An exploration of syndromes that are unique to particular cultures.

You can’t get your genitals stolen in America.

At least, not while they’re attached to your body. But people can in Nigeria, Benin, China, Singapore, and Hong Kong. In all of these places, there have been cases of koro (also called suo yang in some places), “a cultural syndrome where people feel like their genitals are being sucked into their body,” says Frank Bures. “And there’s a fear of death.” It’s often thought to be caused by some kind of curse, or spell, or spirit—something otherworldly.

This is the condition that sparked Bures’s interest and led to his new book The Geography of Madness: Penis Thieves, Voodoo Death, and the Search for the Meaning of the World’s Strangest Syndromes. In it, he investigates mostly penis theft, but also other examples of what are called “cultural syndromes” or “culture-bound syndromes”—conditions that only exist in, and seem to stem from, particular cultures. Other examples include “frigophobia” in China, “a fear of cold which has its roots in traditional Chinese cosmology of balancing between hot and cold”; running “amok” in Malaysia, when people go on a killing spree they can’t remember later; and “hikikomori,” in Japan, when people socially withdraw to the point where they never leave home.

It would be easy just to gawk at the strangeness of these syndromes, or to dismiss them as unscientific or psychosomatic. Bures doesn’t do that. He carefully considers the relationships between culture, health, the mind, and the body, which can lead people to experience seemingly impossible things.

I spoke to Bures about cultural syndromes, why the United States is not immune from them, and why asking if they’re “real” is the wrong question. Below is a lightly edited and condensed transcript of our conversation.

Julie Beck: The way I actually came across the book was, I guess a copy got mailed to The Atlantic and I was in our kitchen where we keep books and another editor held it up and was like “Well, this is a subtitle.”

Frank Bures: [Laughs]

Beck: So I took it back to my desk because, well, that is titillating, and it turned it out that it circles around literally everything I’m interested in—belief, culture, stories, how all of those things affect our experiences. So I don’t know what the process was for trying to pick a title for this.

Bures: It was slightly random yes, but it worked, anyway, it gets people to pick up the book. So that’s the whole idea.

Beck: It’s not wrong—it does begin and end with magical penis theft. How much of your life have you spent looking into that condition?

Bures: A long time, I first read about it in the BBC in 2001 and I sort of filed those [cases] away and but I couldn’t get them out of my mind. So I just kept researching it little by little until I had to actually go there. Those things are so hard to research from afar, I really wanted to talk to somebody who’d experienced it and find out what is it like. It’s something we can’t really have in our culture because we don’t believe in the things that underlie them.

Beck: By giving it the designation of “culture-bound syndrome,” does that imply that it is a made-up condition or is it treated as “real?”

Bures: That’s always been the issue with the culture-bound syndromes. In the DSM-V they call them cultural syndromes, putting them in an appendix at the back, which implies that they’re not real. Whereas the ones in the main text of the book are real. Putting the ones in the back, saying these are from other cultures implies that those are less real or not real.

Beck: It seemed like most people you talked to were saying that these syndromes weren’t real, that people just believed in them because they were uneducated, and they tended to go away once people became more educated. And even people in the places where these syndromes used to be common were telling you this. This suggests that these syndromes are just a product of ignorance, which seems rude and overly simplistic. Why do you think people think that way?

Bures: That’s a good question, I don’t really know. That’s kind of the larger narrative of Westernization—that once we get the correct science and the correct view of things that these old primitive beliefs will all go away. And I tried to challenge that in my book because I don’t think that’s correct exactly.

If that was correct, it would imply that we don’t have a culture, or that our diseases are culture-free and that’s obviously not the case. Some of our syndromes either vary from culture to culture in their rates or in their symptomatology, or don’t exist in other cultures. Like premenstrual syndrome doesn’t exist in a lot of places. There’s some suggestion that should be considered related to American culture.

Beck: There’s a certain amount of American or Western judge-iness that seems to be involved in this—that our conceptualization of medicine and how the body works is correct and so we say what’s real, what’s worthy of attention, and what’s just all in your head. You mention PMS as a syndrome that could be bound to our culture, and I feel like that’s a very treacherous thing to say. People might feel like you’re stigmatizing or delegitimizing their experiences. But that’s kind of what we’re doing with these other ones in other cultures.

Bures: What a person in our culture would feel if you said PMS is a cultural syndrome, is the same thing that people in Nigeria would feel, who’ve had their penises stolen, if you told them that was a cultural syndrome they were undergoing. This questions their fundamental assumptions about the body and the world and how things work. Even though you go to another culture they don’t have PMS, they don’t have any of the emotional and psychological symptoms. They would have some of the physical symptoms.

Beck: Are there other conditions that Americans experience and other countries don’t so much that could be our culture-bound syndromes?

Bures: Some of the more obvious syndromes would be anorexia; bigorexia which is like muscle dysmorphia, where men think they’re not muscular and they keep exercising; pet hoarding. This is controversial but some people talk about fibromyalgia and chronic fatigue syndrome as possible cultural syndromes. Wind turbine syndrome would possibly be one, where people who live near wind farms feel like they’re getting disturbed sleep, headaches, tinnitus, nervousness, from the wind turbines. There’s no real evidence for it. But people feel these things for real.

One of the problems is this whole distinction between real and not real, because the symptoms can be real even if the cause is not exactly what you think it is. You can see that in a lot of the placebo and nocebo research, how it’s kind of how those mechanisms work. Gluten intolerance is one that is a really good candidate for cultural syndrome.

You feel something’s wrong and you believe it’s caused by these things, like gluten or wind turbines or hormones or magical spells or something like that. Depending on your conception of those things, you could have certain symptoms that you’re, in a way, kind of generating by belief in them.

Beck: What would be the beliefs that these revolve around?

Bures: Well that’s where it gets interesting, and it would be interesting to see research on those. You could imagine that gluten intolerance is a way of saying something is wrong with our diet, our food, disapproval of the Western diet or something like that. One that was just kind of called into question was seasonal affective disorder. That’s been recognized as a treatable disease for a while and now people are saying it doesn’t exist. But the belief there would be in the physical value of sunlight on the skin and how it reacts with your body.

Beck: So now we’re getting into very contentious territory, right? There’s a dichotomy people will draw, with a lot of things, but it’s just particularly clear here with the cultural syndromes, between things that are real and things that are socially constructed or made up. And I wonder if these fights over whether things like seasonal affective disorder would be better served by a different question rather than is it real or is it not real.

Bures: Yes I definitely think so. Your question gets to this idea of whether something is physical or mental. And historically things that are physical have been considered real and things that are mental have been considered not real, or imagined, or psychosomatic. That’s the biomedical model, that the body is like a machine, all our experience is caused by these biochemical reactions and you should be able to fix things by changing the biochemistry. I think a more accurate or complex model is a biolooping model where our ideas, our mindsets, and our beliefs feed back into the biology and change the biology in a way you can measure. It’s real but it’s not physical first. It’s mental first.

Beck: This reminded me, too, there’s a debate among psychologists about whether emotions are real, biologically innate things, or whether emotion is a concept that humans made up, like money. And it’s interesting because, even if we did make it up, people still experience emotions, so they’re real in that way. It’s a weird thing to say people’s experiences are real or not real.

Bures: Exactly. Exactly. But the point with the biolooping model is that even our imagined experiences have what you could call biological implications. For example, in Kelly McGonigal’s book The Upside of Stress, her whole point in there is how our ideas about stress affect our experience of stress. If you believe that stress is harmful, your body reacts with what’s called a threat response, that elicits certain biological responses that are evolved to deal with danger and threats. If you don’t believe stress is harmful, you have what’s called a challenge response, which has a different biological profile. So that’s how that looping effect can work, where your perception changes your biological response to things.

Beck: To a Western, biology-centric mindset, some of these cultural syndromes seem very extreme, especially voodoo death, when people are cursed to die at a certain time and then they actually do die. But there is tons of scientific research showing people’s beliefs about their health do shape their health. I mean, just take the placebo effect for example. What has this whole investigation taught you about how much expectations and beliefs can shape people’s actual physical experiences?

Bures: It’s taught me that these are hugely important, I’m not saying there’s no biology involved but there’s this other piece that’s been neglected for a long time that’s important in this looping process. It can have a huge effect. Like if you go to the doctor, just the act of going to the doctor is part of your treatment. There’s a therapeutic effect just for seeing a healer. Depending on how much you believe in the treatment, that’s also part of the treatment. We usually don’t think of that as part of this equation but it is.

Beck: Going back to the people telling you that once people got more education then these diseases would go away, how much of that do you think is just being exposed to and starting to believe the Western model, and then that maybe reducing the amount you would see these syndromes?

Bures: That’s a good question, I tried to sort that out. On the one hand, people would say these things are disappearing and you’d find out that they’re actually still around. Koro still exists in some places, in Asia. Also it’s not like the Western idea of the body has steamrolled, in China, the Chinese concept of the body. Now they kind of coexist in this weird space. All Chinese hospitals are integrated with Western medicine and Chinese medicine and you have these kind of competing ideas. Which most people on the street it doesn’t seem to be a problem for. But I find it really fascinating that those two things are kind of mingling in a way.

I think the reality on the ground is complicated. And looking back at our own science, which you assume to be purely biological, you find out that’s also more complicated and has more of these aspects to it than we usually think it does.

Beck: What are you thinking about specifically when you say that?

Bures: I’m thinking about the placebo research. You think when you take an aspirin that your pain relief is coming purely from the aspirin doing something biochemical in your body, but part of that’s also coming from your belief in aspirin, and the knowledge that you took the aspirin. The brand name aspirin seems to work better than the generic aspirin, stuff like this. So our beliefs are active in our own biomedicine as well. Our belief in biomedicine is part of biomedicine.

Beck: What’s the role of story in all of this? Either the stories we tell ourselves on an individual level or the stories that exist in our culture? Like for example, a lot of people in Hainan where there was an outbreak of penis theft, thought that there was a fox spirit wandering around villages stealing people’s genitals at night.

Bures: When you tell a story to somebody, you’re telling them about the things that happened but you’re also telling them about the force at work in that story that is causing one episode to lead to another episode. For example, in Nigeria when you hear a bunch of stories about people getting cursed or magical things happening, it’s a way of communicating that this force is real and it’s in the world and you should watch out for it. As far as the fox spirits, that would be another example of that.

The more you hear those stories and the more the people around you believe those stories are true, that shapes how the world feels or what you think is possible in this world. Stories become possible, and then they become familiar, and then they become real. The more powerful those stories are, the more you believe in the root forces in them and the causal forces that are holding those stories together. In our culture it would be biochemistry, in traditional Chinese medicine it would be balancing between yin and yang, balancing the forces in the universe, in Nigerian traditional beliefs it would be the power of magic and the ability of people to manipulate that. Ted Kaptchuk said that “Medicine is the application of what people think is true about the cosmos to what is experienced in everyday life.” That’s where that comes in.

Beck: It’s just interesting that the very high level beliefs that people might have would play out on very individual and personal levels.

Bures: I mean, cosmological stories are stories about how the world works. And what forces are active in your life. Whatever you believe about those you kind of apply, in a way. If you believe in the creation story in the Bible, the causal force in that is God and God’s will. And by telling that story you’re saying that force also runs through all the world and all our lives. If you tell the story about the Big Bang and believe that the world came into being that way, that’s a way of saying the world is primarily a physical thing. That’s what we believe in our culture, mostly, and so then when you’re sick you want to use that knowledge in some way and that’s why we believe in biochemistry so strongly.