Why Going to the Toilet Is Harder Than It Should Be

I had a client recently — high-functioning, highly stressed, classic HPA axis dysregulation — whose DUTCH results showed elevated free cortisol across the entire day and a total metabolised cortisol significantly above range. He wasn't sleeping well. His gut was a mess. And buried in the clinical history, almost as an aside, he mentioned that he has to sit on the toilet for twenty minutes every morning just to produce anything at all.

He'd tried magnesium citrate. He'd increased his fibre intake. He was drinking plenty of water. Nothing had made a meaningful difference to the effort involved. And he'd never — not once in any previous consultation with any practitioner — been asked about how he was sitting, how he was breathing, what the environment was like, or what was going through his mind while he sat there waiting.

That's the gap this post addresses. Not the biology of when to go — I've covered that elsewhere in the piece on the morning constitutional and circadian rhythm. This post is about the mechanics, the psychology, and the environment of the act itself. The things nobody says out loud because defecation is treated as an inconvenience to be disposed of as quickly as possible rather than a physiological function that deserves the same clinical attention as sleep, exercise, or nutrition.

It deserves more attention than it gets. And the fixes, when you apply them properly, work.

The Anorectal Angle — Why Your Toilet Is Designed Wrong

The single most impactful mechanical change most people can make costs about £25 and takes thirty seconds to understand.

The human rectum is not designed to empty in a seated position. In a standard toilet sitting position — hips at roughly 90 degrees — the puborectalis muscle, which wraps around the rectum like a sling, remains partially contracted. This creates a kink in the anorectal angle — the angle between the rectum and the anal canal — of approximately 90 degrees. The stool has to navigate that bend under muscular pressure.

In a full squat position — knees above hips — the puborectalis muscle relaxes completely. The anorectal angle opens to approximately 126 degrees. The rectum straightens. The path clears. Elimination becomes a gravitational assist rather than a muscular effort against an anatomical obstruction.

This is not alternative medicine. A 2019 study published in the Journal of Clinical Gastroenterology compared three defecation positions — sitting, sitting with a footstool, and squatting — and found that the squatting position resulted in significantly shorter defecation time, less straining, and a greater sense of complete evacuation. A 2010 study by Sikirov found that squatting reduced average straining time from 130 seconds to 51 seconds — a 60% reduction — and that 28 of 30 participants reported the squatting position superior on all measures.

The Western toilet, introduced in the 19th century, is a comfort innovation that happens to be anatomically suboptimal. The rest of the world — where squat toilets remain standard — has substantially lower rates of constipation, haemorrhoids, and diverticular disease. This is not a coincidence.

Breathing — The Missing Piece Nobody Mentions

Most people hold their breath or breathe shallowly during defecation, particularly if they are straining. This is the opposite of what the physiology requires.

Effective defecation requires coordinated relaxation of the external anal sphincter and puborectalis muscle, combined with an appropriate increase in intra-abdominal pressure to move stool through the rectum. That intra-abdominal pressure comes from the diaphragm and abdominal wall — and the way you generate it matters enormously.

The Valsalva manoeuvre — closing the glottis and bearing down — does increase intra-abdominal pressure, but it simultaneously activates the sympathetic nervous system, increases heart rate and blood pressure, and creates the kind of muscular tension that works against the sphincter relaxation you need. It is the physiological equivalent of pressing the accelerator and the brake at the same time. This is why straining rarely works well and often makes things worse.

The correct breathing pattern for defecation is diaphragmatic — breathing that engages the full depth of the abdomen rather than the chest. Here is the sequence that works:

The Psychology — Why Half of This Is Mental

I want to talk about something that rarely appears in clinical gut health writing: toilet anxiety.

A surprising proportion of my clients cannot defecate at work. They can only go in their own bathroom. Some need a specific cubicle. Some need to know that nobody else is nearby. Some have to wait until the house is empty. The stress of a public toilet — the sound, the proximity to other people, the uncertainty about cleanliness — is enough to completely shut down the physiological process.

This is not a character flaw or excessive fastidiousness. It is an entirely predictable consequence of the gut-brain axis under sympathetic activation. The enteric nervous system receives continuous input from the autonomic nervous system. When you feel unsafe — observed, rushed, embarrassed, uncertain — your body reads that as threat. And bowel function is one of the first things threat shuts down.

My dog Dexter takes his time finding his spot. He circles. He investigates. He will not go until the conditions feel right to him. He has no shame about this. He also has no constipation, no haemorrhoids, and no history of sitting somewhere uncomfortable for twenty minutes achieving nothing. There is a lesson in that.

The clinical solution to toilet anxiety is not to push through it. It is to create conditions that allow the parasympathetic nervous system to take over. This means:

• Privacy and time pressure removed. If you are watching the clock, the process will not work. The parasympathetic window needs to feel unhurried. This means building enough time into your morning that the toilet is not something you are rushing through on the way to something else.
• Familiarity and routine. The brain and gut respond to predictability. Using the same toilet at the same time in the same conditions, with the same pre-toilet routine, signals safety. It sounds almost ritualistic because it is — and ritual, in this context, is a clinical tool, not a neurosis.
• Environment that feels acceptable. Clean, private, unhurried. For clients with significant toilet anxiety, I'm not above suggesting they keep their preferred bathroom consistently clean and uncluttered specifically because it matters to their gut function. This is not being precious. It's working with the nervous system rather than against it.
• Phone away. Scrolling on your phone while on the toilet disrupts the proprioceptive awareness you need. It also extends sitting time, which increases pressure on the haemorrhoidal vessels. The toilet is not a reading room. Give the process your attention, use the breathing protocol, and get on with your day.

There is a scene in the film This Is 40 where Paul Rudd's character is repeatedly caught sneaking off to the bathroom with his iPad — ostensibly for peace and quiet, but clearly unable to function without it. It is played for laughs. It is also one of the more clinically accurate depictions of toilet dependency I have seen on screen.

The iPad solves the psychological problem — it removes the performance pressure, creates a private space, gives the mind something to occupy itself so the body can get on with things. But it simultaneously prevents the physiological solution. The screen keeps the nervous system in low-grade sympathetic activation. It prevents the breathing awareness the process needs. It extends sitting time well beyond what is healthy. And over time it becomes a dependency loop: the bowel learns it needs the external stimulation to initiate at all. Taking the phone or tablet away feels impossible — and that is precisely the sign that it has become part of the problem rather than the solution to it.

The fix is not to go cold turkey on day one. It is to introduce the breathing protocol alongside the phone, then gradually reduce the screen time as the technique becomes reliable. You are replacing one initiating stimulus with a better one — and the better one works faster, more completely, and without haemorrhoids.

The Role of Cortisol — Why Stress Turns Defecation Into an Event

Returning to my client with elevated free cortisol and high total metabolised cortisol across the day. His twenty-minute toilet sessions are not primarily a fibre problem or a magnesium problem. They are a cortisol problem wearing a digestive costume.

Chronically elevated cortisol does several things to defecation mechanics simultaneously:

The result is a body that is simultaneously not moving stool efficiently and then presenting it for evacuation under conditions of sphincter tension and nervous system activation — the worst possible combination for effortless defecation.

The breathing protocol and positional changes will help this client significantly. But the complete answer requires addressing the HPA axis driving the cortisol pattern. The DUTCH test is how I identify exactly where in the cortisol metabolism the problem is sitting — whether it's production, clearance, or both — and that shapes the intervention. Magnesium and fibre are downstream. Cortisol is upstream.

The Practical Evidence — What Actually Works

Here is a summary of interventions with genuine evidence behind them, ranked by the strength of effect and the evidence base:

Note what is at the top of that list and what is at the bottom. Most people start with magnesium and fibre because they are the easiest to buy. They are also the least mechanistically targeted unless position, breathing, timing, and nervous system state are already optimised. They work better when everything above them is in place.

The Things Nobody Says — But Should

I want to address the dimension of this that is almost never discussed in clinical practice because practitioners are as uncomfortable with it as their clients.

A significant number of people experience genuine distress around bowel function — not just inconvenience, but anxiety, shame, and avoidance behaviours that meaningfully reduce their quality of life. They schedule their day around toilet access. They decline social events that involve unfamiliar bathrooms. They rush through the process out of embarrassment about noise or smell, which means they never achieve complete evacuation, which means they spend more time on the toilet than they need to, which increases the embarrassment, which makes the whole thing worse.

The smell issue — which nobody ever addresses — is primarily a microbiome and diet issue. A gut with healthy bacterial populations and adequate fibre produces substantially less offensive odour than a dysbiotic gut processing a low-fibre diet high in processed food and animal protein. This is not a moral judgement. It is biochemistry. Improving gut health directly improves this, and for some clients this alone is motivating enough to make meaningful dietary changes.

The noise issue is best addressed by the same solution as the position issue — proper technique, adequate relaxation, and a reasonably private environment. A bowel movement that is mechanically efficient, properly positioned, and breathing-assisted takes under two minutes and is substantially quieter than one achieved through sustained straining. Efficiency solves most of the social problem.

The mess issue — incomplete evacuation leaving more cleaning than expected — is almost always a sign of incomplete emptying, which is almost always a position and tone issue. The squatting position combined with good sphincter relaxation produces substantially cleaner evacuation in most people. Again, this sounds too simple. It also consistently works.

When the Practical Fixes Aren't Enough

For a proportion of people, applying everything in this post will produce significant improvement but not complete resolution. This is usually because there is an underlying biological driver that mechanical and behavioural changes cannot fully overcome:

• Chronic HPA axis dysregulation — elevated or dysregulated cortisol that is maintaining sympathetic tone regardless of what you do at the toilet. Identified via DUTCH testing.
• Gut dysbiosis or pathogen load — bacterial imbalances or organisms like Blastocystis that are generating inflammation and disrupting motility at a microbial level. Identified via GI-MAP.
• Hypothyroid states — low free T3 slows gut transit directly and is one of the most consistently underdiagnosed drivers of chronic constipation. Identified via comprehensive blood chemistry including free T3, not just TSH.
• Pelvic floor dysfunction — genuine dyssynergia between the pelvic floor and anal sphincter during defecation attempts. This requires pelvic floor physiotherapy, which is beyond the scope of functional testing but worth raising with your GP.
• Low magnesium — not just supplemental magnesium, but cellular magnesium status, which is not reliably shown on a standard serum test. The RBC magnesium on a comprehensive blood panel is more informative.

The GI-MAP and DUTCH Plus together cover the biological drivers. The blood chemistry panel covers thyroid, magnesium, and inflammatory status. Between those three tests, the picture becomes clear — not speculative.