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Paruresis is a psychological problem that hinders the sufferer from urinating while he perceived himself to be under observation. Approximately 6.7% of Americans have this problem.[1] It is caused by a conditioned response in which the subconscious interprets certain stimuli, viz. awareness of being observed, as a threat, and prevents urination by not contracting the detrusor and by not relaxing the internal urethral sphincter, both of which are muscles under involuntary control. The fear of not being able to perform makes it more likely that one will, in fact, not be able to perform.[2]

Economic and social implications

Accommodating employees with paruresis, as is required by 42 U.S.C. § 12102(2)(B) of the Americans with Disabilities Act, could cost employers billions of dollars.[3] The problem was listed under section 300.23 of the DSM-IV-TR as "performance fears . . . using a public restroom."[4] The DSM-5 states, "Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or 'shy bladder syndrome'.)"[5] It also notes, "Paruresis is more common in males.[6]

Federal Bureau of Prisons Program Statement 6060.08 states, "Ordinarily, an inmate is expected to provide a urine sample within two hours of the request, but the Captain (or Lieutenant) may extend the time if warranted by specific situations (for example, the inmate has a documented medical or psychological problem, is dehydrated, etc.). Staff may consider supervising indirectly an inmate who claims to be willing but unable to provide a urine sample under direct visual supervision. For example, this might be accomplished by allowing the inmate to provide the sample in a secure, dry room after a thorough search has been made of both the inmate and the room."[7] At least six state prison systems — Florida,[8] Massachusetts, Maryland, Michigan, New York[9] and Tennessee[10] — have modified their drug testing regulations to provide accommodations for prisoners with paruresis.[11]

Kaplan & Sadock's Synopsis of Psychiatry states, "Persons with social phobias (also called social anxiety disorder) have excessive fears of humiliation or embarrassment in various social settings, such as in speaking in public, urinating in a public rest room (also called shy bladder), and speaking to a date."[12] The Synopsis describes shy bladder as "inability to void in a public bathroom" and notes that relaxation exercises are an application of behavior therapy for dealing with this disorder.[13]

DSM section 300.23 contains several diagnostic criteria.[14] The Himle Paruresis Inventory, developed by Joseph Himle, is a ten-question questionnaire designed to help diagnose paruresis.[15] Carol Olmert revised Himle's inventory to produce her own eight-question inventory for women. She tweaked one of the questions to ask about worries concerning others' waiting for one to urinate in a bathroom. Olmert reports that women typically do not receive "potty parity." That is, relative to men, they do not have enough public restroom toilets to accommodate the same number of people's needs, and therefore there is a greater chance that women will be waiting in line. Olmert also loosened the threshold of positive responses to inventory questions required to assess paruresis, noting, "If only one or two questions strike home but they are extremely accurate, you might be justified in calling yourself paruretic."[16]

However, it is largely unrecognized by prison psychologists, who find there to be epistemological problems involved in making a diagnosis, since the symptoms are mostly self-reported. This presents a problem when such prisoners are called upon to provide a urine sample under direct visual supervision.[17] The behavior of private sector and public sector entities concerning this problem are quite different. Left to their own devices, private sector entities weigh costs and benefits when deciding whether the contributions of an employee or customer are worth the inconvenience involved in making accommodations. For example, many nicer hotels now include at least one toilet stall with floor-to-ceiling partitions, and many employers have at least one single-occupancy bathroom.

Prison systems, on the other hand, err on the side of not accommodating anyone who did not have a paruresis diagnosis prior to his incarceration. The prison staff and the bureaucrats to whom they report do not pay out of their own pocket for the costs of the extra prison time given to those wrongly found guilty of refusing a drug test, and the government cannot be forced out of business for courses of action that are not cost-effective. Therefore, there is no incentive to implement drug test reforms to address paruresis.

In Trimaine Noreiga v. Warden Paul M. Schult, the court ruled that in the absence of medical evidence of paruresis, the prisoner could not claim that his due process rights were violated by a finding that he purposefully refused a drug test.[18] Likewise, in Snaman v. Thornburgh, the court ruled against an alleged paruretic on the grounds that "due process is not offended by shifting the burden of proof to the defendant to prove his lack of a willful state of mind."[19]

Arguments against accommodations

One argument for not offering paruretic prisoners any accommodations is that if they did not want to be punished for being unable to urinate on demand, then they should not have gone to prison. In other words, their being put in a situation of being penalized for not being able to take a supervised urine screen is part of their punishment for committing a crime. This does not explain, however, why paruretics would be singled out for a punishment from which other prisoners are exempt because of their ability to do what paruretics cannot. If it were truly a penalty levied equally upon all prisoners, then it would affect all of them the same, whether they were paruretic or not.

Another argument against accommodations is that prisoners must all be treated the same; it would be unfair to tell one prisoner that he would have to urinate under supervision and another prisoner that he did not need to do so, unless medical proof were available to show that a prisoner had paruresis. The logic behind this is similar to what would be involved if the prison officials were to give prisoners a job of writing an Javascript compiler and then punishing those who failed to produce working code. A prisoner might claim, "I lack the ability to do it. Specifically, I lack the necessary knowledge, and I'm not smart enough."

The prison official might then say, "Prove that you lack the ability, and are not simply malingering out of laziness." It would be difficult for a prisoner to show that he lacked such ability, unless he could account for every hour of his life and show that he had never gained the knowledge needed to write a compiler; and even then, it would be impossible for him to prove that he was incapable of figuring it out on the spot, without prior experience. He could take an IQ test in an effort to prove his stupidity, but could not disprove any allegations that he was purposefully getting answers wrong in order to get a low score. It is easier to prove what one can do than what one cannot do.

Of course, the same problems arise if someone claims to be not guilty by reason of insanity. Pursuant to 18 U.S.C. § 17, successfully proving such a claim requires clear and convincing evidence that the defendant "was unable to appreciate the nature and quality or the wrongfulness of his acts." Given the limitations of presently existing psychological testing methods, there is always a possibility that a person is faking his condition. Libertarians would argue that the solution is to disregard such questions of mental capacity and simply require that the person pay restitution for whatever harm he has caused. In the case of a drug test refusal, there would probably be no harm caused and therefore no restitution.

A privately-run prison in a free market might or might not deem it expedient to expel a person from the prison based on a failure to take a drug test. The owners might very well find it to be more profitable to spend the extra money to conduct hair or other alternative types of drug tests than to lose a customer over such a matter. Or they might deem the security risks involved in allowing to prisoner to take the urine screen in privacy after a strip-search to be insignificant enough that the accommodation would be worth making.


  1. Landers, Peter (22 April 2003). "Looking for Relief". Wall Street Journal. 
  2. Erb, Robin (18 May 2010). "Shy bladder is nothing to laugh at". The Spokesman. 
  3. Bigler, Taylor (10 May 2012). "Americans with Disabilities Act covers ‘bashful bladder syndrome,’ could cost employers billions". The Daily Caller. 
  4. "Social Phobia (Social Anxiety Disorder". Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Text Revised. American Psychiatric Association. 2000. pp. 453. 
  5. "Social Anxiety Disorder (Social Phobia)". DSM-5. American Psychiatric Association. 2013. pp. 203. 
  6. "Social Anxiety Disorder (Social Phobia)". DSM-5. American Psychiatric Association. 2013. pp. 206. 
  7. Federal Bureau of Prisons (11/24/99). "Urine Surveillance and Narcotic Identification". 
  8. Florida Department of Corrections Procedure 602.010, mentioned in footnote 12 of Pate v. Peel, 256 F.Supp.2d 1326 (N.D. Florida, Panama City Division) (“DOC's Procedure 602.010, Bashful Bladder Procedure, which outlines the steps to be taken to obtain a urine specimen from an inmate who claims that he suffers from BBS.”).
  9. "Procedure for Inmates Claiming to be Unable to Urinate in Presence of Others: The following procedures shall be employed when the watch commander reasonably believes that the inmate is unable to provide a urine specimen due to an alleged inability to urinate in the presence of others (shy bladder). Reasonable belief is based upon the following criteria, including, but not limited to: Medical or mental health records supporting the inmate's claim (to be evaluated by health services or OMH staff), prior disciplinary and/or computerized urinalysis testing data indicating a history of urinalysis testing violations, if applicable, and the inmate's behavior and demeanor at the time of request for the urine sample . . . . Staff shall not witness the inmate urinate into the specimen container." "7 NYCRR 1020.4(e)". New York Department of Correctional Services. 
  10. "There may be extenuating medical (e.g., dehydration, kidney problems, medication, etc.) and psychological (e.g., social phobias) conditions that may preclude the giving of a sample. In such cases, the inmate must provide written evidence from the health care staff indicating such a condition. The Warden shall, in extreme cases, authorize the use of an alternative drug testing method for those inmates who have a documented medical condition that would prohibit the use of urinalysis testing. Approval of the commissioner or his designee is required prior to the use of any alternate drug testing method or instrument." Tennessee Department of Correction (June 1, 2011). "Policy #506.21(VI)(B)(9), Inmate Drug/Alcohol Testing and Sanctions". 
  11. Soifer, Steven (2001). "Evolving Legal Ramifications". Shy Bladder Syndrome. New Harbinger. pp. 98. ISBN 1-57224-227-2. 
  12. Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. "16.3 Specific Phobia and Social Phobia". Kaplan & Sadock's Synopsis of Psychiatry. pp. 597. 
  13. Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. "35.8 Behavior Therapy. Table 35.8-2: Some Common Clinical Applications of Behavior Therapy". Kaplan & Sadock's Synopsis of Psychiatry. pp. 957. 
  14. "DSM-5 Definition of Social Anxiety Disorder". Social Anxiety Institute. 
  15. Soifer, Steven (2001). "What is Bashful Bladder Syndrome and How Do You Know You Have It?". Shy Bladder Syndrome. New Harbinger Publications. pp. 8-9. ISBN 1-57224-227-2. 
  16. Olmert, Carol (2008). "Do You Suffer from Paruresis?". Bathrooms Make Me Nervous. pp. 9-10. ISBN 978-0-6152-4024-4. 
  17. International Paruresis Association. "Drug-Testing Reform". 
  18. Trimaine Noreiga v. Warden Paul M. Schultz (U.S. District Court, New Jersey 12 May 2011). Text
  19. Snaman v. Thornburgh, 956 F.2d 275 (9th Cir. 25 February 1992).