School toilets can be fearful places. They're out of sight of teachers and can be colonised by bullies and smokers. More than half the pupils in some schools avoid using them, and toilets top many students' lists of areas for improvements in schools. They don't want much - just the basics of toilet paper, soap and hand-drying equipment, and the privacy of lockable cubicles. School toilets are easy targets for vandalism and graffiti. And because they are often unclean and unpleasant, they go unused. All of which can have serious consequences for children's health.
In January, school toilets made the headlines when researchers in Newcastle upon Tyne reported that 62 per cent of primary age boys and 35 per cent of girls avoided using them. A parallel study in Sweden found pupils there just as reluctant to go, with 28 per cent never using the toilet to defecate. The majority (around 80 per cent) of both sets of children said toilets were unpleasant, dirty, smelly and frightening, and places where bullying proliferated. The story generated a massive response. The BBC's Newsround website was inundated with messages from dozens of pupils, most of them decrying the state of "the bogs". Jessica, 13, from Leicester, said: "The school says we may be able to redecorate them, but only if we raise the money ourselves and they approve the design." Emma, 13, from Middlesbrough, said: "Me and my friends end up taking tissues to school.
The toilets are a total health risk."
The study also showed that the incidence of urinary tract infections - a common problem in young children, affecting around one in 12 girls and one in 60 boys before the age of seven - rises among children who avoid using the toilet. Cases of constipation also increase.
Among the almost 400 children in Newcastle and 167 in Sweden who were interviewed, it wasn't just poor hygiene but lack of privacy that mattered.
One child said: "People push the door, and anybody can listen." One in three of the children's suggestions for improvements involved increased privacy. The report's co-author Sue Vernon - a senior children's nurse at Royal Victoria Infirmary in Newcastle and an honorary senior research associate at the city's university - says she became aware of the problem when parents told her their children often came out of school "having wet their pants or bursting to use the loo".
What can be done?
Sue Vernon says school toilets should be cleaned regularly, provide adequate privacy and have paper towels and soap available. Not too much to ask, she says. But schools are not bound even to do this. The health and safety regulations that stipulate just such conditions for teachers'
toilets do not apply to the children's loos down the corridor. As one headteacher told Sue Vernon, faced with the choice of spending money on toilets or buying new books, governors will always vote for books.
Her research is not the first to highlight the sorry state of the nation's school toilets. A 1999 study of 87 children from 65 primary schools in south Wales found that 40 per cent would never open their bowels using the toilets in school, and just under one in three would use them only as a last resort, preferring to wait until home-time. By contrast, 70 per cent would pee when they had to; only 4 per cent never would.
This inevitably leads to problems with childhood constipation, which affected one in four children with gastroenterology problems seen by Dr Peter Barnes and Dr Alison Maddock, the paediatricians who conducted the survey.
Again, children's comments are depressingly familiar: "I can only get toilet roll from the teacher when I want to go for a poo"; "I'm not allowed to go in lesson time - only break times"; " There's wee all over the floor"; "The locks have been kicked off the doors"; "They stink and are dirty". "This is an important public health issue that does not seem to have been addressed," the authors conclude.
Matters have improved since a 1944 Women's Institute survey found that one village school in two had an earth or bucket lavatory. But poor sanitation in some schools means that toilets are a breeding ground for germs.
In the early 1990s, Dr Martin Schweiger of the NHS health protection unit in Leeds noticed an increase in the incidence of hepatitis A, diarrhoea and dysentery. So he carried out a study in which 560 children at 20 primary schools in the city were given a simple test to find out how much they knew about hygiene. They were asked what a cartoon character should do in certain situations - for example, after finishing gardening but before eating lunch. This gave each child a "handwashing knowledge score". Swabs were then taken from the children's hands and surfaces in the schools'
toilet areas and classrooms.
The study concluded that the children with most faecal bacteria on their hands were those with poor hygiene knowledge and those from deprived areas.
And, perhaps surprisingly, classroom carpets were found to have higher levels of faecal contamination than toilet areas.
The schools involved acted on Dr Schweiger's recommendations to improve awareness of hygiene and cleaning. But he says many school still ignore basic hygiene procedures. "Children who want a drink are still being told to cup their hands under a tap in the toilets. In 2003, that is simply inexcusable."
As well as being dirty, many toilets are home to smokers and bullies.
"There's a kind of club culture associated with toilets. Children should be able to use them without fear or risk," says Dr Schweiger. This was illustrated to chilling effect in a recent television documentary about a school reunion when a former pupil went to the toilets to be confronted by her tormentors of 15 years earlier.
Children's fear of using toilets can have other health implications. Many get dehydrated at school because they know drinking water will mean they have to go to the toilet, says Nicky Brander, of ERIC, the charity for children with incontinence problems, who also organises the "Water is cool in school" campaign. "They are inextricably linked," she says. "Even if kids have the facilities and access to drinks, many of them deliberately restrict their fluid intake because they don't want to go to the school toilets. Some kids even avoid drinking throughout the school day."
What are the long-term health consequences?
Dr Trevor Brocklebank, a recently retired consultant paediatrician who specialised in renal problems, found that about half the girls who came to him didn't use the toilet at school. "Walking around with a full bladder, they leak a little bit, and sitting in soggy pants makes them prone to infection. Because the toilet seats are in such a bad state - or not there at all - they don't sit down. That means they don't empty their bladder completely, which has been shown to be a major cause of urinary tract infections in women."
Failing to drink water means these bacteria don't get washed away, he says.
"It's a vicious circle. They don't want to drink because they don't want to use the toilets, and if they don't drink, the flow of urine is reduced and any infection can enter the bladder." Urinary tract infections are difficult to detect in young children, but can lead to chronic kidney damage, hypertension, premature birth and even miscarriage in adulthood.
What about the psychological effects?
Avoiding going to the toilet, being embarrassed about it or being bullied may sow the seeds for phobias later in life, specifically the little talked-about but common phobia of paruresis. Also known as pee shy, shy bladder or bashful bladder, paruresis is an inability to go to the toilet when other people are nearby - in severe cases, even in your own home.
Psychologist Alex Gardner says almost everyone has experienced mild paruresis. "Most people have urinary hesitancy at some time in their lives.
And for most people it is not a problem. It is a form of social phobia, but it is a secret phobia because no one will talk about it. It may be connected to toilet training. It may also be that, at school, dirty toilets and bullying in toilets - shoving heads down the pan - could well lay the foundations for the development of a phobia later in life. We don't know this, we can only speculate from individual stories." Anecdotal evidence seems strong but the results of research among sufferers - which might establish a link - is due in April.
Isn't there a law saying toilets should be clean and in working order?
Not exactly. Adult public toilets (and teachers' toilets in schools) must, by law, be kept clean and have handwashing and drying facilities and conform to health and safety standards. Children's toilets in schools, on the other hand, can be in any condition as long as there are enough of them. The Education (Schools Premises) regulations 1999 stipulate only the number of toilets per pupil - one for every 10 children under the age of five or at a special school, and one for every 20 children over the age of five. There should also be two wash basins for every three "sanitary fittings" - toilets or urinals.
In the United States, one child is taking legal action over the lack of free access to the school's toilet facilities. Sophia Gutierrez, 14, is suing her teacher and school in Miami, Florida, after she messed her pants when her maths teacher wouldn't let her go to the toilet. He allegedly told her: "If you can't hold it in you should be wearing Pampers."
Is anybody doing anything about it?
The subject has long been a bugbear of students, says Gideon Lyons from School Councils UK, the umbrella group that encourages children to contribute their views to the running of schools. "One of the perennial issues that comes up is toilets. But councils are rarely able to do anything effective about them. It is more than an issue of cleanliness and hygiene - it imposes on the whole school ethos and educational attainment."
His organisation's survey of 120 secondary pupils identified the following common complaints about toilets:
* Too little toilet paper.
* Lack of cleanliness.
* Locks on doors not working.
* Toilets blockedoverflowing.
* No hot water.
* No towels or dryers.
* No lightingventilation.
"There is a real gap in legislation, and school toilets aren't protected in the same way that adult toilets or even public toilets are," says Gideon Lyons. "It is a human rights issue. Access to sanitation and clean water is something we talk about in relation to the developing world, but there are pupils here refusing to go anywhere near their school toilets all day."
Now Schools Councils UK has teamed up with ERIC and school nurse representatives to lobby for improvements to school toilets, under the banner of the Bog Standard campaign, which will be launched this month. A major survey is being piloted in north Suffolk and Leeds before going nationwide, and the results will be used to put pressure on the Government for more money.
The last major expenditure on school toilets was pound;35 million shared out among schools that were still reliant on outside toilets in 2002. The then education secretary David Blunkett said: "We will bring to an end the scandal whereby children in 600 of our schools, most of them primary, still have to go outside to use the toilets."
The Department for Education and Skills said this month that targets had been achieved and any outside toilets that remained were in addition to indoor facilities.
The issue has already attracted the attention of the children's commissioner for Wales, Peter Clarke. "It was one of the most common complaints young people were telling him when he was meeting them," says his spokeswoman. An investigation of facilities in every local authority in Wales has been carried out, and when the data has been analysed the commissioner is expected to make recommendations to the Welsh Assembly later this year. "The findings weren't all bad. They underline that it is possible with the existing regulatory framework for schools to make sure their toilets are of a very high standard."
Can clean, safe toilets really make a difference?
Some schools are already taking the issue seriously. At Monkwearmouth school in Sunderland, head Alex Machin has started a long-term project to improve the toilets. The school's eight toilet blocks are being replumbed, retiled, repainted and fitted with wooden seats, spotlighting and deodorisers. The school also employs a full-time cleaner whose job it is to make sure the toilets are kept tidy and stocked with toilet paper and soap.
"It's an expensive business - it costs pound;12,000 to completely refurbish a toilet. It's not a cheap option and not something you could do in a large secondary school in one go. But we are committed to it. So far we have only done one but we are about to start another two," says Mr Machin.
South Farnham junior school in Surrey has spent more than pound;100,000 on a new cloakroom block and renovated the other 60-year-old toilets.
Headteacher Andrew Carter says the school's approach has been to try to treat the children with dignity and respect. "If you tell children you care about them, then give them a dirty cloakroom or lavatory, you are giving them mixed messages," he says.
DID YOU KNOW?
* Sixty-two per cent of boys and 35 per cent of girls avoid using school toilets
* Legally, toilets can be in any condition as long as there are enough of them - one for every 10 children under the age of five or at a special school, and one for every 20 children over the age of five
* Although difficult to detect in children, urinary tract infections affect one in 12 girls and one in 60 boys. These can lead to chronic kidney damage, hypertension, premature birth and even miscarriage in adult life
* Health and safety regulations that stipulate washing and drying facilities for teachers' toilets do not apply to children's toilets
* It can cost around pound;12,000 to refurbish a toilet
* Newcastle research (www.ncl.ac.ukpress.
* World toilet organisation (http:www.worldtoilet.orghpwto_hp.htm).
* School buildings regulations (www.teachernet.gov.uk_doc2898SPRs.pdf).
* School nurses (www.msfcphva.org).
* Children's commissioner for Wales (http:www.childcom.org.uk).
* ERIC - incontinence support group (www.eric.org.uk).
* Paruresis support group (www.shybladder.org.uk).
* School councils UK (www.schoolcouncils.org).
* CBBCNewsround (http:news.bbc.co.ukcbbcnews READING MATERIAL
* South Wales research: Journal of Public Health Medicine, June 2002, Vol 24 (2): 85-88.
* Keep it Clean and Healthy, a free booklet produced by three healthcare trusts for pre-school childcare professionals, includes a section on toilet hygiene. Send a large A4 sae (84p) to Pat Cole, Infection Control Nurses Association, Hartford Cottage, 1 Longstaff Way, Hertford, Huntingdon, Cambridgeshire PE29 1XY