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, psy-
chopathology, 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.
2005 Springer Science+Business Media, Inc.
54 VIVIAN A. DZOKOTO AND GLENN ADAMS
or disappear. The above report from a Nigerian newspaper describes one such
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 func-
tioning 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.
Our review begins with eventsthat we personally witnessed: an outbreak of genital-
shrinking episodes in several locations in Ghana.
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).
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 55
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 infor-
mation) 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 genital-
shrinking episodes. The most recent outbreak reported in the media occurred in
Banjul, Gambia in October, 2003 (CNN 2003). Between 1998 and 2001, genital-
shrinking 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
Although news media in Ghana labeled the phenomenon a “genital-shrinking”
epidemic, reports of speciﬁc incidents suggest a variety of gender-speciﬁc pre-
sentations. 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 ex-
perience or represent qualitatively distinct forms of subjective experience (see
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.
When assessment of affected people occurred, it typically involved visual inspec-
tion of affected areas by police or medical personnel. News media mentioned
no cases in which these assessments conﬁrmed claims of shrinking or disappear-
ance. Instead, investigations into allegations of genital shrinking typically revealed
56 VIVIAN A. DZOKOTO AND GLENN ADAMS
an intact organ (Nyinah 1997). Confronted with this disconﬁrming evidence, af-
fected 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
One issue that complicates assessment is temporal stability. None of the visual
assessments occurred when the symptoms were experienced. Instead, a consider-
able 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.
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, genital-
shrinking 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 beat-
ing 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 per-
suade 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 coopera-
tion. 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
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 57
Police and legal action. Given the widespread lynching activity that accom-
panied 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, un-
less 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
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
From a practitioner’s perspective, the important point to note about this ofﬁ-
cial 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 psycholog-
ical 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.
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 syn-
drome 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 shrink-
ing 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.)
58 VIVIAN A. DZOKOTO AND GLENN ADAMS
Likewise, cases of genital shrinking did not seem to involve problems with uro-
logical 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
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 inter-
acting 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
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 espe-
cially 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
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 59
appeared in a response to an informal poll reported in another Ghanaian weekly
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 repre-
sentations, and other constructions of reality that make up the common ground for
interaction in many West African settings. For example, the money juju explana-
tion 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 impo-
tence 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 ref-
erence 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
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 believesin 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
60 VIVIAN A. DZOKOTO AND GLENN ADAMS
(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.
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 African-
American settings: Friedman and Paradis 2002) and ataques de nervios (in Latino
or Latina settings; Lewis-Fern
andez 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 impor-
tance of the body in emotional expression (cf. Priestley 2002; Turpin 2002; Ye
2002). For example, research indicates that many Ghanaian languages employ bod-
ily 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 id-
iom of distress or somatic response to panic (see Nichter 1981; Park and Hinton
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 61
In summary, local constructions of reality may do more than simply render
allegations of genital shrinking sensible. More important, local construc-
tions of reality may also provide fertile common ground for the promotion
of genital-shrinking experience. We return to this possibility in a later
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
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 exacer-
bated by a period of overindulgence during the Christmas and New Year holidays;
religious strain, which she attributes to a period of Christian reawakening; eth-
nic 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
62 VIVIAN A. DZOKOTO AND GLENN ADAMS
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 inci-
dent in Gambia appears to have occurred during a period of economic and political
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.
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
Individual Psychopathology: Koro
Interpreted as a form of psychopathology, the diagnostic category that the genital-
shrinking 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.
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 disor-
der (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
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 63
secondary koro, in which the presentation is comorbid with another psychiatric
disorder (such as anxiety disorder, schizophrenia, or a disease of the central nervous
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 conse-
quence 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) re-
ports use of a self-report questionnaire during the 1984–1985 and 1987 Chinese
epidemics. Chowdury (1994) devised a Draw-A-Penis Test (DAPT) to investi-
gate penis-root and glans penis perceptions of koro patients and reported that
koro patients showed perceptual deviations in phallic images from normal pa-
tients. More typically, however, diagnosis of koro appears to be based on verbal
64 VIVIAN A. DZOKOTO AND GLENN ADAMS
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
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 koro-
like 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.
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.
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 65
Summary of Ghanaian Cases
Perpetrator Victim Contact Location Interaction
Male Female Tap on shoulder Kumasi Conversation
J. A. K. Male, 58 K. B. Male, 24 Not reported Takoradi Market Buyer (from out of town) -seller
Not reported Male Touching Awutu-Bawjiase Market
K. M. Togolese, Male, 27 F. A., Ghanaian Mechanic Male,17 Shook hands Kumasi Asking for directions
F. F. (Juapong T.) Male K.K. Male, 20 No contact Tema Asking for directions
J.N.O. A.O. Male, 17 “Came behind him and
Laterbiokosie, Accra Unclear, teen was fetching
water, J.N.O had an
Woman, No other info N. N., Male, 31 Touched his shirt Koforidua Buying soap, bumped into her.
T.A. Male, 32 3 males, Requested Anonymity Not reported Kaneshie, Accra Not reported
Not reported J.N. Female, 25 Not reported Nungua, Accra Made her voice disappear
Not reported S.A., 12 Bumped into him Nungua, Accra
N.K.K. Male, 24, Carpenter A. K.T., males Not reported Sunyani Not reported
D.K. E.K., Male, 22 Not reported Takoradi Not reported
Ansong Chief of Brahabebome, & M.A.A.
Asked them for
directions, no reported
Obuasi Not reported
B.T.D (Driver) P.K.A. Student, Ofﬁnso Training
Not reported Ofﬁnso Driver had gone to visit friend
at Ofﬁnso training College
I. A., Male F.M., Male, Driver’s mate. Physical Contact. No
Kejetia, Kumasi Not reported
K.G., Male, 16 A.A. (Taxi Driver) Physical Contact: he paid
Roman Hill, Kumasi Not reported
S. N.A., Male P.A., Male, Evangelist No further Info Bantama, Kumasi Not reported
J.A., Male K.O, L.O., Males (driver and mate) No further Info Kumasi Not reported
I.K., Male J.O., Female, Hair Dresser Co-passenger in Taxi Sofoline, Kumasi Not reported
A.I. C.D., Male, Pastor A.A., Driver’s
No further info La, Accra Perp was accused of
“possessing the juju that
causes the shrinking of
Cases that did not provide more than two pieces of information were dropped from this summary.
66 VIVIAN A. DZOKOTO AND GLENN ADAMS
Cross-Cultural Comparison of Genital-Shrinking Distress
West Africa Southeast Asia Europe and North America
Often occurs in
Often occurs in
Typically occurs in
Incidence Often occurs in
Often occurs in
Often comorbid with Axis
Symptoms Emphasis on
Emphasis on retraction. Shrinking or retraction.
Local belief Cause thought to be
juju and other
forms of harm from
Cause thought to be
contaminated food or
Cause thought to lie in
Local treatment Focuses on capture of
Focuses on preventing
Focuses on treating
Prognosis No fear of death
danger for accused.
Despite fear of death,
no known cases of
death by koro.
Treatment of primary,
Axis I disorder results
in remission of
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 genital-
shrinking 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.
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 67
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 differ-
ences in folk beliefs about an underlying koro disease (Ilechukwu 1992)? This in-
terpretation resonates with the biomedical model that dominates contemporary ap-
proaches 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
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
68 VIVIAN A. DZOKOTO AND GLENN ADAMS
typically spread as otherwise undisturbed people appropriate collective represen-
tations 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 cul-
tural models, social representations, idioms of distress, and other constructions of
reality that propose the existence of phenomena referred to as juju. The plausi-
bility 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
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 69
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 epi-
demic 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 contam-
ination 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 psycholog-
ical 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
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 dis-
tress 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.
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.
70 VIVIAN A. DZOKOTO AND GLENN ADAMS
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 partic-
ular 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.
Rather than cases of culture-bound syndromes, our analysis suggests that one
might instead understand epidemic occurrences of genital-shrinking distress as in-
stances 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 oc-
currences 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 im-
perviousness 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
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 71
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 im-
portant 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 crimi-
nals, 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 genital-
shrinking episodes. With respect to medical and law enforcement authorities, we
suggest education about alternative explanations of the genital-shrinking phe-
nomenon. 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 educa-
tion 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.
72 VIVIAN A. DZOKOTO AND GLENN ADAMS
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 set-
tings 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, suf-
ferers 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 genital-
shrinking 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 representa-
tions 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 Amer-
ican 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.
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.
UNDERSTANDING GENITAL SHRINKING EPIDEMICS IN WEST AFRICA 73
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 genital-
shrinking 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.
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VIVIAN AFI DZOKOTO
Department of Psychology
Fayetteville State University
1200 Murchison St
Fayetteville NC 28311, USA
Department of Psychology
University of Kansas
1415 Jayhawk Blvd.
Lawrence, KS 66045–7556, USA