Q&A with Luce Brett, author of PMSL: Or How I Literally Pissed Myself Laughing and Survived the Last Taboo to Tell the Tale

Luce Brett is one of the most brilliant and inspiring women I’ve had the pleasure of connecting with in 2020. We first got to know each other over the summer, when I interviewed her about postnatal incontinence and depression for The i newspaper. This conversation radically changed my own knowledge and understanding of pelvic floor health, as a naive non-mum who’d never previously given it much thought. Since then I’ve also written on the subject for Refinery29, and become a bit of an evangelist for the importance of pelvic floor exercises for prevention, not just as a cure.

Although her book centres around her own experiences of post-birth incontinence, and the impact this had on her life, Luce is also brilliant at placing incontinence in the broader feminist context of women’s health. PMSL is as much a feminist manifesto (a “femroar”, as she calls it) as it is a memoir. So I was absolutely thrilled when she agreed to chat to me again for Hysterical Women, and I can’t think of a better Book of the Month to finish the year on!

Photo: Richard Cannon

SG: You talk a lot in the book about how incontinence is simultaneously stigmatised into silence, while also being totally normalised, as if it’s an inevitable consequence of being a mum, or an older woman. Why do you think it’s so easy for these groups to be dismissed and ignored?

LB: Writing PMSL was definitely the result of a balance tipping. Of me getting more angry and pissed off, and more educated about my condition, than I was ashamed. And realising, when I brought it up, there seemed to be a lot of other people – especially women – who wanted to talk about incontinence properly, what it felt like, what it meant.

Incontinence fits into the broader category of women’s health which is presented as a problem for women to solve, ideally quietly and without carrying on about it too much. I think we’ve spent millennia acting like women should ideally put up with or solve this stuff themselves. Which diminishes it.

We also stigmatise it so, if conversations about birth, continence, hormones, periods come up, they are seen as grim things that women and feminists yak on about to each other, which are just to be lived with – rather than real medical problems, which deserve real attention and cures. It is infuriating as these myths persist when many pelvic and continence issues are well researched, and can be improved or cured.

What do healthcare professionals typically get wrong (and right) about incontinence and how they treat women who are affected?

First off, I had great care – but I am unusual, not least as I actively sought out care right from the start. I’ve been treated mostly with exceptional kindness, patience, almost love you might call it. PMSL is in part a love letter to the staff who work in these areas, which are stigmatised even in medicine. I read that research is underfunded because of the taboos of continence care.

That said, I hear a lot of stories about health professionals themselves dismissing incontinence as a natural part of being a woman or ageing. I’ve heard some quite grim stories of women not being given proper information about operations, pessaries, or tests being done to them. And I think some healthcare workers forget that destigmatisation is only one step away from dismissiveness. Especially when you are talking about someone’s ‘private’ parts.

I think sexual dysfunction – in particular post-childbirth or in old age – is often really easily written off, as if being broken is a price we should all happily pay for having had or potentially had children. As if it is ‘enough’ to have had a child or been through the menopause. You can see the difference when you compare it to the discourse about viagra and problems with penises.

I think screening isn’t always done well enough either. For example, screening patients for mental health problems relating to continence, or sexual dysfunction, when we know both can be impacted by it. I realise those are very delicate and difficult conversations, but the less they happen the less people will get help.

I feel like we’ve really seen a broadening out, beyond abortion and reproductive rights, of the feminist health conversation in recent years – particularly around vulvas/vaginas and periods. Where does incontinence fit in that conversation as a feminist health issue? 

Truly feminist health conversations would explore all aspects of being a woman, and/or having female genitalia, and the wider impact of that, which incontinence definitely does. Incontinence is a feminist issue for lots of reasons.

One, it is an area of healthcare where the old wives’ tale that old women just leak, and should accept it, has dominated. It is still alive and well with some care providers who work with women’s gynaecological health (midwives, GPs, non-specialist physios), though thankfully not many anymore. The bigger obstacle to care is women not realising how much is possible and how easily many of them could be helped.

Two, incontinence affects women socially and economically, as well as physiologically. Women are more likely to go through the menopause, so have hormonal changes that affect their pelvic floor, to have children, and to care for people who are incontinent.

The cost burden of incontinence is paid largely by the patient – so women pay for the pleasure of leaking. And it significantly impacts women in later life – urinary and faecal incontinence, and the risks associated with dashing to the loo, make women more likely to fall, which is a common reason for ending up in care homes. Incontinence also contributes to social isolation and stigma, stopping them leave the house, and adversely affecting or even stopping sexual relationships. Those things can massively impact on quality of life, or even life expectancy in the case of falls.

I know you also live with other chronic conditions – what parallels have you seen in the way your different health concerns have been treated?

I have a rare form of arthritis which can take years to recognise and diagnose, and I do wonder sometimes whether it is ignored because it affects many more women than men. Certainly the fact that I was a working mother, and fairly stretched, made it easy to dismiss concerns about being fatigued and sore. Like I was an unreliable narrator of my own broken body.

The trouble is it rubs off. I often find myself apologising, even when I am quite sick, I feel it is being difficult or making a fuss to challenge people, and I am pathologically scared of time-wasting. It is still fairly new for me, but I feel like it is difficult to be clear about pain unless it is an absolute emergency; like I will be seen as a drama queen. I think it’s connected to the idea of taking up space. It’s easy to imagine this is because women aren’t very good at taking up space, though the older I get the more I think it’s just that we are very badly received when we try.

It goes back to leaving women’s health as some sidelined curio, to be solved in red tents. Over history this means that women’s testimony is linked with myth-making and storytelling and is somehow less reliable, or challenging to ‘proper’ medicine. Women’s testimony about their own bodies in medicine remains something that isn’t always accepted as it should be.

Look at how medical misogyny clearly played a part in the ongoing horrible mesh scandal – how reductive the follow-up was, how issues like painful sex were dismissed as trivial, and patient voices – in particular those of middle-aged women with chronic pain – were muted for years and years…

Where should the onus lie when it comes to improving women’s pelvic health? 

I think it is a bigger issue with education and shame about genitals – and there is a divide between the sexes in that. You have one sex encouraged to talk proudly about theirs and to expect it to work, and another told to be grateful for performing a function and not to mention it. For generations we weren’t even taught about all of our anatomy, or how it changes with age. I’ve seen this a lot around discussion of prolapses, which are presented as totally gross. They happen to almost half of women, and yet we barely have a vocabulary for them!

With childbirth we also have such levels of ignorance around it, and women have been shamed about talking about it – especially difficult birth, which is physically or mentally traumatic, or both. Those stories have been lost to silencing for the sake of politeness or protection, and this stops all of us having proper conversations about consent, healthcare and risk. I suspect it also allows poor practice – where women have a difficult time and are treated terribly for whatever reason – to flourish in areas that are not being scrutinised in the open.

The recent research into the experience of Black and brown mothers in the UK demonstrates how much hiding maternity away, and not properly exploring it, has allowed terrible things to become systemic. For me, having babies, getting broken was radicalising; for others it has even bigger and more dreadful consequences.

When those stories are erased, there aren’t the wider discussions that are needed about improving care, consent, aftercare, the validity of worries about sexual function and relations, the fact that women don’t have to put up with pelvic pain, urinary or faecal leaking, or whatever.

I want people to talk more. But I am very reluctant to blame women or incontinent people for not speaking up. They have millennia of shame surrounding them – that is enough in itself. It is on all of us to have more honest conversations about bodies and inconvenient truths, like continence and ageing. This would perhaps allow us all to educate our children and young people better, and make conversations easier for patients, medics, policy-makers.

What is the one key message you hope readers take away from PMSL? 

I want readers to come away with permission to talk and think about it all, to not feel alone, and to know their feelings about their bodies and health – whether they have continence issues, or anything else – are validated and real. I felt so erased, and I know others do too.

But I also wanted people to be interested and engaged, and to see the whole political, historical, emotional, linguistic landscape of body shaming and women’s health that incontinence epitomises. I have not always been obsessed with piss but, in being forced to learn about this – and to place myself in a bigger narrative and wonder what has gone so wrong that women’s lives can still be ruined by this – I have realised there is a lot to learn and improve, and a lot of thinking and challenging we all need to do about what makes us uncomfortable, why and to what effect.

I also want healthcare professionals to know that their work is important and can be so positive here. Screening patients, enabling them to talk about sex, leaking and hormones, can change a life. So can seeing that, underneath the condition, the stigma, the defences and the fear, there is a real person. A clever, funny, complex, scared, thinking, angry person, who deserves the chance to get well and functioning again.

Luce will be joining Hysterical Women for an Instagram Live book club Q&A at 8pm on Tuesday 15 December. To join in, follow @SarahGraham7writer on Instagram, where you’ll be able to (anonymously) submit your questions in advance.

You can find Luce online, on Twitter and Instagram. 

Buy PMSL: Or How I Literally Pissed Myself Laughing and Survived the Last Taboo to Tell the Tale directly from Bloomsbury and get 20% off using the discount code PMSL20. Or order from Amazon using the link below.*

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