The International Paruresis Association
is involved in advocating for the rights of people with paruresis
who have been unfairly discriminated against in drug testing.
Such discrimination may happen in cases
of applying for a job, keeping an existing job, being in the criminal
justice system as a prisoner or suspect, and for students in school
participating in athletics or other activities. Our position
is simple: If a person with paruresis needs a drug test
for any reason, a method must be provided that doesn't require a
Modern technology provides several
alternatives to urine drug testing, such as oral fluid (saliva),
sweat patch, and hair samples. All of these methods can detect
illegal drug use, and all of them can be done by completely voluntary
means. The main issue with urine testing is that giving a
urine sample requires properly-coordinated involuntary nervous system
activity, something which is impossible for people with paruresis
to do if they are experiencing anxiety.
IPA takes no formal position
on the legality or privacy aspects of urine drug testing.
Our sole purpose is to make sure people subject to drug testing
are treated fairly so that they have the ability to prove their
drug-free status. IPA's strategy for drug-testing reform is
to work on several levels:
At the individual level, IPA
acts to support people subject to a drug test by directly working
with those doing the testing to advocate for providing a non-urine
alternative test. We have been successful in many situations
simply by talking to reasonable people and informing them about
paruresis and how to obtain a valid drug test that is fair, accurate,
and does not rely on a urine sample.
At the statutory level, IPA is
engaged with government officials to modify existing regulations
that are unfair to those with paruresis. The most important
federal agency is SAMHSA, the US Substance Abuse and Mental Health
Services Administration. This agency is responsible for maintaining
the standards for federal workplace drug testing that are often
adopted by private employers. In 2004, IPA submitted a formal
response to SAMHSA asking for a number of changes to the existing
regulations, and over 130 personal responses from IPA supporters
were also submitted as part of the public comment process.
Click here to view IPA's response.
IPA is actively seeking people who are skilled at helping out with
this effort. Please contact us if you have relevant expertise,
or know someone who does.
At the educational level, IPA
seeks to inform the public about paruresis and its impact on people
who must undergo urine drug testing. Many people are unaware
of paruresis and how it affects the ability to urinate, so a number
of policymakers are simply ignorant of the barrier urine drug testing
presents. IPA has collected a great number of stories from
people who have been fired from jobs, unable to obtain employment,
have been taken off parole and put back in jail, or are under-employed
since they cannot apply for a job they are qualified to do without
passing a urine drug test. We hope that if people setting
drug-testing policy become informed about paruresis, they will change
current policy to be fair to those with paruresis. We think
common sense will prevail once people know the facts.
At the litigation level, IPA
advocates in court when a person's rights have been violated.
Successful litigation requires a case that isn't complicated by
suspected drug use, procedural ambiguities, or other factors that
could let an employer plead that they were following regulations
and were in their right to deny employment. IPA has helped
two people settle cases where they were treated unfairly and continues
to seek additional cases so that we can build a history of legal
It is important to talk about
the self-selecting nature of urine drug-testing policy and people
with paruresis. Whenever a person with paruresis knows he
or she will be subjected to a urine drug test, the person is likely
to decline working for that employer, or to choose another career
where drug tests aren't required. This means that people with
paruresis are unlikely to work in positions such as transportation,
athletics, or health care, where drug testing is popular or required
by law. The consequence of this injustice is that approximately
seven percent of the population is barred from working in capacities
where they might be eminently qualified. An airline pilot
needs good vision, quick reflexes, technical knowledge, and a talent
for flying an aircraft. What's missing from this job description
is the ability to urinate into a cup in front of an observer.
That skill isn't needed in order to fly an aircraft. A pilot
can prove one's drug-free status through many alternative test procedures
if regulations allowed them. The sad thing is that most people
with paruresis won't even apply for flight school because they know
they can't get through the drug test once they graduate.
Since people with paruresis often
select themselves out of certain careers, people involved in drug
testing seldom encounter a person with it. The natural conclusion
of a person who's never encountered someone with shy bladder is
that the problem doesn't exist, or a person claiming it might be
trying to evade a drug test because he or she is a drug user.
Misunderstandings such as this one are a difficult problem requiring
diligent effort on our part to correct. IPA's mission
is to ensure qualified, drug-free people can pursue the careers
they choose, and that students and those in the criminal justice
system, who seldom have any choice, receive fair and equitable treatment.
The information below can help
you learn about the legal process and how to influence an employer,
correctional authority, school administrator, or other person about
paruresis and obtain reasonable accommodation. For more specific
information, also see our Frequently-Asked
Drug Tests & Disability Discrimination Under the Americans with
Disabilities Act (ADA)
The Americans with Disabilities
Act (ADA), 42 U.S.C. §§ 12101 et seq, is the world’s first comprehensive
civil rights statute for people with disabilities. The ADA
is the most significant piece of legislation prohibiting discrimination
against the disabled. ADA inquiries, where persons with disabilities
claim discrimination, necessitate the determination of whether persons
initiating the claims are afforded the protection of the ADA. This
determination frequently requires more extensive analysis than does
the determination of whether persons are protected by other nondiscrimination
statutes. It is generally apparent whether persons are of
the particular race, national origin, age, or sex for which they
allege discrimination. Determining whether certain physical
and/or mental conditions constitute impairments, thereby meeting
the definition of individuals with disabilities, is not always so
Specifically, persons suffering from paruresis (a.k.a. “shy bladder”
and “bashful bladder”) continually confront disbelief
that they suffer from valid disabilities. Paruresis is a social
anxiety condition mentioned in the DSM IV under the category 300.23,
creating great difficulty urinating in public places. Paruresis
inflicts persons in the employment context and in the prison context,
when physically unable to provide specimens for urinalysis drug
tests. Resultantly, the inability to produce specimens
on demand is unfairly deemed equivalent to testing positive or refusing
to obey direct orders. As a direct consequence, persons applying
for jobs are denied employment positions and prisoners receive disciplinary
action. The unwillingness to provide reasonable accommodation
is evident as there are alternative methods of conducting drug tests
(such as oral fluid, sweat patch, or hair analysis), and urinalysis
procedures are still exclusively used in most drug testing programs.
By offering the alternative tests, illegal substances can be detected
without engaging in discriminatory behavior towards persons with
paruresis as defined under the ADA.
ADA Title I Employment (42 U.S.C. §§ 12101 et seq.) prohibits discrimination
on the basis of disability in employment, State and local government,
public accommodations, commercial facilities, transportation, and
telecommunications, 29 C.F.R. § 1630.2(h). The ADA prohibits
an employer from discriminating against a "qualified individual
with a disability" based on the disability, 42 U.S.C. § 12112(a).
For employees denied positions subsequent to their inability to
complete a urinalysis drug test, to establish a prima facie case
under the ADA they must show: (1) that they have a disability; (2)
that they were qualified for the jobs; and (3) that they were subject
to an adverse employment decision because of their disabilities.
The foundation of any ADA claim
leads to the issue of what constitutes a person as "disabled."
A person must meet the requirements of at least one of these three
criteria to be an individual with a disability under the Act.
The ADA defines a "disability" as: (1) a mental or physical
impairment that substantially limits one or more major life activities
of an individual, (2) a record of such an impairment, or (3) being
regarded as having such an impairment. A physical or mental
impairment, under 29 C.F.R. § 1630.2(h), consists of: (1) [A]
ny physiological disorder, or condition, cosmetic disfigurement,
or anatomical loss affecting one or more of the following body systems:
neurological, musculoskeletal, special sense organs, respiratory
(including speech organs), cardiovascular, reproductive, digestive,
genito-urinary, hemic and lymphatic, skin, and endocrine; or (2)
[A] ny mental or psychological disorder, such as mental retardation,
organic brain syndrome, emotional or mental illness, and specific
Applying ADA law to persons with paruresis and drug testing, one
must show that paruresis creates an impairment (i.e. inability to
urinate), that this impairment qualifies as a disability for purposes
of the ADA, and that the condition “substantially impairs” one or
more major life activities. Applicable regulations do not
note the “ability to control one’s wastes” as a major life activity,
but what can be more basic than the act of urinating? Therefore,
for courts to find that persons with paruresis are disabled as defined
under the ADA, courts must find in fact and conclude as a matter
of law that such loss substantially limits the major life activity
of urinating. 42 U.S.C. § 12111(8) (1994). Since definition
(1) of a physical or mental impairment in the previous paragraph
includes the genito-urinary system, IPA believes paruresis is a
valid disability requiring reasonable accommodation.
Urinalysis Drug Tests In The Employment Context
Today, millions of people are subjected to
drug tests as a requirement for getting or for keeping a job in
public and private employment sectors. People are increasingly voicing
their objections, believing the process to be unreasonable, unwarranted,
and unconstitutional. There is a debate in society as to whether
or not suspicionless drug testing is an impingement upon the fundamental
right of personal privacy and lacks sufficient accuracy to serve
any public purpose. Employers and authorities tend to be on
the side of wanting to know those they supervise are drug-free,
while those being supervised question why drug testing is used as
an evaluation tool rather than their actual work performance.
IPA views this debate as important and healthy, and regardless of
the outcome the rights of those with paruresis must be protected.
However, there are some people who are punished in spite of their
innocence. For example, pre-employment offers are retracted or employers
fire them from current places of employment. This occurs when people
are drug-free but are physically unable to prove it by way of the
type of drug test offered. The issue is one that people suffering
from paruresis (a.k.a. “shy bladder” and “bashful bladder”) continually
confront. Paruresis is a social anxiety condition mentioned in the
DSM IV under the category 300.23.
When people are required to take drug tests during pre-employment
job screening or as a condition for maintaining one's present position,
most collection sites employ urinalysis procedures. The collection
procedures sometimes stipulate that collectors need to visually
or aurally directly observe the act of urination. Urinalysis drug
testing methods have additional negative consequences for people
with paruresis, whereby they are physically unable to produce a
specimen. The inability to produce specimens on demand is deemed
equivalent to testing positive or refusing to obey direct orders.
As a direct consequence, people are denied employment positions
for which they otherwise are capable.
The purpose of this article is not to dismiss the significance of
drug-free workplaces. If employees are in fact using drugs and placing
themselves and/or others at risk, those employees should have the
opportunity to be treated for their drug abuse or face dismissal
if necessary. But regulations enforcing such procedures must take
into account the estimated 7% of the US population suffering from
paruresis. (1994 National Co-Morbidity Study). There have
yet to be any conclusive statistics reflecting the percentage of
persons with paruresis affected by urinalysis drug tests.
The US Department of Transportation (DOT) may argue that there are
rarely any complaints pertaining to paruresis and the inability
to perform urinalysis drug tests. This is probably accurate since
most people with paruresis are well aware of their inability to
perform urinalysis tests. Therefore, it is only logical to refrain
from seeking employment at agencies that use urinalysis procedures.
Regardless of the exact number, what remains relevant is that people
are denied employment based solely upon their inability to urinate
in front of others. Employers should rely upon hair specimens, oral
fluid (saliva), or sweat (patch) rather than urine for their drug
testing programs. In this manner, employers can effectively
detect illegal substances without engaging in discriminatory behavior.
Paruresis And Urinalysis Drug
Tests In The School Context
A recent trend has developed where schools
perform drug testing of students involved in athletics or other
extracurricular activities. Some people are even calling for
random testing of all students. This growing practice creates
special problems for our children if they have paruresis.
Young people with paruresis are ashamed to admit it to another person.
Because they can't use public restrooms around their peers, they
think they are strange or weird and are afraid to say anything about
this to parents, teachers, friends, or their doctor. This fear and
shame causes major problems for a student. Paruresis is believed
to be a form of social anxiety disorder, but not much is understood
about it yet. Once people with paruresis have an anxiety attack
brought on by having another person watching them urinate or placing
them under time pressure or the threat of failing a drug test because
they could not provide a sample, their urinary muscles "lock
up" and there is no way they can urinate until they can get
away from the perceived threat and find a safe restroom, usually
Students with paruresis facing a urine drug
test would likely decide not to participate in the activity requiring
the test. Unfortunately, social interaction and participation outside
the classroom is the most important thing these people need so they
do not enter a cycle of increasing avoidance and isolation from
their peers. The fear, shame, and guilt from suffering with paruresis
creates special problems for young people, because they are not
emotionally mature. Risks of more serious problems, such as
depression and suicide, could be the result for a young person facing
a drug test who is unprepared and uneducated about how to treat
paruresis. If implemented on a school-wide basis, urine drug
testing could lead to students with paruresis dropping out of school
or a reduction in students' performance and motivation due to excessive
worry about their paruresis.
There is a solution to the problem urine tests
create that is fair, and that is to allow students to have an alternative
test that doesn't require a urine sample. If drug testing
in schools is to become a common practice, IPA believes the following
measures must be taken in order to ensure young people are treated
fairly, receive equal access to activities that help with social
development, and reduce the chances of worsening or creating a mental
- Drug-testing authorities need to publish
training materials that are sensitive to the needs of students
with paruresis and educate school officials who set up testing
programs. IPA is ready to assist with this process.
- Any grant of government money to schools
must require that the testing will include non-urine alternatives
so that there is no chance of discrimination against students
- Students who are drug tested must receive
information on paruresis so that they are aware that treatment
is available and that they are not strange or weird for having
difficulty urinating around others.
Paruresis, Prisoners, And Urinalysis
In recent years, drug testing has increasingly
become the focus of efforts to detect and control drug use in prisons.
Prisons rely on various assessment tools in selecting prisoners
for drug testing. Some prisons test all inmates upon entry for the
first time; other prisons select inmates randomly after a set length
of stay or at unpredictable times or upon indication of illegal
drug use. When inmates are selected for drug testing, most prisons
employ urinalysis collection procedures, whereby inmates are forced
to urinate upon direct observation. The inability to produce specimens
on demand is deemed equivalent to testing positive or refusing to
obey direct orders. These regulations fail to recognize that there
are prisoners who suffer from paruresis, (a.k.a. “shy bladder” and
“bashful bladder”) whereby they are physically unable to produce
a specimen. Paruresis is a social anxiety condition mentioned in
the DSM IV under the category 300.23.
A catch-22 dilemma arises when prisoners assert that, due to paruresis,
they are unable to perform urinalysis tests in the presence of others.
Accommodations are only made if prison records contain medical documentation
before they are selected for urinalysis testing. Most prisoners
lack this necessary documentation because, subsequent to incarceration,
the majority of prisoners were not diagnosed for paruresis. Mental
health professionals often lack necessary knowledge of paruresis
and are unable to confirm or substantiate such allegations. Physicians
cannot make a determination for adequate medical documentation because,
presently, paruresis lacks any physiological evidence. Resultantly,
prisoners develop a greater sense of hopelessness and frustration
whilst prison officials often reinforce their allegations that prisoners
are engaging in acts of deceptions.
Presently, prisoners with paruresis are living in fear not knowing
when they will be randomly selected to face their social phobia.
Department of Corrections should administer tests to detect if inmates
are taking illegal substances, not to detect whether they have the
ability to urinate in front of others. Paruretic prisoners, rather
than receive treatment, receive the same punitive sanctions imposed
when inmates test positive for drugs. Legal and administrative sanctions
may include one or more of the following disciplinary actions: removal
of inmates’ privileges, taking away inmates’ good time, reclassifying
inmates’ security to higher levels, extending inmates’ incarceration
time, charging inmates with a new offense, increasing inmates’ drug
testing, and postponing or preventing inmates’ release.
The purpose of this article is not to dismiss the significance of
drug testing. Prisoners should be tested when there is reasonable
suspicion of drug use and if drugs are detected, disciplinary actions
are justifiable. Negative sanctions are unjustified when physical
and psychological conditions prevent compliance with these regulations.
All prisons should implement drug-testing regulations that comprehend
the needs of prisoners with paruresis so that the need to decrease
drugs in prison facilities is accomplished in a way that is both
effective and fair to everyone. Amendments in prison regulations
may very well present some inconveniences. However, paruretic prisoners
endure disciplinary sanctions, which are considerably greater. Complaints
of inmates with paruresis will continue until action is taken to
eradicate this dilemma.