Blog Global Health Center

Gender, education, and global health: What’s the big deal about toilets?

Written by Jessica K. Levy, PhD, MPH, associate professor of the practice at the Brown School; and April Houston, OTD, MSCI, assistant professor in the School of Medicine

Last year, the United Nations formalized their commitment to gender equality and women and girls’ empowerment by including it as one of their 17 Sustainable Development Goals (SDGs). The United Nations Development Program explained their reason for doing so as both humanitarian and utilitarian:

Ending all forms of discrimination against women and girls is not only a basic human right, but it is also crucial to accelerating sustainable development. It has been proven time and again, that empowering women and girls has a multiplier effect, and helps drive up economic growth and development across the board. [1]

Need an example of how this plays out in real life? Let’s consider education.

Researchers have determined that education, especially in early childhood and adolescence, can make a significant and positive difference on a number of factors related to an individual’s human development, health, empowerment, and socioeconomic status. It also has a profound impact at the community level. For example, providing high levels of education for both boys and girls is normally linked to lower mortality rates and overall macroeconomic growth.

A 2014 World Bank study found that education can also have a protective effect on girls, diminishing their risk for domestic and sexual violence and strengthening their independence and resilience. School settings can also be ideal for delivering gender-sensitive messages that gradually reshape social norms in favor of improving rights for women and girls, engaging boys in discrimination reduction, and in decreasing gender-based violence overall.

Despite great strides in decreasing the global gender gap in education, there are still many low-income countries in which girls do not have the same access to education as boys. There are a number of reasons behind this inequity, but here we will consider one that is often overlooked and relatively easy to rectify: toilets.

Infographic by WaterAid, We Can’t Wait Report.

Not a lot of people want to talk about it, but in much of the developing world, one of the top barriers to girls’ education is the lack of separate toilets/latrines for girls and boys. In fact, in many areas it’s the number one cause of school absenteeism, ahead of malaria and other diseases. In the United States, being able to find a safe, private bathroom is something that most of us take for granted. But only 45% of schools in the least developed and low-income countries have adequate sanitation facilities.

When a girl reaches puberty, access to a safe, private toilet can make a crucial difference in whether she continues her education. Girls need clean water to wash themselves or their menstrual cloths and a place to dispose of their menstrual pads if they are using them. If girls do not have access to these facilities at school, they will often stay at home while they’re menstruating. In fact, lack of safe, private toilets can cause girls to miss up to 20% of the school year. As one might imagine, irregular attendance can result in lower grades and may, eventually, lead to dropping out of school altogether.

Student at primary school in Freetown Sierra Leone. Photo © Dominic Chavez/World Bank

Also, gender segregated toilets that are located in convenient, safe locations at school can protect girls from violence and assault. Women and girls are often vulnerable to harassment or violence when they must use shared toilets or are forced to go to the bathroom outside. In one survey of schoolgirls in South Africa, for example, more than 30% reported having been raped at school; often these incidences occurred in school toilets that were either shared or in unsafe, isolated locations. Such violence is a major deterrent to school attendance, not to mention a girl’s self-esteem and desire to learn.

Some schools have no toilet facilities available at all, forcing students to go outside. To retain some sense of privacy (and dignity), many girls will choose to ‘hold it’ or limit their consumption of food and drink to delay the need to relieve themselves. Not only can these actions increase the chance of urinary tract infections, but it also means that girls aren’t eating and drinking as they should, which can lead to dehydration and malnourishment and subsequent dropout because they are too sick to travel or pay attention in class.

So, what’s the big deal about toilets? Although they may not be the key to accomplishing SDG5, we’ve offered a clear example of how increasing gender equality and women’s empowerment (in this case – through education) can positively impact health and development, and how a relatively simple gender-aware intervention (like installing private sanitation facilities) can play a big role in facilitating the process.

In this vein, we applaud the SDGs for their focus on gender and encourage public health researchers and practitioners to continue to follow suit. The world’s health depends on it.


(1) UNDP. (n.d.). SDG 5. Retrieved from

(2) Cohen, A. K., & Syme, S. L. (2013). Education: A missed opportunity for public health intervention. American Journal of Public Health, 103(6), 997–1001. doi: 10.2105/AJPH.2012.300993

(3) Cutler, D. M., & Lleras-Muney, A. (2006, July). Education and health: Evaluating theories and evidence. National Bureau of Economic Research. Retrieved from

(4) The World Bank. (2014). Voice and agency: Empowering women and girls for shared prosperity. Retrieved from

(5) WHO. (2005). WHO multi-country study on women’s health and domestic violence against women. Retrieved from

(6) UNICEF. (2015). Girls’ education and gender equality. Retrieved from

(7) Jansz, S. (2013). Wilbur J. Women and WASH: Water, sanitation and hygiene for women’s rights and gender equality. WaterAid Briefing. Retrieved from

(8) Prinsloo, S. (2006). Sexual Harassment and violence in South African Schools. South African Journal of Education, 26(2), 305–318.

(9) UNICEF. (2012). Raising even more clean hands: Advancing health, learning and equity through WASH in schools. Retrieved from

(10) WaterAid. (2014). We can’t wait: A report on sanitation and hygiene for women and girls. Retrieved from