Why try to be continent? Social rules maintained by embarrassment (Edelmenn 1981) Stigma: “individual who is disqualified from full social acceptance” (Goffman, 1963). Is avoidance of faeces innate or learned? Incontinence is a major threat to social identity. Dread of being discredited. “Art of impression management” (Goffman, 1959)

Communicating about bowels Difficult because –Lack vocabulary –Never before articulated –Cannot describe easily –Too embarrassed –Too ashamed –Too guilty –Not legitimate to seek health care

Lawler 1991 Nurses must break society's rules and become involved with the excreta of others Difficult to articulate knowledge In turn have developed rituals in order to enable detachment from their emotions on the subject, such that they can deal with incontinence without having to think about it too much Dealing with excreta in a highly ritualised manner may help to manage the nurse’s own distaste and embarrassment, but militates against exploring the issue in any depth

Schwartz, 1977 “Mutual pretence” in relation to urinary incontinence, with both nurses and patients reluctant to initiate a discussion about the topic. Care for incontinence is seen as a job to be hurried and finished so as to get on to the more pleasant aspects of nursing; patients carefully guard their embarrassing secret. Both nurse and patient see the other as unconcerned by incontinence

Taboos Universal human taboos on dirt and elimination Survival value? “Civilisation” implies manners, development of taboos Each culture different taboos: Nyakusa in Africa believe eating dirt causes madness (excreta, mud & frogs), prophylactic use in mourning rituals (Douglas, 1966) “Dirt is matter in the wrong place” (Freud 1908)

Patient: Biofeedback study “I felt very safe talking to the correct people, who gave me a choice of things to try. It was nice to have somebody who fully knew what I was going through and could guide me with calm, medication, diet, exercises to suit my daily family life. It is lovely to feel the change and also to see the results changing with progress. Support is very important. I found I had great support which gave me a little more confidence in myself”

Perceived impact of FI Unpredictability “I never know when I’m going to have an accident” “I passed wind and it, (stool), just went all over the kitchen floor” Coping strategies “I have to avoid leaving home until late morning everyday” “…especially in the mornings, unless I go at least twice I do not leave the house” Coping strategies may mask the true severity of incontinence

Urgent need for more public awareness Long delays in health seeking Negative attitudes of health professionals Lack of clinical services (investigation & treatment)

Reference Norton C. Nurses, Bowel Continence, Stigma and Taboos. Journal of Wound Ostomy and Continence Nursing 2004; 31(2):85-94.