son gags when toileting

  I'm not sure if I'm in the right area but my son is 4 years old and has had quite a significant medical past which included having a kidney removed at 3 weeks of age and exploratory throat surgery due to severe chhronic croup. His throat was within the normal limits and his remaining kidney has finally been diagnosed as "normal" as well. He has been seen by a developmental peditrician and is in the early childhood program at school. He is very delayed in speech and the school had a psycological consult and they were did not want to diagnose him for sure at this time because of his circumstances. They said he showed some autistic traits "parallel play-does not seek out friends" and also selective mutism which has basically corrected itself after changing classrooms, teacher & babysitter. The consult said she thought his delays were mainly due to the constant medical trauma he had the 1st 3 years (over 200 dr visits first 3 yrs). Anyway, toileting was not easy but he was potty trained at 3 yrs 8 months. When he stands to urinate he keeps gaging as if it makes him want to throw up. When he is sitting and having a bowel movement he does not begin gaging until after he sees it to flush the toilet. I am sure it is a mental thing. I have tried to tell him not to look or I have tried to ignore the gaging. I don't think it is to get attention because he does this even when he thinks no one is watching. I'm sorry this is so long I just think he has had enough dificulties already. We saw a psycologist previously when his selective mutism was in full swing. He currently goes to speech therapy 2X weeks. Thanks in advance for your help.

[HVM Ph.D. - KDK]

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Dear Karen,
Yours is a perfectly fine question to address in this forum, and thank you for the very lucid description you offered of your son. He certainly has been through a lot in his very young life. You are undoubtedly correct in thinking that your son's gagging is a psychologically-based response. He has, apparently, developed an association having to do with the viewing of his urine/feces (he does not seem to gag otherwise). Has he verbalized any thought about this?
You are wise to basically ignore the gagging response - there's no need to focus on it. If your son conveys some distorted or unusual thought re: toileting, you can reassure him. Since the visual stimulus is what appears to bring on the gagging, he could sit while urinating and  you could help him learn to avert his glance and close the lid to the toilet before flushing. But, to be frank, I wouldn't pursue such a course. Development will proceed and the response likely will wane over time. He (and you) have enough other things that need your attention. For the time being, there does not seem to be a pressing need to pursue additional mental health evaluation. If your son was avoiding the bathroom, I would be suggesting such a course. But that doesn't seem to be the case.
This information is provided for purposes of general medical education. Please consult your health care providers for diagnostic and treatment options that pertain to your specific situation/condition.
*Keyword: toileting