I’ll admit, I was less than thrilled when asked if I would write an article about toilets! Hmm, had I fallen so low on the pecking order? Did I really want to delve into all of the details and nuances of bathroom hygiene, research the pros and cons of western style vs. the squat?! Then again, don’t we all wonder about these things, but are just too squeamish to ask? So, yes, I agreed to write this article. It was a worthwhile endeavor, and I hope this answers some of the questions you pretend you don’t have.

Toilets: a brief history

In the third millennium B.C., there is archaeological evidence of primitive sit-down toilets made of bricks with wooden seats and chutes through which waste fell into drains and cesspits. These toilets were only used by the wealthy. Most people squatted over pots in the ground or used open pits.

According to the Sulabh Toilet Museum (India) website, the “eighteenth century was a century of toilets.” During this time the water closet, invented in 1596 by John Harrington, came into more widespread use. In 1738, JF Brondel introduced the valve-type flush toilet, the technology of which gradually evolved into the cantilever type toilet. From the late 1800s the emphasis was more on aesthetics, a trend that continues even today.

Toilets in China

While most Chinese favor the use of the squat toilet and most Westerners prefer the sit-down, China has made great efforts to offer both options. Interestingly, when China lost its bid to host the 2000 Olympics, they decided that improving toilets should be made a high priority. China Daily ran an article headlined “Capital Flushes Out Low Standard Loos.” Since 2005 China has spent $29 million to fix up 14,500 public toilets.

Despite the fact that most locals favor the squat toilet and will wait in a long line rather than use a sit-down, there clearly is demand here for western-style toilets.  David Pierson wrote in the LA Times on October 21, 2010, “China’s housing boom has unleashed a bull market in fancy plumbing” and “although many are satisfied with Western-style toilets that often cost no more than $20 here, pricier name brands are gaining traction. Models costing anywhere from $150 to $6,000 now account for about 5% of the toilets sold in China each year.”

Squat or not?

So, is one type better – hygiene-wise, health-wise – or is one type cleaner? Personal preferences aside, are there objective reasons to choose one over the other?

There is much written about the health benefits of the natural squatting position for elimination. A sit-down toilet allows for constriction of the rectum by the puborectalis muscle and thus necessitates straining to force it open. Some hypothesize that, because this sitting position causes incomplete evacuation, waste then backs up into the sigmoid colon, putting continuous pressure on the sigmoid colon. This may be a significant factor in causing diverticulosis and hemorrhoids, both of which are seen in much higher numbers in Western countries.  Additionally, straining requires pushing down with the diaphragm while holding one’s breath. Repeated straining is also thought to be a factor in the relatively higher incidence of gastroesophageal reflux disease (GERD) and hiatal hernias in the West. Straining during defecation has also been linked to cardiovascular events.

In contrast, squatting pushes the colon against the thighs by force of gravity, thus providing the pressure needed for expulsion. Instead of pushing down with the diaphragm, squatting allows one to push upward with the thighs. The weight of the torso naturally compresses the colon. Squatting also causes relaxation of the puborectalis muscle and allows the rectum to straighten, allowing ease of evacuation.

Many non-westerners consider the sit-down toilet to be filthy and unsanitary. Since squatting eliminates any direct contact with the toilet, the sit-down toilet requires the added step of either using a paper cover (not often available) or extra toilet paper to cover the seat for more sanitary conditions. One can always stand over the toilet rather than sit on it, but that involves its own host of inconveniences.

Toilet-transmitted infections: fact or fiction?

And, what if you did sit directly on the toilet (ewww!) – can you pick up infections from a toilet seat? Can you get STIs (sexually transmitted infections) from toilet seats?

In general, the answer to this is NO. The toilet seat is not a common vehicle for transmitting infection. While infectious organisms can survive on inanimate objects for minutes or days, most microorganisms causing STIs cannot survive for long outside the human body. Furthermore, in order to acquire infection from the toilet, one would have to have direct contact between the seat and one’s urethra or genitals, or organisms could be transferred into a cut or wound on the skin. According to Abigail Salyers, a former president of the American Society for Microbiology, “To my knowledge, no one has ever acquired an STD on the toilet seat…” though this has been used as an excuse by cheating partners.

Good toilet hygiene practices

One is more likely to pick up germs from doorknobs, urinals, tap handles and contaminated areas around sinks than toilet seats. Poor personal hygiene, not washing hands properly, is the bigger cause for concern. Rather than the seat, one is more likely to pick up germs on the toilet stall handle (think about it – we use the toilet, then flush, then open the stall door, THEN wash our hands).

If possible, flush the lever with your foot, and avoid touching anything. After washing your hands, shut the faucet with a paper towel, and use the towel to let yourself out through the bathroom door! Your immune system and good hand washing techniques are your best defenses against contracting infections in public restrooms. About 80% of infections are spread through touch, yet statistics from research by the British Toilet Association shows that 30% of the general public does not wash their hands after using the toilet. Of those that do, 64% do not use soap, and 88% do not wash their hands long enough to kill germs! Don’t let this be you.

Another problem is that germs can be released into the air when the toilet is flushed, so it’s not a bad idea to close the lid (on a sit-down toilet) and leave the stall ASAP. Leaving the lid up when flushing can release a plume of bacteria into the air, which will settle on surrounding surfaces. However, even with the lid closed, bacteria can seep. In a University of Arizona study, bacteria were found on surfaces as far as 32 inches away from the toilet after flushing. Therefore, toothbrushes, hand towels, contact lenses and the like should be kept at least 3 feet from the toilet, or better, in a cabinet. Also, towels should be changed every few days. Toilets and surrounding surfaces should regularly be cleaned with bleach and hot water.

Enjoy your porcelain express

Whichever type is your preference, it’s important to know that we are still among the privileged to have toilets at all. Sadly, large parts of the world still lack proper sanitation, and stand alone toilets are a completely unknown entity. According to a U.N. report, half the world’s population lacks access to a toilet or clean latrine.

So before you turn your nose up at the next public facility, take a moment to be grateful that you have a private place to find relief.

 

This article is written by my BJU colleague, our infectious disease Dr. Jane Eason. This was originally published on my hospital’s website last month here. It was such an interesting and unusual topic, I had to share it with my readers (with her permission)! You can access previous BJU health articles here. 

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