Lactation in the LGBTQ+ community
The information on the whole HIFN website will be relevant to LGBTQ+ individuals. This page goes through some specific areas of lactation that healthcare professionals may not be familiar with. First we will describe the available tools and then the ways in which these may be combined in different scenarios. Finally the specific needs of transmasculine parents are discussed.
A list of specific resources is available in the resources section of the website. The Academy of Breastfeeding Medicine has a thorough protocol on the same topics described here (protocol number 33).
In general, LGBTQ+ individuals experience significant discrimination both within and outside the healthcare system and may avoid seeking medical advice because of this. It is therefore particularly important for healthcare professionals to educate themselves about issues faced by the LGBTQ+ community and to understand the importance of appropriate language. Using 'additive' language in general (for example mother or parent; breastfeeding or chestfeeding) and the parent's own preferred terms in particular (pronouns and how they refer to lactation/body parts) can signal understanding and acceptance. This document from Brighton & Sussex NHS Trust describes this approach more fully.
It is well known that both men and women can produce milk without having birthed a baby, with the right hormonal stimulation - for example galactorrhoea due to pituitary tumour secretion of prolactin. Lactation was first induced in a semi-scientific manner by adoptive parents wanting to breastfeed their children. The protocol was designed by Dr Jack Newman and his patient Lenore Goldfarb and uses a combination of contraceptive hormones, physical stimulation through a breast pump and domperidone medication to mimic the hormonal changes of pregnancy and birth.
There is little evidence related to the success or safety of the protocol, the impact of specific elements/doses or the constituents of the milk produced. Lactation professionals report anecdotally that there is significant variability, with some people able to produce a large amount of milk and most able to produce a partial milk supply. In general domperidone must be continued throughout the period of lactation, which is challenging in the UK due to the MHRA notification that domperidone should only be used for nausea and vomiting, at the lowest effective dose and for the shortest possible time, due to reports of cardiac conduction side effects.
Another form of induced lactation is relactation, if the parent has lactated in the past after a previous birth. This can involve simply frequent and prolonged breast stimulation with a breast pump.
In the LGBTQ+ community, induced lactation or relactation may be used by lesbian parents who have not given birth - for example after adoption or by the non-birthing partner. A lesbian couple may both breastfeed a baby ('co-nursing'). Attention should be paid to the birthing parent's milk supply to ensure this is well established, either through waiting for 4-6 weeks before the non-birthing parent starts to breastfeed or through regular breast expression to make up for the reduced stimulation while the baby is being fed by the non-birthing parent.
The other situation where induced lactation has been used in the LGBTQ+ community is for transfeminine individuals. All humans have mammary tissue on the chest and oestrogen taken by transfeminine people increases the extent of mammary tissue in a way that is histologically and radiologically indistinguishable from cis female breast tissue. The maximum effect is seen after several years of oestrogen use. One case study reported the use of an induced lactation protocol for a trans woman who fed her child for six weeks after birth with no obvious difficulties, then introducing some infant formula at that point due to concerns over reaching a ceiling of milk supply. The growth pattern of the baby was not reported.
At breast/chest supplementation
Extra milk can be delivered to a baby feeding at the breast/chest with the use of a 'supplemental nursing system' (SNS), if the parent is not producing sufficient milk to fully satisfy the baby. It is simply a thin tube, similar to a nasogastric tube, which has one end in a container of milk and the other end is held next to the nipple within the baby's mouth so that as the baby sucks they will receive both milk from the parent and milk from the supplementer (see picture at the bottom of the screen of a supplementer used alongside a nipple shield). There are several commercial products available. They can be difficult to use initially and parents will benefit from experienced support in the practicalities of their use, which is generally from a lactation professional. The milk within the supplementer can be human milk (donated or parental) or infant formula.
Supplementers can be used within the LGBTQ+ community by anyone who is not producing a full milk supply, either because of limited mammary tissue, use of an induced lactation protocol or simply because of low milk supply.
There are many complex issues for trans men to think about when considering the role of lactation in feeding their child, described thoroughly in this useful article, which informs the rest of this section. Each individual will have different concerns and motivation around lactation and it should not be assumed that someone either wants to or doesn't want to feed their child at the chest. Some people may want to use infant formula or donor human milk and suppress any lactation from their own body. Others may want to do everything to maximise their potential to feed their child at their chest or with their own expressed milk. Chestfeeding is a common term to describe transmasculine lactation, however some may prefer to use the term nursing, breastfeeding, feeding or another term.
After puberty, trans men have more extensive mammary tissue than cisgender men and at the point of having a child they may or may not have had surgery to reduce the amount and appearance of this tissue. This 'top surgery' will reduce the amount of tissue available for lactation. In some cases milk ducts may be severed and there may no longer be a connection between mammary tissue and the nipple. This may reduce the amount of milk a trans man can produce or make any lactation impossible.
Trans men report difficulties with discussing the effect of surgery on lactation with their surgeon, and given that the area is new their surgeons may not know the potential effects either. Lactation is likely to be more affected by 'double incision' surgery where nipples are repositioned than surgeries that preserve the nipple pedicle. However it appears that trans men who have had surgery of all kinds can experience changes in the mammary tissue if they become pregnant and may produce milk of various amounts.
Even when a trans man doesn't want to continue lactation they should be advised on what to look out for in their chest tissue after birth to avoid engorgement and mastitis. The shape and amount of mammary tissue after top surgery may bring difficulties with how to best position a baby at the chest to effectively latch - several techniques have been advised such as forming a 'sandwich' with the parent's hand, using a nipple shield and avoiding any laid back positions that stretch the chest tissue. An at-chest supplementer and/or the use of a galactogogue may be useful if milk supply is low.
Some transmasculine individuals suffer gender dysphoria related to their chest appearance and therefore lactation may exacerbate this. Some may limit the length of lactation in order to go back to binding their chest, taking testosterone or having top surgery (for which it is generally advised to wait at least six months after lactation). However not everyone experiences dysphoria in this way - in fact some report that using their chest tissue for this practical purpose and to connect with their child reduces dysphoria.
There are also practical issues relating more widely to gender dysphoria as chestfeeding may lead others to misgender them (using a different gendered pronoun, name, or description from that which the patient uses) or may challenge a desire for privacy around their body. The world of pregnancy and lactation is steeped in feminine language and imagery. Some trans men may find it particularly difficult to seek help with lactation from professionals for these reasons.
It is generally advised not to bind the chest or use testosterone while chestfeeding or lactating. Low dose testosterone does not appear to enter human milk but the higher doses used for cross-sex hormone therapy are likely to enter human milk. Several case studies support the idea that testosterone levels in the child remain normal despite parental testosterone use due to first pass metabolism and no clinical effects were seen in the children in these reports. Testosterone may reduce milk supply. Some trans men have reported using gentle chest binding during lactation with careful attention to any signs of blocked ducts or mastitis.
Trans women may choose to use induced lactation protocols and supplemental nursing systems as discussed above. There are two others areas to discuss. Firstly a trans woman may be taking an anti-androgen medication such as spironolactone so this should be checked with a trusted source of information about medications and lactation. For example, spironolactone is not a contraindication to breastfeeding.
Secondly trans women may have had breast augmentation surgery. Just like for cis women having this surgery, this may interrupt mammary tissue and nerves, reducing lactation potential. Specific information can be given related to the form of surgery.