Note: I have drawn some of this material from tip sheets that I published previously on my blog and for La Leche League Canada.
Overview
Photo used with permission.
Transgender men and women, and non-binary and genderqueer individuals, are physiologically capable of breast or chestfeeding, even if they have had previous chest surgery or have never given birth. It is equally important to note that some trans people experience severe gender dysphoria when breast or chestfeeding, and that they may decide not to nurse their babies for mental health reasons. Trans parents choosing to breast or chestfeed and those choosing to suppress lactation and bottlefeed may require the support of breastfeeding counselors or lactation professionals.
Now infants can get
all their vitamin D
from their mothers’ milk;
no drops needed with
our sponsor's
TheraNatal Lactation Complete
by THERALOGIX. Use PRC code “KELLY” for a special discount!
This article covers:
- key terms and concepts that are important for understanding transgender identity and health
- transgender women and breastfeeding
- hormone replacement therapy
- inducing lactation
- finding health care professionals
- breastfeeding goals
- support meetings
- transgender men and chestfeeding
- language
- gender dysphoria
- testosterone use
- top surgery
- binding
- chestfeeding goals
- supporting the decision not to nurse
- support meetings
- additional resources
Key terms and concepts
Gender vs. Sex
Our reproductive organs and sexual anatomy define our physical sex – male, female, or intersex. Gender, however, is a person’s inner awareness of their femininity/masculinity.
In most cases, a person’s biological sex conforms to their gender and gender expression. The term for such people is cisgender. Transgender, transsexual, and genderfluid people have a gender identity or gender expression that does not match what their particular society expects of them according to their anatomy. Some trans people choose to use medical therapies such as hormone treatments and/or surgeries to alter their bodies. Others do not want or are unable to obtain such interventions, but may express their gender in other ways such as choices of clothing or makeup.
Gender Identity vs Sexual Orientation
A person’s gender identity has to do with how they self-identify in terms of their inner sense of gender. Their sexual orientation refers to what kind of person they are sexually attracted to. A person can be trans and gay, or trans and straight, or trans and bisexual, etc.
chestfeeding: Some masculine-identified trans people use this term to describe the act of feeding their baby from their chest, regardless of whether they have had chest surgery. Note that others prefer to say breastfeeding or nursing. The choice is individual, and health care providers should ask clients what they prefer.
FtM: female-to-male trans person
MtF: male-to-female trans person
gender binary: The assumption that there are two genders, male and female. Many trans people understand gender as a spectrum.
gender expression: a person’s outward presentation of their gender through physical traits, clothing, makeup, etc.
genderfluid/genderqueer: someone who identifies between or beyond the extremes of female and male on the gender spectrum, or who identifies as both female and male at once or as some combination of genders.
intersex: a condition in which an individual is born with reproductive and/or sexual anatomy that does not fit the usual male or female definitions.
trans: an umbrella term meant to include transgender, transsexual and genderfluid people
transgender: a person whose gender identity or expression does not match the typical societal expectations of their birth-assigned gender. Transgender people may or may not wish to modify their bodies to varying degrees by taking hormones or having surgery.
transition: a change in one’s public gender identity (one’s inner gender identity may have been the same since birth).
transsexual: a person whose gender identity does not match their sex as it was assigned at birth. Transsexual people usually wish to modify their bodies in order to alleviate this incongruence. This older term is narrower in its definition than the newer umbrella term, transgender (see above), but is still preferred by some trans individuals.
Language
Always use the pronouns that refer to an individual’s expressed gender, not their assigned birth sex. For example, a male-to-female transsexual woman is ‘she’. If you are unsure of which pronouns a particular individual may use, simply ask in a respectful manner. If you make a mistake, apologize promptly and move on. Some people use gender-neutral pronouns, such as ‘them’ and ‘they’ or ‘ze’ and ‘zir’.
The following terms are derogatory. Do not use: tranny, he-she, she-male, gender-bender.
Do not refer to someone ‘masquerading’, ‘pretending’, ‘disguising’, etc. in their gender.
Use ‘transgender’ as an adjective, not a noun or verb.
He is a transgender person, not “He is a transgender.”
A person is transgender, not transgendered. It is never necessary to add the suffix ‘ed’ to transgender.
Avoid the phrases “biologically female (or male)”, “genetically female”, and “born a woman.” Biological sex is complex and it is dependent on multiple factors including chromosomes, hormones, secondary sex characteristics, and internal and external reproductive organs. Biological sex is not purely binary, as various international sports organizations have been finding out when they pursue sex testing of athletes. It is more accurate and respectful to mention someone’s sex as it was “assigned at birth” rather than their “biological sex” or “genetic sex”. The phrasing “assigned at birth” reminds us that parents and health care providers commonly presume a baby’s sex and gender based on the baby’s visible reproductive organs.
Information for trans women and their helpers
Trans women are individuals who were designated as male at birth based on their anatomy but identify on the feminine side of the gender spectrum. Some trans women may wish to breastfeed their children via induced lactation and/or using a supplementer.
Hormone replacement therapy
Trans women commonly take anti-androgen medication if they have not had orchiectomy (bilateral testicle removal). Following orchiectomy, anti-androgen therapy may be ceased and estrogen dosage decreased.
Some physicians prescribe estrogen but not progestin for trans women under the assumption that adding progestin does not increase breast size over estrogen alone. However, progesterone plays an important role in lobuloalveolar development. For this reason, a trans woman may wish to take progestin in addition to estrogen if she intends to breastfeed in the future.
Inducing Lactation
Trans women may induce lactation by following the Newman-Goldfarb protocol. A physician may prescribe the appropriate medications. Birth control pills should be started about six months before the baby is expected or as soon as possible. Domperidone is also suggested in the protocol. 6-8 weeks before the birth, the birth control pills should be stopped, and the woman should begin pumping frequently to stimulate glandular tissue and to remove milk. The domperidone is normally continued for the duration of the lactation period.
A trans woman should discuss with a physician, such as a reproductive endocrinologist, what kind of hormone treatment is best to take during lactation. Unfortunately, there has been little to no research done in this area. One trans woman reported that she successfully took a decreased dose of her usual estrogen while lactating. Medications, such as anti-androgens or estrogens, should be carefully considered for safety during lactation on an individual basis, like with any medication or supplement.
Finding health care professionals
To date, there has been much more extensive media coverage and interest from health care providers and researchers regarding the needs of trans men around lactation than for trans women. Trans women also typically face higher levels of discrimination and violence in society in general. Anecdotally speaking, I have received several reports of trans women unable to find local breastfeeding counselors or lactation consultants willing to assist them. Consultations online or by phone may be necessary for this reason. Trans women are welcome to join the Facebook group Birthing and Breast or Chestfeeding Trans People and Allies for support and to locate lactation helpers.
Breastfeeding goals
Some trans women have induced lactation with impressive results, providing nearly a full supply to their babies. The amount of milk that is produced will depend somewhat on how many years the woman used hormones prior to inducing lactation, and how fully her glandular tissue developed during that time. If the woman had implant surgery, she may encounter some difficulty with severed ducts, damaged nerves, compressed glandular tissue, and/or scarring.
As is the case with chestfeeding trans men, the amount of milk that is produced is not the only consideration since the nursing relationship may be equally or even more important to the nursing couple. An at-breast supplementer may be used to support a nursing relationship.
Group meetings
Health care providers and breastfeeding counselors should encourage trans breastfeeding parents to attend group meetings. Those leading meetings should ensure that a safe and positive environment is provided. We know that peer support is an important predictor of a parent’s success achieving their personal breastfeeding goals. Trans parents may already feel isolated, especially if they do not know other LGBT families. Group meetings can be tremendously beneficial.
Information for transmasculine individuals and their helpers
Transmasculine individuals are people who were designated as female at birth according to their anatomy but identify on the masculine side of the gender spectrum. Some choose to give birth and/or nurse their babies, and may require lactation support.
Language
Although both men and women have breast tissue, the word ‘breast’ is most often associated with women. Trans men may be more comfortable referring to their ‘chest’ and ‘chestfeeding’ or ‘nursing’ their infants (regardless of whether they have had chest surgery), rather than ‘breastfeeding’. Trans men may refer to themselves as ‘dad’, ‘papa’, or another term, rather than ‘mom’. As a helper, don’t make assumptions. Remember that if you are unsure, it is best to ask about which names and pronouns an individual uses. If you make a mistake, apologize promptly and move on.
Health care providers and volunteers should update language on web sites, intake forms and information sheets to be inclusive of trans men and genderfluid individuals. This could involve using the word “parent” instead of or in addition to “mother” or using “you” language. Eg. Instead of “our practice aims to support new mothers in their personal feeding goals”, one could state, “We aim to support you in your personal feeding goals.”
Gender Dysphoria
Gender dysphoria occurs when an individual feels discomfort due to parts of their body that do not match their gender identity. Growth (or re-growth after top surgery) of chest tissue during pregnancy may bring up extreme feelings of gender dysphoria in some individuals, possibly causing anxiety or even depression. Chestfeeding can do the same. For this reason, deciding to chestfeed is a very personal choice.
Feelings of gender dysphoria may be triggered or exacerbated when a trans individual is misgendered by others, including health care providers and lactation helpers.
Testosterone Use
Many, but not all, trans men choose to take testosterone. Testosterone normally causes the cessation of menstruation and ovulation, and brings about male secondary sex characteristics.
When a trans man stops taking testosterone, his cycles are likely to return after several weeks or months, depending on how long he took the medication and his own physical particularities. Throughout the medical literature, it has been assumed that testosterone use permanently affects secondary sex characteristics. However, my study group reported in 2016 in BMC Pregnancy and Childbirth that this is not always the case. Some trans men may retain their facial hair and deeper voice when they stop taking testosterone, but others may not. Loss of facial hair and other typical male secondary sex characteristics may result in increased feelings of gender dysphoria and may affect the way that others perceive the individual’s gender identity.
Although rare, some trans men have been known to become pregnant accidentally while taking testosterone. Testosterone is highly toxic to the fetus and should never be used during pregnancy. However, because the body metabolizes and clears testosterone rapidly, it is considered safe to conceive within a few months of discontinuing most forms of testosterone therapy.
In our research article, my study group reported the first documented instance of a trans individual taking testosterone during the lactation period. The study participant explained that he made an informed choice under the guidance of his physician, and that his child’s pediatrician monitored the child through blood tests. The participant reported that the blood tests showed no evidence of testosterone exposure in the child. The participant did not feel that his milk supply was adversely affected by taking testosterone.
Top Surgery
Some trans men choose to have male chest-contouring surgery, also known as ‘top surgery’. This is different from a mastectomy (a cancer treatment), or a breast reduction, which is performed to make a smaller but still female chest. The goal of top surgery is to create a male-appearing chest. In order to do this some, but not all, of the client’s mammary tissue is removed. Complete removal of the mammary tissue would result in a sunken chest shape.
The preferred surgical technique for top surgery is variable, depending on factors such as volume of tissue and skin elasticity of the client. The ‘double incision’ technique usually involves nipple grafts, and is not ideal for maintaining nipple sensation or preserving milk ducts. However, some surgeons performing the double incision surgery use a pedicle technique to keep the nipple attached to a thin stalk of tissue throughout the procedure. The ‘peri-areolar’ approach, with incisions that go around the outer borders of the areolae, leaves the nipple stalks intact and likely has better results than nipple grafting does in terms of future breastfeeding and milk production.
Trans men who are planning top surgery after weaning should note that many surgeons require clients to wait six months after the end of lactation before having chest or breast surgery.
Binding
A trans man who has not had top surgery may choose to bind his chest in order to flatten it, thereby managing his gender dysphoria. Many years of binding may adversely affect the glandular tissue. Binding during the immediate postpartum period will increase the risk of blocked ducts and mastitis and may damage the milk supply. However, some individuals have had success with occasional, careful binding once the milk supply is well established and regulated. Anyone who practices binding during the lactation period should be advised of the risks of doing so, and should monitor the health of their chest closely.
Chestfeeding Goals
Some trans men who give birth do not want to chestfeed at all, in some cases for reasons to do with mental health and gender dysphoria. Others do, and sometimes opt to postpone desired top surgery so that they will be able to produce a full milk supply.
Health care providers should be respectful when providing ‘hands-on’ care. As in most health care situations, ask permission before touching an individual’s body, explaining what you are planning to do and why. If an individual is not comfortable being touched, find other ways to help, such as demonstrating on yourself. Watch for signs of postpartum depression. Trans individuals may be at risk due to experiences of gender dysphoria in addition to the usual challenges of giving birth and caring for a newborn.
Photo used with permission.
When assisting those who wish to chestfeed after a previous top surgery, it is essential to remember that nursing a baby is not only about the milk. An individual who has had surgery may produce a surprising amount of milk, or only drops, or nothing at all. Any amount of milk is valuable. By using an at-chest (at-breast) supplementer, the parent and baby can gain the benefit of bonding through a nursing relationship even in the absence of milk production. In addition, the action of nursing helps promote the normal development of the jaws and teeth in the infant.
Latching may be challenging for a parent who has had previous top surgery due to a relative lack of pliable tissue and skin. The parent may need to learn how to vigorously mould the chest tissue (make a ‘sandwich’). When providing assistance, be creative and expect to try many different grasps from varying angles in order to find what works. A reclining position may unfortunately cause the chest tissue to become even more taut and difficult to latch to. In this case, football hold or cross cradle may be easier.
A nipple shield might also be considered although it may be impractical to juggle both a nipple shield and a supplementer.
Supporting the Decision NOT to Nurse
Lactation helpers can support an individual who has chosen not to chestfeed by sharing how to quickly and safely reduce the milk supply after the birth. Explain the supply and demand system that governs lactation. Encourage the client to remove only as much milk as necessary to feel relatively comfortable, since removing more milk will cause the body to increase production. Cold compresses and cold cabbage leaves may help reduce pain and swelling. The parent should not bind at this time due to the increased risk of pain, blocked ducts, and mastitis. Several herbs such as sage, peppermint, and parsley are said to decrease milk supply.
Trans men who have had top surgery, regardless of surgical technique, should not assume that their body will not make milk following birth. If they plan not to chestfeed, they and their health care providers should watch for signs of engorgement and mastitis.
Discuss the many other ways of bonding with baby, such as bed-sharing, babywearing, and loving, attentive feeding. You may wish to let the client know about the possibility of obtaining human milk through milk sharing sites such as Human Milk 4 Human Babies or Eats on Feets.
Support Meetings
Health care providers and breastfeeding counselors should encourage trans breast or chestfeeding parents to attend group meetings. Those leading meetings should ensure that a safe and positive environment is provided. We know that peer support is an important predictor of a parent’s success achieving their personal breastfeeding goals. Trans parents may already feel isolated, especially if they do not know other LGBT families. Group meetings can be tremendously beneficial.
Those facilitating the meeting should know the location of a men’s washroom or gender-neutral washroom near the meeting room. They should use gender-neutral language such as “breastfeeding parent” instead of “mother” when addressing the group.
Resources and Further Information
Language:
For more detailed information about using respectful, accurate language, see the GLAAD media guide: www.glaad.org/reference/transgender
Trans women and breastfeeding:
Facebook-based Birthing and Breast or Chestfeeding Trans People and Allies: www.facebook.com/groups/TransReproductiveSupport
MacDonald, T. “Trans Women and Breastfeeding: A Personal Interview”, 2013, available at www.milkjunkies.net/2013/05/trans-women-and-breastfeeding-personal.html.
MacDonald, T. “Trans Women and Breastfeeding: The Health Care Provider”, 2013, available at www.milkjunkies.net/2013/07/trans-women-and-breastfeeding-health.html
West, D. Defining Your Own Success: Breastfeeding After Reduction Surgery, La Leche League International, 2001. Contains information relevant to trans women and men who have had breast or chest surgery. Also see Diana’s web site, bfar.org.
Trans men and chestfeeding:
Facebook-based Birthing and Breast or Chestfeeding Trans People and Allies: www.facebook.com/groups/TransReproductiveSupport
MacDonald, T, et. al, “Transmasculine individuals’ experiences with lactation, chestfeeding and gender identity: a qualitative study,” BMC Pregnancy and Childbirth, 2016. bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0907-y
West, D. Defining Your Own Success: Breastfeeding After Reduction Surgery, La Leche League International, 2001. Contains information relevant to trans women and men who have had breast or chest surgery. Also see Diana’s web site, bfar.org.
Trevor MacDonald is a transgender man from Manitoba who birthed both his children at home and nurses them. In 2011, he began a blog that is popular with both transgender individuals and health care providers looking for information on transgender reproduction and infant feeding. Trevor started the first online support group for transgender individuals interested in birth and breast/chestfeeding. He wrote tip sheets published by La Leche League Canada and has presented lectures on gender and reproduction in numerous conferences, seminars, and university courses. Trevor has written for publications including The Guardian, The Advocate, and Breastfeeding Today, and is the author of the memoir, Where’s the Mother? Stories from a Transgender Dad.