms were taken to hospitals for medical examination. However, in no reported cases were affected individuals provided psychiatric treatment. Rather than a psychological disturbance, genitalshrinking incidents were treated as different forms of criminal activity.

Genital theft and instant justice. A popular interpretation of genital-shrinking allegations was as genital theft, and people reacted to these allegations as they would to other forms of theft (cf. Ilechukwu 1992; Sackey 1997). In many cases, this involved a practice referred to in Ghanaian English as instant justice. People who suspected theft shouted an alarm and enlisted the aid of bystanders in capturing the suspected thief, whereupon the assembled crowd beat the suspect, often to the point of death. Although almost certainly underestimates, news media reported at least eight deaths from this practice during the 1997 outbreak in Ghana, eight deaths during the 1997 outbreak in Senegal, 14 deaths during separate outbreaks in Nigeria in 2001, five deaths in Benin during the 2001 outbreak, and one death in the Gambia in 2003. In addition to being a common response to theft, the practice of instant justice appeared to gain further momentum in the present cases from the belief that beating the alleged thief would restore the affected organ. In some cases this belief was phrased in terms of persuasion; through the act of beating, one could persuade the thief to relinquish the stolen body part. In other cases, the belief was phrased in terms of interference; through the act of beating, one could interfere with the thief’s power and restore the organ with or without the thief’s cooperation. In either case, it appears that the purpose of instant justice was not simply punishment of wrongdoers, but also treatment for alleged victims. By beating the alleged thief, bystanders hoped to restore the vanishing organ (cf. Ilechukwu 1992).


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Police and legal action. Given the widespread lynching activity that accompanied genital-shrinking outbreaks, it is no surprise that police and government officials became involved to preserve law and order. News reports at the beginning of the 1997 Ghanaian outbreak were ambiguous about the nature of this police involvement. Initially, they portrayed police involvement as the arrest of penis snatchers. Later, they portrayed this same activity as holding accused individuals in protective custody. By the end of the outbreak, they portrayed police involvement unambiguously as the arrest of “false alarmists.” Authorities made it clear that, unless accusers could provide proof of harm, allegations of genital shrinking would be treated as criminal acts. Accordingly, there were numerous reports of individuals held in custody and charged with making false accusations (Nyinah and Aboagye 1997). This “official response” to genital-shrinking allegations appears to have been the crucial element in controlling outbreaks of the phenomenon. Once people observed that it was those who reported genital shrinking who would be arrested, and not those accused of genital theft, reports of genital shrinking ceased. What is not clear is whether reports ceased because police action convinced people that allegations of genital shrinking was false or merely made people afraid to report this experience. From a practitioner’s perspective, the important point to note about this official response is that authorities framed allegations of shrinking as the product of criminal activity rather than psychological distress, and they treated individuals who made these accusations as criminals rather than people in need of psychological treatment. The arrest of such individuals may have been necessary to control outbreaks of the genital-shrinking epidemic. However, the construction of these allegations as intentional deception, rather than misperception or mis-attribution, does little to advance understanding of the genital-shrinking epidemics. In fact, as we discuss in the section about explanations for genital-shrinking distress, this construction reflects a misunderstanding of events. Prognosis Assessments of prognosis are difficult because news reports did not follow alleged victims over time. As a result, there is no information about the course of the syndrome and whether (or how soon) affected individuals reported a return to normal experience. However, news reports do permit some insight into local expectations regarding prognosis. First, unlike cases of genital-shrinking distress in Southeast Asian settings (which we describe in a later section), cases of genital shrinking in West African settings did not appear to involve fear of impending death, at least not for the person who experienced shrinking. (Instead, the people in the gravest danger were those individuals who were accused of causing the shrinking.)

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Likewise, cases of genital shrinking did not seem to involve problems with urological function. Finally, although some sources seemed to imply that genital shrinking would affect sexual function (Hesse 1997), there were no confirmed cases of sexual impairment.

POTENTIAL EXPLANATIONS FOR GENITAL-SHRINKING DISTRESS

Given the basic outline that emerges from media reports, how can one explain cases of genital-shrinking distress in West African settings? The section that follows considers possible explanations. “Folk” Theories: Penis-Napping and Money Juju In 15 cases, the precipitating circumstance that triggered the experience of genital shrinking was physical contact in public spaces: not necessarily contact with the affected body part, but instead everyday sorts of contact like exchange of money, shaking hands, or incidental bumping on public transportation. In another six cases, the precipitating circumstance was interpersonal interaction without physical contact. How could interpersonal interaction cause penises to disappear and breasts to shrink? People who claimed to experience genital shrinking typically interpreted this experience as theft. They accused someone with whom they had been interacting of “stealing” the affected organ (cf. Ilechukwu 1992; Sackey 1997). One perceived motive for genital theft was the “penis-napping” interpretation proposed by an editorial in a Ghanaian weekly newspaper (People and Places 1997): Reports reaching [the paper] indicate that these so-called jujumen who are operating under cover, “infect” innocent people with this mysterious “disease” through body contact especially by shaking hands with their victims. Soon after this, the victims allegedly experience a burning sensation and realise that their manhood have [sic] disappeared. According to the reports, whilst these innocent victims are going through this nightmarish experience, a member of the syndicate quickly approaches them claiming to know someone who could restore the manhood at an exorbitant fee.

According to this explanation, a syndicate of jujumen stole organs and held them for ransom. Another perceived motive for genital theft was that people were stealing penises to make money juju (a.k.a. ‘money medicine’ or sika aduro), with no intention of returning the organs to their owners. The best statement of this explanation


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appeared in a response to an informal poll reported in another Ghanaian weekly (Mirror 1997): I understand there is a cult in Nigeria where people go for these supernatural powers and I hear if a penis vanish [sic] it goes to the cult and vomits money and the person who causes this is rewarded financially.

Although such beliefs may sound strange or suggestive of delusion in European or North American settings, they are less so given cultural models, social representations, and other constructions of reality that make up the common ground for interaction in many West African settings. For example, the money juju explanation makes sense given models of agency (Markus and Kitayama 2004) that tend to prevail across diverse West African settings. Rather than locate agency in the internal qualities of persons, these models often locate agency in an interactive relationship between a powerful person and external forces, especially spiritual agencies. Although specifics vary across settings, these agencies typically demand some sort of “food” in return for their allegiance or services. Thus, the general sense of the money juju explanation is that people steal genitalia to feed a spiritual agency and thereby maintain its loyalty and productivity (see Akyeampong 1996; Jackson 1990; Kirby 1986). Another local model that underlies genital-shrinking experience is evident in beliefs about phenomena referred to in English as witchcraft, sorcery, or juju. When people in many West African settings accuse witches of causing impotence or infertility, they often say that the witch has hidden or eaten the penis or womb. Likewise, people describe death from witchcraft as a slow wasting while the offending witches gradually devour the victim’s body. In both cases, the reference is not to the physical body or organs, but the “spiritual” body or organs: the essence that underlies the observable, physical manifestations (cf. Assimeng 1989; Bannerman-Richter 1982; Geschiere 1997). In similar fashion, allegations of genital shrinking may refer to theft of spiritual essence more than theft of physical organs. Although a comprehensive discussion of witchcraft beliefs is beyond the scope of the present paper (see Assimeng 1989; Bannerman-Richter 1982; Ciekawy and Geschiere 1998; Meyer 1998), it is important to emphasize the extent to which these social representations constitute consensual realities in many West African settings. Social representations about witchcraft, sorcery, and juju are not limited to rural villages, less educated populations, and other “traditional” settings. Instead, they are also prominent in urban settings, university campuses, and other “modern” spaces. Regardless of whether or not one believes in the efficacy of magical powers, social representations about witchcraft, sorcery, and juju constitute consensual realities that propose both a means (theft of spiritual essence) and motivation

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(feeding spiritual agency) for genital-shrinking experience. Accordingly, one can interpret references to sorcery or money juju, not as evidence of individual delusion or lack of engagement with reality, but instead as the product of engagement with these consensual realities. From this perspective, belief in penis-shrinking jujumen is no more deluded than belief in divine protection or faith healing. Besides specific beliefs like the existence of spiritual agencies or the realty of witchcraft, one can speak of more general constructions of reality in which beliefs about genital shrinking make sense. For example, related to models of agency are what one might refer to as implicit selfways (Markus et al. 1997). In contrast to the atomistic or independent selfways that prevail in North American settings or highly educated worlds, the selfways that prevail across diverse West African settings tend to be more relational or interdependent varieties that afford an experience of self that is inherently connected to social and physical context (Adams and Dzokoto 2003; Piot 1999; Shaw 2000). This sense of fundamental connection both reflects and promotes the belief that a person is susceptible to external influences like those alleged in the genital-shrinking episodes.3 Associated with different selfways are tendencies of perception and bodily experience. A history of engagement with many West African worlds may foster “holistic” perceptual and cognitive habits that emphasize context (cf. Nisbett et al. 2001). These habits of mind may increase the salience of interpersonal forces in causal attribution and render plausible the notion that one person can steal another person’s sexual force. Similarly, a history of engagement with many West African worlds may foster somatization: the tendency to express negative emotions and distress in bodily rather than psychological forms (Dzokoto et al. 2003; cf. Kleinman and Kleinman 1985). Research on the cultural grounding of distress has noted tendencies to express panic symptoms in such bodily forms as dizziness (in Chinese settings: Park and Hinton 2002), palpitations, neck tensions and wind-overload (in Khmer refugee populations: Hinton et al. 2003), isolated sleep paralysis (in AfricanAmerican settings: Friedman and Paradis 2002) and ataques de nervios (in Latino or Latina settings; Lewis-Fernández et al. 2002). Although research has yet to document somatization of panic in West African settings, it has revealed a pattern found in settings where somatization of distress has been documented: the importance of the body in emotional expression (cf. Priestley 2002; Turpin 2002; Ye 2002). For example, research indicates that many Ghanaian languages employ bodily metaphors in emotion talk (Ameka 2002; Guerts 2002; Dzokoto and Okazaki 2003). Likewise, research suggests that Ghanaian students are more attentive to bodily experience than are American students (Dzokoto et al. 2003). Together, this research suggests that genital shrinking may be a culturally grounded idiom of distress or somatic response to panic (see Nichter 1981; Park and Hinton 2002).


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In summary, local constructions of reality may do more than simply render allegations of genital shrinking sensible. More important, local constructions of reality may also provide fertile common ground for the promotion of genital-shrinking experience. We return to this possibility in a later section. Official Accounts In contrast to folk beliefs, the explanation favored by government authorities was that allegations of genital shrinking represented deliberate acts of intentional deception: “a ploy by confident tricksters to create a crowd so that they can rob them” (Nyinah and Aboagye 1997; Djiwan et al. 2001). However, evidence from newspaper reports suggests that this explanation is implausible in many cases, mainly because alleged victims of genital shrinking often sought police involvement. For example, the Ghanaian Daily Graphic reported an incident in which a taxi driver accused a shoeshiner of causing his penis to vanish. After severely beating the shoeshiner, the taxi driver conducted him to the police station. To the surprise of the alleged victim driver, it was he—rather than the alleged perpetrator shoeshiner—whom the police held in custody (Ablekpe and Opoku, 1997). Rather than intentional deception, the actions of people who solicited police involvement suggest that they truly believed their allegations. This official explanation of genital-shrinking episodes as criminal deception may initially seem more plausible to modern sensibilities than explanations that emphasize magical powers. However, further consideration suggests that this explanation, too, may be more a product of local constructions of reality— specifically, worlds in which corruption and criminal activity figure prominently in people’s explanations for everyday events—than a direct reflection of actual episodes. Social Science Accounts: Social Tension Standard social science accounts of the genital-shrinking episodes linked them to larger social tensions. For example, Sackey (1997) identifies several tensions that might have precipitated the 1997 Ghanaian outbreak: political tensions, which she associates with presidential and parliamentary elections held a month earlier; economic strain, which she associates with a high baseline level of poverty exacerbated by a period of overindulgence during the Christmas and New Year holidays; religious strain, which she attributes to a period of Christian reawakening; ethnic tension related to accusations of “tribalism” during the general election; and pervasive lawlessness, which she associates with a military coup that occurred 18 years earlier. Scientists in Senegal cited “lack of education among African males, a widespread belief in black magic, and a loss of identity in the face of

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an increasingly complex world” (Trull 1996). Ilechukwu (1992) observed that earlier Nigerian episodes “occurred in a setting of severe economic depression amidst speculation about currency change and elections” (p. 91), and suggested that these political events might have precipitated the outbreak. The recent incident in Gambia appears to have occurred during a period of economic and political tensions. Although social tensions may have contributed to genital-shrinking episodes, they are unsatisfactory as a single explanation. First, there is little evidence that social tensions before or during genital-shrinking episodes were necessarily higher than during other periods.4 Accordingly, one must suggest some other reason to explain why social tension led to genital-shrinking episodes in some situations but not in others. More important, social-tension explanations do not make clear how or why instability results in the experience of genital shrinking rather than forms of distress. Individual Psychopathology: Koro Interpreted as a form of psychopathology, the diagnostic category that the genitalshrinking episodes most resemble is koro, a “culture-bound syndrome” that is found mostly in southern China and Southeast Asia. Indeed, some authors have even referred to genital-shrinking episodes in West African settings as koro-like cases (Ilechukwu 1992). In order to determine the appropriateness of the koro label for episodes of genital shrinking in West African settings, it is necessary to consider this diagnostic category in detail. As described in the DSM IV, koro is characterized by “an episode of sudden and intense anxiety that the penis (or, in females, the vulva and the nipples) will recede into the body and possibly cause death” (APA 1994: 846). Although this is the typical profile, some authors (e.g., Cheng 1996) include atypical symptoms like shrunken ears, nose, and tongues. Similarly, although the syndrome is associated with Chinese and Southeast Asian settings, there are reports of koro-like cases in Britain, Canada, France, Hungary, Israel, Nigeria, South Africa, the USA, and Tanzania (Chowdhury 1996; Holden 1987; Kovacs and Osvath 1998; Modai et al. 1986). Classification. Koro has been variously classified as a form of a neurosis, a panic disorder, a culturally bound depersonalization syndrome (Yap 1965), a body dysmorphic disorder (Stein et al. 1991), an atypical somatoform disorder (Bernstein and Gaw 1990), a psychotic symptom (Edwards 1984), and a psychopathological expression of castration anxiety (Cheng 1996). Chowdhury (1996, 1998) argues for the distinction between primary koro (either in sporadic or epidemic form), in which genital shrinking is the presenting complaint, and


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secondary koro, in which the presentation is comorbid with another psychiatric disorder (such as anxiety disorder, schizophrenia, or a disease of the central nervous system). Several criteria are typically used to make a diagnosis of koro: penile (or breast) retraction, anxiety related to the retraction, fear of death as a result of retraction, and use of mechanical means to prevent full retraction. Cases that do not meet these requirements are generally classified as koro-like symptoms or given a diagnosis of partial koro syndrome (e.g., Ang and Weller 1984; Fishbain et al. 1989). Chowdhury (1996) argues that these criteria are sufficient, but not necessary for a koro diagnosis. Incidence. Cheng (1996) reports overall incidence rates ranging from .32% to .72% during a Chinese epidemic in 1984–1985, with incidence in the most severely affected villages ranging from 6 to 19%. The total number of reported cases for the duration of the year-long epidemic was 3,000, with a large number of people being affected within a short period of time. Koro typically affects people between the ages of 8 and 45 (Chowdhury 1996), although cases of koro by proxy—in which parents perceive penile retraction or shrinkage in their toddlers or young children—have also been observed (Mun 1968). Presentation. With some exceptions, koro in China, India, Malaysia, Singapore, and Thailand occurs mainly in epidemic form. Most episodes are acute, brief, and have a low recurrence rate (Cheung 1996). However, a few ‘chronic’ cases of koro have been reported, with individuals experiencing multiple episodes several times daily or weekly (Chowdhury, 1996). Etiology. Folk theories of etiology play an important role in the spread of koro epidemics. Chowdhury (1996) reports that koro has been attributed to external causative agents such as contaminated pork, poisoned food, a fox spirit, and excessive body heat. Berrios and Marley (1984) propose that koro is a consequence of real or imagined “violations of the folklore systems concerning sexual behavior.” Malinck et al. (1985) suggest that koro may be a culturally-shaped depersonalization response to acute stress. Assessment. Information about assessment of koro is scarce. Cheng (1996) reports use of a self-report questionnaire during the 1984–1985 and 1987 Chinese epidemics. Chowdury (1994) devised a Draw-A-Penis Test (DAPT) to investigate penis-root and glans penis perceptions of koro patients and reported that koro patients showed perceptual deviations in phallic images from normal patients. More typically, however, diagnosis of koro appears to be based on verbal self-report.

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Treatment. Afflicted individuals typically respond to the experience of koro by attempting to stop or reverse genital retraction through manual, mechanical or chemical means (Edwards 1984). Chowdury (1996) and Cheng (1996) observe that the first two treatments typically result in complications that include tissue damage. Prognosis. To date, there have been no published reports of death from koro. However, in 87% of koro cases analyzed by Chowdury (1993) and 12.5% of cases reported by Berrios and Morley (1994), affected individuals endorsed the belief that total retraction of genitalia would cause death. Experts suggest that the expectation of death is based more in folk beliefs than actual cases of death by koro (Berrios and Morley 1984, Edwards, 1984). Koro-like Symptoms in Non-Asian Settings. Besides epidemic outbreaks of koro in Chinese or Southeast Asian settings, there have also been reports of koro-like cases in European and North American settings (cf. Berrios and Morley 1984; Yap 1951). However, unlike episodes of koro in Southeast Asia and episodes of genital shrinking in West Africa, koro-like symptoms in Europe and North America tend to occur as isolated cases, with the patients typically experiencing comorbid Axis I disorders such as depression, anxiety, or psychotic disorders (Berrios and Morley 1984; Chowdury 1998; Fishbain et al. 1989). In some instances, these isolated cases of secondary, koro-like symptoms may be side effects of medication for a primary disorder, such that discontinuation of the medication alleviates the korolike symptoms (Edwards 1984). More typically, however, the literature on koro does not indicate naturally occurring biomedical factors as directly precipitating koro symptoms. Instead, the secondary nature of koro-like symptoms to other psychopathology suggests that the etiology of these cases may be linked to that of the primary disorder. Treatments that are associated with a remission of the primary disorder are also associated with a remission of koro-like symptoms.5 (Table 1) Comparison with West African Cases. How do genital-shrinking episodes in West African settings compare to cases of koro in Southeast Asian settings or cases of koro-like distress in North American and European settings? Table 2 provides a summary of this comparison. On one hand, our analysis suggests that episodes of genital shrinking in West African settings share many similarities with cases of koro in Southeast Asian settings. Both phenomena involve real or perceived body disturbance, usually located in the penis. This bodily disturbance appears to be a short-lived, intense experience rather than a chronic concern. Finally, both phenomena tend to occur in epidemic outbreaks rather than isolated, individual cases.

Victim

Female K. B. Male, 24 Male F. A., Ghanaian Mechanic Male,17 K.K. Male, 20 A.O. Male, 17

N. N., Male, 31 3 males, Requested Anonymity J.N. Female, 25 S.A., 12 A. K.T., males E.K., Male, 22 Chief of Brahabebome, & M.A.A. (miner)

P.K.A. Student, Offinso Training College F.M., Male, Driver’s mate.

A.A. (Taxi Driver)

P.A., Male, Evangelist K.O, L.O., Males (driver and mate) J.O., Female, Hair Dresser C.D., Male, Pastor A.A., Driver’s Mate

Perpetrator

Male J. A. K. Male, 58 Not reported K. M. Togolese, Male, 27 F. F. (Juapong T.) Male J.N.O.

Woman, No other info T.A. Male, 32 Not reported Not reported N.K.K. Male, 24, Carpenter D.K. Ansong

B.T.D (Driver)

K.G., Male, 16

S. N.A., Male J.A., Male I.K., Male A.I.

∗ Cases

Physical Contact. No further info Physical Contact: he paid driver No further Info No further Info Co-passenger in Taxi No further info

Touched his shirt Not reported Not reported Bumped into him Not reported Not reported Asked them for directions, no reported contact. Not reported

Tap on shoulder Not reported Touching Shook hands No contact “Came behind him and touched him”

Contact

that did not provide more than two pieces of information were dropped from this summary.

I. A., Male

TABLE 1 Summary of Ghanaian Cases∗

Bantama, Kumasi Kumasi Sofoline, Kumasi La, Accra

Roman Hill, Kumasi

Kejetia, Kumasi

Offinso

Koforidua Kaneshie, Accra Nungua, Accra Nungua, Accra Sunyani Takoradi Obuasi

Kumasi Takoradi Market Awutu-Bawjiase Kumasi Tema Laterbiokosie, Accra

Location

Not reported Not reported Not reported Perp was accused of “possessing the juju that causes the shrinking of organs.”

Not reported

Driver had gone to visit friend at Offinso training College Not reported

Not reported Not reported Not reported

Conversation Buyer (from out of town) -seller Market Asking for directions Asking for directions Unclear, teen was fetching water, J.N.O had an appointment. Buying soap, bumped into her. Not reported Made her voice disappear

Interaction UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA

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TABLE 2 Cross-Cultural Comparison of Genital-Shrinking Distress West Africa Population dynamics Incidence

Symptoms

Local belief

Local treatment Prognosis

Often occurs in epidemic outbreaks. Often occurs in “normal” individuals. Emphasis on shrinking or vanishing. Cause thought to be juju and other forms of harm from human sources. Focuses on capture of alleged thief. No fear of death among alleged victims; mortal danger for accused.

Southeast Asia Often occurs in epidemic outbreaks.

Europe and North America Typically occurs in isolated cases.

Often occurs in Often comorbid with Axis “normal” individuals. I disorder. Emphasis on retraction. Shrinking or retraction.

Cause thought to lie in Cause thought to be individual contaminated food or psychopathology. malicious spirits. Focuses on preventing retraction. Despite fear of death, no known cases of death by koro.

Focuses on treating psychopathology. Treatment of primary, Axis I disorder results in remission of symptoms.

On the other hand, our analysis indicates that there are also important differences between cases of koro in Southeast Asian settings and genital-shrinking episodes in West Africa. The first difference concerns the nature of bodily disturbance. Koro involves retraction of penis or breasts into the body. In contrast, reports of West African cases tend to refer to shrinking or disappearance of penises and breasts; rarely do they describe this experience as retraction. As noted earlier, it is unclear whether this difference in terminology reflects different labels applied to the same experience or corresponds to qualitatively different experiences. Another difference concerns the experience of anxiety. Part of the anxiety associated with koro comes from the belief that death will result from full retraction of the affected organ. In contrast, fear of death from genital shrinking does not appear to be a concern in West African cases. Instead, the anxiety associated with this experience appears to center on loss of sexual functioning and reproductive capacity. Although this loss might promote anxiety in any setting, these capacities loom particularly large in West African worlds where local models emphasize the importance of having children for becoming an ancestor and thereby achieving full personhood (e.g., Fortes 1978). Perhaps the most important difference between koro in Asia and the genitalshrinking episodes in West Africa is the perceived source of bodily disturbance. Cases of koro in Southeast Asian settings are typically thought to be the result of some non-human cause, like contaminated food, or attacks by malicious spirits.


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In contrast, the source of genital shrinking in West African cases is thought to be spiritual power wielded by human sources, and the remedy for the experience of genital shrinking lies in capturing and punishing those human sources. This difference in beliefs about etiology is related to the final difference between koro in Asia and the genital-shrinking incidents in West Africa. Although affected individuals fear death, there have been no reports of death from koro. In contrast, there have been many deaths associated with the experience of genital shrinking in West Africa: not those who are affected with the experience of shrinking genitals, but those who are accused of causing that experience. Mass Psychogenic Illness How is one to interpret differences in beliefs about the etiology of genital shrinking in Southeast Asian and West African settings? Are they merely superficial differences in folk beliefs about an underlying koro disease (Ilechukwu 1992)? This interpretation resonates with the biomedical model that dominates contemporary approaches to psychological distress. From the perspective of the biomedical model, koro epidemics in Asia and koro-like epidemics in West Africa appear to be local variants of the same psychological disease, and beliefs about etiology and other cultural patterns simply moderate the experience of that psychological disease. Our analysis of news reports suggests a different interpretation. Rather than superficial differences in presentation of the same disease, this analysis suggests that differences in beliefs about etiology in Southeast Asian and West African settings may be essential components in different forms of distress phenomena. From this perspective, different beliefs about genital shrinking are components of larger cultural models or social representations that prevail in Southeast Asian and West African settings. These models and representations play a constitutive role in genital-shrinking distress, such that epidemic episodes would not occur at all without the fertile cultural ground that these models or representations provide (Good 1994). A useful concept in this regard is the notion of mass psychogenic illness (MPI): collective occurrence of physical symptoms and related beliefs among two or more persons in the absence of an identifiable pathogen. (Colligan and Murphy 1982: 33). Although an extended discussion of MPI is beyond the scope of this paper (see Colligan and Murphy 1982), a brief description reveals interesting parallels with reports of the genital-shrinking episodes (Bartholomew 1998, 2001). The typical profile of MPI occurrences begins with an environment of tension or social strain that promotes the heightened experience of physical and psychological arousal. Mass experience of symptoms occurs when (a) some triggering event suggests the relevance of a locally plausible explanation for these prevailing feelings of diffuse arousal, and (b) this explanation receives widespread attention in local communication networks (whether news media or unofficial rumor). Symptoms

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typically spread as otherwise undisturbed people appropriate collective representations about cause as an explanation for their individual experience of arousal. Spread of symptoms gains momentum when—as in the case of genital-shrinking episodes in West Africa—the somatic referent for illness beliefs is relatively plastic and sources of arousal are vague or undifferentiated (Schachter and Singer 1962). Symptoms continue to spread until information comes to light that forcefully discredits the prevailing explanation. The concept of MPI is particularly useful for understanding the epidemic nature of genital-shrinking episodes in West African settings. The MPI explanation does not deny that isolated cases of genital-shrinking distress in any setting—whether North America and Europe, Southeast Asia, or West Africa—might have a similar source in individual psychopathology. However, this explanation suggests that epidemic episodes of genital-shrinking distress, like those that occur in Southeast Asian and West African settings, have their source in local constructions of reality that promote the experience of genital-shrinking distress. Why do koro-like episodes in Southeast Asia and West Africa tend to occur in epidemic outbreaks, but koro-like episodes in Europe and North America tend to be rare, isolated cases? The MPI explanation suggests that the determining factors are the plausibility of genital shrinking in local constructions of reality and the prominence of cultural patterns that promote genital shrinking as an idiom of distress. The experience of genital shrinking is implausible given the constructions of reality and idioms of distress that prevail in European and North American settings. As a result, reports of koro-like symptoms are usually associated with psychopathology or restricted to disturbed individuals whose grasp of local reality is relatively tenuous. (As noted earlier, the isolated cases of koro-like symptoms in Europe and North America are typically perceived as unusual symptoms secondary to a primary Axis I diagnosis.) Moreover, the implausibility of this experience prevents it from “catching” among individuals with a firmer grounding in local constructions of reality. As a result, the isolated cases that do occur do not trigger the process of mass psychogenic illness and do not result in an epidemic outbreak. In contrast, genital shrinking is rendered plausible in Southeast Asian settings by cultural models, social representations, idioms of distress, and other constructions of reality that propose the existence of a disease called koro (Bartholomew 1998). Likewise, genital shrinking is rendered plausible in West African settings by cultural models, social representations, idioms of distress, and other constructions of reality that propose the existence of phenomena referred to as juju. The plausibility of genital shrinking symptoms in these settings means that susceptibility is not restricted to mentally disturbed individuals, but instead extends to “normal” individuals whose experience is firmly rooted in local realities. Moreover, even if initial cases are the reflection of individual psychopathology (Ilechukwu 1992), the plausibility of the genital-shrinking experience in local constructions of reality


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gives it the potential to catch among “normal” individuals, trigger the process of MPI, and produce epidemic episodes. This reasoning suggests that isolated cases of koro-like symptoms in North American or European settings might also “catch”—that is, transform into epidemic episodes via processes associated with MPI—if the experience of genital shrinking were linked to a locally plausible source. Research on episodes of MPI in North American settings suggests one such source: chemical and biological agents. Typical episodes of MPI in North American settings involve the belief in contamination by chemical or biological agents that trigger symptoms of dizziness and nausea (Colligan and Murphy 1982; Johnson 1945; Kerckhoff and Back 1968). If popular understandings linked the action of chemical or biological agents to shrinking genitals, then one might also observe an epidemic outbreak of koro-like symptoms in these settings. The concept of MPI is also useful for addressing the questions that we posed in the introduction. Are genital-shrinking episodes the product of normal psychological functioning in undisturbed individuals, or do they reflect psychopathology? Without denying the possibility of personality factors or individual differences that predispose some people to experience MPI more than others, the research literature on MPI emphasizes that “contagious psychogenic illness appears to be a social phenomenon affecting a certain proportion of a normal population under conditions of psychological and/or physical stress.” (Colligan and Murphy 1982: 43) In this way, the MPI characterization deviates from the DSM-IV conception of koro, which implies a construction of koro as a culture-specific form of individual psychopathology. Likewise, the concept of MPI is useful for addressing the question of whether genital-shrinking episodes represent a sort of culture-bound syndrome or a more universal phenomenon. Although particular epidemics of genital-shrinking distress may depend upon community-specific beliefs, idioms of distress, and other constructions of reality, these constructions foster the mass experience of distress via a well-documented, general phenomenon—that is, MPI.6 IMPLICATIONS FOR CONCEPTIONS OF CULTURE AND PSYCHOPATHOLOGY

In summary, our analysis of news reports suggests that different beliefs about the etiology of genital-shrinking distress are essential components of different phenomena such that, in the absence of associated beliefs, epidemic outbreaks of genital-shrinking distress would not happen in the particular forms that they do. From this perspective, recent episodes of genital-shrinking in West African settings are not outbreaks of koro, if what one means by koro is a culture-bound syndrome, rooted in Southeast Asian societies, in which people fear genital retraction due to contamination or malicious spiritual agency.

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Does this mean that one should regard genital-shrinking episodes in West African and Southeast Asian settings as distinct, culture-bound syndromes? A potential problem with this conclusion concerns the notion of a culture-bound syndrome. Defined as a pattern of psychosocial distress emergent within a particular cultural context (Parzen 2003), the notion of culture-bound syndrome is based in an entity conception of culture as a monolithic group or reified system (Adams and Markus 2004). Although perhaps useful for alerting clinicians to the forms of distress that are common among members of bounded cultural groups, the entity conception of culture that underlies the notion of culture-bound is less useful for theorizing the cultural grounding of distress. What makes koro or genital-shrinking episodes cultural is not their association with monolithic cultural groups; instead, these phenomena are cultural because they are based in and require particular cultural patterns: common-ground understandings of distress made manifest in institutions, practices, and artifacts.7 Rather than cases of culture-bound syndromes, our analysis suggests that one might instead understand epidemic occurrences of genital-shrinking distress as instances of the more general process known as MPI. However, a satisfactory account of genital-shrinking epidemics requires an extension of the MPI concept. First, the characterization of this process as psychogenic appears to locate the source of genital-shrinking experience in mistaken beliefs of bounded individuals. It tends to obscure the extent to which epidemic occurrences of genital-shrinking distress have their source in cultural models, social representations, and other constructions of collective reality. From this perspective, a more appropriate characterization of this process might be mass sociogenic illness (Kerckhoff 1982). Second, there is a tendency to refer to genital-shrinking episodes (and cases of MPI in general) as instances of collective delusion, a characterization that— despite the intentions of the writers who use it (Bartholomew 1998, 2001)— suggests that the experience of genital-shrinking distress has no basis in reality. In contrast, the present perspective emphasizes the extent to which epidemic occurrences of genital-shrinking distress are rooted in socially constructed realities that posit the existence of phenomena like juju, direct attention to interpersonal causation, and promote somatization of negative affect. These socially constructed realities are no less real than potentially irrational beliefs, like the sense of imperviousness to interpersonal influence, that are prominent in North American constructions of self and social reality (Adams 2000). LIMITATIONS, RECOMMENDATIONS, AND CONCLUSIONS

The primary limitation of this study is that it is based on secondary data from news reports. These reports lack the scientific rigor that one would desire before making firm conclusions. Moreover, these reports provide little information about


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demographic characteristics of either people who experienced shrinking or people accused of causing shrinking. It would be particularly interesting to know the psychiatric history of individuals who reported the experience of genital shrinking. Although news reports suggest that the majority of affected individuals were in touch with local reality (perhaps even too much so), the initial cases that triggered the larger, mass outbreak may have been the product of individual psychopathology. Likewise, it would be interesting to know whether foreigners were over-represented among the people accused of causing genital shrinking. Although sensationalist editorials initially suggested that the perpetrators of penis theft in the Ghanaian incidents were Nigerians, our analysis of these incidents suggests that the majority of those accused were Ghanaians. Similarly, although news reports focused on cases that led to outbreaks of violence, the experience of genital shrinking may be a more widespread phenomenon that results in violence only occasionally. Information about the base rate of genital-shrinking experience in West African settings would be useful to evaluate these possibilities. What recommendations does our initial study suggest? Perhaps the most important suggestion concerns treatment of people who report genital-shrinking symptoms. By sending a clear message of zero tolerance for false accusations, law enforcement officials have been able to restrain genital-shrinking outbreaks in almost as dramatic fashion as they begin. However, by treating accusers as criminals, officials have perpetrated a different form of injustice. The implicit rationale for treating accusers as criminals appears to be that they deliberately do harm by reporting symptoms that they know to be false. Instead, our review suggests that accusers often believe their accusations and are suffering from a form of distress even if they are incorrect about the source of distress. This conclusion suggests that a more appropriate response to false accusations would be treatment that addresses their distress rather than incarceration and punishment. Beyond this appeal for just and humane treatment, our review suggests that governments need to prepare programs of action for responding to future genitalshrinking episodes. With respect to medical and law enforcement authorities, we suggest education about alternative explanations of the genital-shrinking phenomenon. Besides the alternatives of genital-shrinking jujumen and intentional deception, there are other possibilities—like processes associated with MPI—that may underlie epidemic occurrences of genital-shrinking distress. With respect to the general population, we suspect that a potential focus of public education campaigns—convincing people that phenomena like juju, witchcraft, and sorcery do not exist—is likely to meet with limited success (see Assimeng 1989; Geschiere 1997; Jahoda 1970; Meyer 1998). Instead of attacking beliefs about sorcery and juju, a more successful focus might be public education campaigns designed to delegitimate the phenomenon that produces the greatest suffering in genital-shrinking episodes: the practice of instant justice.

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To conclude, we return to the two questions that we posed in the introduction. The first question is whether the genital-shrinking episodes in West African settings reflect psychopathology or instead are the product of normal psychological functioning in undisturbed individuals. Our analysis (and the characterization of genital-shrinking episodes as MPI rather than a culture-bound syndrome) suggests the latter. That is, experience of genital-shrinking distress does not appear to be limited to disturbed individuals who lack contact with local reality. Instead, sufferers from genital-shrinking distress often appear to be normal individuals whose experience is compatible with local constructions of reality. In other words, the source of genital-shrinking distress is not decreased contact with local realities, but instead may be increased openness to local constructions of reality. The second question that we posed in the introduction is whether genitalshrinking episodes in West African settings represent a sort of culture-bound syndrome or a more universal phenomenon. On one hand, we have argued that epidemic occurrences of genital-shrinking distress in West African settings are the product of particular cultural models or social representations (e.g., beliefs about juju) that not only influence the presentation of distress, but also play a key role in the production of distress (see Good 1994). Accordingly, any account of the genital-shrinking episodes must emphasize these specific cultural patterns. On the other hand, we have argued that these particular models or representations play a constitutive role in the experience of distress through more general processes associated with normal psychological functioning. These processes are not limited to West African, Southeast Asian, or “other” cultural settings, but can also underlie epidemic occurrences of distress in European and North American settings. Rather than a separate, culture-bound syndrome, this suggests that genital-shrinking episodes in West African settings are a local manifestation of a universal process: the sociocultural grounding of distress.

NOTES

1. The accounts upon which this overview is based appeared in The Ghanaian Times, The Daily Graphic (Ghana), People and Places (Ghana), and online news reports about the incidents from the British Broadcasting Corporation, the Cable News Network, Matinal Politique (Benin), Allafrica, the Vanguard (Nigeria), and The Post Express (Nigeria). Frequency counts that appear in the summary below do not include “double counting” (i.e., the same case reported in different publications) or instances for which it was unclear whether different publications were referring to the same case. 2. Although we began our review with reports of the 1997 Ghanaian outbreak, there are reports of similar epidemics throughout the West Africa region prior to 1997. During the 1997 outbreak, the Ghanaian Minister of Information reported that a similar episode had occurred in Ghana 20 years earlier (Owusu 1997). Ilechukwu (1992) reports several cases that occurred in urban areas in Nigeria during October and November, 1990.


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3. As Riesman (1986: 77) writes in his review of African conceptions of person, “The common African understanding of the person, which perceives the self as connected to forces and entities outside it, carries considerable risks and dangers of its own.” 4. See Goody (1957) for a similar critique of the practice of citing social tension as an explanation for increased activity by witch-finding organizations. 5. This could be a reporting bias, based on the publishing bias for effective treatment studies. Additionally, it is unclear whether the cessation in the koro symptoms is due to spontaneous remission, as is the norm for koro-like symptoms in general, or is an effect of the medication. Several cases of the use of psychotherapy in koro treatment have been reported. For example, Fishbain et al. (1989) report a case in which eight supportive psychotherapeutic sessions were included in a patient’s treatment regimen. Chlordiazepoxide and Thioridazine were also prescribed. In another case, the same authors designed a treatment plan of 15 months of insight-oriented therapy, lithium (300 mgs b.i.d.) and chlorpromazine (600 mgs daily) for a patient with a diagnosis of Atypical Bipolar Disorder with Koro symptoms. 6. Moreover, the beliefs, models, or representations that promote MPI are not limited to the community-specific variety. In addition, the earlier section on folk theories suggests more general models or representations that may promote epidemic outbreaks of genitalshrinking distress by promoting the phenomenon of MPI. For example, research suggests that a predisposing factor in MPI is an individual’s tendency to experience affect in somatic terms (Schachter and Singer 1962). Likewise, relational or interdependent selfways may promote experience of MPI by promoting openness of self-experience to external influences (Markus et al. 1997; Reisman 1986). Accordingly, if interdependent selfways or tendencies toward somatization are greater among people in Southeast Asian and West African settings than North American and European settings, then it suggests that experience of MPI in general—and epidemic occurrences of genital-shrinking distress in particular—might also be greater in the former settings than the latter. 7. For more extensive critiques of the notion of culture-bound syndrome, see Hughes (1996) and Kleinman (1988). REFERENCES

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VIVIAN AFI DZOKOTO Department of Psychology Fayetteville State University 1200 Murchison St Fayetteville NC 28311, USA E-mail: [email protected]

GLENN ADAMS Department of Psychology University of Kansas 1415 Jayhawk Blvd. Lawrence, KS 66045–7556, USA