Paruresis and the Sensitivity to Judgment from Others

Imagine being so fearful of judgment that it inhibits your ability to use a public restroom. Now imagine that your fear is so gripping that it prevents you from going to work, going to parties, or going on vacation. For many adults, this is not a hypothetical situation; these scenarios are their secret realities. In fact, for approximately seven percent of individuals in the United States, urinating in public restrooms is difficult – if not impossible.

Paruresis, the inability to “pee in public,” most often originates in adolescence and is perpetuated by an individual’s sensitivity to judgment from other people who are in close proximity in a public restroom. The nature of this problem, however, makes it a sensitive issue for those who suffer from it. Moreover, most people who live with this condition never seek treatment for it.

How prevalent is paruresis? According to a Harvard Medical School sub-analysis in 1997 – derived from a 1994 Co-Morbidity Study – a random sample of individuals indicated that 6.7% of respondents had difficulty urinating in public restrooms. Accordingly, a Canadian study of Social Phobia involving 1956 respondents revealed that 178 people – 9.1% — experienced fear when using a “toilet away from home.”

Because of the shame surrounding this condition, these statistics are purely anecdotal and their numbers may be an underestimate of the problem at large. In fact, it is feasible to surmise that more people live with this condition than the reported numbers, albeit undiagnosed. Furthermore, it appears to affect more men than women at a ratio of 9:1.

Regardless of the “true” numbers of men and women who live with paruresis, it can be debilitating, affecting relationships, careers, and social lives. In fact, for some individuals, paruresis grips all aspects of their lives, causing them to remain housebound, avoiding public situations altogether.

Primary versus Secondary Paruresis

According to Christopher McCullough, Ph.D., there are two forms of paruresis: primary and secondary. Although paruretics (individuals diagnosed with paruresis) may not understand the origin of their condition, most cite the onset during adolescence. Often, the inception of this disorder is related to a teasing or bullying incident in a public restroom. To a lesser degree, it may occur as a result of traumatic toilet training or sexual abuse.

To understand this condition, it’s important to understand the two stages of onset. Primary paruresis is the physical inability to urinate around other people in public restrooms. Secondary paruresis, however, is the meaning – or importance – that paruretics assign to their condition. Paruretics may suffer from feelings of guilt, shame, low self-esteem, feelings of helplessness, and anxiety. According to McCullough, these feelings result in avoidant behaviors in paruretics, including secrecy regarding their condition.

Secondary Paruresis and the Sensitivity of Judgment from Others

The meaning that individuals assign to their paruresis directly correlates with the severity of their physical dysfunction.  The more anxiety and shame attributed to the meaning of their paruresis, the less control they have over the ability to relieve themselves away from home.

Individuals diagnosed with paruresis often regard their inability to urinate as evidence of their inadequacies. As the condition progresses, these fears of judgment reinforce the primary paruresis, thus causing a cycle of avoidance that can range from mild to severe. Many individuals who fear being judged in public restrooms, schedule their lives around the need to urinate.

The main issue surrounding the fear of judgment is that it continues to reinforce the feelings of anxiety by the paruretic. In other words, by avoiding the “threat” of judgment, the individual is actually perpetuating the very fears he or she wants to avoid.

For the sufferer of paruresis, these situations typically induce anxiety:

• Public restrooms, including on public transportation such as trains, busses, and airplanes
• Urinals. Paruretics will choose toilets with stalls, if available.
• Sitting on a toilet, even with a stall, to urinate

Often referred to as a “secret anxiety disorder,” paruresis is classified as a form of social anxiety. Individuals with paruresis are often too embarrassed to speak to their physicians or therapists, fearing ridicule or judgment even from these trained professionals. Because of this sensitivity to judgment, many paruretics remain undiagnosed and never received treatment for their conditions.

Often, family members are unaware of the problem. In fact, many paruretics have no difficulty urinating in close proximity of family members; instead, their fear of judgment is reserved for strangers in public lavatories. This fear of judgment, consequently, causes them to react negatively and “choke under pressure.” The more the paruretic attempts to confront this issue, the more difficult the act of urination becomes.

Because the individual knows this fear of judgment will interfere with urination, he or she expects to fail. This failure to urinate – perpetuated by the fear of judgment – reinforces recurrent expectations of failure.

Prognosis of Recovery

For individuals whose fear of judgment prevents them from discussing their condition with a physician or therapist, the prognosis for recovery is not favorable. In fact, most paruretics go undiagnosed, never seeking treatment.
The good news is that for paruretics who discuss their condition and symptoms with primary care physicians and/or therapists, the prognosis for a full recovery is quite positive. Some manage full recovery within a few weeks; others may take a year – or slightly longer – to recover.

Although there are a variety of treatment options available, there are typically three common treatments for paruresis:

• Cognitive therapy – In cognitive therapy, the therapist works with the patient to modify the thoughts that prevent him or her from urinating in public.
• Behavioral therapy – Behavioral therapy involves a step-by-step “re-learning” to urinate in public, slowly desensitizing the patient to anxiety-provoking situations.
• Relaxation – This process involves working with the paruretic to relax physically and emotionally so that he or she may learn to successfully urinate in public.

Some paruretics are not successful or ready for the treatments specified above. Instead, they may choose self-catheterization to relieve themselves in public, thus allowing them to lead active lives.

Paruresis is a condition that can have a devastating effect on an individual’s life. Though fear of judgment drives the individual’s inability to urinate away from home, with proper treatment, most paruretics can not only manage their condition but also conquer their anxiety surrounding the fear of being judged by others in public restrooms.

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