Continuing our report on the coexistence of two culture-bound syndromes, namely Koro and Dhat syndrome coexisting with OCD [1], we will discuss some relevant psychosexual issues in this context. It is pretty interesting to note that how two culture-bound syndromes facilitate sexual symptom formation among vulnerable individuals. India has now become a Koro-prone country, especially after six large-scale epidemics since 1982 [2-7]. Penile shrinking or retraction or contraction is now a potential social cognitive construct in different forms of actual or alleged complaints of sexual dysfunctions. We want to highlight four specific issues in this context.

Koro is a culturally related psychogenic syndrome, clinically characterized by acute panic reaction concerning the perception of genital hyper-involution and fear of impending death. In the male, the cardinal feature is retraction of the penis and testes into the abdomen. In the female, shrinkage of vulval labia into the belly and/or nipple or breast into the chest cavity is the predominant presentation [8].

The term ‘Dhat’ has its root in the Sanskrit word ‘Dhatus’, which means elixir of life that constitutes the body and the mind. Wig first described it [9], which is characterized primarily with vague psychosomatic symptoms of fatigue, weakness, anxiety, loss of appetite, guilt, and sexual dysfunction, attributed by the patient to loss of semen in nocturnal emission, through urine or masturbation. It is often associated with sexual dysfunction (impotence and premature ejaculation) and psychiatric illness (depression, anxiety neurosis or phobia) [10]. The International Classification of Diseases (ICD-10) classifies Dhat syndrome as both a neurotic disorder (code F48.8) and a culture-specific disorder.

Recently, two large-scale Koro epidemics (2010 and 2016) in West Bengal [3,4] created widespread social fear of potential penile pathology among vulnerable individuals. Many individuals in the mental health clinics of tertiary hospitals expressed their doubt about alleged penile shortening or contraction and requested a physical examination. However, they did not manifest any of the classical presentations of Koro but had some overt anxiety and obsessive-compulsive rumination with varied health anxiety, including genitally focused concern. The typical features of this group are: young adult (between 20-30 yrs. of age), single, some are with heavy masturbatory guilt, and some are doubting their masculine (sexual) strength [11]. Koro is also reported with erectile dysfunction [12]. Koro as a disease entity (‘penis shortening illness’ or locally called Disco illness) is now well-known among urban and rural populations.

Concern with dhat (semen) is a chief complaint of patients with various comorbidity and age range [13,14]. There are many socio-cultural myths about dhat in Indian society. It is considered a Culture-bound syndrome from the Indian subcontinent [15]. As a strong taboo persists in Indian society about sexuality, and many male youngsters harbor faulty notions about semen since their teen ages. Nocturnal emission is one such highly stigmatized issue that compelled many adolescents to seek medical consultation. Many alleged culture-based standards regarding color, density, odor, and force of ejection (during masturbation) of semen circulate in the teenage world. Individuals with suspected or actual sexual dysfunction often have a highly anxious preoccupation with seminal discharge, and quite a few of them develop Dhat Syndrome. Genital secretions, both in men and women, are considered the most highly purified form of “dhatu”, and loss of “dhatu” is thought dangerous, a source of the person’s inner strength. Among South Asian people, preoccupation about the loss of “dhatu” reflects the overvalued role of semen as a vital substance of the human body, deeper concerns about powerlessness, social stress, and sexual energy [16]. Many ancient and modern sources provide evidence that the loss of genital secretions in men and women have similar meanings, linking these two conditions as “idioms of bodily distresses.” [17].

Interestingly, in women, a variation of Dhat syndrome has been identified. Some female patients are presenting with excessive vaginal secretions in third-world countries. They also report various somatic symptoms such as tingling sensations, dizziness, ache and pains, weakness, and numbness. When an individual falls ill, the diseases have metaphorical meanings within their cultural context, meanings that may be empowering or profoundly disempowering. Sometimes these symptoms have underlying somatic referents – malfunctions of a body part or the whole body itself. Sometimes these symptoms have little or no somatic referent in the physical body [18,19]. This holds for female ‘Dhat syndrome,’ as the symptom of excessive discharge speaks of a loss of energy, vitality, and strength. Women who talk about their experience of “dhatu loss” or excessive vaginal discharge (safed pani or shada shrub- while discharge) may be speaking on several levels about their life experiences. They may be talking about their physical body’s experience, debilitated by physical disease in the forms of anemia, malnutrition, overwork, and exhaustion. They may also be speaking more metaphorically about a loss of energy and vitality in the social sphere, expressing the powerlessness and oppression within their daily lives. Genital secretions in females also have a sexual significance in South Asian life, and loss of genital secretions may also speak of repressed sexuality or denied issues [20,21].

Identification of a female variant of Dhat Syndrome is essential. They may be a subgroup of patients seeking help from the gynecologists for their excessive, non-pathological vaginal discharge (often misdiagnosed as leucorrhea and treated for the same) or a referral from mental health professionals for symptoms like depression and somatoform disorders [22]. Actually, they are suffering from some psychological distress or illness. Thus, Dhat syndrome, in the Indian cultural context, has a deep symbolic meaning as the essence of life and health in both men and women. It has been seen after the Koro epidemic; more cases of Dhat Syndrome visited Psychiatry outpatient clinics. Koro with Dhat Syndrome is also reported [23].

In Koro and Dhat syndrome cases, the underlying hallmark is the excessive anxious preoccupation with genitals – bordering on sexual obsessive-compulsive presentation. Obsessive rumination with morphology or functional aspect of sexuality is a nucleus upon which compulsive behaviors are evolving. Frequent physical scrutiny of genitals and keen observation of morphological changes during sexual arousal or multiple help-seeking behavior despite assurance are examples. Penile dysmorphophobia with recurrent Koro is also reported [24]. This could lead us to speculate about underlying Obsessive-Compulsive psychopathology whose clinical presentation is colored by cultural and religious beliefs. Transcultural studies have shown similar conceptual shifts in diagnosing certain culture-bound phenomena like the ‘suchi bai’ syndrome from West Bengal, India. Certain groups of individuals, especially Hindu widows, are subjected to multitudinous taboos. Maintenance of high standards of personal cleanliness or purity was socially expected from these groups of individuals [25]. Repetitive, compulsive cleaning and washing for fear of contamination was a common feature in these individuals, often based upon unfounded socio-religious fears of becoming ‘polluted’ or ‘unclean’ if customary rituals were not adhered to.

Penis image perception is heavily dependent on socio-cultural beliefs, and individuals with OCD-personality traits are more prone to generate heightened penis awareness. They engage in visual scrutiny, which is crucial because they usually attribute their sexual dysfunction and anxiety to self-alleged anatomic-physiological penis conditions. These conditions ultimately earn a ‘disease’ or ‘abnormal’ character at par with the subject’s sexual beliefs and misconceptions. Thus, an impotent patient suddenly discovers that his penis is slightly left-titled or the urine flow is not with ‘enough’ expulsive force. A patient with dhat issues may notice the length of the penis has decreased or alleged excessive liquidity of discharged semen. In some, even the cremasteric contractions are viewed with great pathological significance or the ‘changed palpability’ of testicles (hard or soft) carries a definite illness message. These are a few examples where psychosexual anxiety transmits to organ anxiety and makes a firm ground for sexual morbidity. Several research studies have recently shown that the SPS (small penis syndrome) [26] or supposed penile deficiency [27,28] is quite common in a cohort of men seeking treatment for a short penis.

In the current health service set up in India, there is no designated clinic or facility to discuss sexual matters. The only recognized clinic in the tertiary hospitals is the VD (Vernal Diseases) or STD (Sexually Transmitted Diseases) clinics. Usually, people avoid this clinic with fear of the stigma that if people (or friends) know that they visited Venereal Disease clinics- it is a social shame (with the suspicion that they probably visited prostitutes). They constantly avoid Psychiatry clinics with the same social stigma of being labeled as ‘mental’. So, the only opportunity is the several folk and herbal healers (including palmist, fortune tellers, astrologers) and a group of non-medical health care providers who openly advertise their understanding in dealing with sexual problems (e.g., impotence, quick discharge of semen or night pollution, etc.). Their treatment methods are often unscientific, mystic, and unethical. Many prescribe allopathic drugs covertly (like anabolic steroids or multivitamins) and offer charming talismans or sacred thread for wearing on the body. The most dangerous aspect of their treatment methods is strengthening existing myths about sexual potency and the activity of sorcery (by envious neighbors or someone else) [12,29].

Very rarely do clinicians get the opportunity to discuss sexual anxiety with their intended clients. It is urgent to organize a sexual counseling clinic under a different name (to ease stigma) like Saturday Clinic or Adolescent health clinic in the Psychiatry Department. Currently, in the whole country, a few Andrology clinics operate in some super-specialty hospitals, which is beyond the scope of the significant population. It is believed that there are many cases of Penile dysmorphophobia, Small Penis Syndrome, and Dhat syndrome or psychogenic impotence among the people who lack proper health-seeking contact and are either untreated or wrongly treated by folk healers or unregistered health care providers.