Given the choice, you probably prefer your home porcelain throne to using a public toilet. But for more than 20 million people in North America, peeing in a public restroom is no simple matter.
People with a "shy bladder," a real condition also known as paruresis, are fearful of urinating when other people are nearby.
"What people worry about is being in a bathroom near other people and not being able to urinate, and that others will notice and form judgements about them -- that they're weird, defective, inferior, or for men, not masculine," says Carl Robbins, director of training for the Anxiety and Stress Disorders Institute of Maryland in Baltimore, who has worked with paruresis patients for more than 20 years.
There's a tremendous amount of shame and embarrassment because sufferers feel they can't urinate like everyone else so they keep it a secret and may go to great lengths to hold it in.
"Probably my worst experience was going to the Brickyard 400 [a 400-mile NASCAR race] with coworkers and customers -- and holding it in for 14 hours," says Brian Beatty, a 51-year-old machine shop manager from Munster, Ind. "While this sounds incredible, this is an everyday reality for individuals with a shy bladder."
Beatty further explains that the two most common avoidance techniques used by those with a "bashful bladder" are to limit fluid intake and to hold it until you can reach a "safe" bathroom. Before he sought help for this social phobia, Beatty couldn't urinate in a public restroom unless he was the only one in there or in a closed stall.
"My major issue is privacy, so standing next to someone at a urinal is difficult," Beatty admits. "I'm not totally sure what brought this on but there are a couple of childhood incidents of embarrassment by friends and bullying in the school restroom that come to mind."
That's a common story. In his experience as a therapist, Carl Robbins says about 50 percent of the paruresis patients he sees can identify some traumatic or stressful incident -- being bullied in the bathroom or pressured by parents -- where they couldn't urinate in a public restroom.
This creates a vicious cycle of fear of not being able to go, which causes urinary sphincter muscles to tighten up, and the fear itself makes it even harder to urinate in public. (And, yes, there is a "shy bowel" syndrome, too. Interestingly, people with shy bladder can usually do No. 2 in a public restroom.)
"It's clearly a mind-body problem," says Robbins, "you need to interrupt the self-perpetuating cycle of fear."
Steven Soifer is familiar with that fear. He suffered in silence with shy bladder for three decades before stumbling upon an article about it in a woman's magazine. These days, Soifer, an associate professor at the University of Maryland School of Social Work in Baltimore, is working to raise awareness of the issue as CEO of theInternational Paruresis Association, a nonprofit educational organization he founded 15 years ago.
Soifer says that men, women, and children suffer equally from shy bladder, and that situations where people lack privacy when urinating -- workplace drug testing, the military, prisoners -- can be nightmarish for paruretics.
Eighty to 90 percent of sufferers can get considerably better through cognitive-behavioral therapy, which gradually exposes people to their feared situation in small steps, says Soifer, author of "The Shy Bladder Syndrome."
The Association's website has online bulletin boards, treatment information, and lists of workshops, support groups, and therapists familiar with shy bladder.
"Shy bladder is a real disorder," says Soifer, "not something to be snickered about or laughed at."