Matt is a 36-year-old man with autism who lives with three other men of similar age and functioning level. He is a proficient verbal communicator both expressively and receptively. Matt enjoys social interactions with peers, staff, and family, and frequently participates in various activities in the community. 

Matt has several medical conditions that can impact his daily life and his psychobehavioral status. He is diagnosed with and has a history of the following: anemia, irritable bowel syndrome, abnormal weight loss, constipation, hemorrhage from the anus, hemorrhoids, and rectal ulcers. He also takes medications to treat anxiety and depression. 

Sometimes, Matt repeats things, and they seem to be statements he has heard or been told by others in the past. These statements can include things such as, “Matt is bad,” or “STOP doing that.’ Matt recently returned from a home visit and was heard moaning, grunting, and yelling phrases in the bathroom, such as “Matt STOP!”  

When Matt left the bathroom, staff noticed there was feces and blood on the floor around the toilet, on the counter, all the towels were soiled, and the toilet was clogged with toilet paper. In the past, staff have noted they believe Matt goes into the bathroom to masturbate and are concerned that he has injured himself by doing this.  

Working Backwards

Feces smearing garners a lot of attention quickly, especially if it is on another person! The key to understanding this behavior is a willingness to “work backwards” and think like the person engaging in it. Initial thoughts could be, “Where is the feces coming from? Are they digging in their rectum, defecating outside of the toilet, or reaching into the toilet? Do they wear an adult brief and are reaching into it?” 

Generally, the answers will indicate that the person is experiencing some discomfort that they are trying to relieve. Behaviorally, there are several important considerations that can help clarify the characteristics of the behaviors. 

Are they itching? Are they possibly in pain? Are there certain times of day when they are engaging in the behavior? When was their last bowel movement? If they wear an adult brief, was it soiled? Do they have a rash or irritation? When did this behavior start? Do they have a history of the behavior? 

The primary role of a behavior analyst upon the initial presentation is to gather as much data as possible, while clearly identifying the characteristics beyond the presenting behavior to assist the interdisciplinary team. Future behavior and environmental approaches could include implementing a toileting schedule, increasing supervision, or expanding the use of effective communication to request assistance. 

On some occasions, rectal digging and feces smearing may not be related to a medical diagnosis. These instances are likely idiosyncratic and require more in-depth behavior review. For example, a person may have learned routines in the bathroom where they defecate in the shower, or their feces have been removed from the toilet to be disposed of in other places.  

How One Problem Can Lead to Another 

From the standpoint of thinking of behavioral presentations of medical diagnoses, a few common diagnoses related to feces smearing and rectal digging are constipation, hemorrhoids, and even parasites. Environmental issues can be related to poor hygiene after bowel movements, bowel accidents that lead to trying to clean up without assistance, and clogged toilets. 

When putting yourself in the shoes of the person exhibiting feces smearing, their thought process could be the following: “I have this pain and discomfort in my rectum, I have tried to make it better, but now I have another problem. I have this offensive matter on my hands, I don’t like it, and I want it off.”  

They then wipe it on available surfaces (or themselves or others!).

For Matt, the feces and blood that were found in the bathroom were related to his chronic gastrointestinal concerns. Matt was experiencing constipation, which led to hemorrhoids. 

When he was in the bathroom, he was trying to remove feces from his rectum manually. This resulted in feces on his hands, which ended up on various surfaces as he wiped and tried to clean himself. Matt was seen by his primary care physician, who treated the hemorrhoids and ordered medication for constipation. The residential team also increased support and supervision while in the bathroom to ensure Matt’s health and safety and promote successful toileting. 

Of special note from Ley’s experience, he has never seen rectal digging and feces smearing related to sexual gratification. When compared to behaviors that serve a sexual function, rectal digging and feces smearing do not present the same.  

All of Ley’s work is original and no form of AI was used to write this blog. 

This piece originally appeared in HELEN as part of Ley’s co-authored series on “Unlocking Behaviors.”

Never disregard professional medical advice or delay seeking medical treatment because of something you have read in this article.