Health & Medicine

Sit-down toilets? Meh. In Asia, many say squatting is superior

toilet philippines.jpg

A man reads a newspaper while sitting on a second-hand toilet bowl he's selling in Manila, Philippines, on November 19, 2012.

Credit:

Romeo Ranoco/Reuters

Suthep, a scruffy Thai day laborer, has a message for all you fancy people who sit down to empty your bowels.

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“Sitting down on a toilet is weird,” says Suthep, 60, a native of Bangkok’s working-class Klong Toei neighborhood. “It doesn’t matter if you’ve got a big butt or a small butt. You’re going to touch the seat. It’s just not clean.”

The sort of toilet this man prefers — essentially a tiled room with a hole in the floor — would cause many Westerners to reflexively clench up.

But if you favor the commode, heed his words. You are in the minority, not Suthep the squatter. It appears that, globally speaking, toilet sitters are outnumbered.

“Here? In the slums? We squat,” Suthep says. “We’re busy. We’ve got to get back to work. Toilets are for rich people who can relax all day, reading the paper, like ‘Oh, I’ll just sit here and chill. No worries for me!’”

In the US, where practically everyone sits, toilets are a forgettable fixture. In parts of the world where squatters and sitters mingle, however, toilets can become entangled in culture and class.

Through Western eyes, a squat toilet can seem cumbersome. Or intimidating. Or just gross. But those are exactly the sorts of words many squatters conjure up when they stumble across a Western-style commode.

“Sit-down toilets are for big shots,” says Nakhon, a truck driver from Klong Toei. “But I don’t see how they’re more hygienic. Especially if you clean your butt with paper. Using water seems cleaner to me.”

Squat toilets are common across Asia, Africa and the Middle East — just as they once were across the United States. Most are hooked up to sewage lines. Others are not.

Those who squat often use water from a nearby bucket or basin to clean themselves. Toilet paper is optional. (Hint: Your left hand can double as a wet wipe. Just wash it afterward.) To flush, you just chuck a few pails of water into the hole — a method that forces waste down with gravity’s help.

Children visit the Toilet Culture Park in Suwon, South Korea (about 29 miles south of Seoul) on November 22, 2012.

Children visit the Toilet Culture Park in Suwon, South Korea (about 29 miles south of Seoul) on November 22, 2012. The park, which is the only one of its type in the world, exhibits a variety of bowls from Korean traditional squat toilets to Western bedpans.

Credit:

Kim Hong-Ji /Reuters

Even in squat-friendly nations, health officials will sometimes promote the Western commode. Bureaucrats often view it as more modern or, in the parlance of the United Nations, the marker of a “developed” country.

In China, for example, a campaign is underway to install commodes in public restrooms so that travelers can “avoid the embarrassment of using pit toilets.” In Thailand, health officials have launched a “master plan” to get commodes inside 50 percent of all homes and practically all public restrooms.

Their rationale: Squatting is hell on elderly knees — and Thailand needs commodes to help out its rapidly aging population.

Sit-down commodes are already quite common in Thailand’s middle-class homes. After all, a new toilet costs only about $100.

But in the countryside, and in poorer urban enclaves, many still view sitting on commodes as unnatural. They wholeheartedly believe squatting is the superior method.

And they may be on to something.

“If you’re sitting, it’s difficult for the poo to come out,” says Yudhtana Sattawatthamrong. He’s a gastroenterologist at Bangkok’s Bumrungrad International Hospital, one of the top private medical facilities in Southeast Asia.

“When you squat,” he says, “the rectum or colon is like a straight tube. So the poo can come out more easily.”

Squatting arranges your intestines in a nice, neat line. It also relaxes a muscle called the puborectalis that regulates continence: when you’re releasing your bowels and when you’re holding it all in.

When sitting down on toilet, this muscle is still a bit taut. “But if you do the squat technique,” Yudhtana explains, “the puborectalis muscle will relax so the poo will come out easily.”

His hospital, Bumrungrad, is a resort-like medical complex that attracts patients from across the world from Asia to Africa to the Middle East. There are no squat toilets there, only commodes and toilet paper. But Yudhtana has found that some people who are rich enough to travel abroad for medical care are also hell-bent on squatting.

“Some nationalities, they come to my hospital and see modern toilets,” he says. “What do they do? They jump on the toilet and squat.”

Patients who perch on a Western toilet’s rim to squat over the bowl risk “big problems,” he says — namely collapsing the ceramic bowl and cracking their heads on the floor.

For life-long squatters, however, this appears to be a natural impulse. It’s common to find signage in Asia’s public toilets that warn against toilet perching.

Related: South Korea claims 'world's first toilet theme park' (VIDEO)

Squatting has other downsides as well, Yudhtana says. “It causes wear and tear on the knee joints,” he says. “It puts a lot of pressure on the cartilage in your knee. It can even cause degenerative joint disease.”

Even in Bangkok’s Klong Toei neighborhood — home to many unrepentant squatters — age has a way of converting squatters to sitters.

“If you’re old, or fat, you need to sit down,” says Sui, a 57-year-old who works odd jobs. “I grew up squatting. But I’ve worked all my life. Now my knees hurt. Who doesn’t want to sit down and relax?”

The best scenario, Yudhtana says, is making both squatting and sitting toilets available.

The country that has come closest to actualizing this ideal is Japan — a technological frontrunner with a massive elderly population.

Those lucky enough to wander into a Japanese public restroom may see a tidy squat toilet. Or they may also find an electric commode that sprays the sitter clean with satisfying jets of warm water. Or they may find both.

But few human beings are so fortunate. According to the UN, one-third of the global population lacks “improved sanitation,” which means they may rely on a bucket or dirt latrine. This leads to rampant disease — a crisis the UN rails against annually on “World Toilet Day,” when it tries to rally nations in a crusade against shoddy toilets.

However, these well-funded campaigns shouldn’t imply that squatting is doomed to a slow extinction. Even in the US, more people are embracing the benefits of squatting — albeit in a roundabout way.

While sitting on a commode, you can slide a footstool under your feet to raise the knees, thus straightening the intestines in a position that mimics squatting. These plastic footrests are increasingly popular, thanks in part to a psychedelic, slightly nauseating YouTube ad with more than 26 million views.

According to Yudhtana, these footstools actually work, and they’re an effective compromise between squatting and sitting.

“Anything that causes your knees to go up will cause your puborectalis muscle to relax,” Yudhtana says. “So, yes, putting your feet on something will make your rectum straight. And that will help so the poo can come out more easily.”