Transgender students who have been fighting for access to public facilities — including restrooms — that align with their gender identity are just going to have to hold it.
That's the message LGBTQ advocates say President Donald Trump sent after his administration rescinded past guidance on transgender protections in public schools, which they fear opens trans students to physical and psychological harm.
"It makes me feel unimportant. It makes me feel angry. It makes me feel invisible," 16-year-old transgender student Grace Dolan-Sandrino told NBC Out.
"Obviously, my education and my life don't matter to [the Trump administration], because they don't believe that I should be able to just use the bathroom," she said.
In 2016, former President Barack Obama instructed public schools to allow transgender students to use restrooms and locker rooms that align with their gender identity, but the policy was blocked by a federal court shortly after it was issued last May. With the guidelines officially rescinded by the new administration, the decision is left to states and local school districts.
'Culture of Discrimination'
There were no policies to protect transgender students at the Maryland middle school where Dolan-Sandrino came out as trans in 2014. She said administrators would not allow her to use the girls' facilities.
"I definitely subconsciously started eating and drinking less so that I wouldn't have to go to the bathroom," said Dolan-Sandrino, who was in the 8th grade at the time. She said she was permitted to use the nurse's bathroom in a separate building across a court yard. But walking there took a long time, which angered her teachers, she said.
"I would ask to go to the bathroom, and I would be denied in front of the entire class, whereas a cis[gender] girl or a cis[gender] boy would ask to go to the bathroom and they would get the pass," she said.
Dolan-Sandrino got accustomed to holding her bladder for hours at a time. "It was hard, and it was very uncomfortable," she said, adding that she began to perform "terribly" in her school work.
"That came from the culture of discrimination and me feeling that I didn't have a place in the classroom," she added.
Health Implications for Trans Students
The American Academy of Pediatrics was among the health organizations that released a statement opposing the White House's decision.
"Policies excluding transgender youth from facilities consistent with their gender identity have detrimental effects on their physical and mental health, safety and well-being," the statement read.
When transgender and gender-nonconforming children refrain from going to the bathroom, it puts them at an increased risk for urinary tract infections and constipation, according to Dr. Robert Garofalo, division head of adolescent medicine at Lurie Children's Hospital in Chicago. In extreme cases, it can lead to encopresis, or uncontrollable soiling, which Garofalo has seen in a few of his younger gender-nonconforming patients.
"You take some of these school-aged kids that are gender-nonconforming, and maybe at the very age that they're developing some kind of a consistency and an ability to defecate, now they're being asked to withhold their stool for extended periods of time, and it can be a real set up for this positive sort of feedback loop of constipation and then encopresis," Garofalo said.
Restricting access to bathrooms can be particularly harmful to transgender boys who are experiencing menstruation, according to Dr. Madeline Deutsch, clinical director for the Center of Excellence for Transgender Health.
"When you add on top of the gender dysphoria that can be associated with menstruation and then you think about a trans boy who is faced with having to go to either the girls' room or a teachers' bathroom that is far away, or has to walk past all the teachers who maybe are not supporting him every time he just wants to go to the bathroom, [he has to] decide is he going to take care of his menstrual needs, or sit in his blood all day because he doesn't want to go to the bathroom," Deutsch said.
The psychological problems transgender students suffer can be even more damaging, according to Dr. Eric Yarbrough, president of the Association of LGBTQ Psychiatrists.
"It's going to reinforce what we call internalized transphobia," Yarbrough said. "So [transgender youth] are going to take opinions that people have about transgender people and incorporate them into the thoughts that they have about themselves, and that's going to lead to things like depression and anxiety, and that's where we get higher rates of suicide."
According to the 2015 U.S. Transgender Survey, 40 percent of respondents reported attempting suicide in their lifetimes, nearly nine times the rate in the U.S. population.
States Rights vs. Transgender Health
Tony Perkins, president of the conservative policy and lobbying organization Family Research Council, defended the Trump administration's decision, and reiterated its position that the Obama-era guidelines took authority away from state and local jurisdictions.
"Almost half the states filed suit with the government over this policy," Perkins said. He called the Obama guidelines "a solution in search of a problem."
"Those jurisdictions where this is an issue, the local officials were able to deal with it," Perkins said. "This one-size-fits-all policy imposed by the White House that the White House is going to set shower policies for America clearly was overreach, and the American people responded."
Perkins argued that some students may feel uncomfortable sharing a bathroom or locker room with individuals who are not the same biological sex, and that non-transgender students have a right to their own privacy.
"I think it's a much better solution to have [separate public] accommodations made if you're concerned about people making fun of students, intimidating them or bullying them," he added.
But advocates argue separate accommodations make transgender students targets for discrimination.
'The Ability to Exist in Public Spaces'
When Dolan-Sandrino was transitioning in middle school, not being able to use the girls' facilities made her feel alienated, she said.
"Being a trans girl is already making me different from everybody else, and now I'm not even allowed to use the same bathroom as the girls, so people weren't seeing me as a girl," she explained.
She said using a separate bathroom called attention to the fact that she was different, and believes the Trump administration's decision to rescind the guidelines has nothing to do with states' rights.
"This is really an issue about whether trans people should have the ability to exist in public spaces," she said.
Dolan-Sandrino said teachers and classmates frequently misgendered her in middle school. When she spoke up in class, they mocked her voice. In the hallways, boys threw shoes at her and called her a f****t, she said. She developed depression and anxiety. Her grades suffered.
"I felt scared of what would happen in high school, because I wasn't being recognized as a girl, and it really affected me with my gender dysphoria," Dolan-Sandrino said.
She constantly asked herself: "What is wrong with me that they don't let me be who I am?"
The Maryland student said her mother is paying to send her to a public high school in Washington D.C., which has non-discrimination policies that protect transgender students. There, she can use the girls' facilities. She said her grades have greatly improved, and students don't bully her.
"I'm treated with acceptance, and I'm treated just like any other girl," she said. "I don't have to worry about holding my bladder anymore. I can just think about being a teenager for the most part, and I can focus on my education."
NBC Out reached out to the White House Press Office and the U.S. Department of Education for comment but did not receive an immediate response.