Abstract
Background
Transgender and nonbinary young people report disparities in both physical and mental health due to negative experiences associated with their identity. Despite bathrooms being an everyday necessity, transgender and nonbinary young people may avoid using them due to previous negative experiences or anxieties surrounding them, which may be related to poor health. This study examines the association of avoiding public bathrooms and mental health indicators among transgender and nonbinary young people.
Methods
Data were collected in 2021 via a cross-sectional survey of 33,993 lesbian, gay, bisexual, transgender, queer, and questioning young people ages 13–24, including 12,596 transgender or nonbinary young people. Bivariate analyses were used to examine the prevalence of avoiding public bathrooms and the health issues associated with that avoidance. Adjusted logistic regression models examined whether sometimes or always avoiding public bathrooms was associated with higher rates of anxiety symptoms, depression symptoms, and suicide risk.
Results
In the past year, 49% of transgender and nonbinary young people reported sometimes avoiding public bathrooms due to concerns around using them and 22% always avoided them. Respondents reported a number of negative physical effects from avoiding public bathrooms: 67% reported “holding it” when they needed to use the bathroom and 38% abstained from drinking or eating to avoid using these facilities. Transgender and nonbinary young people who reported sometimes or always avoiding public bathrooms reported significantly higher odds of all assessed mental health indicators. Notably, those who reported always or sometimes avoiding public bathrooms had almost twice the odds of attempting suicide in the past year (aOR = 1.95, 95% CI = 1.77–2.16, p < .001) compared to their transgender and nonbinary peers who never reported avoiding public bathrooms.
Conclusions
These findings highlight the need for policies protecting transgender and nonbinary young people’s safety and access to public bathrooms, which align with their gender identity.
Implications and contributions
Transgender and nonbinary young people report poorer mental health and higher suicide risk than their cisgender peers. Avoiding public bathrooms when one needs to use them can result in negative physical health problems and, in our sample, is associated with worse mental health and higher suicide risk. These findings demonstrate that implementing inclusive bathroom policies may improve physical and mental health and decrease suicide risk among transgender and nonbinary young people.
Keywords: Bathroom access, LGBTQ youth mental health, nonbinary youth, suicide, transgender youth
Introduction
Public bathroom use, essential in daily life, poses unique challenges for transgender and nonbinary individuals, many of whom avoid public bathrooms due to concerns ranging from personal safety to societal acceptance (James et al., 2016). While legislative battles have arisen around the issue, such as North Carolina’s 2016 bill known as House Bill 2 or the Public Facilities Privacy & Security Act, this study shifts focus to the practical and health implications of bathroom avoidance among transgender and nonbinary individuals.
Bathroom discrimination, often the reason behind the avoidance, can occur in a variety of settings. For example, 26% of transgender and nonbinary people reported that they were denied access to gender-appropriate bathrooms in educational settings and 22% reported that they were denied access in the workplace (Grant et al., 2011). Even in the absence of formal restrictions, debates and the ensuing media coverage surrounding transgender and nonbinary individuals’ access to bathrooms and other spaces can amplify stress, as seen in a study where lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) adults exposed to these negative discourses reported heightened stress and mental health challenges (Horne et al., 2022). These hostile environments, coupled with broader societal discrimination, can intensify the minority stress experienced by many in the transgender and nonbinary community (Brooks, 1981; Meyer, 2003; Rich et al., 2020). Indeed, 59% of transgender and nonbinary adults in the US Trans Survey sample reported sometimes or always avoiding bathrooms in the past year (James et al., 2016), which may have been tied to these experiences of minority stress. Transgender and nonbinary adults who felt that other people can tell they are transgender or nonbinary and had previous negative experiences using public bathrooms were more likely to report bathroom avoidance (James et al., 2016). Furthermore, bathroom avoidance itself is associated with suicidal ideation among transgender and nonbinary adults (Lerner, 2021).
There is a growing body of research documenting the mental health impact that bathroom access can have among transgender and nonbinary individuals. Transgender and nonbinary adults reported experiencing hypervigilance when using public bathrooms, which contributes to feelings of fatigue and stress, making it harder for them to work toward meeting other needs (McGuire et al., 2022). Among high school students, disparities in overall school safety, self-esteem, and academic achievement between transgender and nonbinary and cisgender students were mediated by a lack of bathroom safety (Wernick et al., 2017). Among transgender college students, denial of gender-affirming housing or bathroom facilities has been associated with higher rates of attempting suicide (Seelman, 2016). Among transgender and nonbinary young people overall, experiences of bathroom discrimination, specifically, were associated with a variety of mental health challenges, including depressed mood, considering suicide, attempting suicide, and multiple suicide attempts (Price-Feeney et al., 2021). While the relationship between lack of access to inclusive and safe bathroom facilities and poor mental health has been established, more detailed information is needed about the extent of bathroom avoidance among transgender and nonbinary young people and its impact on their physical and mental health.
The consequences of withholding bathroom use are not just psychological but also physical. Research suggests that avoiding the bathroom can lead to dehydration, urinary tract infections, and kidney infections (Herman, 2013). A Virginia-based study highlighted that transgender individuals might skip health care services due to the absence of accommodating bathroom facilities (Xavier et al., 2007). Over time, this avoidance could contribute to the development of serious physical health complications.
Prior studies have highlighted the psychological and physical impact of bathroom discrimination on transgender and nonbinary individuals (Price-Feeney et al., 2021) and the factors associated with bathroom avoidance among transgender and nonbinary adults (Lerner, 2021). However, a deeper understanding of how bathroom avoidance behaviors relate to mental health outcomes among a large sample of transgender and nonbinary young people is needed. Using a large sample of 12,596 young people from diverse gender identities, the study sought to understand 1) the prevalence of bathroom avoidance among transgender and nonbinary young people, 2) the prevalence of health issues related to bathroom avoidance among transgender and nonbinary young people, and 3) the relationship between bathroom avoidance and symptoms of anxiety, symptoms of depressions, seriously considering suicide in the past year, and attempting suicide in the past year.
Methods
Procedure
A nonprobability sample of 33,993 LGBTQ+ young people ages 13 to 24 residing in the United States (U.S.) was collected online from October 2021 to December 2021. Potential participants were recruited via targeted ads on social media (Facebook, Instagram, SnapChat, and TikTok). Targeted recruitment was conducted to ensure adequate sample representation across race/ethnicity, gender identity, and geography. Participants were defined as being LGBTQ+ if they reported a gender identity other than cisgender, a sexual identity other than heterosexual, or both. Qualified participants completed an online survey which included a maximum of 142 questions.
All study materials were approved by an independent Institutional Review Board (IRB), Solutions IRB. Solutions IRB is accredited by the Association for the Accreditation of Human Research Protection Programs. Young people’s participation in the study was voluntary and informed assent/consent was obtained at the start of the survey. A waiver of parental consent for young people aged 13 to 17 years was obtained from the IRB, as the research was determined to pose minimal risk to participants and presented some potential harm for young people who were not out to their parents about their LGBTQ+ identity. No names or personal details were collected in the survey to ensure anonymity.
Participants
A total of 12,596 young people from unique IP addresses indicated that they were transgender or nonbinary and provided answers to all three questions about bathroom avoidance. The demographic characteristics of the sample can be found in Table 1. The majority of this non-probability sample was nonbinary assigned female at birth (AFAB; 58%), followed by transgender boys and men (19%), nonbinary assigned male at birth (AMAB; 14%), and transgender girls and women (9%). The average age was 17.00 (SD = 3.07) and 23% reported that they were either just able to financially meet basic needs or struggled to meet basic needs. Overall, 26% identified as pansexual, 25% as bisexual, 20% as gay or lesbian, 14% as queer, 11% as asexual, 3% as questioning their sexual identity, and 1% as straight. The majority of the sample was non-Hispanic White (54%), followed by Latinx (16%), multiracial (16%), Black (7%), Asian/Pacific Islander (4%), American Indian/Alaskan Native (1%), and Middle Eastern/North African (1%).
Table 1.
Sample characteristics.
| Overall ssample n = 12,596 (%) | |
|---|---|
| Age | |
| 13–17 | 8,094 (64.3) |
| 18–24 | 4,502 (35.7) |
| Gender identity | |
| Transgender boy/man | 2,443 (19.4) |
| Transgender girl/woman | 1,172 (9.3) |
| Nonbinary assigned male at birth | 1,719 (13.6) |
| Nonbinary assigned female at birth | 7,262 (57.7) |
| Sexual identity | |
| Gay or lesbian | 2,542 (20.3) |
| Straight | 152 (1.2) |
| Bisexual | 3,096 (24.7) |
| Queer | 1,742 (13.9) |
| Pansexual | 3,228 (25.6) |
| Asexual | 1,345 (10.7) |
| I am not sure | 431 (3.4) |
| Race/ethnicity | |
| African American/Black | 805 (6.7) |
| Asian/Pacific Islander | 529 (4.4) |
| Latinx | 1,981 (16.4) |
| Native/Indigenous | 173 (1.4) |
| Middle Eastern/North African | 80 (0.7) |
| Multiracial | 2,016 (16.4) |
| White | 6,508 (53.8) |
| Income | |
| Just meeting basic needs or below | 2,741 (23.3) |
| More than meets basic needs | 9,002 (76.7) |
| U.S. Census Region | |
| Northeast | 1,866 (14.8) |
| South | 4,380 (34.8) |
| Midwest | 2,916 (23.2) |
| West | 3,434 (27.3) |
| Mental health variables | |
| Recent anxiety symptoms | 9,826 (78.3) |
| Recent depression symptoms | 8,100 (64.7) |
| Seriously considered suicide | 6,251 (53.3) |
| Attempted suicide | 2,134 (18.5) |
Measures
Bathroom avoidance
Respondents who identified themselves as transgender or nonbinary were pathed in specific questions on the survey that assessed experiences related to their transgender or nonbinary identity. To assess bathroom avoidance, respondents were asked “In the past year, did you avoid going to the bathroom because you were afraid of having problems using them? This would include bathrooms in public, at work, or at school.” Response options included 1) I have never avoided them, 2) I have sometimes avoided them, and 3) I have always avoided them. A dichotomized variable was created to compare young people who had sometimes or always avoided public bathrooms in the last year, compared to those who had never avoided public bathrooms in the past year. Regarding adverse experiences due to avoiding bathrooms, transgender and nonbinary respondents were asked, “Have you experienced any of the following because you avoided using bathrooms in public places, at work, or at school?” Response options included 1) Not going when needed (“holding it”), 2) I avoided drinking or eating, 3) Urinary tract infection, 4) Kidney infection, 5) Other kidney-related problems, 6) I have never had physical problems from avoiding bathrooms, and 7) Not listed above (please specify).
Mental health and suicide risk
Recent symptoms of anxiety were assessed using the General Anxiety Disorder Scale-2 (GAD-2; Plummer et al., 2016). Recent symptoms of depression were assessed using the Patient Health Questionnaire-2 (PHQ-2; Richardson et al., 2010). Items assessing suicide risk in the last year were from the Center for Disease Control’s (CDC) Youth Risk Behavior Survey (YRBS; Centers for Disease Control and Prevention, 2021). Respondents were asked “During the past 12 months, did you ever seriously consider attempting suicide?” Response options included 1) No and 2) Yes. Respondents who reported seriously considering suicide in the past 12 months were then asked, “During the past 12 months, how many times did you actually attempt suicide?” Responses were dichotomized such that zero times were coded as “0” and one or more were coded as “1”.
Sociodemographic covariates
Gender identity was measured using a two-part question of gender identity and sex assigned at birth (DeChants et al., 2021). Respondents were first asked “What sex were you assigned at birth, on your original birth certificate?” with response options 1) Male, and 2) Female. Respondents were then asked “Which of the following terms best describes your current gender identity? We understand that there are many different ways youth identify, please pick the one that best describes you here first.” with response options 1) Girl or woman, 2) Boy or man, 3) Nonbinary, genderfluid, or gender non-conforming, 4) I am not sure or questioning, or 5) I don’t know what this question means. From these questions, the following gender identity categories were created: 1) transgender girl/woman, 2) transgender boy/man, 3) nonbinary assigned male at birth, and 4) nonbinary assigned female at birth.
Other sociodemographic variables included age, sexual identity (gay/lesbian, bisexual, pansexual, queer, asexual, questioning, or straight), race/ethnicity (Alaska Native/American Indian, Asian/Pacific Islander, Black/African American, Latinx, Middle Eastern/North African, Multiracial, or White), income (just able to meet basic needs or less, more than able to meet basic needs), and U.S. Census Region (Northeast, South, Midwest, West).
Analyses
SPSS was used to conduct all analyses (Version 28). Descriptive statistics were used to examine rates of respondents avoiding public bathrooms in the last year and rates of negative experiences due to avoiding public bathrooms. Multivariate logistic regression was used to determine the relative odds of recent symptoms of anxiety, recent symptoms of depression, considering suicide in the past 12 months and, separately, of attempting suicide in the past 12 months among transgender and nonbinary young people who reported sometimes or always avoiding public bathrooms in the last year compared to those who reported never avoiding public bathrooms in the last year. These models adjusted for age, sexual identity (reference category: gay or lesbian), race/ethnicity (reference category: White), income, and U.S. Census region (reference category: Northeast).
Results
Prevalence of bathroom avoidance
Due to fears of having problems using public bathrooms, 49% of transgender and nonbinary young people reported that they sometimes avoided public bathrooms and 22% reported that they always avoided public bathrooms in the past year (Table 2). Only 27% of transgender and nonbinary young people reported that they had never avoided bathrooms in public, at work, or school in the past year. Binary transgender young people reported the highest rates of always or sometimes avoiding bathrooms, with 91% of transgender boys and men and 85% of transgender girls and women reporting that they always or sometimes avoid public bathrooms in the past year. Nonbinary young people also reported high rates of avoiding bathrooms, with 68% of nonbinary young people assigned female at birth and 62% of nonbinary young people assigned male at birth reporting that they always or sometimes avoid public bathrooms.
Table 2.
Rates of bathroom avoidance among transgender and nonbinary young people.
| Overall sample n = 12,596 (%) | |
|---|---|
| In the past year, did you avoid going to the bathroom because you were afraid of having problems using them? This would include bathrooms in public, at work, or at school. | |
| I have never avoided them. | 3,363 (26.7) |
| I have sometimes avoided them | 6,331 (50.3) |
| I have always avoided them | 2,902 (23.0) |
| Rates of sometimes or always avoiding public bathrooms by gender identity. | |
| Transgender boy/man | 2,215 (90.7) |
| Transgender girl/woman | 991 (84.6) |
| Nonbinary assigned female at birth | 4,958 (68.3) |
| Nonbinary assigned male at birth | 1,069 (62.2) |
Prevalence of health issues from avoiding public bathrooms
Rates of health issues, including both behaviors such as avoiding food and infections, were first calculated among the full sample of transgender and nonbinary young people in order to capture both those who avoided bathrooms in the past year and those who may not have avoided them in the past year but did avoid them in earlier years. Only 28% of transgender and nonbinary young people reported never experiencing any health issues from avoiding bathrooms (Table 3). The majority of the sample (67%) reported not going to the bathroom when they needed to (“holding it”) in order to avoid using bathrooms in public places, at work, or at school. In addition, 38% of transgender and nonbinary young people reported that they avoided drinking or eating in order to avoid using bathrooms in public places, at work, or at school. Less commonly reported among transgender and nonbinary young people were urinary tract infections (10%), kidney infections (1%), and other kidney-related problems (1%) due to avoiding using bathrooms in public places, at work, or at school.
Table 3.
Rates of health issues due to bathroom avoidance among transgender and nonbinary young people.
| Have you experienced any of the following because you avoided using bathrooms in public places, at work, or at school? | Overall sample n = 12,596 (%) | Sometimes avoided public bathrooms in the past year n = 6,331 (%) | Always avoided bathrooms in the past year n = 2,902 (%) | |
|---|---|---|---|---|
| I have never had physical problems from avoiding bathrooms | 3,478 (27.6) | 850 (13.6) | 172 (5.9) | X2 (1) = 117.13, p < .001 |
| Not going when needed (“holding it”) | 8,425 (66.9) | 5,094 (80.5) | 2,591 (89.3) | X2 (1) = 110.98, p < .001 |
| I avoided drinking or eating | 4,828 (38.3) | 2,748 (43.4) | 1,701 (61.7) | X2 (1) = 266.94, p < .001 |
| Urinary tract infection | 1,213 (9.6) | 674 (10.6) | 463 (16.0) | X2 (1) = 51.93, p < .001 |
| Kidney infection | 145 (1.2) | 73 (1.2) | 64 (2.2) | X2 (1) = 15.07, p < .001 |
| Other kidney-related problems | 164 (1.3) | 91 (1.4) | 68 (2.3) | X2 (1) = 9.65, p < .01 |
Significant differences in rates of health issues were observed among transgender and nonbinary young people who sometimes avoided public bathrooms and transgender and nonbinary young people who always avoided them. Significantly more transgender and nonbinary young who reported sometimes avoiding public bathroom in the past year reported never having health issues (14%) compared to their peers who reported always avoiding public bathrooms in the past year (6%, X2 (1, N = 9,233) = 117.13, p < .001). Transgender and nonbinary young people who reported having always avoided public bathrooms in the past year reported higher rates of not going to the bathroom when they needed to (“holding it”) (89%), compared to their peers who reported only sometimes reporting avoiding public bathrooms in the past year (81%; X2 (1, N = 9,233) = 110.98, p < .001). Transgender and nonbinary young people who reported having always avoided public bathrooms in the past year also reported higher rates of avoiding drinking or eating in order to avoid using bathrooms in public places (62%), compared to their peers who reported only sometimes reporting avoiding public bathrooms in the past year (43%; X2 (1, N = 9,233) = 266.94, p < .001). Compared to their peers who reported only sometimes avoiding public bathrooms in the past year, transgender and nonbinary young people who always avoided these facilities showed significantly higher rates of the health issues: urinary tract infections were reported by 16% (compared to 11%, X2 (1, N = 9,233) = 51.93, p < .001), kidney infections by 2% (compared to 1%, X2 (1, N = 9,233) = 15.07, p < .001), and other kidney-related problems also by 2% (compared to 1%, X2 (1, N = 9,233) = 9.65, p < .01).
Avoiding public bathrooms and mental health
Adjusted log regression was used to examine the association between avoiding public bathrooms in the last year and mental health symptoms, controlling for age, race/ethnicity, sexual identity, income, and census region (see Tables 4–7). Transgender and nonbinary young people who reported sometimes or always avoiding public bathrooms in the past year reported significantly higher odds of recent symptoms of anxiety (aOR = 1.64, 95% CI = 1.52–1.76, p < .001), recent symptoms of depression (aOR = 1.64, 95% CI = 1.54–1.75, p < .001), and seriously considering suicide in the past year (aOR = 1.68, 95% CI = 1.57–1.80, p < .001) compared to their transgender and nonbinary peers who never avoided using public bathrooms in the past year. Transgender and nonbinary young people who reported sometimes or always avoiding public bathrooms also reported nearly twice the odds of attempting suicide at least once in the past year (aOR = 1.95, 95% CI = 1.77–2.16, p < .001), compared to their transgender and nonbinary peers who never avoided using public bathroom in the past year.
Table 4.
Multivariate logistic regression of avoiding bathrooms in the last year on mental health on recent symptoms of anxiety.
| Covariate | aOR (95% CI) | p-value |
|---|---|---|
| Sometimes or always avoid public bathrooms in last year | 1.64 (1.52–1.76) | <.001 |
| Age | 0.95 (0.94–0.96) | <.001 |
| Census region | ||
| Northeast | (Ref) | (Ref) |
| South | 1.11 (1.0–1.24) | 0.06 |
| Midwest | 1.14 (1.01–1.28) | 0.03 |
| West | 1.01 (0.90–1.13) | 0.84 |
| Low SES | 1.63(1.48–1.79) | <.001 |
| Sexual orientation | ||
| Gay or lesbian | (Ref) | (Ref) |
| Straight | 0.53 (0.38–0.72) | <.001 |
| Bisexual | 0.96 (0.87–1.06) | 0.39 |
| Queer | 1.14 (1.01–1.29) | 0.04 |
| Pansexual | 1.27 (1.14–1.41) | <.001 |
| Asexual | 1.06 (0.93–1.21) | 0.41 |
| Questioning | 0.87 (0.72–1.06) | 0.16 |
| Race/Ethnicity | ||
| White | (Ref) | (Ref) |
| Asian American/Pacific Islander | 0.69 (0.59–0.81) | <.001 |
| Black/African-American | 0.67 (0.58–0.78) | <.001 |
| Hispanic/Latinx | 0.94 (0.85–1.05) | 0.26 |
| Native/Indigenous | 1.43 (0.98–2.07) | 0.06 |
| Middle Eastern/North African | 1.76 (1.06–2.90) | 0.03 |
| Multiracial | 1.01 (0.91–1.12) | 0.84 |
Table 5.
Multivariate logistic regression of avoiding bathrooms in the last year on mental health on recent symptoms of depression.
| Covariate | aOR (95% CI) | p-value |
|---|---|---|
| Sometimes or always avoid public bathrooms in last year | 1.64 (1.54–1.75) | <.001 |
| Age | 0.94 (0.93–0.95) | <.001 |
| Census Region | ||
| Northeast | (Ref) | (Ref) |
| South | 1.16 (1.05–1.28) | 0.02 |
| Midwest | 1.10 (1.00–1.22) | 0.06 |
| West | 1.12 (1.01–1.23) | 0.03 |
| Low SES | 1.93 (1.77–2.09) | <.001 |
| Sexual Orientation | ||
| Gay or Lesbian | (Ref) | (Ref) |
| Straight | 0.89 (0.65–1.21) | 0.45 |
| Bisexual | 1.01 (0.93–1.11) | 0.77 |
| Queer | 1.10 (0.99–1.23) | 0.08 |
| Pansexual | 1.31 (1.19–1.44) | <.001 |
| Asexual | 1.07 (0.95–1.20) | 0.28 |
| Questioning | 1.14 (0.95–1.36) | 0.15 |
| Race / Ethnicity | ||
| White | (Ref) | (Ref) |
| Asian American / Pacific Islander | 0.92 (0.79–1.06) | 0.25 |
| Black / African-American | 1.01 (0.88–1.15) | 0.94 |
| Hispanic / Latinx | 1.12 (1.02–1.23) | 0.02 |
| Native / Indigenous | 1.34 (0.99–1.80) | 0.06 |
| Middle Eastern / North African | 1.43 (0.98–2.10) | 0.06 |
| Multiracial | 1.02 (0.94–1.12) | 0.62 |
Table 6.
Multivariate logistic regression of avoiding bathrooms in the last year on mental health on seriously considering suicide in the past year.
| Covariate | aOR (95% CI) | p-value |
|---|---|---|
| Sometimes or always avoid public bathrooms in last year | 1.68 (1.57–1.80) | <.001 |
| Age | 0.91 (0.90–0.92) | <.001 |
| Census Region | ||
| Northeast | (Ref) | (Ref) |
| South | 1.15 (1.05–1.27) | 0.00 |
| Midwest | 1.14 (1.03–1.27) | 0.01 |
| West | 1.10 (0.99–1.21) | 0.07 |
| Low SES | 1.66 (1.54–1.80) | <.001 |
| Sexual Orientation | ||
| Gay or Lesbian | (Ref) | (Ref) |
| Straight | 0.89 (0.64–1.23) | 0.47 |
| Bisexual | 1.10 (1.00–1.20) | 0.05 |
| Queer | 1.01 (0.98–1.22) | 0.09 |
| Pansexual | 1.27 (1.16–1.40) | <.001 |
| Asexual | 0.81 (0.72–0.92) | <.001 |
| Questioning | 1.03 (0.86–1.24) | 0.74 |
| Race / Ethnicity | ||
| White | (Ref) | (Ref) |
| Asian American / Pacific Islander | 0.92 (0.79–1.07) | 0.28 |
| Black / African-American | 1.22 (1.07–1.40) | 0.00 |
| Hispanic / Latinx | 1.03 (0.94–1.13) | 0.57 |
| Native / Indigenous | 1.10 (0.83–1.50) | 0.52 |
| Middle Eastern / North African | 1.24 (0.86–1.78) | 0.25 |
| Multiracial | 1.03 (0.94–1.12) | 0.56 |
Table 7.
Multivariate logistic regression of avoiding bathrooms in the last year on mental health on attempting suicide in the past year.
| Covariate | aOR (95% CI) | p-value |
|---|---|---|
| Sometimes or always avoid public bathrooms in last year | 1.95, (1.77–2.16) | <.001 |
| Age | 0.85 (0.84–0.87) | <.001 |
| Census Region | ||
| Northeast | (Ref) | (Ref) |
| South | 1.18 (1.03–1.35) | .02 |
| Midwest | 1.27 (1.10–1.47) | .00 |
| West | 1.13 (0.98–1.31) | .09 |
| Low SES | 2.10 (1.90–2.31) | <.001 |
| Sexual Orientation | ||
| Gay or Lesbian | (Ref) | (Ref) |
| Straight | 0.72 (0.42–1.23) | .23 |
| Bisexual | 1.09 (0.96–1.23) | .21 |
| Queer | 1.03 (0.89–1.20) | .67 |
| Pansexual | 1.42 (1.26–1.61) | <.001 |
| Asexual | 0.79 (0.66–0.95) | .01 |
| Questioning | 1.01 (0.79–1.29) | .95 |
| Race / Ethnicity | ||
| White | (Ref) | (Ref) |
| Asian American / Pacific Islander | 0.94 (0.75–1.17) | .55 |
| Black / African-American | 1.47 (1.24–1.74) | <.001 |
| Hispanic / Latinx | 1.19 (1.06–1.35) | .01 |
| Native / Indigenous | 1.22 (0.85–1.73) | .28 |
| Middle Eastern / North African | 1.82 (1.20–2.77) | .01 |
| Multiracial | 1.25 (1.11–1.41) | <.001 |
Discussion
Transgender and nonbinary young people report frequently avoiding public bathrooms in the past year. Nearly three-quarters of transgender and nonbinary young people (73%) in the current study reported that they sometimes or always avoided public bathrooms in the past year, which is higher than that reported in studies among transgender and nonbinary adults (James et al., 2016). This difference may be due to transgender and nonbinary young people being often required to be in educational settings without gender neutral bathrooms for extended periods of the day, whereas transgender and nonbinary adults may have more autonomy in choosing to avoid public bathrooms or in finding safer public bathrooms options. Transgender and nonbinary young people may also be more likely to avoid public bathrooms than their adult peers because they may have limited access to gender-affirming health care or tools for expressing their gender identity, leading to increased discomfort and self-consciousness about using public bathrooms where others may recognize them as transgender.
Transgender and nonbinary young people in this sample also reported a number of physical health problems related to bathroom avoidance, including “holding it,” avoiding food or water, and medical issues such as urinary tract infections and kidney infections, with transgender and nonbinary young people who reported always avoiding public bathrooms in the past year reporting significantly higher rates of physical health problems compared to their peers who only sometimes avoided public bathrooms in the past year. Nearly two in five transgender and nonbinary young people reported restricting their food or water intake to avoid needing a restroom. These experiences have serious health consequences for transgender and nonbinary young people, as food and water restriction may lead to dehydration, malnutrition, disordered eating practices, or other physical health problems. Given the connection between physical and mental health, it is possible that these health issues due to avoiding public bathrooms also contribute to poor mental health among transgender and nonbinary young people. Previous scholarship has found that transgender and nonbinary young adults are more likely to report disordered eating that their cisgender peers (Diemer et al., 2015) and recommended that practitioners working with transgender and nonbinary young people should consider regular screening for disordered eating thoughts or behaviors among this group (Pham et al., 2023). While commonly attributed to body esteem and dysmorphia in transgender and nonbinary youth, it could also be driven by a desire to avoid having to use the bathroom. Given this increased risk, it is imperative that transgender and nonbinary young people have access to safe public bathrooms and are not subjected to health risks due to restricted bathroom access.
This study adds to the growing body of literature documenting the mental health risks of a lack of bathroom access for transgender and nonbinary individuals. Avoidance of public bathrooms, either sometimes or always in the past year, was associated with higher odds of reporting recent symptoms of anxiety, recent symptoms of depression, seriously considering suicide in the past year, and attempting suicide at least once in the past year. These findings align with previous scholarship which has found that bathroom avoidance is associated with suicidal ideation and psychological distress among transgender and nonbinary adults (Lerner, 2021) and highlight the urgent need for policies which protect transgender and nonbinary young people’s right to safe access public bathrooms which align with their gender identity. Having to plan one’s day around avoiding bathrooms, finding safe bathrooms, or not eating or drinking to prevent needing a bathroom, is stressful and may contribute to poorer mental health and higher suicide risk among transgender and nonbinary young people who report higher frequencies of avoiding public bathrooms (Meyer, 2003; Platt & Milam, 2018). School policies or legislation which restrict transgender and nonbinary young people’s right to safe public bathrooms may have detrimental effects on transgender and nonbinary young people’s mental health, as they may contribute to transgender and nonbinary’s fears of experiencing problems in public bathrooms and their avoidance, resulting in higher distress and poorer mental health.
Limitations
The cross-sectional design used in this study cannot determine causation or directionality of association. It is possible that experiences of anxiety and depression may cause young people to feel more trepidation when using public bathrooms and therefore avoid them more than their peers with better mental health. These data come from self-reports by transgender and nonbinary young people, and although there were several validity checks in the survey design, there may be bias in young people’s self-reports on their experiences using public bathrooms.
More research is needed on transgender and nonbinary young people’s experiences accessing public bathrooms and their impact on mental health and suicide risk. In particular, future research should consider the rise of anti-transgender policies and rhetoric and their impact on the bathroom habits and mental health of transgender and nonbinary young people. Young people hearing anti-transgender discourse in the news or from elected officials may be more motivated to avoid public bathrooms, regardless of their own experiences of discrimination while using them. Research should also document the implementation of anti-transgender bathroom policies in schools and their impact on the mental health of transgender and nonbinary students.
Conclusion
These findings illuminate the relationship between bathroom avoidance and health among transgender and nonbinary young people and highlight the need to combat policies that limit their access to bathrooms aligning with their gender identity. No person should be burdened with fear or concern about performing necessary bodily functions in public spaces. And yet, being forced to use public bathrooms aligned with their sex assigned at birth is a source of distress for many transgender and nonbinary young people. Anti-transgender rhetoric, as well as experiences of harassment or violence while trying to access public bathrooms, can cause transgender and nonbinary young people to avoid public bathrooms, which is associated with poorer mental health and higher suicide risk. School administrators, policy makers, and business owners should work to decrease barriers for safe bathroom use among transgender and nonbinary young people by creating policies that explicitly state that people are permitted to use the bathroom that matches their gender identity, providing gender neutral bathrooms or simply removing labels on single-use bathrooms, and by having anti-harassment and victimization policies that specifically address transgender and nonbinary identities. These affirming policies may improve the health outcomes and have potential life-saving effects among transgender and nonbinary young people.
Funding Statement
The author(s) reported there is no funding associated with the work featured in this article.
Disclosure statement
The authors declare that they have no conflict of interest. All research materials were reviewed and approved by an independent Institutional Review Board, Solutions IRB (IRB# 20210726). Solutions IRB is fully accredited by the Association for the Accreditation of Human Research Protection Programs. Informed consent was obtained from all individual participants included in the study.
References
- Brooks, V. R. (1981). Minority stress and lesbian women. Lexington Books. [Google Scholar]
- Centers for Disease Control and Prevention (2021). Youth Risk Behavior Surveillance System (YRBSS). https://www.cdc.gov/healthyyouth/data/yrbs/index.htm
- DeChants, J., Green, A. E., Price, M. N., Davis, C. (2021). Measuring youth sexual orientation and gender identity. The Trevor Project https://www.thetrevorproject.org/wp-content/uploads/2021/07/Measuring-Youth-Sexual-Orientation-and-Gender-Identity.pdf
- Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 57(2), 144–149. 10.1016/j.jadohealth.2015.03.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., Keisling, M. (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force. https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf
- Herman, J. L. (2013). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management & Social Policy, 19(1), 65–80. [Google Scholar]
- Horne, S. G., McGinley, M., Yel, N., & Maroney, M. R. (2022). The stench of bathroom bills and anti-transgender legislation: Anxiety and depression among transgender, nonbinary, and cisgender LGBQ people during a state referendum. Journal of Counseling Psychology, 69(1), 1–13. 10.1037/cou0000558 [DOI] [PubMed] [Google Scholar]
- James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
- Lerner, J. E. (2021). Having to “hold it”: Factors that influence the avoidance of using public bathrooms among transgender people. Health & Social Work, 46(4), 260–267. 10.1093/hsw/hlab027 [DOI] [PubMed] [Google Scholar]
- McGuire, J. K., Okrey Anderson, S., & Michaels, C. (2022). “I don’t think you belong in here:” The impact of gender segregated bathrooms on the safety, health, and equality of transgender people. Journal of Gay & Lesbian Social Services, 34(1), 40–62. 10.1080/10538720.2021.1920539 [DOI] [Google Scholar]
- Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pham, A. H., Eadeh, H.-M., Garrison, M. M., & Ahrens, K. R. (2023). A longitudinal study on disordered eating in transgender and nonbinary adolescents. Academic Pediatrics, 23(6), 1247–1251. 10.1016/j.acap.2022.12.013 [DOI] [PubMed] [Google Scholar]
- Platt, L. F., & Milam, S. R. B. (2018). Public discomfort with gender appearance-inconsistent bathroom use: The oppressive bind of bathroom laws for transgender individuals. Gender Issues, 35(3), 181–201. 10.1007/s12147-017-9197-6 [DOI] [Google Scholar]
- Plummer, F., Manea, L., Trepel, D., & McMillan, D. (2016). Screening for anxiety disorders with the GAD-7 and GAD-2: A systematic review and diagnostic metaanalysis. General Hospital Psychiatry, 39, 24–31. 10.1016/j.genhosppsych.2015.11.005 [DOI] [PubMed] [Google Scholar]
- Price-Feeney, M., Green, A. E., & Dorison, S. H. (2021). Impact of bathroom discrimination on mental health among transgender and nonbinary youth. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 68(6), 1142–1147. 10.1016/j.jadohealth.2020.11.001 [DOI] [PubMed] [Google Scholar]
- Rich, A. J., Salway, T., Scheim, A., & Poteat, T. (2020). Sexual minority stress theory: Remembering and honoring the work of Virginia Brooks. LGBT Health, 7(3), 124–127. 10.1089/lgbt.2019.0223 [DOI] [PubMed] [Google Scholar]
- Richardson, L. P., Rockhill, C., Russo, J. E., Grossman, D. C., Richards, J., McCarty, C., McCauley, E., & Katon, W. (2010). Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics, 126(6), 1117–1123. 10.1542/peds.2010-0852 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Seelman, K. L. (2016). Transgender adults’ access to college bathrooms and housing and the relationship to suicidality. Journal of Homosexuality, 63(10), 1378–1399. 10.1080/00918369.2016.1157998 [DOI] [PubMed] [Google Scholar]
- Wernick, L. J., Kulick, A., & Chin, M. (2017). Gender identity disparities in bathroom safety and wellbeing among high school students. Journal of Youth and Adolescence, 46(5), 917–930. 10.1007/s10964-017-0652-1 [DOI] [PubMed] [Google Scholar]
- Xavier, J., Honnold, J. A., Bradford, J. B., Health, V. D. O (2007). The Health, Health-related Needs, and Lifecourse Experiences of Transgender Virginians. Virginia Department of Health. https://books.google.com/books?id=FiMCoQEACAAJ