Transphobia in public restrooms and its association with lower urinary tract disorders: a cross-sectional study

ABSTRACT

Objective:  To analyze the health behaviors of transgender individuals in Brazil and their association with lower urinary tract dysfunction.

Method:  An exploratory-descriptive, cross-sectional study using a convergent mixed-methods approach, conducted with transgender individuals in Brazil. Data collection took place between October 2024 and March 2025 via an online questionnaire that included sociodemographic data, the International Consultation on Incontinence Questionnaire – Lower Urinary Tract Symptoms, and the Toileting Behavior – Women’s Elimination Behaviors, as well as open-ended questions about experiences in public restrooms. The sample was obtained through convenience and snowball sampling. Quantitative data were analyzed using descriptive and inferential statistics (p < 0.05), and qualitative data were analyzed according to Bardin.

Results:  A total of 131 participants took part, predominantly transmen, young, single, white, and with a college education. Harmful habits were identified, such as delaying, forcing, and anticipating urination, in addition to reports of embarrassment, insecurity, and transphobia. The most common urinary dysfunctions were overactive bladder, urinary retention, and incontinence.

Conclusion:  There was evidence of a high prevalence of inappropriate practices, associated with negative experiences and a higher incidence of urinary dysfunctions.

DESCRIPTORS
Transgender Persons; Lower Urinary Tract Symptoms; Health Behavior; Toilet Facilities; Nursing

RESUMO

Objetivo:  Analisar o comportamento sanitário de pessoas trans no Brasil e sua associação com disfunções do trato urinário inferior.

Método:  Estudo exploratório-descritivo, transversal, com método misto convergente, realizado com pessoas trans no Brasil. A coleta ocorreu entre outubro de 2024 e março de 2025, por questionário online com dados sociodemográficos, aplicação dos instrumentos International Consultation on Incontinence Questionnaire – Lower Urinary Tract Symptoms e Toileting Behavior – Women’s Elimination Behaviours, além de questões abertas sobre experiências em banheiros públicos. A amostra foi obtida por conveniência e bola de neve. Os dados quantitativos foram analisados por estatística descritiva e inferencial (p < 0,05), e os qualitativos conforme Bardin.

Resultados:  Participaram 131 pessoas, predominantemente transmasculinas, jovens, solteiras, brancas e com ensino superior. Identificaram-se hábitos prejudiciais, como adiar, forçar e antecipar a micção, além de relatos de constrangimento, insegurança e transfobia. As disfunções mais frequentes foram bexiga hiperativa, retenção urinária e incontinência.

Conclusão:  Evidenciou-se elevada adoção de práticas inadequadas, associadas a experiências negativas e maior ocorrência de disfunções urinárias.

DESCRITORES
Pessoas Transgênero; Sintomas do Trato Urinário Inferior; Comportamentos Relacionados com a Saúde; Instalações Sanitárias; Enfermagem

RESUMEN

Objetivo:  Analizar los hábitos de higiene de las personas trans en Brasil y su relación con las disfunciones del tracto urinario inferior.

Método:  Estudio exploratorio-descriptivo, transversal, con un método mixto convergente, realizado con personas trans en Brasil. La recolección de datos se llevó a cabo entre octubre de 2024 y marzo de 2025, mediante un cuestionario en línea con datos sociodemográficos, la aplicación de los instrumentos International Consultation on Incontinence Questionnaire – Lower Urinary Tract Symptoms y Toileting Behavior – Women’s Elimination Behaviours, además de preguntas abiertas sobre experiencias en baños públicos. La muestra se obtuvo mediante conveniencia y reclutamiento en cadena. Los datos cuantitativos se analizaron mediante estadística descriptiva e inferencial (p < 0,05), y los cualitativos según el método de Bardin.

Resultados:  Participaron 131 personas, en su mayoría transmasculinas, jóvenes, solteras, de raza blanca y con educación superior. Se identificaron hábitos perjudiciales, como posponer, forzar y anticipar la micción, además de relatos de vergüenza, inseguridad y transfobia. Las disfunciones más frecuentes fueron la vejiga hiperactiva, la retención urinaria y la incontinencia.

Conclusión:  Se evidenció una elevada adopción de prácticas inadecuadas, asociadas a experiencias negativas y una mayor incidencia de disfunciones urinarias.

DESCRIPTORES
Personas Transgénero; Síntomas del Sistema Urinario Inferior; Conductas Relacionadas con la Salud; Instalaciones Sanitarias; Enfermería

INTRODUCTION

Sanitary behavior refers to how a person responds to the urge to urinate, including the frequency with which they use the restroom in response to that urge and the posture adopted during urination. These behaviors can become harmful when a person adopts habits such as delaying urination, straining to urinate quickly, or adopting non-physiological postures(¹). Social, environmental, and cultural factors can influence the adoption of these harmful habits, which pose risks for the development of lower urinary tract symptoms (LUTS). When these symptoms result in clinical impact or compromise quality of life, they are defined as lower urinary tract dysfunction (LUTD), such as overactive bladder, incomplete bladder emptying, and urinary incontinence (UI)(²,³).

Access to public restrooms is not always equitable, despite being a basic human need. Among cisgender women, a study found that ethnic, racial, and socioeconomic factors influence the use of these spaces, suggesting structural inequalities(⁴). Among transgender and non-binary people, however, this issue is even more acute. A study conducted in the United States involving 12.596 transgender youth found that 71% avoided public restrooms for fear of facing discrimination or hostility. Consequently, many reported harmful coping strategies, such as holding back urination (67%) or reducing fluid or food intake (38%), and experienced complications such as urinary tract infections and kidney problems. Furthermore, they exhibited higher rates of anxiety and depression and were twice as likely to attempt suicide compared to those who never avoided restrooms(⁵).

In this context, nursing emerges as a strategic profession for the clinical care of individuals with LUTD, particularly through conservative, educational, and person-centered interventions. In Brazil, the COFEN/COREN system provides ethical and legal support for nurses to engage in the prevention and conservative treatment of these dysfunctions(⁶). National evidence indicates that Primary Health Care (PHC) nurses already care for people with LUTD, reinforcing the feasibility of incorporating this care into daily practice(⁷). Additionally, recent international evidence shows that structured, nurse-led programs improve outcomes such as incontinence severity, self-efficacy, and quality of life, and highlight the benefits of nurse-led organizational models for LUTD(⁸,⁹). These findings support the potential of nursing to contribute to strategies for the prevention, assessment, and treatment of LUTD in populations facing social and environmental barriers, such as transgender people.

Furthermore, most studies on health-related behavioral issues focus on cisgender women. The scarcity or absence of research in the transgender population should serve as a warning to the scientific community and indicates a gap in understanding issues that link gender, urinary health, and access to public restrooms. In this context, this study aims to analyze the bathroom-use behavior of transgender people in Brazil and its association with LUTD. We hypothesize that delaying urination—adopted as a strategy to avoid using public restrooms—is associated with a higher prevalence of LUTD in this population. It is expected that the results will contribute to the development of public health campaigns and policies, both regarding access to public restrooms and access to pelvic health assessment and treatment for this population, in addition to filling a significant gap in the scientific literature.

METHOD

Study Design

A cross-sectional, exploratory-descriptive study using a convergent mixed-methods approach, reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology)(¹⁰) guidelines for the quantitative component and GRAMMS (Good Reporting of a Mixed Methods Study)(¹¹) guidelines for the mixed-methods component.

The adoption of the convergent mixed-methods approach is justified by the multidimensional nature of the phenomenon under investigation: quantitative data allow for estimating the prevalence of inadequate hygiene behaviors and their association with LUTD, while qualitative data capture the subjective experience of using public restrooms—a dimension that scores and frequencies alone cannot fully capture. The integration of these two components enabled a more comprehensive understanding of the barriers faced by transgender people in this context. The quantitative and qualitative components were conducted in parallel, with equal analytical priority, and integrated during the results interpretation phase.

Location

The study was conducted in Brazil through online data collection (Google Forms), with the survey publicized by civil society organizations representing trans people, who were contacted via social media and email.

Population and Selection Criteria

The study population consisted of people who identify as transgender, transvestite, or non-binary, who reside in Brazil, are literate, and are aged ≥18 years. It is worth noting that, in this study, the term “trans people” is used as an umbrella category, encompassing trans men, trans women, transvestites, and non-binary people, in accordance with the definition adopted in the literature(¹²).

Sample Definition

The sample size was calculated for cross-sectional studies with proportional outcomes, considering a 95% confidence level (Z = 1.96), a proportion of 50%, and a maximum margin of error of 9 percentage points, resulting in a minimum sample size of 120 participants. Sampling was non-probabilistic and based on convenience, achieved by publicizing the study through civil society organizations for transgender people, contacting participants via social media and email, and using the snowball sampling method.

Data Collection

Data collection took place from October 2024 to March 2025 and was conducted using an online questionnaire (Google Forms) that included sociodemographic and clinical characteristics of the participants, as well as questions from the ICIQ-FLUTS (International Consultation on Incontinence Questionnaire—Female Lower Urinary Tract Symptoms)(¹³) or the ICIQ-MLUTS (International Consultation on Incontinence Questionnaire—Male Lower Urinary Tract Symptoms)(¹⁴)—completed according to sex assigned at birth—binary (yes/no) questions based on the five domains of the TB-WEB (Toileting Behavior: Women’s Elimination Behaviors)(¹⁵) as a conceptual framework, and two open-ended questions about the experience of using public restrooms: “What is the main reason you delay urination when you feel the urge to urinate?” and “Describe your experience using public restrooms.”

Data Analysis and Processing

For quantitative analysis, the R statistical package, version 4.5.1, was used. Possible associations between toileting behavior and LUTD were analyzed using the following tests: Pearson’s chi-square or Fisher’s exact test for bivariate statistics, and the Wilcoxon-Mann-Whitney test for numerical variables and dichotomous categorical variables. The significance level was set at 5%. Qualitative analysis followed Bardin’s framework(¹⁶), taking into account the phases of pre-analysis, exploration, processing, and interpretation. The written responses were transcribed using standardized spelling, while preserving the original semantic content. The Atlas.ti software, version 2002–2025, was used to support the systematization process.

The integration of the components took place during the interpretive phase through convergent triangulation: the quantitative findings—prevalences, statistical associations, and instrument scores—were compared with the categories and subcategories emerging from the qualitative analysis, seeking convergences, complementarities, and possible divergences. This process was conducted jointly by the research team, with a collective discussion of the results of each component prior to the final interpretive synthesis.

Ethical Considerations

Access to the questionnaire began with the Informed Consent Form (ICF), and participation was permitted only after the participant had read and accepted it.

The study was cleared by the Research Ethics Committee of the School of Nursing at the University of São Paulo, under opinion no. 7.028.208 and CAAE 79383124.2.0000.5392, in accordance with Resolutions no. 466/12 and no. 510/16.

RESULTS

A total of 131 individuals participated in the study, the majority of whom were trans men, young, single, white, highly educated, and with an average income of R$ 2.891.71.

Regarding bathroom behaviors, forced urination (70.23%) and delaying the urge to urinate (87.02%) were particularly common. A high prevalence of embarrassment (93.55%), insecurity (89.25%), and transphobia (47.31%) was also observed when using public restrooms (Table 1).

Table 1
Sociodemographic characteristics, bathroom behaviors, and experiences related to public restrooms among transgender people in Brazil – São Paulo, 2025.

Sample characteristics
	Answers	N			%
Gender Identity	Trans man/transmasculine	68			51.91
	Trans woman/transvestite	38			29.23
	Non-binary/gender-fluid	24			18.32
	No response	1			0.76
Marital Status	Single	96			73.85
	Married/cohabiting	32			24.62
	Separated/divorced	2			1.54
	No response	1			0.76
Self-Identified Ethnicity	White	88			67.18
	Indigenous	1			0.76
	Mixed-race	30			22.90
	Black	11			8.40
Missing Responses		1			0.76
Education Level	Elementary	3			2.29
	Middle	29			22.14
	High	94			71.76
	No responses	5			3.82
Do you feel the urge to urinate early?	Yes	80			61.07
Do you have to strain to urinate?	Yes	92			70.23
Do you have a preferred place to urinate?	Yes	116			88.55
Do you hold off on urinating?	Yes	114			87.02
Do you have a preferred position for urinating?	Yes	75			58.14
Have you ever felt embarrassed using a public restroom?	Yes	87			93.55
Have you ever felt unsafe using a public restroom?	Yes	83			89.25
Have you ever experienced transphobia while using a public restroom?	Yes	44			47.31
Have you ever avoided using public restrooms?	Yes	82			88.17
	Answers (N)	Missing answers	Average	Min	Max	SD
Age (years)	126	5	28.21	15.00	63.00	8.63
Income (reais)	119	12	2.891.71	0.00	22.000.00	3.066.20

• Note: (N) number of valid responses; (Min) minimum; (Max) maximum; (SD) standard deviation. *Valid N = 93 (71.0%) for the variables related to experiences in public restrooms (embarrassment, insecurity, transphobia, and avoidance), due to an operational error in the form’s routing logic, which was corrected during data collection.

The ICIQ-FLUTS and ICIQ-MLUTS instruments revealed the following UTI symptoms: overactive bladder, incomplete voiding, and urinary incontinence (UI) in the sample, with mean scores of 10.05 (SD 10.16), 10.71 (SD 11.11), and 12.02 (SD 14.08), respectively; scores greater than or equal to three are considered indicative of dysfunction.

Overactive bladder was more common among trans men (73.85%), while incomplete emptying (70.27%) and urinary incontinence (62.16%) predominated among trans women and transvestites. Non-binary individuals had a higher prevalence of the three LUTD disorders investigated, compared to the other groups (Table 2).

Table 2
Prevalence of LUTD by gender identity – São Paulo, 2025.

FLUTS – trans men
Urinary disorders	Number of answers > 2	Prevalence (%)	Average score	Minimum	Maximum	Total answers
Overactive Bladder > 2	48	73.85	7.65	0	40	65
Incomplete Bladder Emptying > 2	37	56.92	6.09	0	30
Urinary Incontinence > 2	31	47.69	6.66	0	50
MLUTS – trans women and transvestites
Overactive Bladder > 2	20	54.05	1.53	0	20	37
Incomplete Bladder Emptying > 2	26	70.27	4.39	0	47
Urinary Incontinence > 2	23	62.16	4.5	0	60
MLUTS OR FLUTS – non binary, gender-fluid and others
Overactive Bladder > 2	20	76.92	12.69	0	35	26
Incomplete Bladder Emptying > 2	19	73.08	10.8	0	33
Urinary Incontinence > 2	18	69.23	14.7	0	43

• Note: (LUTS) Lower Urinary Tract Symptoms (FLUTS) International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract Symptoms (MLUTS) International Consultation on Incontinence Questionnaire – Male Lower Urinary Tract Symptoms.

Regarding the associations between hygiene behaviors and LUTD, Overactive Bladder was associated with the behaviors of anticipating or delaying the urge to urinate, straining to urinate, and avoiding the use of public restrooms. Incomplete Bladder Emptying was associated with the behavior of straining to urinate (Table 3).

Table 3
Association between hygiene practices and urinary tract dysfunction among transgender people in Brazil – São Paulo, 2025.

Health-related behaviors that increase the risk of overactive bladder
Toilet habits	Answer	N	%	Missing answers	Average score	SD	Min	Q1	Median	Q3	Max	P-value
Feels the urge to urinate early	No	51	39.84	0	8.22	10.31	0	0	4	14	38	0.018
	Yes	77	60.16	3	11.27	9.94	0	3	8	19	40
Urges to urinate	No	37	28.91	2	6.08	7.64	0	0	2	10	24	0.001
	Yes	91	71.09	1	11.67	10.64	0	3	8	19	40
Puts off the urge to urinate	No	17	13.28	0	5.71	7.05	0	0	5	7	24	0.042
	Yes	111	86.72	3	10.72	10.42	0	2	8	18.5	40
Has stopped using public restrooms	No	11	12.09	0	4.46	5.68	0	0.5	2	7	19	0.021
	Yes	80	87.91	2	11.15	10.75	0	2	8	19	40
Health-related risk behaviors associated with symptoms of incomplete bladder emptying
Forced Urination	No	37	28.91	2.00	7.62	11.50	0	0	2	8	39	0.014
	Yes	91	71.09	1.00	11.97	10.76	0	1.5	11	20.5	47

• Note: (N) Number of valid answers; (%) Percentage; (SD) Standard Deviation; (Min) Minimum; (Q1) First quartile—the value below which 1/4 of the sample lies—; (Q3) Third quartile—the value above which 3/4 of the sample lies—; (Max) Maximum.

Forced urination is more prevalent among transmen (73.91%), non-binary individuals (87.50%), and single individuals (76.04%), while anticipating the urge to urinate is associated with marital status—specifically, being single (66.67%). Regarding the position used for urination, trans men use the toilet seat without sitting down (68.65%), and with regard to feelings of insecurity when using public restrooms, single individuals (91.67%) are again more likely to report this (Table 4).

Table 4
Associations between health behavior, sociodemographic variables, and experiences in public restrooms among transgender people – Brazil, São Paulo, 2025.

	Sociodemographic and gender factors that influence the habit of forced urination
	Answers		No			Yes			P-value
			N	%		N	%
Gender identity	Trans man/transmasculine		18	26.09		50	73.91		0.018
	Trans woman/transvestite		18	47.37		20	52.63
	Non-binary/gender-fluid		3	12.50		21	87.50
Marital status	Single		23	23.96		73	76.04		0.027
	Married/cohabiting		15	46.88		17	53.12
	Separated/divorced		1	50.00		1	50.00
The decision to urinate earlier in relation to marital status
Marital status	Single		32	33.33		64	66.67		0.022
	Married/cohabiting		17	53.12		15	46.88
	Separated/divorced		2	100.00		0	0.00
Preferred urination position and gender
			Squatting or without touching the seat			Seated
			N	%		N	%
Gender identity	Trans man/transmasculine		46	68.65		21	31.35		0.038
	Trans woman/transvestite		15	39.47		23	60.53
	Non-binary/gender-fluid		13	56.52		10	43.48
Marital status in the experience of feeling unsafe in public restrooms
Marital status	Single		6	8.33		66	91.67		0.049
	Married/cohabiting		3	15.00		17	85.00
	Separated/divorced		1	100.00		0	0.00

• Note: (N) Number of valid responses; (%) percentage.

With regard to the qualitative data, extracted from the responses to the open-ended questions: “What is the main reason you delay urination when you feel the urge to urinate?” and “Describe your experience using public restrooms,” 424 statements were obtained. From these, 426 codes were assigned, which, after grouping and excluding duplicates, resulted in 124 distinct codes, as shown in Figure 1. Grouping these codes enabled the development of two main analytical categories, subdivided into six subcategories.

Figure 1
Groupings, categories, and subcategories of the qualitative analysis.

Negative Experiences

This grouping includes reports in which participants expressed discomfort, insecurity, or vulnerability related to the use of public restrooms and the postponement of urination.

Inadequate Structural and Hygiene Conditions

The poor condition of public restrooms was cited as one of the main reasons for avoiding their use, with participants highlighting dirt, a lack of toilet paper, and a lack of privacy.

“However, even when there’s a toilet, I’ve been to restrooms where the door wouldn’t close, so it was really hard to use…”

“Sometimes I don’t go because there’s no toilet paper or no door, and it’s very dirty”

Prejudice, Transphobia, and Insecurity

The accounts demonstrate how fear of violence, verbal or physical discrimination, and hostile stares constitute significant barriers.

“…so I feel even more unsafe using them, especially since I don’t look passable”

“There are usually a lot of stares and even mean comments when I’m there”

Gender Dysphoria and Embarrassment Related to Gender Identity

Feelings of bodily inadequacy and exposure increase embarrassment, especially in restrooms without privacy or with urinals.

“As a trans man, I don’t like restrooms with urinals too close to the entrance, because it usually turns into an uncomfortable situation.”

“Also, doors that don’t extend all the way to the floor make me feel self-conscious, since people can see that I’m sitting on the toilet instead of having my back turned, as a cis man usually would…”

Non-Negative/Adaptive Experiences

This category includes situations where there is no intense distress or direct prejudice, but rather strategic choices, preferences, or adaptive behaviors.

Successful Protective Strategies

Some participants reported adopting strategies to avoid embarrassment, such as choosing specific locations, using the restroom during quiet times, or going to the restroom with someone else.

“I only use it when I’m familiar with the place and know when it’s empty.”

“I’ve had to walk quite a distance with a full bladder to get to a restroom where I felt more comfortable.”

Preference for the Home Environment as a Safe Space

The home environment is seen as the most comfortable and safe, and is chosen as the ideal place to urinate.

“Now that I’m an adult, I can go many hours without using the restroom; even if I’ve had something to drink, I hold it until I get home.”

“I hate restrooms that aren’t in my own home or at a friend’s house. I don’t use public restrooms because of transphobia.”

Situations that Bring Greater Peace of Mind (Empty or Genderless Restrooms)

The presence of empty or genderless restrooms allowed for more peaceful and embarrassment-free experiences.

“What puts me most at ease is going somewhere (there are very few such places) where it says: accessible restroom/unisex/gender-neutral; I feel much more included…”

“Fortunately, in my work routine, the restroom is private, so I don’t run into many problems in that regard on a day-to-day basis.

DISCUSSION

The sample for this study consisted predominantly of white people with a high level of education and socioeconomic status. This profile does not accurately reflect the profile of Brazil’s trans population. National studies indicate that social exclusion and limited opportunities for labor market integration are common among transgender people(¹⁷). This discrepancy is explained by the difficulty in reaching marginalized populations using the data collection method adopted and raises concerns that the prevalence of inappropriate restroom behaviors and LUTD among the transgender population may be higher than the already alarming figures presented in this study.

As published in an editorial in The Lancet, being able to affirm one’s gender identity is directly related to human rights and dignity(¹⁸). In this sense, access to public restrooms is an intrinsic part of this affirmation. Even so, approximately 20% of transgender people are denied access to these spaces, largely because they do not conform to social expectations regarding gender stereotypes(¹⁹). Nevertheless, even when they are allowed to use them, they are exposed to sexual harassment, violence, and transphobia(¹²). This study was no exception, as nearly all participants who answered this question (N = 93) reported having felt embarrassment or insecurity in public restrooms, and nearly half reported having been victims of transphobia.

Fear and insecurity influence the decision to use a public, gender-binary restroom(²⁰). Based on negative experiences, people alter their restroom behaviors in order to avoid using these spaces(¹²,²¹). According to the U.S. National Center for Transgender Equality, approximately 32% of transgender people monitor their food and beverage intake to avoid the need to use public restrooms, while 8% report having experienced health consequences from these habits, particularly urinary tract infections (UTIs)(¹²). In the present study, the adoption of behaviors that increase the risk of UTIs—such as delaying or rushing to urinate and straining to urinate—was also observed with high prevalence, as were their consequences, including overactive bladder, incomplete bladder emptying, and urinary incontinence.

The impact of bathroom habits on LUTD is significant not only among the transgender population but is also an essential factor in the treatment and prevention of these conditions(²²). In this study, trans women and transvestites had a higher prevalence of incomplete bladder emptying (70.27%) and UI (62.16%) than trans men; however, both groups showed alarming figures. UI was also observed in a 2019 study, which found that 36.6% of transgender people experience urine leakage, and 27% even exhibit post-void UI(²³).

In the present study, the coexistence of LUTD conditions that could be considered exclusionary—such as incomplete bladder emptying and UI—was also observed; this finding can be explained by pathophysiological mechanisms related to pelvic floor muscle hypertonicity. This pattern was also identified in a qualitative study of transgender women, in which participants reported urinary leakage concurrent with a persistent sensation of residual urine, leading to repeated straining during urination(²⁴).

As a result of this study, it was also evident that marital status was a factor influencing the decision to anticipate the urge to urinate among transgender individuals. Noting that married individuals anticipate the urge to urinate less often than single individuals, one might infer that being in a stable relationship means being accompanied in public settings, which serves as a protective factor. Consistent with this, an article sought to understand the strategies of transgender individuals using restrooms, and among the actions employed was “being accompanied by a friend or ally”(²⁵). According to the participants, companions can assess the environment, its safety, and accessibility, and provide support during any undesirable situation—a finding that also aligns with the greater sense of insecurity reported among single people in this study.

When analyzing preferred postures adopted while urinating, it was reported that trans men choose not to sit on the toilet seat. This may be related to Brazilian culture itself, which teaches children assigned female at birth from childhood that toilet seats are unhygienic and sources of disease. However, it is known that sitting to urinate is essential for the pelvic floor muscles to relax and prevent residual urine, which poses a risk for UTIs(²⁶). In contrast, trans women and transvestites preferred to urinate while sitting on the toilet, even though they were anatomically capable of urinating while standing in most cases. This behavior is physiologically appropriate and may be related to the fact that males are not constantly bombarded during childhood with warnings about the “risks of sitting in public restrooms” or, to some extent, may be related to a form of gender reaffirmation.

Finally, it should be noted that, in addition to all the structural and social barriers that transgender people face when using public restrooms, there is also a lack of access to health information and education among this population(²⁷), which hinders prevention, diagnosis, and treatment related to pelvic health, including urinary issues. Health services must therefore be prepared and adapted to meet this demand, as the current situation reflects a serious restriction on access to health care that runs counter to the Organic Health Law(²⁸) and the Accessibility Law(²⁹).

Brazilian evidence shows that primary care nurses frequently care for people with LUTD and recognize this care as part of their scope of practice. In a mixed-methods study involving 145 nurses in the quantitative phase and 20 in the qualitative phase, 93.1% reported having already cared for people with LUTD, and the qualitative findings reinforce the professionals’ interest and motivation to act in a more structured manner in prevention and conservative treatment, especially when training and support are available to enhance clinical practice(⁷). In this regard, the COFEN/CORENs System provides ethical and legal support for nurses’ role in the prevention and conservative management of these disorders, including pelvic floor muscle training, electrostimulation, biofeedback, and bladder training(⁶), as well as for the prescription and insertion of urogynecological pessaries by duly qualified nurses(¹⁰). Thus, national data indicate that there is a solid basis for expanding the role of nursing in continence care within primary health care.

In addition to its feasibility in the primary health care context, recent evidence from international studies demonstrates measurable clinical benefits when urinary health care is structured and led by nurses, especially with a focus on self-management and longitudinal follow-up. In a randomized clinical trial published in the International Journal of Nursing Studies, a hybrid self-management program led by nurses for people with UI showed significant improvement in self-efficacy (p < 0.001), knowledge (p < 0.001), attitude (p < 0.001), and quality of life (p < 0.001), as well as a reduction in the severity of UI as measured by the ICIQ-SF (p < 0.001). Additionally, a systematic review of organizational models of nursing care for lower urinary tract disorders identified approaches such as nurse-led continence care, continuous care, and transitional care, which were associated with improved bladder management and outcomes related to quality of life and care organization. Taken together, this evidence supports the notion that nursing practice in urinary and pelvic health, when supported by structured models, training, and follow-up, can produce sustained and measurable benefits, which is particularly relevant for populations exposed to environmental and social barriers that affect health-seeking behavior and influence the prevalence of lower urinary tract symptoms —as observed in the present study.

Among the limitations, the difficulty in accessing the diversity of the trans population stands out, since the convenience-based online data collection favored participants with higher levels of education and digital access, compounded by the absence of trans individuals on the research team. The lack of validated instruments for this population required the use of questionnaires developed for cisgender populations, which may not fully address their specific needs. In the mixed-methods design, the qualitative component was based on open-ended questions in the online form itself, which limits the depth of the narratives compared to individual interviews. Finally, a flaw in the form’s navigation logic omitted the section on experiences in public restrooms for some of the initial respondents; after correction, the variables of embarrassment, insecurity, transphobia, and avoidance were analyzed using the available data (N = 93; 71.0% of the sample).

This study makes a unique contribution by highlighting the association between experiences of transphobia in public restrooms, bathroom-related behaviors, and LUTD in transgender people in Brazil—a topic that remains largely unexplored in the literature. The research increases scientific visibility regarding the urinary health of the transgender population and reinforces the urgency of public policies that guarantee equitable, safe, and inclusive access to restrooms, in addition to supporting professional practices that are more sensitive to the specific needs of this group. The integration of quantitative and qualitative components allowed us to go beyond simply estimating prevalence rates: participants’ narratives contextualized and deepened the statistical findings, revealing the subjective mechanisms—fear, dysphoria, and adaptive strategies—that underlie the risky bathroom behaviors identified in the quantitative data. This interpretive insight reinforces the relevance of a mixed-methods approach for investigating phenomena in which lived experience and clinical outcomes are inseparable.

CONCLUSION

The adoption of inappropriate bathroom behaviors is highly prevalent among transgender people and is directly related to negative experiences when using public restrooms. Situations involving insecurity, embarrassment, and transphobia lead many to avoid or delay urination, leading them to develop compensatory strategies that compromise their health. These behaviors are associated with an increase in LUTD.

DATA AVAILABILITY

The entire dataset supporting the results of this study was published in the article itself.

Financial support

To conduct this research, the authors received two undergraduate research grants, one through the Universidade de São Paulo’s Unified Scholarship Program (PUB-USP) and the other through the Institutional Undergraduate Research Scholarship Program of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

REFERENCES

• ^1. O’Connell KA, Newman DK, Palmer MH. When did they start? Age of onset of toileting behaviors and urinary cues as reported by older women. Womens Health Rep (New Rochelle). 2023;4(1):387–99. doi: https://doi.org/10.1089/whr.2023.0022. PubMed PMID: 37529759.
  » https://doi.org/10.1089/whr.2023.0022
• ^2. Frost DM, Meyer IH. Minority stress theory: application, critique, and continued relevance. Curr Opin Psychol. 2023;51:101579. doi: https://doi.org/10.1016/j.copsyc.2023.101579. PubMed PMID: 37270877.
  » https://doi.org/10.1016/j.copsyc.2023.101579
• ^3. Assis GM, Coelho MMF, Rosa TS, Oliveira FF, Silva CPC, Brito MLP, et al. Proposta de protocolo clínico para tratamento conservador da incontinência urinária de urgência. ESTIMA, Braz J Enterostomal Ther. 2023;21:e0123. doi: https://doi.org/10.30886/estima.v21.1295_PT.
  » https://doi.org/10.30886/estima.v21.1295_PT
• ^4. Newman DK, Burgio KL, Cain C, Hebert-Beirne J, Kane Low L, Palmer MH, et al. Toileting behaviors and lower urinary tract symptoms: A cross-sectional study of diverse women in the United States. Int J Nurs Stud Adv. 2021;3:100052. doi: https://doi.org/10.1016/j.ijnsa.2021.100052. PubMed PMID: 35498154.
  » https://doi.org/10.1016/j.ijnsa.2021.100052
• ^5. Lerner JE. Having to “hold it”: factors that influence the avoidance of using public bathrooms among transgender people. Health Soc Work. 2021;46(4):260–7. doi: https://doi.org/10.1093/hsw/hlab027. PubMed PMID: 34595532.
  » https://doi.org/10.1093/hsw/hlab027
• ^6. Brasil. Conselho Federal de Enfermagem. Parecer de Câmara Técnica no 04/2016/CTAS/COFEN. Brasília: COFEN; 2016. [cited 2025 Jan 5]. Available from: https://www.cofen.gov.br/parecer-no-042016ctascofen/
  » https://www.cofen.gov.br/parecer-no-042016ctascofen/
• ^7. Assis GM, Rodrigues S, Oliveira FF, Silva CPC, Arruda DF, Nunes ACS, et al. Atuação do enfermeiro da Atenção Primária à Saúde no tratamento da Disfunção do Trato Urinário Inferior. Rev Esc Enferm USP. 2024;58:4. doi: https://doi.org/10.1590/1980-220x-reeusp-2023-0146pt.
  » https://doi.org/10.1590/1980-220x-reeusp-2023-0146pt
• ^8. Yan F, Xiao L, Huang C, Tang S, Li L. Effectiveness of a nurse-led hybrid self-management program for community-dwelling older people with urinary incontinence: a randomized controlled trial. Int J Nurs Stud. 2025;170:105157. doi: https://doi.org/10.1016/j.ijnurstu.2025.105157. PubMed PMID: 40639206.
  » https://doi.org/10.1016/j.ijnurstu.2025.105157
• ^9. Bannò B, Bella VD, Fiorini J, Iacovelli V, Carilli M, Bove P, et al. Nursing care organisational model for patients with bladder diseases: a systematic review. Int J Urol Nurs. 2025;19(2):e70019. doi: https://doi.org/10.1111/ijun.70019.
  » https://doi.org/10.1111/ijun.70019
• ^10. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344–9. doi: https://doi.org/10.1016/j.jclinepi.2007.11.008. PubMed PMID: 18313558.
  » https://doi.org/10.1016/j.jclinepi.2007.11.008
• ^11. O’Cathain A, Murphy E, Nicholl J. The quality of mixed methods studies in health services research. J Health Serv Res Policy. 2008;13(2):92–8. doi: https://doi.org/10.1258/jhsrp.2007.007074. PubMed PMID: 18416914.
  » https://doi.org/10.1258/jhsrp.2007.007074
• ^12. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The report of the 2015 U.S. transgender survey. Washington: National Center for Transgender Equality; 2016 [citado em 2025 jan 5]. Disponível em: https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
  » https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
• ^13. Tamanini JT, Dambros M, D’Ancona CA, Palma PC, Rodrigues Netto Jr N. Validação para o português do “International Consultation on Incontinence Questionnaire – Female Lower Urinary Tract Symptoms” (ICIQ-FLUTS). Rev Saude Publica. 2004;38(3):396–401. doi: https://doi.org/10.1590/S0034-89102004000300015. PubMed PMID: 15243675.
  » https://doi.org/10.1590/S0034-89102004000300015
• ^14. Ferreira RS, D’Ancona CAL, Nunes RLV, Tamanini JTN, Faisano LV, Silva CAM, et al. Translation and validation into Brazilian Portuguese of the English version of the International Consultation on Incontinence Modular Questionnaire for Male Lower Urinary Tract Symptoms (ICIQ-MLUTS). Neurourol Urodyn. 2024;43(1):63–8. doi: https://doi.org/10.1002/nau.25299. PubMed PMID: 37876359.
  » https://doi.org/10.1002/nau.25299
• ^15. Wang K, Palmer MH. Development and validation of an instrument to assess women’s toileting behavior related to urinary elimination: preliminary results. Nurs Res. 2011;60(3):158–64. doi: https://doi.org/10.1097/NNR.0b013e3182159cc7. PubMed PMID: 21522032.
  » https://doi.org/10.1097/NNR.0b013e3182159cc7
• ^16. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.
• ^17. Souza ES, Tanaka LH. Healthcare: action research with trans people living on the streets. Rev Bras Enferm. 2021;75(Suppl 2):e20210016. PubMed PMID: 34787278.
• ^18. National Center for Transgender Equality Report. Center for American Progress, Stonewall Report, Australian College of Physicians letter, UN expert statement. Transgender health, identity, and dignity. Lancet Public Health. 2020;5(4):e177. PubMed PMID: 32243848.
• ^19. Herman J. Gendered restrooms and minority stress: the public regulation of gender and its impact on transgender people’s lives. 2013 [cited 2025 Jan 5]. p. 65–80. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Restrooms-Minority-Stress-Jun-2013.pdf
  » https://williamsinstitute.law.ucla.edu/wp-content/uploads/Restrooms-Minority-Stress-Jun-2013.pdf
• ^20. Bender-Baird K. Peeing under surveillance: bathrooms, gender policing, and hate violence. Gend Place Cult. 2015;23(7):983–8. doi: https://doi.org/10.1080/0966369X.2015.1073699.
  » https://doi.org/10.1080/0966369X.2015.1073699
• ^21. Occupational Safety and Health Administration. A guide to restroom access for transgender workers. Occupational Safety and Health Administration; 2015 [cited 2025 Jan 5]. Available from: https://www.govinfo.gov/content/pkg/GOVPUB-L35-PURL-gpo73159/pdf/GOVPUB-L35-PURL-gpo73159.pdf
  » https://www.govinfo.gov/content/pkg/GOVPUB-L35-PURL-gpo73159/pdf/GOVPUB-L35-PURL-gpo73159.pdf
• ^22. O’Connell KA, Nicholas TB, Palmer MH. Toileting behaviors, urinary cues, overactive bladder, and urinary incontinence in older women. Int Urogynecol J. 2023;34(3):707–16. doi: https://doi.org/10.1007/s00192-022-05228-z. PubMed PMID: 35588320.
  » https://doi.org/10.1007/s00192-022-05228-z
• ^23. Hardacker CT, Baccellieri A, Mueller ER, Brubaker L, Hutchins G, Zhang JLY, et al. Bladder health experiences, perceptions and knowledge of sexual and gender minorities. Int J Environ Res Public Health. 2019;16(17):3170. doi: https://doi.org/10.3390/ijerph16173170. PubMed PMID: 31480302.
  » https://doi.org/10.3390/ijerph16173170
• ^24. Chung PH, Swaminathan V, Spigner ST, Leong JY, Bulafka J, Frasso R. Genitourinary and sexual symptoms and treatments in transfeminine individuals: a qualitative exploration of patients’ needs. Sex Med. 2022;10(5):100566. doi: https://doi.org/10.1016/j.esxm.2022.100566. PubMed PMID: 36063656.
  » https://doi.org/10.1016/j.esxm.2022.100566
• ^25. Greey AD. “It’s just safer when i don’t go there”: trans people’s locker room membership and participation in physical activity. J Homosex. 2023;70(8):1609–31. PubMed PMID: 35179445.
• ^26. Assis GM, Goulart ML, Nunes ACS, Oliveira FF. Prevenindo e tratando a incontinência urinária feminina. Taubaté: Casa Cultura, 2020 [cited 2025 Jan 5]. Available from: https://sobest.com.br/wp-content/uploads/2020/11/Cartilha-Sobest-Incontinencia.pdf
  » https://sobest.com.br/wp-content/uploads/2020/11/Cartilha-Sobest-Incontinencia.pdf
• ^27. Cicero EC, Reisner SL, Silva SG, Merwin EI, Humphreys JC. Health care experiences of transgender adults. ANS Adv Nurs Sci. 2019;42(2):123–38. doi: https://doi.org/10.1097/ANS.0000000000000256. PubMed PMID: 30839332.
  » https://doi.org/10.1097/ANS.0000000000000256
• ^28. Brasil. Lei n° 8.080, de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União; Brasília; 1990 [cited 2025 Jan 5]. Available from: https://www.planalto.gov.br/ccivil_03/LEIS/L8080.htm
  » https://www.planalto.gov.br/ccivil_03/LEIS/L8080.htm
• ^29. Brasil. Lei n° 10.098, de 19 de Dezembro de 2000. Estabelece normas gerais e critérios básicos para a promoção da acessibilidade das pessoas portadoras de deficiência ou com mobilidade reduzida, e dá outras providências. Diário Oficial da União; Brasília; 2000 [cited 2025 Jan 5]. Available from: https://www.planalto.gov.br/ccivil_03/LEIS/L10098.htm
  » https://www.planalto.gov.br/ccivil_03/LEIS/L10098.htm

Correspondence

Corresponding author: Brunna Ciarcia dos Santos Arnandes Av. Dr. Enéas Carvalho de Aguiar, 419 – Cerqueira César 05403-000 – São Paulo, SP, Brazil. [e-mail]

ASSOCIATE EDITOR

Vanessa de Brito Poveda

Publication Dates

• Publication in this collection
  02 Nov 2026
• Date of issue
  2026

History

• Received
  23 Mar 2026
• Accepted
  24 July 2026