Now he can't pee.
Urinating in public has been a cloak-and-dagger affair for almost as long as Alan can remember. He's reluctant to give his last name because everybody knows him as a regular guy, a 44-year-old St. Louisan with plenty of friends and a responsible job. He also has a son who looks up to him, as well as an ex-wife he never, ever told about his problem -- not once in 17 years of tense, evasive marriage. He spent those years fibbing ("Yeah, they were working on that restroom -- I had to find another one") and holding urine for hours, bladder stretched taut. He also deftly avoided daylong conferences, travel opportunities, crowded rock concerts and bars. "Halftime at a game? Forget it."
With the turn of the millennium, Alan decided he'd reached the level of ridiculousness: Being "pee-shy" was interfering with his career choices, his social life and his peace of mind. So he sought therapy -- and found that he shared the problem with an estimated 7 percent of the population (17 million people). "It's probably second only to the fear of public speaking," he reports happily, adding, "It was silly that I wouldn't open up to anybody about it. I thought I was choosing not to give this disorder any ability to control me -- when in fact I was giving it total control."
Once coyly termed "bashful bladder," difficulty urinating in public is now dubbed paruresis, or avoidant paruresis (AP), and it's fast emerging from the water closet. "Far fewer men than we think can just go up to a trough and go," observes Steven Soifer, an associate professor of social work at the University of Maryland who suffered with AP for 35 years before learning how to desensitize himself. Relieved by his own progress, he founded the International Paruresis Association and now gives workshops across the country. "Probably at least half of men would opt for the stall, given a choice," he remarks. "And both men and women generally experience discomfort in making noise while eliminating, especially if others are around to hear them."
Soifer says nobody's sure whether AP is physiological or psychological at its root, but very little can be traced to the most likely suspect: toilet training. In all his workshops, he's heard only a few anecdotes from that age -- "one man remembered his sister sitting on the toilet, and he tried to pee between her legs and their mother came in and bawled him out." Most emotional traumas come later, he says, as self-consciousness and social sensitivity intensify. He remembers, at 10, being teased at the urinal and going into a stall instead -- at which point the other boys ran at the door and tried to break it down. "If you're sensitive, you're going to remember an incident like that," he adds, resuming a clinical tone. "About two-thirds of the people at workshops will report some kind of traumatic incident at puberty or a little before, and that's usually when AP begins. There may even be a hormonal link; at puberty the male prostate begins to grow from pea to walnut size and might have a different impact on the bladder neck."
Alan's heard a few toilet-training horror stories and a few complaints about parents' pressuring kids to "hurry up and go already -- if you don't go now, you won't be able to go until we get to Grandma's," but he can't point to any such incident in his own past. He's more interested in practical solutions. In March, after attending one of Soifer's workshops, he returned to St. Louis inspired to start a local paruresis support group (see "Calendar"). "Basically, you go out and pee wherever you can," he explains. "Typically you start in a home or a hotel room, someplace safe. Then you go to a public venue -- a mall, zoo, museum, medical building -- and work on what you need to work on as a group." Members use relaxation, visualization and distraction techniques to aid their efforts, but mainly "it's a matter of being willing to wait," he adds. "We get frustrated and anxious, so we flush and walk away unsatisfied instead of realizing that nobody's really paying attention."
Alan's convinced that being intensely sensitive, self-conscious and self-critical paves the way for AP, but Soifer says anxiety and pessimism could just as easily be consequences. "I don't know how a happy paruretic would react," he says dryly, "although there are 'stall men,' men who are quite content and happy to use stalls and don't feel like less of a man because of it." Crude restroom design is, in fact, AP's main culprit, with bowl-shaped urinals splashing loudly and urine flying back up into the air when men try to "hug" the urinal to gain some privacy.
People plagued by lifelong paruresis travel happily in Europe, which builds more small, individual restrooms and uses civilized full doors instead of cattle stalls. But America's rugged individualists are said to shun such niceties, preferring to rub elbows at the trough and compare streams. That works fine at a campout, but in modern adult life, publicness places us in the presence of strangers, magnifying any hangups we already have about the body, sex, elimination, privacy and cleanliness. We're afraid strangers will judge or mock these sounds, odors and acts that make us so self-conscious -- and we're not wild about the instant intimacy of hearing their bodily functions, either.
Culturally, we've lost the primeval innocence that let us squat together, chatting and defecating in a companionable morning ritual. We've lost the arrogance of kings who held audience from their porcelain throne (Louis XIV was on the commode when he announced his coming marriage to Madame de Maintenon, and generals have forged military campaign strategies from similar positions). We've lost the carefree Parisian notion of the unconcealed pay-as-you-go public pissoir. And our problems with paruresis seem to be increasing steadily -- at least in Britain and its offshoots Canada, Australia and the U.S., where privacy is valued rather unevenly, people guard against crowds and strangers, and men are expected to numb themselves to social embarrassment. "The vast number of reported cases of AP have been in English-speaking countries," notes Soifer. "I think it's a legacy of the Victorians."
The problem itself is ancient ("In the Middle Ages, armies would curse their enemies with the inability to void," chuckles Soifer), but the first clinical reference to AP didn't come until the 1920s. Just past Freud, in other words -- and the patients were women. "Doctors would diagnose them with 'psychogenic urinary retention' and perform a transurethral resection, widening the bladder neck," explains Soifer. "It didn't work. Then, in the 1950s, two U.S. researchers surveyed college students and found that a full 25 percent had difficulty voiding around other people. By the 1970s, many people -- now predominantly men -- were being treated."
Some took radical steps and still do today; as a worst-case example, Soifer cites a man so desperate he underwent surgery to cause incontinence. Others do self-catheterization or try transurethral microwave therapy, destroying some of the smooth-muscle tissue at the bladder neck. The procedure was developed to ease blockage or restriction to flow but surprised urologists by also helping people with no apparent physiological blockage.
The treatment of choice, however, remains desensitization: gradually introducing the feared stimuli in real-life situations until they lose their power to paralyze the body. "When we get fearful, we have an adrenaline reaction," explains Soifer, "and the body automatically shuts down the internal sphincter muscle. It's a protection, because if you're running for your life, the last thing you want to do is stop to urinate." When people have paruresis, the fear, anxiety and adrenal response spiral until, no matter how hard they try, they simply can't go. Desensitization short-circuits that panic, placing the fear in a situation controllable enough to be tolerable, so the mind can learn new habits. It's a slow process, though, because successes don't weigh nearly as much as failures. "Failure is magnified in the psyche," remarks Soifer, "and people minimize their successes. One man started peeing at urinals for the first time in 25 years and reported it like he'd picked up a newspaper. He couldn't even enjoy his accomplishment, because all he'd done was relearn what felt like it should've been a normal function all along."
The discussion forum on the International Paruresis Association Web site (www.paruresis.com) registers more than 42,000 visitors, with posts from all over the world -- including a 22-year-old Dutch guy who's found his own solution when he goes dancing at crowded clubs: "THE GOOD NEWS IS: I DON'T CARE ANYMORE!!!! I SIMPLY GO OUTSIDE!" Others try to "pee for the porcelain" to minimize noise, or run the water, or mutter verbal cues ("urinate urinate urinate") or wait until the need is urgent, so there's better chance of "success." Asked whether waiting ever risks the even greater humiliation of wetting one's pants, Alan smiles wryly. "No, that hasn't been a problem. Most of us have unbelievable bladder control. We've been practicing this all our lives."
The language of performance anxiety riddles these posts, and the occasional reports of triumph are as moving as the "failures": "The last couple of days at work and at a grocery store I have been able to start a stream and continue it when people have walked in," one man confides. "Say a prayer that we will all have courage." Another man offers practical reassurance: "Notice when in rest rooms what so called 'normal pissing' guys do. They all have a VERY PERSONAL WAY OF GETTIN IT GOIN. Some look down, some look up, some look at wall in front of them, some lean on top of urinal with arm, etc.... DO take a FUCK IT attitude ... you are there to piss -- will damn well take as much time as is needed -- and will learn from the experience even if you fail to void. Just go on to the next RR and try again -- and again -- and again!"
Some participants speculate about head injuries, past drug use and anxiety levels; others recall disturbing incidents in their past, desperate to unlock the cause of their locked sphincter muscles. "I was very young, maybe 5," writes one man, "when my grandmother took me to her can. I believe I was in a hurry to piss, so she made sure I got my pants down in time. My piss, I remember, forked into two streams. Grandma freaked out as I tried in vain to keep all the piss in the toilet." As she yelled, he giggled -- so she decided he was "pissing everywhere on purpose" and spanked him good.
A 31-year-old sadly reports that he turned down a sexy young woman's invitation to accompany her on a European bus tour -- "How could I enjoy seeing Europe whiz by the window in all its greatness while I have a bladder POUNDING into the third hour of retention and beyond? Then the public rest stops overflowing with tourists, and the packed urban washrooms.... I'm pissed off," he finishes, adding that he's now "seriously thinking of desensing myself. I think I'm going to jump on my bike, drink 7 liters of water all day long, and hit every public washroom in the city."