I recently visited Japan and was fortunate enough to arrive in the gleaming new international terminal at Tokyo Haneda Airport. After passing through immigration and having collected my baggage, I decided to look for the washroom as I had a long bus journey ahead. Toilet facilities are always a pleasure to visit in Japan, due to their cleanliness and their technological advances, including automatic taps, heated toilet seats, and automatic bidet function. As I entered the washroom, I noticed a sign that I had not seen before (Figure 1). This sign was on the door of only one of the cubicles in the men's toilet. I could not work out what this sign meant. Curiosity got the better of me and I decided to investigate. I pushed the bifold door and stepped inside the cubicle. To my surprise, not only did I find a standard toilet at one end but also a large sink and shower unit to the side (Figure 2). This struck me as being an odd setup for a shower. I was thinking to myself, "Why would a shower unit not have a proper shower tray and curtain?" and "Wouldn't the water spray go all over the floor?" Then I noticed another sign (Figure 3), which clearly stated that this facility was for ostomates' use only, not for general showering. I was very impressed that there were specific facilities for persons with ostomies.
Even in Japan, ostomate toilets are not widespread, but they are increasingly being installed in newly built airports, train stations, and government offices. The Japan Ostomy Association (http://www.joa-net.org/) has laid out guidelines that specify what facilities should be installed for persons with ostomies including (1) a deep sink with a flush for the removal of human waste, (2) thermostatic hand shower with mixer tap, soap dispenser, and paper holder, providing warm water to rinse the peristomal skin, to wash clothes, and to aid wiping and cleaning of ostomy appliances, (3) countertop space to allow the wearer to place their ostomy appliances and supplies, (4) hooks for clothing and luggage, (5) a mirror to help with the mounting of ostomy appliances, (6) a foot operated waste disposal box for used ostomy appliances, and (7) clear consistent signage to show the person with an ostomy that toilet facilities are available (Figure 1).
Ostomate facilities like these are extremely rare in the Western world, even though there are an estimated 100,000 patients with stomas in the United Kingdom alone.1 Psychological reactions and the need for social support are important factors that influence patients' experiences of caring for their own stomas.2 Patients are hesitant to go out due to the risk of leakage and difficulties in finding suitable locations to change their appliances. The provision of specific ostomate toilet facilities and a greater acceptance by society will help patients overcome these fears.
Without these toilets, persons with ostomies often use facilities for disabled persons to change their pouches, but this is far from ideal. Use of the disabled toilet is not the most efficient use of this specialized toilet. In addition, these toilets may be occupied and not available for use when an urgent pouching change is required. Disabled toilets are not designed for stoma changing; persons with ostomies often have to kneel on the floor to be at the right height to empty their appliances. Using a toilet for the disabled person gives the false impression to the general public that people with stomas are somehow "disabled." Furthermore, a member of the general public may question why a seemingly able-bodied person would require the use of a disabled toilet, leading to an embarrassing encounter.
I wish to start a discussion of how we can start implementing the installation of ostomate-specific facilities in the Western world. Clearly, change will not happen overnight and will require slow but steady progress. Patient support groups such as the Colostomy Association in the United Kingdom have started a campaign for the installation of hooks in all toilets. The success of this campaign would result in a small step in the right direction in a potentially long journey in the campaign for better facilities for ostomates. In the United Kingdom, there is no legislation making it mandatory for businesses or government organizations to provide additional facilities for ostomates. By contrast, the enactment of the Transportation Barrier-Free Law in April 2000 in Japan sparked the installation of ostomate facilities across the country. This legislation was implemented to improve access and enhance the travel experience for senior citizens and passengers with disabilities. It laid down specifications for toilets and marked the first time the requirements of ostomates were incorporated into law. Crucially, subsidies from the central government were available to help finance these changes. Since 2000, the number of ostomate toilets in Japan has increased steadily, and there are even Web sites that can direct patients to the nearest ones (http://www.ostomate.jp/).
There are clearly many areas in which facilities for persons with ostomies can be improved in the Western world. Retrofitting older toilet facilities to meet some of the recommendations issued by the Japan Ostomy Association is a good start. New toilets could be designed from scratch to incorporate cubicles with specific adaptations for persons with ostomies, enabling them to discretely manage their stomas without having to block the use of disabled toilets. Small changes can happen locally with the help of patient support groups, but a consistent rollout nationwide of upgraded ostomate facilities will require central government support and legislative changes in each country.
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