The biggest problem is not even that it looks unfamiliar, but that the majority of “westerners” have insufficient ankle flexibility to squat, due to a lifetime of sitting in chairs and no experience squatting.

You might be able to build a squat toilet where the feet rested on a ramp (i.e. raised at the heel side), though I suspect most Americans would still refuse to use it.

Not just westerners; squat toilets, while in theory are good for the rectum, are not accessible to the disabled.

You don't need a ramp to squat on tiptoe. I squat with my feet flat on the ground, but I have been told that doing that is hard for most (US) people. Still, Americans do squat. They just don't do it with flat feet.

Have you actually tried pooping while on tiptoes??

No, for multiple reasons. But if you're looking for people with that experience, I suggest talking to some American backpackers.

That comes pretty fast with time. I was surprised I could crouch like a baby, after 3 monthes, something I couldn't do anymore for decades. I believe your back will thank you too.

That’s how many public toilets work in China.

Many of those I saw were pretty disgusting, and my travel companion reported that it also applied to the toilets for the opposite sex.

Sounds like a waste of water, though.