America Has a Public Restroom Problem

A scarcity of places to go when you’re traveling to a new city is a major issue for people living with inflammatory bowel disease. In partnership with the Crohn’s & Colitis Foundation, HealthCentral reports on the little-discussed crisis.

By Marygrace Taylor

This content was created as a collaboration between HealthCentral and the Crohn’s & Colitis Foundation.

Billy Riddle isn’t a big traveler. The Philadelphia, PA-based chef has struggled with urgency since he was diagnosed with ulcerative colitis (UC) three years ago, and having to find a public restroom in an unfamiliar city at a moment’s notice is usually too stressful. “Emotionally, I want to make sure I’m not going to be embarrassed. I have that anxiety built up to the point where my wife bought a traveling toilet to keep in our car [for when we do need to travel],” he says.

Riddle isn’t alone. “We know that 75% of IBD patients report staying at home and avoiding activities because they have no confidence that they’ll be able to access a public restroom,” says Michael Osso, the president and CEO of the Crohn’s & Colitis Foundation in New York City.

This isn’t a once-in-a-while problem. More than half (53%) of people with inflammatory bowel disease (IBD) say they’ve had difficulty accessing a public toilet in the last seven days, found a recent survey conducted by the Crohn’s & Colitis Foundation. “It’s one of the top stressors that patients with IBD experience,” says Laurie Keefer, Ph.D., director for psychobehavioral research in the division of gastroenterology at the Icahn School of Medicine at Mount Sinai in New York City.

Of course, it’s not just people with IBD who sometimes need fast bathroom access. Older adults, pregnant women, and people with a range of other health conditions (including multiple sclerosis, Parkinson’s disease, or pelvic floor disorders) can all experience bladder or bowel urgency. In fact, almost 8% of the general population has had a bowel or urinary accident within the last 12 months, with nearly three-quarters of those people saying they would have been able to avoid their accident if there had been a nearby restroom, the Crohn’s & Colitis survey found. For people with Crohn’s or UC, concern over such occurrences is so high, it’s easier to stay home than face potential consequences.

These numbers “help you recognize that people can’t find a restroom here in the U.S. It’s really a public health crisis,” Osso says. So just how bad is the current bathroom situation—and what can folks with IBD do to improve their access? Let’s talk about it.

Restroom Accessibility

State of the (Restroom) Union

Restroom accessibility specifics vary widely from city to city. The U.S. locale with the greatest number of public restrooms per capita is Madison, WI, with 35 toilets per 100,000 people, found a 2021 survey conducted by the British bathroom supply brand QS Supplies. There are 26 toilets per 100,000 people in San Francisco. Meanwhile, public restrooms average out to a measly four per 100,000 people in New York City. And in states like Mississippi and Louisiana, the number is one. That’s right: Just one public toilet per 100,000 people.

The situation wasn’t always so dire. More than two million public toilets were built during the Great Depression under Franklin D. Roosevelt’s New Deal program, and some 50,000 coin-operated pay toilets were scattered around the country well into the 1970’s, according to the Close Up Foundation. The fees people paid to use the toilets were typically put towards basic restroom maintenance, like cleaning, restocking supplies, and repairs.

Many of these public toilets fell into disrepair in the 1970s and 1980s as U.S. cities declined. At the same time, activists began speaking out against pay toilets. Their argument: Making people cough up money to access a bathroom infringed on basic human rights, Smart Cities Dive notes. As a result, the number of public bathrooms gradually dwindled.

It's not like this in other parts of the world. Countries like Iceland, Switzerland, and New Zealand have at least 45 public toilets per 100,000 people, the QS Supplies survey found. And pay toilets are popular in many European countries, which typically charge the equivalent of a dollar or less per use, and put the funds towards basic restroom maintenance and staffing. In other words, there are plenty of existing, effective examples for the U.S. to draw on when it comes to giving the public more places to go.

Cleanliness and Crime

Cleanliness and Crime

It’s not just a lack of physical structures that makes it difficult for the IBD community to travel freely in U.S. cities, it’s also a problem of safety. Public restrooms are frequently poorly maintained, allowing potentially harmful germs to thrive. Substandard or infrequent cleaning, blocked drains, and uncovered trash cans have all been implicated in the spread of infectious diseases, concluded a recent review published in the journal Science of the Total Environment.

While the average healthy person might opt to just skip a dirty bathroom and hold it until they get home, people with urgency issues don’t have that luxury. At the same time, the stakes are higher, since those with IBD specifically are at higher risk of complications from infectious illnesses, per BMJ Open Gastroenterology research.

“I’ve had experiences where public bathrooms have felt very unsanitary. It doesn’t feel great, to not have a choice of whether I can use this dingy restroom or not,” says Chealynn Feaster, a New York City resident who's had Crohn's disease for 24 years and received a permanent ostomy 10 years ago. For her, foregoing any available bathroom could mean that her ostomy bag gets full and begins to leak, which has happened on occasion. “It’s unnerving,” she adds.

Riddle is squeamish about the lack of cleanliness, too. For that reason, even though he knows the location of a few public restrooms in Philadelphia, he avoids them at all costs when he’s out and about. “I see how the city is taken care of in general. If they’re treating the streets like this, I have no reason to even go into those bathrooms,” he says.

Crime can also be an issue. Unstaffed public restrooms—which is the case for most facilities in the U.S.—can be a harbor for vandalism, prostitution, illegal drug activity, and even assault when they’re not properly managed, notes a report on security and design considerations for restrooms at public transportation facilities published by the American Public Transit Association.

In fact, crime at one intersection in San Diego spiked by 20% after a public restroom was installed, according to a local report. WBUR, Boston’s local NPR outlet, declared the city’s public restrooms “ground zero” of the opioid epidemic. Even more alarmingly, a man was recently arrested for planting explosives under public toilet seats in San Antonio, TX.

Fears surrounding cleanliness and safety certainly aren’t unique to people with Crohn’s or ulcerative colitis or other urgency issues. “The concerns probably mirror the general public’s concerns, except that people with IBD may need to use public restrooms more often,” Osso says.

Too often, the dilapidation and disrepair of public restrooms in major U.S. cities leads to the local government shuttering them entirely. That’s not a solution the IBD community needs. “I’d like to see a situation where there are funds put towards putting public restrooms outside of any type of building, where the restrooms have an attendant,” says Feaster. Budgeting for restrooms that can be regularly cleaned and adequately protected is essential so those who need to go, can, she adds.

Coffee Shop Route

What About Coffee Shops?

IBD or not, most of us have popped into a cafe to buy a drink or a snack just to use the bathroom at one point or another. “It’s the 'guilty biscotti’ at Starbucks,” Keefer says. The option is better than nothing when a free, public toilet is nowhere in sight, and many people who are generally healthy and don’t struggle with urgency don't think twice about doing it from time to time.

But the coffee shop or restaurant route can sometimes present problems, especially for folks with IBD. When you have to go immediately, there isn’t time to stand in line to buy something first. On the other hand, trying to head straight to the restroom with the intent to buy later rubs some shop owners and employees the wrong way. When Feaster tried to do this at a bar she frequents regularly, the owner “followed me and said, ’you weren’t going to buy anything anyway,’” she recalls. “I was really upset about that. I don’t understand why he was even watching me in the first place.”

Some states have adopted the Restroom Access Act, a law that requires retail businesses to allow people with certain medical conditions access to the employee restroom if a public facility isn’t available. (You can check your state’s status here.) It's a good idea in theory, but in practice, it doesn’t always work out. “The laws are very difficult to enforce, and there’s very little knowledge that the laws even exist,” Osso explains.

As a result, the burden is often put on the individual to explain that they’re entitled to use the bathroom because they have a condition that causes bowel or urinary urgency. That can be embarrassing for some, but even more crucial, explaining the nature and symptoms of IBD eats up precious time you don’t have when you’re trying to hold it in while having to go. “When you’re urgently having to go, you don’t want to get into a conversation with an employee, drawing more attention to yourself,” says Keefer.

Improving Access

Improving the System

To be frank, the national picture is pretty bleak. But some cities are working to improve their public bathroom access. The Portland Loo, a new type of freestanding public restroom designed to deter criminal activity, has been installed in more than 20 cities across the country, according to the brand.

Philadelphia, for instance, secured funding for six Portland Loo units as part of a new public restroom pilot program. The units are installed in close proximity to local police stations to deter criminal activity, and full-time staff have been hired to clean and maintain the restrooms, which are locked at night and reopened in the morning.

Other efforts are also under way. In Atlanta, Metropolitan Atlanta Rapid Transit hubs are receiving funding for SMART restrooms, which discourage loitering with virtual room attendants that monitor activity with an outside overhead camera. San Francisco even had a party to celebrate the opening of a new public restroom in a recently-built town square.

But much more is needed. “The government could potentially build, clean, and maintain public restrooms all over the country. That’s a good longer-term solution,” Osso says. But “in the short-term, we could incentivize businesses to open existing restrooms to the public, perhaps with tax incentive mechanisms, for instance.”

Individuals can help make that happen. The Crohn’s & Colitis Foundation and the United Ostomy Associations of America have toolkits with resources you can use to encourage your local officials to pass and enforce local restroom access laws. You can also report restroom access issues if a business denies access to you or someone you know, using the steps shared by the American Restroom Association.

Finally, don’t discount the power of education. Consider teaming up with a local IBD group to hand out fliers to businesses in your city, informing them about the local restroom access act or post about the issue on social media and explain why it matters to you. “If businesses understood that not all illnesses are visible, it could be helpful,” Feaster says.

How to Cope

Coping in the Meantime

America’s public bathroom problem won’t change overnight. But there are things you can do right now to improve your own access and reduce your chances for embarrassing or uncomfortable situations, so you can feel a little more freedom when you're out and about.

Use a Bathroom Finder App or Map

The Crohn’s & Colitis Foundation’s We Can’t Wait app makes it easy to track down publicly accessible restrooms wherever you are, with more than 56,000 bathrooms currently listed. Businesses can add theirs to the app, and if you find a great spot, you can add that, too.

You can find bathroom maps for many individual cities too, so check to see what’s available for where you live or a place you’re planning to visit. A few resources for major cities:

Boston Public Restrooms
Denver Public Restrooms
Got2GoNYC
Madison Parks Restrooms (Madison, WI)
Philadelphia Bathroom Access Map Project
Portland Public Restrooms Parks
San Diego Public Restroom Map
San Francisco Pit Stop Program

This list is far from complete. If you're looking for bathrooms elsewhere, you can also Google something like “[city name] public restroom map.”

Map Out Your Options Ahead of Time

Having to pull up an app or a map when your stomach starts to churn can be nerve-wracking. When Riddle travels, he’ll compile a list of bathrooms on his route before leaving home, so he knows exactly where he’ll be able to stop if needed.

Find a Go-To Tension Tamer

The urgency of needing to go and not having a place to do so while traveling through a major city quickly can turn into panic, causing your heart rate to rise and leading to additional gastro distress.

When Riddle starts to stress about not being able to access a bathroom, he’ll sometimes turn to simple, calming exercises like deep breathing or even pausing and counting to 10. “Learning how to slow yourself down when you’re in that heightened state becomes part of your shield for how you respond in these situations,” he says.

Carry an Emergency Kit

Keep some extra supplies in your bag so you’re prepared for inadequately stocked bathrooms as well as accidents, Riddle recommends. Think an extra pair of underwear, a pack of tissues, and hand sanitizer. If you have an ostomy bag, include supplies you’ll need to change your bag and clean the surrounding area in case of leaks. Tuck everything in a gallon-sized zip-top bag that can also be used to stash any of your own clothes that get soiled.

Don't Be Afraid to Assert Yourself

It can be uncomfortable to have to explain yourself to the cafe employee or ask a crowd if you can cut the long bathroom line. But speaking up often isn’t as big of a deal as it feels like in your head. “Most people understand and have been in that situation where they have to go urgently,” says Keefer. “It happens to everyone, so don't be afraid to ask for what you need.”

Shift Your Perspective

Bathroom incidents and accidents feel truly awful in the moment. Even if you’re beyond mortified, try to remind yourself that whatever predicament you’re in, it’s temporary. It will end and life will move on. “It seems big when it’s happening, but five minutes after it’s over, you’re out of that bathroom and you’ll probably never see those people again,” Keefer says.

And remember: Use your voice for change. It won’t happen overnight and improvements may be small. But until we say something loudly, America’s public restroom crisis will continue.

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