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Pam Richardson never thought much about public bathrooms until she started driving for a rideshare company in Seattle. Now, they’re always on her mind.

“Places where you would expect to be able to use the bathroom, they’re locked, or for employees only, or you have to be a customer,” she says. “In downtown Seattle, I can’t think of any place where there’s not a code or a key.”

Richardson recently contracted a urinary tract infection, and a urologist diagnosed her with an overactive bladder, both conditions exacerbated by holding for too long. Her take-home pay has taken a hit because she’s forced to spend money at fast food restaurants in order to use the facilities, and on more than one occasion an accident has forced her to return home for clean clothes.

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“I would be so grateful just to have a port-a-potty,” she says.

Lyft and Uber drivers are not the only ones who may find themselves in trouble when they feel the urge. A dearth of public restrooms also harms children, pregnant women, the elderly, people with digestive ailments, and especially homeless people, who in addition to suffering the indignity of having no proper toilets are also blamed for leaving feces on city sidewalks.

The United Nations recognizes sanitation as a human rights issue, which is why it observes World Toilet Day on November 19, and why international organizations prioritize providing poor communities around the world with toilets and latrines. Globally, as many as 4.5 billion people still don’t have sanitary toilets in their homes, a shortfall linked to disease and even rape in places where women are forced to venture outdoors at night. On the surface, the United States seems to have the toilet problem solved. But while indoor plumbing may be ubiquitous here, that doesn’t mean everyone gets to use it when they need to. And while we may be loath to discuss what goes on behind stall doors, lack of bathroom access is about health, equity, and human decency, and it can affect anyone who ever finds themselves out and about with no place to go.

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In the West, the availability of public bathrooms has long been linked to notions about whom public spaces are intended for. Women faced a shortage from the early days of indoor plumbing until second-wave feminists began fighting for so-called “potty parity” laws in the 1970s and 1980s. (That struggle has continued into this decade; it was only in 2011 that congresswomen got their own bathroom just off the floor of the House of Representatives.) During the Jim Crow era, facilities were segregated by race. Before the 1990 Americans with Disabilities Act, disabled people often found public restrooms inaccessible. More recently, transgender people have fought for their right to use bathrooms consistent with their gender identity.

Meanwhile, there are fewer and fewer truly public bathrooms available — the New York City subway, for example, had more than 1,600 “comfort stations” during the early 1900s; a century later, only a few dozen remain open, thanks to fears that they will be used by terrorists, drug addicts, and homeless people.

“It’s all part of a larger effort to make public places unlivable for people who have no other place to live,” says Tristia Bauman, senior attorney with the National Law Center on Homelessness & Poverty. “There is no way to end the biological need to urinate and defecate, so we need to be able to provide safe places for people to do that.”

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For homeless people, lack of bathroom access criminalizes necessary bodily functions, especially in jurisdictions where public urination can land a person on the sex offender registry. G.W. Rolle, a Florida pastor and advocate for the homeless who spent several years living on the street, remembers being followed by police in the early morning as he looked for a safe place to empty his bladder. “It’s criminal that bathrooms aren’t provided,” Rolle says. “Being stopped from going to the bathroom, that’s a violation of your human rights.”

A quarter buys access to a public bathroom on Congress Street near City Hall.
A quarter buys access to a public bathroom on Congress Street near City Hall. Lane Turner

The problem might be obvious, but solutions have so far proven elusive. The default approach has long been to rely on businesses, especially restaurants and cafes, which if they’re large enough are usually mandated by law to provide restrooms for customers. But business owners — and the employees responsible for scrubbing toilets — don’t necessarily agree, and in urban areas many keep bathrooms locked, accessible only to customers who request a key or code. An answer may lie with a German program called “Nette Toilette” (“Nice Toilet”), under which cities subsidize businesses that open their bathrooms to the public at large, compensating them for the extra cleaning and supplies. Here in the United States, on the other hand, a new mobile app called Good2Go lets businesses manage restroom access even more tightly. Users who pay for a pass get a QR code they scan to enter — a business model that effectively keeps out not only those without change to spare, but anyone who doesn’t have a smartphone.

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Recognizing that toilets can’t be the sole responsibility of the private sector, some cities have installed standalone stalls on sidewalks, but these are notoriously expensive and hard to maintain. Boston’s “self-cleaning” City Toilets, for example, cost $250,000 to install (and 25 cents to use) but are reportedly often out of order. The “Portland Loo,” a more spartan model pioneered in that Oregon city, has caught on across the country — Cambridge now has three. Depressingly, however, the Loo seems to work well mainly because its drafty, unpleasant interior discourages users from staying long enough to cause trouble.

Meanwhile, some citizens are taking things into their own hands. The editors of Facility, a New York-based literary magazine that explores the culture, history, and politics of the lavatory, host a list of crowd-sourced numerical codes for locked bathrooms at cafes and convenience stores, a sort of guerilla campaign justified by the idea that keepers of toilets have a moral obligation to make them accessible to those who can’t afford to pay for the privilege. The online directory Refuge Restrooms maps thousands of bathrooms around the country, with a focus on those that accommodate trans or gender-nonconforming people. And alongside this crowdsourced activism are more traditional advocacy groups, including PHLUSH (“Public Hygiene Lets Us Stay Human”), which publishes a toolkit for people seeking to improve restroom access in their communities, and the Crohn’s & Colitis Foundation, which backs model state legislation called Ally’s Law that requires retail establishments to let anyone with a relevant medical condition use employee bathrooms if they need to.

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“There’s a stigma that prevents this needed conversation from happening, but the more you talk about it, the more it becomes a common sense, human decency issue,” says Ally Bain, a Crohn’s patient who came up with the idea as a high school freshman, after she was denied access to an employee restroom at a Chicago-area Old Navy and had an embarrassing accident. Since Illinois passed Ally’s Law in 2005, at least 15 states have followed suit, including Massachusetts. “I think it would be great to turn it into a broader bathroom equity issue,” Bain says. “No matter your housing or employment status, no one should be denied access.”

Ally’s Law has faced some opposition from retail and restaurant groups, and employees are not always aware of it, as Crohn’s patient Stephen Marcus found out earlier this year, when he was denied the use of an employee restroom at a Starbucks near Boston Common and didn’t find another toilet in time. “It was totally humiliating and totally unnecessary,” Marcus told Globe columnist Sean P. Murphy — and if this senior citizen in a suit was refused, it stands to reason people of color, or anyone who looks poor, would have even worse luck.

Given the failures of the piecemeal approach, achieving true toilet equity might require us to radically rethink what a city owes its citizens — not just orderly streets, streetlights, and storm sewers, but a guaranteed accommodation of our most intimate needs.

“Toilets should be considered urban infrastructure — they should be taken for granted, like paved sidewalks,” says sociologist Harvey Molotch, an emeritus professor at New York University and editor of “Toilet: Public Restrooms and the Politics of Sharing.” And when human waste winds up on city streets, he argues, it’s the fault of a society that has failed to give humans anywhere else to put it.

“If we could get people to wake up and smell the [expletive] — that is the odor of injustice!” Molotch says. “Be mad about that, rather than mad at the people who produced it.”

Amy Crawford is a writer living in Michigan. Follow her on Twitter @amymcrawf.