The Bathroom Debate: A legal argument that is causing a public health crisis

Co-founders, Linda Hawkins, PhD, MSEd, LPC, Nadia Dowshen, MD, and research manager, Susan Lee, MPH, lead work at the Gender and Sexuality Development Clinic at The Children’s Hospital of Philadelphia (CHOP). The Gender and Sexuality Development Clinic offers medical and psychosocial support for gender variant, gender non-conforming and transgender children and youth up to 21 years of age and their families. To learn more about the clinic, click here.



Several state policy proposals that would require public school students to use bathrooms based on their “anatomy and chromosome” at birth, rather than their gender identity, are raising major concerns for the rights and well-being of transgender students. These policies, which have been introduced in 19 states, can result in negative emotional and physical outcomes for transgender youth. States that enforce such bathroom policies are also discriminating based on sex and thus are out of compliance with federal law.

Have you ever found yourself limiting the amount of food you eat or the fluids you drink because you are concerned about using the bathroom at school?

This is a question that is part of every assessment conducted with transgender, gender variant and gender expansive children and youth in our Gender & Sexuality Development Clinic at The Children’s Hospital of Philadelphia (CHOP). Over half of the youth will indicate that navigating which bathroom to use can be stressful, frustrating, and in several cases, traumatic. Responses from youth include:

“I NEVER use the bathroom at school.”
“I don’t eat breakfast or drink anything in the morning or throughout the day so I don’t have to use the bathroom. I eat and drink after school.”
“Yes, I’ve had several UTIs (urinary tract infections) because I will hold it as long as possible.”
“I taught myself not to be hungry, so that I wouldn’t need to eat during the day.”

The children and youth are not confused about which bathroom makes the most sense for them to use. It’s the negative reactions from others that causes these students to have disordered eating patterns, urinary tract infections, gastrointestinal (GI) distress, and in many cases, depression and anxiety so great that students stop attending school altogether. Of the nearly 300 children and youth who are part of our clinic, nearly half are having a significant challenge navigating the bathrooms at their schools. Many are no longer attending their local schools due to the bathroom debate, and many opt for home or cyber school. This is a public health crisis for transgender students.

Philadelphia has acknowledged hardships for transgender individuals and has taken strides to increase gender equality. In 2015, former Mayor Michael Nutter signed a bill, which was sponsored by current Mayor Jim Kenney, requiring single occupant gender-neutral bathrooms in city-owned buildings. The bill also gives tax credits to businesses that offer the same health coverage to their LGBT employees’ partners and children that is offered to heterosexual spouses and children. It is our hope that policies like these keep expanding across local ordinances and states to help improve the emotional and physical well-being of transgender individuals.

In anticipation of these changes in Philadelphia, CHOP convened a working group to assess the bathroom facility needs throughout the hospital and primary care network. All new construction is compliant with the new city regulations, but CHOP is also rectifying the existing buildings. Staff and families weighed in on new signage that would be more gender inclusive, such as removing “Male/Female” signs from outside of private restrooms and replacing them with “Individual Bathroom” signs. Additionally, near signage for group bathrooms, there will be signs that specify and direct patients and families to the nearest “Individual Bathroom.”

Watching various schools, communities and states come up with legal arguments to justify creating more roadblocks for transgender students in school has been incredibly aggravating. It continues to feel that with every step forward in securing rights for health and happiness of transgender children and youth, a new way to frame discrimination and oppression pops up. 

Claims that students will fear for their safety if forced to share a bathroom with a student who may not identically match their sex chromosomes seems to ignore the fact that the students are all able to function well together for the other 98% of their school day. And how does this distress stack up to the nutritional and hydration-related distress that transgender students self-impose in an effort to avoid the bathroom altogether? With all of this fear and distress and its consequences for physical and emotional health, little time is left for transgender students to learn in school.

If the movement is for all students to feel safe in their school bathrooms, let’s focus on solutions that will be best for everyone:

  • Boys’ bathrooms with doors on all of the stalls (many school have them removed);
  • More locations throughout the building so that students don’t have to debate between going to the bathroom or being late to class;
  • Single-room bathroom options for all students who may need additional privacy; and
  • The right for all children to utilize the bathroom that aligns with their gender identity.

The crisis rings clear when we are able to hear the opposite side of this story. A youth shared: "I’m so lucky this year, I am able to use the boy’s bathroom at my new school. Nobody has a problem with it. I don’t have to worry about what I eat or drink anymore."

No student should have to worry about eating and drinking anymore. School should be a safe place for all children to learn and be healthy regardless, no matter their gender identity.


* To learn more about legal and other challenges facing transgender youth please see our brief, Ensuring Comprehensive Care and Support for Gender Non-Conforming Children and Adolescents.

Additionally watch the video below featuring Dr. Hawkins and physicians describing the challenges faced by transgender youth.

Check out our new Publications. View Publications