April is embarrassing subject month for my podcast.  I am covering the following problems:

  • Hemorrhoids
  • Digestive problems (constipation/diarrhea)
  • Urinary incontinence
  • "Male problems"

It should be fun, and it will be promoted on iTunes, so it should drum up more subscribers and downloads.

But it begs the question: why are certain conditions embarrassing to people?  Why can people open up to me about so many personal things, yet be embarrassed to discuss hemorrhoids?  Why is it easier to talk about your marriage falling apart than your urinary "accidents?"  Why is diarrhea more embarrassing than vomiting?

I don't have science to go to about this, so I'll try to take a stab at it on my own.  Here's why I think certain conditions are embarrassing:

1.  Social Conditioning

I'll get the obvious one out of the way first.  Embarrassment is something you have in front of other people, so social pressures have a strong influence on what is embarrassing.  Belching may be considered embarrassing in some cultures, while acceptable in others.  Men in a fraternity don't feel shame for passing gas (in fact, many take pride in their gaseous ability), while doing so in high-society is not so accepted.

Certainly this is malleable, as the ads for ED on television demonstrate, but there will always be social mores.

2.  Location, location, location

Consider the list of topics.  Is there a geographic similarity between these embarrassing subjects?  Yes, they all covered by underwear.  For some reason, this part of the body is embarrassing.  Is that cultural?  Probably.  Is it wrong that it is embarrassing to talk about someone's groin or rear-end?  I don't think it's wrong per se, but it does sometimes prevent people from mentioning things they should be mentioning.

I don't think our culture needs to change in this way.  Do you want to know about your coworkers' hemorrhoids or constipation?  Sure, it may explain why they act the way they do, but there is a degree of invasiveness that occurs with sharing that knowledge.  The problem happens when the cultural mores come into the exam room.

3.  Smell

There is probably a cultural reason for this as well, but it seems that giving off an odor or having a problem with a body part that gives off an odor is more embarrassing than having problems in other non-odiferous parts of the body.  Maybe it's that the part of the brain dealing with odors is close to the embarrassment center.

Again, I don't see this changing much culturally.  It is unlikely that we will enjoy being around others that put off body smells.  I still have strong negative emotions when thinking about a college ethics class I took in which I sat next to a guy with bad gas.  It was pure torture.  Those who don't pay attention to this are clearly socially disadvantaged (as was my buddy in ethics class).

Shame vs. Embarrassment

There is a big difference between being ashamed and being embarrassed about something.  Shame is a judgement the person makes on themself.  It is a guilty verdict when it comes to something about the person.  Shame usually has its roots in the choices the person makes, but a lot of people become ashamed of things out of their control.

The doctor's office is not a place for moral grand-standing.  It is not a place to place the blame for something.  It is not a place for shame, in fact it should be the one place where the person can show themself openly without fear of finger-pointing (I wrote about this in the past in regard to obesity).  My job as a clinician is to listen to the person and help them come up with solutions.  They are the ones who choose to implement or not.  They are the ones who pay the personal consequence of their problems.  They are the ones who feel the shame.  My job is to listen without judgement, speak the truth, and come up with solutions that are realistic.

Some have tried to abdicate responsibility by hiding behind words like addiction and genetic. This takes away the moral responsibility of behavior and implies the person has no control.  I for one believe people have the ability to change despite addictions and genetics.  It is certainly harder when you have to fight these things (which is why clinicians should not morally judge the patients' failures), but choices are choices.

What's the bottom-line? (An appropriate term when talking about hemorrhoids).  Embarrassment and shame are part of the human condition - it's in our character's core.  They will never go away totally.  But all rules change in the exam room; patients shouldn't hold back due to embarrassment or shame and I shouldn't foster that in any way as a doctor.

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