A patient came to see me recently (all my stories start like this: “A patient walked into the room…,” akin to “A guy walked into a bar…”), and she was so embarrassed to be there. That’s not uncommon for me. What was unusual was that she refused to talk about her bowel habits. She couldn’t say what her symptoms were or what her poop looked like. To her, it was all dirty, uncouth, and taboo. With a little patience, she eventually opened up (literally and figuratively). I reassured her that nothing she told me would leave the room, and with me, you’re in the right place, or your butt is in the right hands, at least. Humor helps sometimes. Tears welled in her eyes as she told me about the pain she felt having a bowel movement, just months after giving birth. Add to it that her husband acted immaturely and would knock on the door incessantly whenever she went to the bathroom as if women aren’t allowed to poop. She had been to her OB/GYN, whom she said was great but was a man and dismissed her anorectal symptoms entirely. She was relieved to hear that her symptoms were fairly common and that many treatment options would help. She thanked me profusely and was glad that I made her first visit to a butt doctor a painless experience. Well, if you can’t talk about poop with me, then you can’t talk about poop with anyone. There’s no judgment here, no raised eyebrows, no wrinkled noses. Poop isn’t stinky or gross. It just is.
If you have kids, you’re no stranger to talking about poop, but my patients often ask me, “When did you decide you would make a career … of this?” The truth is, I didn’t know I would spend the rest of my adult life thinking and talking about poop. I became a colorectal surgeon so that I could cure cancer. Along the way, I found that there are many, many more patients with hemorrhoids, constipation, and bowel problems of all sorts, and most physicians and the general public aren’t equipped to talk about it. The embarrassment is standard, but it needn’t be on both sides, for both the patient and the physician. Defecation is a basic human function, and yet we act like we don’t have to do it. So often I see patients relieved they can finally discuss their bowel habits outside the hushed whispers of their gal pals or locker room humor. These days the amount of pursed lips I see are fewer and far between, mostly from the older generation of pearl-clutching matrons who perpetuate the fantasy that their shit don’t stink. But everyone shits. And it all smells like shit. The thing is, society still finds it uncouth to talk about pooping. Poop-shaming abounds, such that people find themselves holding in their bowel movements or farts until a more convenient time, causing more anorectal problems. We try not to poop-shame in our household by saying “ew” when we have to change a diaper so our children don’t learn to hold it in for fear of embarrassment. Children think poop is funny — where along the way did we lose that? Studies such as Fecal Matters have shown that we have societal constructs around pooping. In this Indiana University study, straight women and gay men spend much more time thinking about bowel functions than straight men and gay women, for example. That sounds about right.
In 2019, the New York Times published an article about the lengths women will go to so that they don’t poop in public. The article generated a lot of commentary from the public and inspired one of the chapters in my book. Poop-shaming means how we were raised to hide our poops and the extremes that some people will go to NOT POOP or NOT FART in public. As a colorectal surgeon who spends most of my time addressing anal diseases (a true proctologist, as the old jokes go), can I tell you the number of times I do an exam and find poop in the anal canal? You don’t want to hear this, right? You want to escape to the sterility of doing knee replacements in astronaut suits or listening to lungs in three-piece suits, but here I am, in a scrub suit, looking inside asses. And I love what I do.
I admit I didn’t think about poop at all when I was younger. I don’t recall pooping at all in college, which is probably a good thing. I just went when I had to go, and that was it. I didn’t particularly deal with constipation or diarrhea. I know that’s a blessing.
Some of my nonchalance with poop stems from a formative moment with my very practical, no-nonsense grandmother. When I was a teenager, we went to her apartment and I had to go to the restroom. I walked into the guest bathroom and noticed that there was a splatter of poop on the inside of the toilet. When I went out to announce this, everyone else in the room remained quiet. Nobody copped to recent toilet usage, and it was like a game of Clue — trying to recall who the perp was, who had just walked out of the bathroom, or who had wet hands. But my grandmother, in her bold, unwavering way, proclaimed, “Si ze ma!” which translates literally into “It’s just poop!” And she grabbed a piece of toilet paper and in one barehanded swipe, wiped it off and flushed it down the toilet as everyone else ran away screaming. It has been about 20 years, and I still tell myself, “Si ze ma!” It’s that same no-nonsense, no-embarrassment, no-judgment attitude that I take when approaching my patients. It’s just poop. There are way worse things to me, like phlegm or toenails. Indeed, based on this narrative and the fact that I was mostly raised by my grandmother, I can say I was probably never poop-shamed. I wouldn’t say it was encouraged, but we were always encouraged to eat, and what goes in must come out. It’s just a matter of life and a matter of fact. After writing my book, I discussed it with my aunts and uncles around the dinner table one night, and they regaled me with the story of my father’s hemorrhoids, a story that he conspicuously does not recall, although my aunts and uncles recall it with great clarity, including my grandpa’s magic salve, the ingredients of which to this day remain unidentified.
And yet it is and it isn’t just shit, isn’t it? When you’re pooping well and not thinking about it a day in your life, it’s just shit. When you can’t poop at all, or worse, poop too much, then you can be miserable. The trouble is, there are so many variables involved in pooping that a generic answer doesn’t work for everyone. There are plenty of “healthy” active people who work out and only eat kale and can’t poop. And there are plenty of “unhealthy” people who eat only greasy food and sit around and poop multiple times a day. What gives? And when they get hemorrhoids, do you tell them sitz bath, donut cushion, stool softener, hydrocortisone suppository? Or send them to GI to get a colonoscopy for chronic constipation?
In residency, every morning rounds started with, “Have you had a BM? Have you passed gas?” Lending too much importance to stools and bowel function, in retrospect, but perhaps not enough insight. Even now, when I reflect on my practice, sticking my finger into dozens of butts a day wasn’t what I had planned. I don’t love the rectal exam part, but I love what I do, and I love that I can help people. I’m good at it, and it takes a certain temperament to be able to look at butts and poop all day. As I remove my double-gloved finger from a patient’s anus for the 25th time that day, about 30 percent will invariably chuckle and ask, why do you do this? How did you get into this business? Trust me, there are days when I’m peering down an anoscope that I ask the same question of myself: How did I get here? I remember I had one attending surgeon who would constantly stand over a jackknife-prone patient with his finger in the air, staring at it, and me, with his eyebrow raised as if to say, Here we go again. I did not know it then but I know it now: He asked himself that same question.
Did I wake up one day and say, I must deal with poop all day? No, no, I did not. But seeing as how he is now a surgical director of a hospital and I just wrote a book about poop, I guess we all end up right where we belong. Constipation Nation is about more than constipation; it’s about opening up the conversation around bowel habits and awareness around poop shaming, all to regain our collective bowel health as a nation.
We need to talk about poop more, in primary and specialty care and society in general. Taking away the stigma of having bowel habits and anorectal problems will empower patients to seek help earlier — maybe even finding some cancers sooner, which is what I wanted to do in the end (pun intended).
Carmen Fong is a colorectal surgeon.
