Reality and the Toilet Seat, Revisited

Originally published in April 2011, this practical post featuring a real patient encounter that took place in our clinic bathroom (and the scientific questions raised by that whole humorous situation) has been viewed many thousands of times.* In the ten years since, the evidence and general guidance around the infection potential of direct contact with public toilets hasn’t really changed. What has changed is COVID, and the more realistic concerns around all the other people in the restroom (and flushing toilets) that may be aerosolizing virus particles into the air. So the only update for 2021 is: Definitely wash your hands, and seriously consider wearing a mask, too.

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Last week I was in clinic, running 30 minutes behind, with several patients waiting to be seen. I had just finished up with a new patient and was showing her where the lab waiting area was located, down the hall. Just then a very elderly woman came around the bend with a walker. She was looking around as if she were lost.

“Can I help you?” I asked.

“I just need the bathroom!” She exclaimed, looking desperate.

“OK, right this way”, I said and held open the door to my exam room suite. She pushed and rolled through. I then ran to also hold the bathroom door open for her. “Here you go,” I said. “Do you need any help?” I asked, realizing just then that my medical assistant was nowhere to be seen and I was actually offering to help her myself if necessary.

“As long as you have a toilet seat cover in there, I’ll be OK,” she said.

We do not, in fact, supply toilet seat covers in our bathrooms. I’m sure there are reasons for this, having to do with the potential hazards to our plumbing, the lack of evidence that they are at all effective for the prevention of disease, and the availability of toilet paper.

“I’m so sorry,” I said, “we don’t have toilet seat covers.” I withheld further commentary.

“Oh dear,” she said. “I’ve had quite a morning and I’ve used several toilets at the hospital today. I feel I need to use a cover of some sort!”

I wasn’t sure if she was implying that her bottom was contaminated from using all those other toilets, and that by using a toilet seat cover, she was protecting others who would use the same toilet, or if she had reached her personal upper limit of toilet seat germs. In any case, I had never constructed an impromptu toilet seat cover out of toilet paper and I wasn’t quite sure how to handle the task.

“Can you help me please? Can you make one for me out of toilet paper?” She implored. My heart went out to the poor lady, who was now bending over and moaning.

“Um, sure,” I agreed to help her. I figured I have enough degrees after my name to be able to tackle this. I’m into creative problem-solving. I squeezed past her into the bathroom and laid down two strips of toilet paper on either side of the seat, and one more across the back, and I stood back and said, “There you go!”

“…And one across the front,” she said.

I looked at her and then back at the covered seat, confused.

“There’s a gap at the front, a strip needs to go there also,” she said, “and you need to hurry.” She was starting to unbutton her pants.

I jumped to tear one more strip and placed it across the top. She was already making a move to get to the seat herself.

“OK,” I said, hastily beating my retreat, “I’ll leave you now, and you may want to lock the door behind me, just in case someone walks in on you,” I suggested.

“Oh no, dear, I’m too old to care,” she laughed. “Thanks for your help!”

“Anytime,” I replied. I went into an empty exam room and washed my hands, THOROUGHLY, then hustled to the room where the next patient was waiting.

“I’m so sorry I’m running late,” I apologized. “There was an emergency just now I had to attend to.”

I chuckled over this incident all afternoon. But when I shared the story with friends, I was surprised to learn that many perfectly intelligent and educated individuals use toilet seat covers regularly. I guess I see some utility in the case of a damp toilet seat (eewww), but it is beyond me that even if you could catch an infection from a toilet seat, how that wispy and famously shifty paper “O” could possibly act as an effective barrier. As a medical professional with a bit of a research background (i.e. a total dork), I just HAD to look at the scientific literature to see if there have been any good studies on the topic of toilet seats and infections.

A quick Pubmed search search on “toilet seat” and “STD” turned up several historical articles on gonorrhea, my favorite of which was a 1979 research study in the New England Journal of Medicine titled “The Gonococcus and the Toilet Seat”. I couldn’t help thinking of The Owl and the Pussycat, and I started inventing an equally silly poem. But, I digress.

There have been several studies, and the gist of the matter is, STD organisms survive a very short while on the seat, and for transmission to occur they would have to be introduced into the genital tract, which is highly unlikely. Even crab lice that do fall off of someone onto the seat are generally dead or dying anyways, so that old tale can also be put to rest. I found a fun article on this topic on Web MD titled “Bathroom Paranoia”. In the article, Abigail Salyers, PhD, president of the American Society for Microbiology (ASM) is quoted:

“To my knowledge, no one has ever acquired an STD on the toilet seat — unless they were having sex on the toilet seat!”

The public perception that STDs could be caught from a toilet seat seems to have come from early outbreaks of STDs, such as gonorrhea, in schools. It was originally claimed by the students (and probably the administrators) that this had to be from the school restrooms. We now know that such outbreaks were due to, you guessed it, sex.

However, as an uber-dorky researcher, I was also curious about other infections and toilet seats. There have been a few articles looking at MRSA (Methcillin Resistant Staph Aureus), a bug known to cause nasty skin infections, and toilet seats. In one, researchers took samples from random toilet seats at their hospital and found that a small percentage harbored MRSA. But when they cleaned the toilets seats with an alcohol wipe, and then tested, there was no MRSA. Since MRSA can theoretically get into any small break in the skin and cause an infection, some experts recommend wiping down public toilet seats with alcohol prior to making contact. However, I didn’t come across any studies presenting evidence that such infections actually happen, or that such preventive action is actually effective. I will say that if I had Bathroom Paranoia, and I had to choose between a toilet seat cover and an alcohol wipe in order to alleviate my anxiety, I would opt for the wipe.

And after all that, I say the major take-home lesson is: Just wash your hands.

*As I’m redesigning my website, I realized I have some pretty good content hiding waaay back in the archives, so I’ll be sharing more of my top posts in coming weeks.

Yun-yun Li (李云云), Ji-Xiang Wang (王霁翔), and Xi Chen (陈希) , “Can a toilet promote virus transmission? From a fluid dynamics perspective”, Physics of Fluids 32, 065107 (2020)https://doi.org/10.1063/5.0013318

Gilbaud and Fuchs. The Gonococcus and the Toilet Seat. New Engl J Med 1979 Jul 12;301(2):91-3

http://www.webmd.com/balance/features/what-can-you-catch-in-restrooms

Krasnick-Warsh and Strong-Boag. Children’s Health Issues in Historical Perspective. Wilfrid Laurier University Press 2005.

Giannini et al. Am J Infect Control. 2009 Aug;37(6):505-6. Epub 2009 Feb 25.