Trans Women and Breastfeeding: The Health Care Provider

Disclaimer: Nothing in this post (or elsewhere on this blog) constitutes medical advice. This is a brainstorming post for information purposes only. It is full of conjecture and based on limited experience and research. Please consult your doctor or other qualified medical professional if you require medical advice.

For the previous post in this series, I interviewed a trans woman who is enjoying a wonderful breastfeeding relationship with her baby. It was amazing and so valuable to get a firsthand perspective from someone who has "been there, done that."

Today's post focuses on the health care provider's perspective. Over the last few weeks, I've chatted with Mary Lynne Biener, IBCLC, and Jack Newman, MD, at the International Breastfeeding Centre in Toronto, as well as Diana West, IBCLC, a co-author of The Womanly Art of Breastfeeding and other titles. Mary Lynne and Jack have some limited experience working with trans women interested in breastfeeding.

You'll notice that several times my questions were answered with some variation of, "We just don't know!" I think it's important to point that out. We need research in this area. I'll try here to share what is known and highlight what is not.

Trevor MacDonald: Generally speaking, what do you think health care providers need to know in order to assist trans women interested in breastfeeding?

MaryLynne Biener, IBCLC: I think it's important to have at least a basic working knowledge of the various aspects of transition (medical, social, and emotional). While it's great to ask questions about an individual's experience (where appropriate) and breastfeeding goals, it's not ok to expect a "trans 101" lesson from a client/patient. Don't try to learn off of someone's back. As practitioners, we must examine our own assumptions and do our own work around educating ourselves. Also, there are aspects of transition that are not relevant to lactation – it's important to stick to what is within one's scope of practice. Be knowledgable about terminology and if you're not sure, ask about pronouns and language relevant to an individual.

I think it's also important to inform the client about what induced lactation can look like – that she may or may not produce all the milk her baby needs. At the same time, help her learn that there's way more to breastfeeding than just the milk. How can we support her in 1) maximizing what she produces and 2) supplementing (if needed) in a way that is compatible with breastfeeding (including accessing donated human milk)?

Realize that a lot of this is unknown territory and that this aspect of lactation support is evolving. Be open to new information, and be open to feedback.

Trevor: Which medications should trans women take to induce lactation? Is this recommendation the same as the protocol for inducing lactation in adoptive cisgender mothers?

Mary Lynne: So far we have done the same protocol. In a nutshell, and depending on the number of months before the estimated "due" date, we suggest a combination of the birth control pill (to mimic pregnancy, one should take the active pills only and no placebos) and domperidone. One would stop the birth control pill about 6-8 weeks before the baby is expected and start the pumping protocol but stay on the domperidone. Pumping is key, as it is stimulation of the glandular tissue and milk removal that promote milk production. Especially if there is not another breastfeeding or chestfeeding partner with a full supply, it makes sense to have a head start in promoting milk production via pumping and domperidone. Sometimes we also suggest starting herbs such as fenugreek, blessed thistle and, more recently, moringa leaf.

Is this enough? We don't know. I'm guessing that it could become challenging once the birth control pill is stopped…does the woman continue to require hormones (for a variety of reasons) and would this have an impact on milk supply? Unfortunately, I don't have an answer to that.

Trevor: In what ways do you think factors such as previous breast implant surgery, number of years on hormone therapy, or the age at which a woman began her transition would affect her milk supply?

Diana West, IBCLC: Any woman's ability to breastfeed depends on her lactation infrastructure, which includes intact nerves, ducts, and well-developed glandular tissue. Assuming the surgery was done in such a way that the nerves are intact and she has normal nipple sensation, the next question becomes where the implants are. Those below the muscle tend to result in the best milk production, probably because they don't compress the glandular tissue directly.

Severed ducts is a more complex issue. In cis-women, each menstrual cycle prompts glandular growth so that by her early twenties, there is usually a bare-bones glandular infrastructure. Unless they began hormonal therapy during adolescence, trans women may not have this head start. But it's possible that this could actually work in their favor. Fewer ducts at the time of the surgery may mean fewer ducts available to cut. If most of the glandular tissue growth is prompted after the surgery, most of the ducts that develop will be intact.

The amount of glandular tissue that develops will not be affected by implants, but if she induces lactation with a hormonal therapy and the implants are above the muscle, she may find that her breasts become painful as the glandular tissue develops.

The most important thing that a trans mother who has had implant surgery should take to heart is that nursing a baby is not about the amount of milk she makes, but rather the amount of love that she pours into her baby while she nurses him.

MaryLynne: As with cisgender women, there may be an issue regarding scarring (especially if the scars are periareolar) – this has to do with the pliability of the nipples and areolae and the ability of the baby to latch deeply. I'm guessing that the more years of hormone therapy, the better in terms of breast tissue development (and the older the surgery is, the greater chance of recanalization of nerves and ducts). Age at transition may be a factor simply in terms of the potential number of years on hormonal therapy.

Trevor: Do trans women typically face any special challenges in latching their babies?

MaryLynne: I'm not sure. It would depend on an individual woman's anatomy, history of surgeries, what interventions happened during and following the birth (issues on the baby's end), how much support she has, etc.

Trevor: Could there be particular troubles due to having less fully developed glandular tissue? Do folks with insufficient glandular tissue (IGT) have more latching issues than others?

MaryLynne: I don't think that IGT necessarily interferes with latching per se. What can be problematic are common interventions that interfere with breastfeeding. For example, if someone has IGT and isn't producing enough milk (even colostrum), one of the more common interventions is to supplement with a bottle, which we know can cause significant latching issues.

Trevor: In my last post, the trans woman I interviewed about her experience with induced lactation told me that when she produced her first drops of milk they were waxy in consistency. They became thinner until like normal milk. Is this a common experience with induced lactation?

MaryLynne: Sounds like colostrum to me (which can be quite thick and waxy). And yes, I have seen that with induced lactation in cisgender women as well.

Trevor: Are there any trans-related medications that women should avoid while breastfeeding? eg. I've been told that some anti-androgens may not safe be to take while breastfeeding.

MaryLynne: I think we would have to judge each medication individually as we do with any medications (for example, antidepressants are compatible with breastfeeding, however some are more compatible than others). There are few medications that are completely incompatible with breastfeeding, so I think we would treat anti-androgens like any other medication: we would consider the half-life, degree to which it is protein-bound, its solubility, its molecular size, etc, and then help the client understand the risks and benefits involved.

Dr. Jack Newman: We can worry about anti-androgen medications if the mother produces significant amounts of milk. But in theory, they should help with production.

Trevor: How successful have female trans clients you've known or communicated with been in their breastfeeding journeys?

MaryLynne: I have only worked with one woman and it was a prenatal visit. I haven't heard any feedback. Yet :)

Jack: Our experience is limited. But the idea is feeding the baby at the breast, not necessarily making lots of milk. The latter would be nice, but most women inducing lactation don’t produce all the milk the baby needs.

Health care providers need to know that this is a worthwhile thing to do. The rest will follow. They can refer. They can learn.