What a Relief!

What a Relief! Back from Bashful Bladder
By Daniel

[Long read – originally published Nov. 7, 2015. Click for downloadable .pdf file]

I remember very well the first time I found myself unable to urinate in a public bathroom.

My family were city-dwellers but we had country relatives so long car trips were a regular feature of my childhood. Pit-stops at McDonalds to have lunch and to relieve bladders were an invariable part of these journeys and it was during just such a stop that. aged six or seven at the most, I found myself standing in front of a urinal in a busy restroom. unable to wee. Perhaps six or eight other young boys came and stood on either side of me and emptied their bladders without hesitation. But I did not, could not. I just stood there, confused and embarrassed.
Two things consumed my attention during this episode and echo in my memory now. One was the noise. I do not know why there were only other young boys and no men in the bathroom at the time but they made the kind of unself-conscious racket that unsupervised young boys make. None of them said anything disparaging, although maybe one or two wondered why I stood there so frozen and shy, but they made a loud and raucous, Coke-and-Fanta-charged commotion. It was a smallish bathroom – a urinal perhaps three-abreast, a couple of cubicles and some basins – and the noises rebounded off the tiled walls and filled my ears. It was not a private moment.
The other was the frustration. I stood in front of this trough-like urinal, willing the wee to come, but it would not. The problem was not that I did not need to go – I did – the problem was that my body would not oblige. I did whatever it is that we do when we want mine to flow – I released that part-mental part· physical latch below the bladder – but my body would not respond. The muscles in the floor of my pelvis simply would not release. And, the more I concentrated on loosening them, the less cooperative they were. Everyone else in that bathroom could urinate; why was I not able to?
My brother, five years older, was there too, waiting patiently for me. After minutes of trying, I told him I could not wee. He said it was because I was nervous and suggested that I use a cubicle. His advice was good: I went into a cubicle and was able to pass mine right away. But my brother was the last person to know anything of this anxiety for a long time. I had stalled down a long and dark and lonely path.
* * *
One does not quickly revisit something that distresses them. So, having discovered that I was more comfortable relieving myself with a little extra privacy, I decided that I would just use cubicles, rather than urinals, in public bathrooms. And so it was. For many years following – ten fifteen years – I would always urinate in cubicles in public bathrooms.
For me this was not a problem; it was a solution to a problem. I did not like urinating at urinals so I used alternative facilities. My fear about using urinals was not so much that other people in the bathroom would see me urinating. Rather, my fear was that, like that one uncomfortable episode in the bathroom of a fast-food restaurant, people would see me unable to urinate.

What inference might one draw if they noticed that someone else in a bathroom was trying to urinate but could not do so? I did not really know then and do not really know now. Perhaps they would infer

that that person had some sort of health problem. Perhaps they would infer that that person was simply trying to empty their bladder when they did not actually need to. Perhaps they would think that that person had never gained full control of their bladder. Perhaps they would infer that that person was nervous and insecure and vulnerable.
It was really the last of these possibilities which concerned me. I was nervous and insecure and, as a result, vulnerable. I feared the judgement of my peers and hated being ridiculed. Moreover, it was just because I was nervous and insecure that, in truth, I had not gained complete control of my bladder and the thought that someone might have the perceptiveness to combine the two inferences was what scared me most. When you are already vulnerable, your greatest fear is that someone else will realise this.
Doubtless, no sensible person would draw any certain inference .from someone’s inability to urinate because any number of things could explain the fact. And, perhaps more to the point, no sensible person would ever even advert to the question of whether someone else in a public bathroom was actually succeeding in emptying their bladder or not. Regardless, for many years the rationality or irrationality of my fear was not and did not need to be an issue for me. The increased privacy and security of a cubicle always allowed me to empty my bladder. At worst, I would have to wait ten or fifteen minutes until one became available. Throughout the remainder of primary school and throughout most of high school, then, I had no reason to address a problem which I could hide behind a closed cubicle door.
Eventually, however, this strange, unfounded fear that I had developed would become a phobia which would impair every aspect of my life.
* * *

Worse, and worse, and worse.

I would go into a cubicle and try to pee but nothing would happen. So I would sit down and try. Sometimes this would help; sometimes it would not. And it was always harder if I was in a hurry or if I knew that someone was waiting for me.

Sixteen and 17 and 18 now. On occasion, I would simply not be able to empty my bladder, no matter how long I stood or sat in a cubicle. Exasperated, I would have to give up, return to whatever I had been doing previously, and fly again later.
A little older. Parties were incredibly difficult. It was even harder to urinate in the bathroom at someone else’s house than it was in public facilities, especially when there was a line of tipsy teenagers waiting their turn outside. I would try to pee, though knowing I would soon leave the bathroom not having succeeded. And then how does one socialise and have fun, make friends and dance, when their bladder feels like it could burst?
It was always difficult if I was stressed or upset – if I was nervous about something or agitated about a fight with someone close.
Hours on end, with a bladder I could not empty, and not prepared to tell anyone about it. This became
a familiar experience – and one I dreaded.

So then the evasive behaviors started. I sought out the most secluded facilities I could find at my school and then at my university. If meeting friends in public, I would plan to arrive half an hour before they did, so I could visit a bathroom without the added pressure their presence would bring. I would stop consuming any fluid hours before going to a party. I avoided travelling with others.

Long an plane flights (which I took alone) were almost unbearable. The bathrooms were private and secure but I always had a sense that the other passengers, seated in rows on the other side of the thin partition, were arranged like an audience. I felt like they were watching me, as if through a one-way window. The hum of the aircraft engines and the vibration of the cabin did not help either.

A little older still, and I found myself unable to relieve myself for ever longer periods. Sometimes I had difficulty voiding even at home. On one occasion, I could not wee for almost a full 24 hours. The earth completed a rotation, and I could not wee.
* * *
Nothing that anyone had said to me before this incident, nor anything that anyone has said to me since, has hurt me so deeply.

It was during my first year at university· I was 19. University, of course, brings many freedoms and one of the more unusual freedoms it brought me was the opportunity to urinate in greater privacy. No longer having to adhere to the timetabled routine of school-life I had begun to rely very much on the tactic of finding more and more private bathrooms in which to relieve myself. If I felt uncomfortable trying to urinate in a crowded bathroom, I could take whatever time was necessary to find a more secluded one, without having to worry about arriving late for class and incurring the wrath of some persnickety history teacher.
If this strategy allowed me some short-term relief, however, I could very soon see that it was exacerbating what was becoming an intractable problem. For every time I avoided confronting my fear
– every time I retreated to a quieter, hopefully empty bathroom – the control which I bad over my
bladder, and the confidence which goes with this basic life-skill, were diminished.

It was with the purpose of arresting this decline and of regaining control over a problem which was starting to control me, then that I marched into the men’s bathroom on the ground floor of the university library one afternoon, resolute in my intention simply to walk into a cubicle to shut the door behind me and to empty my bladder, without having any regard for how many other people were m the bathroom and whether they might have any idea what I was doing. For most people, this would not be a challenge of significant proportions. For me, it was no unambitious project.

The goal was achieved with surprising ease. I walked into a cubicle, shut the door, stood before the toilet urinated, flushed opened the door, and went to the basin to wash my hands.

“You should use the urinal,” snapped someone to my left. “It uses less water.” Initially, I only caught the second part of these bizarre remarks and I thought that they were directed at a young man who was washing his hands next to me and had neglected to tum off the tap while he lathered his hands with soap. But I noticed that he looked a little amused or bemused or something – not like a man accosted by a complete stranger – and I suddenly comprehended both halves of the reproof at once. It was directed at me; this nasty stranger had been complaining about the volume of water used to flush a toilet, as opposed to a urinal. “There’s no need to be shy,” he sneered as he left the restroom.
The remote possibility which had concerned me for so long – the possibility that someone might realise that I could not urinate at a urinal but only (if at all) in a cubicle and deride me for it – had, at this most inopportune moment, become reality. But, apparently, this man had somehow realised – I suspect he observed that I was in the cubicle only for long enough to have urinated – and was now intent on humiliating me. I was later re-assured by a psychologist that this event was almost impossibly unlikely;

that one could live for 500 years without something like this happening to them that the man who made the remarks probably suffered from a psychological disorder himself. At that moment, however, I saw my own self-belief destroyed. I felt warm, kindling with humiliation.
* * *
Like many others, the student association at my university produced a weekly newspaper. Needless to say, the quality of this organ never really attained even the unextravagant aspirations its readership might have had for it. Indeed, it combined a tastelessness of subject matter with an inelegance of style in a way that only an undergraduate journal can. If it deserved to be read at all, it deserved to be read while one was defecating – and that ironically enough, is exactly what I was doing when I discovered in it one day a shallow article which would offer me, for the first time, some real relief.
Every year, this unillustrious serial would publish a review of the toilets on the university’s campus. I was casually perusing this account of the university’s facilities one afternoon while sitting on a toilet (one which had, incidentally, escaped the reviewers’ attention) when I discovered a small text-box within the article which was dedicated to explaining the condition of paruresis. “Do you ever find that you can’t wee in public bathrooms?” it began. “Do you sit in cubicles trying to pee but find that it just won’t come?” If you do, it suggested, you may very well suffer from paruresis.
Otherwise known as bashful bladder syndrome, this condition, the article explained, was essentially a phobia of public bathrooms. Sufferers would become anxious when trying to urinate in public settings and the effect of this anxiety was effectively to freeze the urinal system. Its development was often, but not always a consequence of enduring some traumatic or humiliating experience in a public restroom as a child and it was much more common in men than in women. It provided a reference to the website of the International Paruresis Association.

For many years – indeed, for as long as I had had this strange fear – I had wondered if anybody else suffered from it too. Ashamed, embarrassed and afraid that I was the only one, however, I had never told anyone about it, even when it started to seriously impact my life. The first thing this short, almost parenthetic snippet of a side-article offered me, then, was reassurance that I was not alone.
Just as useful, though, was the information which I found when I consulted the website it referenced to. It provided information on the history of bashful bladder, from the point of its first identification to its increasing recognition: it listed the different sources of anxiety which can trigger bashful bladder and described the behaviours sufferers exhibit to avoid difficult situations; it provided information about support groups which were available and explained how to attempt behavioural therapy; and it provided information on pharmaceutical treatments which were being tested. One disheartening theme recurred: there is no certain cure. Nonetheless, the little article provided reassurance and support.
* * * What does it feel like, this bashful bladder syndrome?
When you are standing or sitting in a cubicle, trying to urinate, you feel nervous and frustrated. You become increasingly agitated, and maybe shuffle about or swallow, as if these actions might help to initiate the flow of urine. And you feel vulnerable. You are intensely aware of sounds especially sudden sounds. There is a sense of disconnect between yow· mind – so clear in what it wants to do – and your body – which will not do it. And when you realise that you just cannot wee, that you will leave the bathroom with a full bladder, you feel defeated and pathetic.

When you have been unable to urinate for hours – because you are at a social gathering or out with friends or on an aircraft – then you start to feel physically unwell. Your bladder bulges against adjacent organs. You feel queasy, and it becomes more comfortable to stand than to sit. Even your chest feels a little tighter. You can concentrate on nothing else; and you can do nothing to relieve the distraction. At worst, you feel like you are a bladder, with aims, legs and head merely attached.
When you leave some event early just because you need to go home to go to the toilet you feel like a loser, and you say it to yourself. Likewise when you arrange parts of your life around your phobia, going to extreme lengths to avoid visiting a public bathroom.

And when you reflect on the problem that you have you feel inadequate and ashamed. Children in their infancy have proper control of their bladders; why don’t you? What would people think – and say – if they knew?

* * *

Bashful bladder was not the only manifestation of my anxiety. Perhaps it never is in such serious cases.

As a child, between about six and twelve, I obsessed over the tightness of my shoelaces. I could not bear it if one shoe was tied more tightly than the other. If I perceived any difference in the tightness of my shoes – as one always can, if one really concentrates on it – then I would untie and re-tie them. Over and over again. Many times, each morning.

I had a bad habit – actually, worse than a habit – of picking at scabs. Minor grazes on my hands and on my elbows and knees were never left to heal. I could prevent a single, small abrasion from healing for months on end, and would do myself much more damage in that period than the initial injury did.
Those who were closest to me – those who loved me and cared for me – were more than slightly worried about these behaviours. They rightly predicted that I would grow out of them and refrained from intervening. Maybe they would have intervened if they had also known about the anxiety I experienced in bathrooms. But they did not know. They could not, for I did not tell them.

I also worried too much about school. I worried about the judgement of my peers and of my teachers. I worried, in my final year, about grades – to an extent which was unhealthy, and which ultimately impeded my performance in the exams for which I had slavishly prepared.

It is so obvious now that there was a serious anxiety disorder at the root of all of this. But it was not so obvious then. Children do odd things. It is normal to worry about school, and not so abnormal to experience severe stress about public exams. The unmistakable symptom was the bashful bladder – but as a boy and as an adolescent, there was no possibility that I was going to tell anyone about that. Or perhaps that was another sign of the anxiety.
* * *

I bad reached the point where something needed to be done. I was 21 and I was soon to take a very long flight, from Australia to Europe. I knew from experience that I could not urinate on aircraft. What if I could not urinate for the duration of the trip? Might I somehow injure myself? Would my bladder just start to leak? And long flights aside, this was a problem getting worse, not better. So I turned to the family doctor.

Sitting in the doctor’s waiting room, knowing what I was about to tell him, I felt like a schoolboy about to divulge a dark secret in the confessional. The nervousness combined with the shame felt very much like guilt and I teared the judgement which awaited me. I seriously considered simply getting up and leaving – though I also knew that was hardly an option.
The doctor asked what was bothering me. I had rehearsed what I was to tell him and delivering the speech was straightforward. What I wanted to discuss was not so much an illness as a social phobia; the problem had afflicted me for fifteen years or more; essentially, I did not have full control over my bladder and was frequently unable to urinate in public bathrooms or even sometimes in private ones at home; I was experiencing ever worse episodes; I needed help.

He was respectful and professional but he was also surprised and puzzled. He had never encountered the issue before and he had some trouble understanding exactly what the problem was. When I tried to explain that I would not be able to urinate if I knew that someone was waiting for the bathroom, he thought I was saying that I would be unable to urinate if I had had to wait for someone else to vacate the bathroom first. Eventually though I managed to communicate the problem. He assured me that people have all sorts of fears and phobias and that this was not at all bizarre. He told me that taking some counselling would likely be the best approach but that he would have to talk to a urologist first to see if there could be a physical explanation for the problem.
It was, overall, a successful consultation. I left feeling relieved and even cautiously optimistic. It seemed there was a way forward.
* * *
But now I had boarded the medical men-y-go-round: tests, referrals, appointments, diagnoses.

First, there were tests. Having consulted a urologist, my GP ordered a urine sample and an ultrasound to check whether there might actually be some physical impediment to my urinating properly. To my surprise. the ultrasounds indicated that my bladder did not void fully when I urinated. This meant that I may indeed have a physical, rather than a psychological, problem. So I was referred to the urologist – who, at the first appointment, promptly ordered more extensive testing. This testing made it clear that there was in fact no physical problem so he surprised that the problem was psychological after all – and that it also accounted for the post-voiding residue.

It is a very strange thing to be devastated when one is cleared of having some physical impediment but this was the situation I now found myself in. If I had had some recognised physical condition then there may have been some reliable, tested intervention – whether a drug or even an operation – which would have solved my problem. Not only was there no such treatment available for my condition, but I had now to confront afresh the truth which I thought I had avoided: that my problem was mental.

Most likely, I was informed again, I would benefit from seeing a psychologist. But this was not on my agenda. If you have a physical problem, then there is something wrong with your body. You cannot help it; it is just the body you have. But if you have a psychological problem, there is something wrong with you: with who you are and how you are. Or so I felt then, anyway. Now I know better. Now I know that counselling is about the subject defeating his or her problems; that it facilitates not the treatment, but the triumph, of the subject. But I did not know that then.
There were a couple of other things we could try, but it was made plain that we could not really expect them to work. First, the urologist referred me on to a pelvic-floor physiotherapist – an allied health

professional who works primarily with incontinent patients – in the hope that she might help me to gain better control of the muscles below my bladder. The physiotherapist taught me two types of exercises which I was to practise every day: some general relaxation exercises consisting of deep breathing and concentration; and some exercises in relaxing the muscles under my bladder. I did try but I was skeptical from the outset: I knew how severe the problem was and doubted very much that a few weeks of retraining would help.

Next, the urologist tried a medication typically indicated for prostate problems but which, he said, had produced some results for some patients like me in the past. I was more enthusiastic about this, perhaps because I would have preferred – indeed, bad almost wanted – a medical diagnosis. In any case, there seemed to be something automatic about the approach of just taking a drug: if it worked, the problem would just go away like an infection or a vims. Realistically, though, I knew I was relying on little more than a placebo effect – an unpromising treatment for a problem which was itself psychological. In any case, there was no effect other than the unpalatable side-effects, so this treatment too was abandoned.

What then? It was clear enough: no physical treatment was going to work. We had searched for a physical problem and found none. We had tried some physical treatments anyway – and found them no more efficacious than we were entitled to hope. But at least this forced me to acknowledge what I really knew at the outset: I needed psychological help. I had also, however, had enough of doctors’ waiting rooms; of hying to explain my embarrassing problem; of invasive questions; of never-completely­ confident prognoses. I decided I would see a psychologist at the end of the year, following my university exams. I could not put everything on hold, just because of my problems in the bathroom.
* * *

One cause for hope did emerge during the fiustrati.ng time of medical consultations. I had read that some other sufferers of bashful bladder syndrome – some of the most severe sufferers, like me – had found some relief through self-catheterisation. It was, of course, not an enticing prospect but my situation was desperate – and becoming more so, as any prospect of a straightforward medical solution receded. So, tentatively, I raised the idea with my GP. He was reluctant at first· he thought the risk of infection was too great. But he agreed soon enough that it was worth trying and referred me to a home­ visit nursing service, whose urological nurses· could teach me how to empty my bladder with a catheter.

The endless patience, intuitive understanding and unjudging compassion of the two nurses who visited me at home to teach me to self-catheterise touched me. Their quiet but concerned manner put me at ease despite the deeply embarrassing reason that I needed their help. That they were already familiar with bashful bladder spared me the torment of describing it yet again. They did not hurry me as I explained the history of my problem; they did not hurry as they explained how to use a catheter.

Leaming the mechanics of self-catheterisation was uncomfortable but bearable. Certainly, it was nothing compared to the discomfort I had sometimes felt after being unable to empty a full bladder for hours on end. To prepare, I had to lubricate a catheter and then gently syringe an anesthetic jelly into my urethra (the latter typically only being necessary until one becomes accustomed to the procedure). I had to insert the catheter, slowly and carefully, some 25 or 30 centimetres until its tip entered my bladder. After this, urine would flow steadily through the plastic tube, much as it ±lows through a urethra when one urinates naturally. Removing the catheter tended to sting a little more than inserting it. The most important part of the process was to keep the catheter completely hygienic between removing it from its package and using it, so as to mitigate the possibility of infection.

At long, long last, I had a failsafe method to empty my bladder when I needed to. It was not something that I could rely on all the time. With the lubricant and anesthetic, it was a messy business; it required a small kit full of paraphernalia; there was always the problem of disposing of the used catheter afterwards; and I did not want to expose myself to the risk (albeit small) of infection more often than was absolutely necessary. Still, it provided an escape route that would always be available when I needed it the most. On long flights; at stressful times in my life; after several failed attempts to urinate naturally, I could always resort to the use of a catheter.

A year or so later, I discovered a product which made self-catheterising much easier. Hidden away in the catalogue of products sold by an online supplier of products for people with disabilities was a very simple but ingenious device – a disposable catheter which could be lubricated within its packaging. The catheter itself was largely the same as the type I had learnt to use but it came in a plastic sheath at the top of which was a sachet of fluid. One simply squeezes the sachet until it bursts, forcing the fluid into the plastic sheath, thereby lubricating the catheter, all within a matter of seconds. The whole package could even, as I would soon discover fold over a couple of times and fit into a trouser pocket.
Why had I not discovered this brilliant product before? The Internet is a treasure-trove if you know what you are looking for but a haystack if you do not: what do you Google for when you need a new way to empty your bladder? In any case, finding these virtually self-lubricating catheters was a breakthrough no smaller than learning to self-catheterise in the first place. I could easily take one with me when I met friends or when I went to a party; I could keep one in my bag at university or work. So long as I always had one to hand, I would need never again find myself with a bladder so full that my midsection bulged visibly – in pain and despair – and completely unable to relieve myself.
* * *
For all the relief and peace of mind they gave me, though, disposable, self-lubricating catheters were a coping mechanism, not a cure. I knew that I could not rely on them forever and I knew that, even if they allowed me to empty my bladder in emergencies they did nothing to address the acute anxiety which caused my problems. I knew, that is, that I could not back away from the decision I had made to consult a psychologist.
There is something uncanny and even slightly jarring about the experience of seeing a psychologist for the first time. It is because the process – making an appointment; sitting in the waiting area; entering the private consulting room – is so medicalised, yet the main treatment dispensed is likely to be listening, understanding and reassurance. One is made to feel like a patient but is then provided with the type of support and care which one typically receives from a friend. If a feeling of uneasiness attended my first visit to a psychologist, though, I can now see that it was a turning point. It did not provide sudden relief like the pocket-sized catheters, but it did mark at least the beginning of a slow crawl out of the despair I had descended into.

It took about 40 minutes of the initial hour-long consultation just to tell the story. I started with that confusing moment in a McDonald’s bathroom as a child; I recounted the deteriorations of the last several years: I described the worst incidents on aircraft and during car trips; and I detailed the series of doctors’ appointments, medical tests and speculative treatments which had led me, eventually, to seek the help of a psychologist.
When I was done, the advice I received was predictable enough: I needed to attempt behavioural therapy. The guiding principle of this treatment is simple. One overcomes a fear by initially confronting the stimulus for it in some minimal form and then graduating through stages of increasing exposure to

the stimulus – until eventually it no longer poses any threat at all. My assignment then, was to practise urinating in whatever setting I could comfortably do so in, and then, gradually, to practise in more and more challenging circumstances.

Going to see a psychologist was not the easiest thing in the world for me. It was something of a relief, then, to be prescribed a treatment which would not involve explorations deep into my subconscious. I knew that, at some point, I would have to find a way to think and talk about the causes of my anxiety directly. To start with, though some practical exercises were about as much as I could manage. I could, of course, have devised a program of behavioural therapy myself But what that initial nervous consultation gave me was a definite assignment; an obligation to report back on progress in a couple of weeks; and the guidance and support of an unjudging tutor who was completely confident that I could be helped.
* * *
My brief was clear: I was required to fill my bladder and then attempt to urinate over and over again in public toilets. I was only to start urinating and then stop after a few seconds so that I would still have a full enough bladder to repeat the exercise. If I was not able to initiate a flow of urine after 30 or so seconds, I was just to stop trying and go to another bathroom, where I could try again. It would be best if I could repeat these practice sessions as often as possible.
And so it was. Every several days I would fill my bladder till it was bulging and then roam around a shopping centre or my university campus, trying to initiate a flow of mine in one bathroom, and then in another and then in another.
It is not magic; it is hard. It is not so hard to initiate a first flow of urine; one can do this in as safe a situation as one likes. But it is hard not to empty your bladder completely, when you have filled it to bursting point and then finally begun to pee, perhaps after an hour of trying. It is hard when you think you can graduate to a more challenging situation and then find that you have not made the progress you had hoped. It is hard that you can have significant success in one session, and then far less in the next. It is hard that success in practice sessions does not automatically translate into improvement in daily life. It is exhausting and more than occasionally frustrating.
It is not magic, but it does work. The key is that the tiniest step forward demonstrates the possibility of great strides. And this changes the dynamic of the whole situation. Progress may not be steady: it may • occur in fits and starts. As soon as one has the slightest success, however, then one no longer feels as if they must defend against a problem which is overwhelming them. One can take the initiative, go on the offensive.
Probably, longer practice sessions are better than shorter ones – they allow more time for one’s initial anxiety to subside – but it is also fine to terminate an unsuccessful and frustrating session. Regularity is important, as is persistence. One is entitled to celebrate success.
Doubtless, behavioural therapy works in different ways for different people. One benefit for me was that it helped to isolate the problem. I worked on my bashful bladder for a few hours a couple of tunes a week. I felt that I did not need to waste thoughts on it at other times.
* * *

There were other aspects to my treatment. My bashful bladder was never going to be cured without behavioural therapy. But I had a serious case – the urologist I consulted had told me it was in the worst one per cent – so it was also unlikely to be cured by behavioral therapy alone.

The psychologist agreed, given the long, frustrating history of my problem, that it may be worthwhile trying anxiety medication. It would hopefully reduce my general anxiety and, in doing so, also make the behavioural therapy sessions a little easier.

It was suggested to me that I should try writing out, with pen and paper, sentences of the following kind: “No one can tell whether I am urinating in a cubicle;” “No one is interested whether I am urinating in a cubicle.” I was to write them out, at least several times over for several days in a row. The reasoning was that I had entertained so many thousands of thoughts expressing the opposite notions; I needed to marshal some common sense against them.

Of course, there had to be conversations about the underlying anxiety. The paruresis was never going to be treated alone – and it would have been something of a Pyrrhic victory even if it was.

And the psychologist had a brilliant idea. He had access to some research assistants and he offered to arrange for them to conduct an experiment. One would stand or sit in a cubicle in a small public bathroom, perhaps reading or listing to music through headphones. Another would approach people who emerged from the bathroom, and ask whether they noticed his colleague in there. Of course, barely anyone could even say whether or not a cubicle was occupied, and no one had any idea what was going on in there. I always knew my fears were irrational; now we had the hard data to confirm it.
* * *
There is no one reason why things are so much better now. Leaming that my problem was not unique changed how I felt about it. It helped me to see that it was a problem to be addressed, not ashamed of.

The catheters gave me an insurance policy. Just having them meant that I often did not need to use them. I could relax and try to urinate naturally, because I knew there was an alternative if I really needed it.
The counselling helped me to see how deeply seated my anxiety was and to face it. The behavioural therapy helped me to see, almost immediately that progress was possible.

The medication gave me space to re-assess and recalibrate. It took the edge off my anxiety; it allowed me to think more clearly. I am told it allowed me to be more like myself

My family and my friends helped – when I trusted them and gave them the chance – more than I could have imagined. No one has joked or laughed; no one has judged. They have only supported.

Writing this has helped too.

My paruresis was smothering me, suffocating me. I had to push out against it in every direction at once.

* *
Some people are scared of heights. Some people are scared of flying. Some people are scared of cats or dogs. Some people are scared of needles; some people are scared of hospitals. Some people have a fear of men; some people have a fear of women.

Coulrophobia is the fear of clowns· anthophobia is the fear of flowers; sonuliphobia is the fear of sleep; and omphalophobia is the fear of belly buttons.
There are phobias of darkness, sunlight nudity crowds, being alone, water, bridges, clouds, rain. snow amphibians, vomiting, laughter, blood minors, clocks, numbers, computers, work, sitting down, cooking love, being touched, the moon.
These things ruin people’s lives. There must be countless personal tragedies. An infinity of tears must have been shed.
Anxiety about urinating is not absurd· far less is it something to be ashamed of. There is help available.
Go and seek it out.

There is not really an ending to my story just yet. I have, of course, left out a lot – including much that I cannot yet bring myself to share. No longer does my anxiety interfere with my life. I take medication only in tiny doses and almost never require a catheter. I have finished with counselling. Sometimes still, there is a temporary relapse – but it never lasts for long. There is no conclusion yet· but so much progress.