A recent United Nations (UN) report highlighted concerns regarding sanitation in places outside a person's home, in locations such as schools, hospitals, clinics, prisons, workplaces and public spaces (Heller, 2019). Public toilets fulfil a crucial basic human need, serving distinctive and diverse groups of people including adults, children, teenagers, transgender individuals, persons with disability, individuals experiencing homelessness, people who menstruate and older persons (Stanwell-Smith, 2010).
The World Health Organization (WHO) strategy highlights that access to safe, clean toilets is crucial for promoting public health (WHO, 2019). However, users of public toilets may feel apprehensive when they identify the need to use these facilities, because of concerns about availability and accessibility, cleanliness and safety (Camenga et al, 2019; Moreira et al, 2021).
People with additional needs make up approximately 15% of the global population (WHO and World Bank, 2011), unfortunately they face physical and social obstacles in accessing sanitation facilities, potentially preventing them from attending school, engaging in employment and using public services and amenities (Groce et al, 2011). Toilets should be safe places to visit, with physical and social barriers removed that could prevent people from using them – the principles of privacy, safety and cleanliness are essential prerequisites (Greed, 2016; Jaglarz, 2019).
Attitudes towards public toilets
In Western societies, it is embedded in the culture that elimination of bodily waste is a private matter that should be done in a secretive manner within formal facilities (Mitteness and Barker, 1995). Failure to have a clean safe place to eliminate waste increases the risks of individuals being stigmatised and vilified if incontinent episodes occur openly (Norton, 2004). The principle of privacy is essential for individuals when the need for elimination arises, ensuring a relaxed, undisturbed environment to urinate and defecate (Logan, 2012).
It is generally accepted that people need access to toilets in all public areas (Greed, 2009; Knight and Bichard, 2011). Historically public toilets were viewed as a place of sanitation provided by local authorities or governmental bodies, however, the maintenance and service of public toilets has become very fragmented (Greed, 2009). Unfortunately, in many European countries governments have cut funding to local authorities for the maintenance of public toilets (Street-Porter, 2016). Greed and Daniels (2002) highlighted that the financial burden of upkeep of public toilets – maintenance, running and repair costs – is increased if there is vandalism, criminal damage or antisocial behaviour.
School age children
Nearly 900 million children worldwide lack basic hygiene services at their school setting (Heller, 2019). In numerous research studies children who live in affluent countries have outlined that uncleanliness, bad odour, lack of privacy and security hazards may deter them from using toilets in schools (Norling et al, 2016; Tatlow-Golden et al, 2017). If children are unwilling to access toilet facilities because of concerns about cleanliness or other factors, this can result in physical discomfort when voiding or defecating and complications such as constipation (Vernon et al, 2003; Society for Women's Health Research, 2018; Toness, 2019: Secor-Turner et al, 2020).
Gender disparity
Historically there have been inequalities in accessing public toilets for women compared with men. The first public toilet in London, fitted in 1851, was for men only; it was another 40 years before public toilets for women were installed (Penner, 2001). This has been tied to the omission of women from social society, and the presumption women should remain at home, caring for children, carrying out chores and out of sight in cities (Kogan, 2007; Greed, 2010).
Several research studies have identified that females use toilets more frequently than males owing to particular physical needs, which are often overlooked in public toileting infrastructure (Stanwell-Smith et al, 2010; Greed, 2016; Camenga et al, 2019; Heller, 2019). Camenga et al (2019) identified that women spend a longer duration of time in toilets, subsequently increasing the demand on public facilitates compared with men, with women also reporting gender disparities in relation to privacy when using toilets, compared with men.
However, many individuals may inhibit elimination away from home. An Australian study involving nurses found a work culture of ‘patient-first’ prioritising care duties over their own self-care and as a result they avoided voiding for long periods of time (Pierce et al, 2019). For women who have occupations where they have restricted access to toilets or have to wait excessive periods of time to urinate, higher rates of lower urinary tract infections have been reported (Xu et al, 2018; Palmer et al, 2019).
Women have identified principles of uncleanliness, bad odour, lack of privacy and safety concerns as major factors for not using public toilets (Camenga et al, 2019; Palmer et al, 2019).
Managing menstruation
Girls, women and other individuals who menstruate can be fearful of menstrual leaks and accidents if they cannot access toilets (Cotropia et al, 2019; Schmitt et al, 2024); staining of clothes can occur if toilets are inaccessible, unhygienic and unusable (Society for Women's Health Research, 2018; Schmitt et al, 2024; Secor-Turner et al, 2020; Rubinsky et al, 2020). In a study in Burkina Faso, Western Africa, many girls who attended school expressed feelings of shame, stress and embarrassment when managing menstruation in toilets outside their home, with many participants refusing to use school toilets if possible (Buitrago-García et al, 2022). McMahon et al (2011) and Johnston-Robledo et al (2013) identified that many people who menstruate may experience stigma, shame and taboo if they do not have access to adequate toilet facilities.
Unfortunately, many public toilets settings and structures are not designed to fulfil the needs of girls, women and individuals that menstruate, however society must take into consideration that menstruation is a natural biological body function and provide sufficient toilet services (Ramster et al, 2018). Menstruation is an issue that many girls, women and other people who experience periods feel demeaned, disgraced, degraded, to manage successfully (Sumpter et al, 2013; Phillips-Howard et al 2016; Hennegan et al, 2019; Crankshaw et al 2020). Inadequate allocation of private toilets, insufficient supply of period products, inadequate physical support such as bins, and ineffective opportunity to change sanitary wear products impact on health and wellbeing of individuals who menstruate, particularly in school settings (Sumpter et al, 2013; Phillips-Howard et al 2016; Hennegan et al, 2019).
Female-friendly toilets have been described as gender-separated facilities that provide safety and privacy, well lit, with hand-washing facilities and a culturally appropriate way to dispose of menstrual waste (Buitrago-García et al, 2022). Other features that public toilets should have include hooks for bags to hang personal belongings (Schmitt et al, 2018). An absence of female-friendly toilets contributes to negative health outcomes among girls and women including even the increased risk of sexual violence against females (Schmitt et al, 2018). Worldwide it is recognised that people who menstruate need privacy when using public toilets, hand-washing facilitates and a clean environment (Sommer and Sahin, 2013).
Individuals with additional needs
Many individuals due to their older age profile, physical disability, diminished mobility may be hampered by inadequate public toilet provision, preventing them from engaging in social activities (Siu and Wong, 2013; Navarro et al, 2015).
Many individuals are unable to eliminate independently due to illness, disability or frailty and these people become dependent on carers, family members or health professionals (Heath, 2009). The principles of dignity, respect, choice and consideration should be upheld when individuals require assistance with the intimate task of toileting to ensure elimination occurs successfully and emotional distress such as embarrassment is reduced (Heath, 2009).
The Irish Census, conducted every 5 years by the Central Statistics Office, gathers information on the number of people reporting a disability and the type of impairment. In the latest census a total of 1 109 557 people reported experiencing at least one long-term condition or difficulty – this accounts for 22% of the population (Central Statistics Office, 2023). In Ireland, the Disability Act 2005 defines ‘disability’, in relation to a person, as a substantial restriction in the capacity of the person to carry on a profession, business or occupation in the state or to participate in social, cultural life in the state by reason of an enduring physical, sensory, mental health or intellectual impairment. The Disability Act 2005 outlines that all public bodies must make their buildings and services accessible, which would include access to toilets for all individuals no matter what ability or disability a person may present with.
Many toilets are poorly designed, omitting some special equipment that individuals with additional needs require, for example, grab rails or ramps (Mamee and Sahachaisaereeb, 2010) – effectively leading to some people being excluded. The absence of ramps or handrails and a lack of grab bars within the toileting area increases health and safety risks such as trips or falls and reduces the opportunity to promote independence within society (Ahuma-Smith and Bavuno, 2020).
The rights of persons with disabilities are assured under the UN Convention on the Rights of Persons with Disabilities (https://tinyurl.com/3fkr6xty). Article 9 of the convention requires all stakeholders to identify and eradicate barriers to accessibility to ensure that people with disabilities can access facilities and services provided to the general population. Governments, societies and communities should be aware of the aims of Article 9, that individuals with disabilities should be helped to participate as independently as possible in all aspects of life.
Public toilets should promote health, wellbeing, holistic human development and social inclusion (Moreira, 2021). In towns and cities, public toilets become one of the most necessary human amenities; however, many toilets are poorly designed, with no attention paid to the special needs of some users, leading to these people being discriminated against (Mamee and Sahachaisaereeb, 2010).
Vulnerable individuals
Public toilets should be designed to facilitate the private practice of voiding urine, defaecation of faeces and the management of menstruation. However, Ramster et al (2018) argued that most public toilets do not provide adequate privacy, space or safety due to the design of partition walls, a lack of audio privacy, and shared hand-washing spaces (Ramster et al, 2018).
People experiencing homelessness are at high risk of experiencing discrimination due to lack of opportunity to use toilets, to void, defecate and carry out proper hygiene (Moreira et al, 2021). Many individuals who are classified as vulnerable in society may be refused access to toilets in shops, restaurants, cinema and leisure centres (Frye et al, 2019; Heller, 2019). Poor access to sanitation and hygiene facilities is a known contributing factor to the spread of infectious diseases worldwide (Freeman et al, 2017). Unfortunately, individuals who experience homelessness may be forced to practice open defecation in parks, streets and disused buildings, which may have detrimental effects on their physical, mental, and social wellbeing (Bartram et al, 2010; Mara et al, 2010). Open defecation also constitutes a public health danger: exposure to faecal contamination in the environment can spread infections (Bartram et al, 2010; Mara et al, 2010). People who are homeless have many challenges, from accessing a suitable place to void urine, defecation of faeces, to the complexity of menstruation management and difficulties in purchasing and using menstrual products – all these factors add to social stigma for these vulnerable individuals (Ensign, 2000; Levit, 2017; Sebert Kuhlmann et al, 2019). In the case of people living in homelessness, the lack of sanitation can reinforce the discrimination suffered on account of lack of hygiene, as they can be forbidden from accessing water for washing themselves or even using toilets for elimination in shopping centres, stores, or restaurants (Frye et al, 2019; Heller, 2019). Many of the women, especially, who experience homelessness, may have no safe, secure, places to change menstrual products and this can be a particularly problematic at night time when many women reported that public toilets were dangerous, unsafe, and their personal safety was threatened (Sebert Kuhlmann et al, 2019).
Another group of people who can be considered as a vulnerable cohort are transgender individuals as they may not conform to the dualistic standards, and experience intimidation, hostility, verbal and physical harassment, or may even be denied access to public toilets (Herman, 2013; Moreira et al, 2021). Sheer (2020) identified that transgender individuals prefer to use toilets that relate to their current gender identity rather than their allotted birth description. Research has identified that transgender individuals may avoid using public toilets, and even reduce their fluid intake to prevent voiding, leading to serious physical and psychological health issues (Herman, 2013; Porta et al, 2017). James and Coley (2023) recommended removing the dualistic concept of toilet use and moving to non-specific gender toilet facilitates.
Incontinence: the impact on individuals
Globally incontinence symptoms are estimated to affect up to 400 million people worldwide. Despite this high prevalence, incontinence remains a taboo subject for numerous people, it may be a low priority for some health professionals, and not on the agenda of policy makers (Milsom et al, 2013). Acquiring, achieving and maintaining continence is considered ‘the most basic of needs’(NHS England, 2018). However, if the symptoms of incontinence develop it can be overcome by assessing and addressing bladder/bowel dysfunction effectively (Health Service Executive, 2019).
Urinary incontinence is described as involuntary leakage of urine in an inappropriate place which has social and hygienic consequences (Abrams et al, 2010). Similarly, faecal incontinence can be defined as involuntary loss of liquid or solid stool, which is a social and hygienic concern (Norton et al, 2010). Physical, psychosocial and emotional consequences for suffers of incontinence are extensive, ranging from embarassment and reduced interaction, to social isolation, breakdown of relationships, depression, anxiety, sleep disturbance, incontinence–associated dermatitis and increased risks of falls (Wagg et al, 2015; Sanses et al, 2017). Incontinence is a health problem that still tends not to get the public awareness or acknowledgement it deserves despite the negative impact that it has on many people's quality of life (Ford, 2022).
Canney et al (2016) reported that one in seven adults in Ireland experience urinary incontinence at some stage of their lives, with women at higher risk of developing symptoms. Unfortunately, incontinence symptoms can occur at any period of time within the life of a person, however the prevalence rates increase with age. In older adults, incontinence is a prominent reason for admission to long-term residential care homes (Schluter et al, 2017). Nationally in Ireland these figures are even higher – within a point prevalence study it was identified that 86% of residents in care homes were incontinent (Wall et al, 2024). A study undertaken in the US (Gorina et al, 2014) it identified that more than 70% of nursing home residents experienced urinary incontinence.
It is often overlooked that provision of sanitary disposal bins is not only related to menstruation, but also impacts anyone who needs to dispose of incontinence products. In the UK there is a campaign, Boys need Bins, which aims to raise awareness about male incontinence and the necessity of sanitary bins in both male and female toilets. https://prostatecanceruk.org/get-involved/campaigning/incontinence/boys-need-bins.
Recommendations
Nationally and internationally public toilets would benefit from the following recommendations. Some of these are straightforward suggestions (such as having access to toilet paper), while others relate to complex construction conditions (such as facilitating access to wheelchairs users to public toilets).
- The public toilets that are available currently should be clean, preserve privacy, be secure, safe to use, have access to toilet paper, flushable cisterns, operational devices to dispose of used menstrual products, continence wear products, and also have a supply of menstruation products
- There is a need for an increase in the number of public toilets on streets, shopping centres, schools and all shared spaces
- To adhere to cleanliness public toilets and increase usability staff should be employed to manage these essential facilities in urban and rural areas
- All public toilets should adhere to health and safety regulations, and construction guidelines, be wheelchair accessible, have hand rails/grab rails, changing table and non-slip flooring
- Governments/policy makers and community groups must be made aware of the basic need of citizens to urinate, defecate, manage menstruation and change continence products when away from their home and by extension the need for public toilets that are accessible to all individuals, safe, secure, private and clean.
Conclusion
Social limitations and isolation may become a reality for individuals if access to quality public toilets is inadequate. Various sections of the population – due to their age profile, additional needs, diminished mobility, vulnerability or even gender – may be prevented from engaging in social activities, recreation, education or employment, due to lack of suitable public toilets. There are behavioural and cultural expectations when eliminating/defecating, managing menstruation or changing continence wear products. All these activities can occur successfully in public toilets with adherence to the principles of privacy, discretion, cleanliness and personal safety.
If people do not have access to public toilets when away from home, there are risks of incontinence episodes–the absence of these essential facilities to eliminate/defecate can cause embarrassment, humiliation and shame. Public toilets can enhance quality of life for people but these facilities need to be clean, safe, secure, accessible and available to all individuals. Health professionals and the general public must lobby for equality, justice and fairness of accessibility of public toilets for all individuals in our communities.
KEY POINTS
- Public toilets must abide by the principles of availability, accessibility and sustainability and be a safe place for all users in modern society.
- Individuals from countless different communities and circumstances, many with complex health conditions or additional needs, will use public toilets. This includes children, older people and people experiencing homelessness.
- Public toilets should be safe, secure, clean and facilitate fundamental body functions, from elimination of urine and defaecation of faeces, to the management of menstruation, and enabling the changing and disposal of continence wear products.
CPD reflective questions
- Can you define urinary and faecal incontinence?
- Public toilets must have certain characteristics to ensure individuals use these toilets facilitates, what are these?
- How do public toilets enhance the quality of life for individuals?