Trey Parker long wanted to feature a Grim Reaper-like death character in the series because since his childhood, Parker enjoyed drawing cartoon images of death riding on a tricycle. This was the inspiration behind a scene in which Death inexplicably rides a tricycle while chasing the South Park boys through the streets.
At the anti-TV profanity rally, Sharon Marsh holds a sign reading "Hearts not farts." This is a parody of the old "Hugs not drugs" slogan from the 1980s.
During one scene, Cartman moons Kyle while making fun of Kyle's mother. Comedy Central censors forced Trey Parker and Matt Stone to remove the image of Cartman's bare bottom, although such images would be allowed in future episodes.
The subplot of Kenny's diarrhea problems came from a real-life high school experience from Matt Stone, who said students used to offer each other $20 if they would pass a note to the teacher explaining they had "explosive diarrhea", like Kenny did in the episode.
Originally, Trey Parker and Matt Stone wanted Marvin Marsh to be known as the "molesting grandpa" who kept making sexual comments to Stan and attempting to play inappropriate games with him, but Comedy Central refused to allow it, which Parker said was "probably the right call".