Indian Journal of Community Medicine

ISSN No. 0970-0218

Amarjeet Singh

One of the changes brought about by Western industrialization has been the posture for defaecation. The traditional posture was squatting and this remains the method used by most of the world’s population. It is only in the past hundred years or so that use of the pedestal toilet has become common in Europe, North America and a few other places.¹ Sitting rather than squatting for defaecation has been reported to be a source of many health problems. Most physiologists and physicians recognize squatting as a natural and physiologically sound posture that encourages the defaecation process.² Yet, there has been remarkably little medical investigation into this topic.

In a normal standing or sitting posture, there is anorectal angle, between the rectum, where faeces are stored and the anal canal. This angle is partially straightened out when squatting. This reduces the pressure required for defaecation and can help treat constipation and prevent haemorrhoids.³ A reduction in overall time and the number of straining episodes required for defaecation have been reported with squatting posture.^4-8

Haemorrhoids are an extremely common problem, especially in Western countries.⁵ A lifetime incidence of 50-85% has also been reported globally. Considering the widespread pain and suffering as well as medical expense involved, it is surprising that there has been so little research into the methods of preventing haemorrhoids.¹ Haemorrhoids are very rare in nations where people squat to defaecate, but a causal relationship has yet to be established.

Certainly there is little public discussion on the issue. Patients and even medical personnel are usually hesitant to discuss topics such as anal incontinence. In recent decades, sexual behaviour-related issues have been discussed more openly (courtesy – HIV/AIDS), but problems such as haemorrhoids, anal incontinence and even bowel cancer do not command enough public concern to break through the reticence about the anal area.¹

It is surprising to note that far more effort is devoted to alleviating or treating haemorrhoids after they develop than is devoted to its prevention. This is consistent with the well-recognized priority in medical research on the treatment compared to the prevention and on procedures requiring advanced training and sophisticated technology rather than a simple technique that anyone can do, like squatting for defaecation.¹

One plausible explanation is that it does not fit the medical model of high-tech intervention. Adopting squatting does not require the professional involvement of doctors, nor does it provide any advantage to other powerful interests such as the pharmaceutical industry. This might be enough to marginalize squatting, but there is the important additional dimension of toilet technology and habits. The vast infrastructure of pedestal toilets in the West, combined with ingrained habits and a reticence to discuss issues associated with the anus, all weigh against the promotion of squatting.¹ But in India, there is no such compulsion.

Seventy percent of Indian population live in villages where the dominant mode of defaecation still is squatting in the fields.^9,10 In cities also, by and large, squatting type of latrine seats have dominated the scenario in Indian set-up till recently. However, these days, it is quite common to see in cities that pedestal latrines are being constructed in both public and private premises. Although apparently pedestal type of latrines are reported to be uncomfortable, unhygienic, unhealthy and alien to our culture/habits and customs, yet these are being installed everywhere… even in cinema halls, trains, offices, hospitals and public toilets where their maintenance leaves much to be desired.

In Indian setting (as per the Indian mindset), defaecation is basically considered a “dirty” act, faecal matter is considered a filthy thing and latrine is considered a “dirty” place. At individual level also, defaecation remains intensely personal matter; public/open discussion about which is usually not encouraged.

Thus, besides the role of pedestal latrines in the aetiology of haemorrhoids, there is also an issue of aesthetics and culture for Indians. In India, usually, personal toilets are kept reasonably clean and people are quite particular about their hygiene. However, such cleanliness is not visible when it comes to public toilets. This is more frequently seen with pedestal latrines. For example, in the pedestal latrines installed in public places, often the seat is broken (plastic/rubber rim cover) or is soiled or people (men folk) may not lift the seat (rim cover) while urinating …thus soiling it.

Although traditionally, squatting has been the conventional posture for defaecation in India, the trend nowadays is to construct the pedestal type of latrines. Perhaps, people do not realize the fact that culturally we have not yet accepted the package deal in totality, i.e. pedestal latrine, its proper maintenance and use of tissue paper roll for wiping after defaecation. Many of us who use pedestal latrines still prefer “washing” after defaecation rather than “wiping”. Perhaps, that is why toilet papers are usually missing from both public and private pedestaltype latrines. In fact, the famous Indian columnist/writer, Jug Suraiya, also lamented about the plight of Southeast Asians who have to endure the difficulties of using pedestal latrines when they visit Western countries. He has dichotomized the society conveniently into “washers” and “wipers” as per the habit of using water or tissue paper for cleaning the bottom after defaecation. Most Indians prefer to wash even after using the tissue paper, he goes on to describe. This becomes troublesome when the pedestal latrines (in UK/USA) do not have any arrangement for washing up after using the tissue paper.¹¹ A woman writer also has recently commented, “when I have a choice, I use an Indian loo.” She goes on to describe that pedestal toilets are more prone to be soiled so much so that she had master the technique of urinating in semi-standing posture over the seat (to avoid her bottom touching the soiled rim of toilet).¹²) In fact, not much thought seems to have been given to the usual semi-solid consistency of faeces in Indians as compared to the Westerners (where cold weather, small volume and hard consistency of faecal matter may make use of tissue paper more suitable). Even otherwise, toilet papers have been criticized for being scratching or for containing chemicals, which may be troublesome in cases of piles.

We, the Indians, are very touchy (sensitive) about our defaecation habits. Thus, our latrines should conform to our culture and physiology. In this context, the problem is more serious when people are forced to change their lifestyle (read – defaecation habits) because of factors beyond their control, e.g. in big cities, the prospective tenants may not be able to get a rented accommodation with an Indian type (squatting) of latrine (because of the rat race of people to adopt Western lifestyle blindly). The tenants are, therefore, forced to use a pedestal-type latrine much against their wishes.

Apart from the role of squatting in prevention of haemorrhoids on account of hygienic and convenience aspects, squatting-type latrines are also better suited for Indians rather than pedestal latrines, e.g. use of pedestal latrines involves touching of the rim of the seat and contact of the thighs with the toilet seat (which many people may not like). Moreover, clothes of the user also touch the seat in pedestal latrines. Again for women, pedestal latrines are not convenient to use during menstruation. Besides haemorrhoids, urinary incontinence has also been reported to be more frequent in women who used pedestal latrines.¹³ Thus, there is a need to rethink about use of squatting type of latrines in India, as this type of latrines suits us from health as well as social/cultural point of view.

However, lest this article may be misinterpreted, it is hereby clarified that pedestal latrines are certainly useful for people who have arthritis or certain other handicaps/ disabilities.

References

1. Dimmer C, Martin B, Reeves N, Sullivan F. Squatting for the prevention of hemorrhoids. Townsend Lett Doc Patients 1996;159:66-70.
2. Kira A. The Bathroom. Revised ed. Harmondsworth: Penguin; 1976.
3. Tagart RE. The anal canal and rectum: Their varying relationship and its effect on anal continence. Dis Colon Rectum 1966;9:449-52.
4. Skirov BA. Management of hemorrhoids: A new approach. Israel J Med Sci 1987;23:284-6.
5. Skirov BA. Straining forces at bowel elimination. Isr J Med Sci 1989;25:55-6.
6. Arullani A, Cappello G. Diagnosis and current treatment of hemorrhoidal disease. Angiology 1994;45:560-5.
7. Dennison AR, Wherry DC, Morris DL. Hemorrhoids: Nonoperative management. Surg Clin North Am 1988;68:1401-9.
8. Lam TC, Islam N, Lubowski DZ, King DW. Does squatting reduce pelvic ß oor descent during defecation? Aust N Z J Surg 1993;63:172-4.
9. Singh AJ, Kaur A. Rural sanitary latrine construction program in North India. Swasth Hind 1996;40:73-7.
10. Singh AJ, Kaur A. Utilization of sanitary latrines in rural north India. Health Population Perspect Issues 1996;19:70-7.
11. Suraiya J. Wash ‘n’ wipe. The Times of India – Sunday Times; Sep 10, 2006.
12. Krishnamurthy V. Loony behaviour: Women Era. 2007. p. 123.
13. Shershan S, Ansari RL. The frequency of urinary incontinence in Pakistani women. J Pak Med Assoc 1989;39:16-7.

Department of Community Medicine, PGIMER, Chandigarh, India

Correspondence to:
Amarjeet Singh,
Department of Community Medicine, PGIMER, Chandigarh – 160 012, India.
E-mail: amarminhas56(at)rediffmail.com
Received: 15.05.07
Accepted: 18.10.07