Tuesday, 22 April 2014

La Leche League Will Allow Male Leaders!

La Leche League International has published a clear, proud press release stating that men who meet the necessary qualifications may apply to be Leaders. Men are now eligible to apply.

From the press release: As an organization dedicated to helping babies breastfeed, the expanded eligibility criteria demonstrates La Leche League International’s commitment to assisting even more parents breastfeed their babies.

YES!!! Thank you La Leche League!

Read the whole press release here.

Monday, 21 April 2014

Happy News From La Leche League on Leader Eligibility

I think? Maybe? The title of this post might better read, “Unclear News From La Leche League, but it’s an Update of Some Sort.”

La Leche League Canada has published a media statement about a change in leader eligibility. Exactly what the change is, we don’t know. The press release states that LLLC’s new approach has come as a direct result of an update from La Leche League International, LLLC’s governing body. From LLLC’s statement:

In recent weeks the La Leche League International Board of Directors has updated their internal Policies regarding eligibility to apply for leadership to be consistent with their Bylaws Preamble: “LLLI is a worldwide, educational, nonsectarian, nondiscriminatory service organization which has been incorporated in Illinois as a general not-for-profit corporation.” LLL Leaders have breastfed a baby for at least nine months and have demonstrated a commitment to the philosophy of La Leche League.

So, this is vague, as it doesn’t explain what the update in policy actually is, but there are a few items of note. We know they probably didn’t update leader eligibility policies to be consistent with being “worldwide” or “educational”: the organization has met both of those ideals for decades. I’m also quite sure you could argue it has always been nonsectarian. Therefore, I’m going to guess that the update in policy has to do with nondiscrimination. I’m hoping that it has to do with gender, and that it means that an individual of any gender can now apply to be a La Leche League Leader if they meet the necessary qualifications. (get caught up by reading LLLC's previous media release about the eligibility of transgender applicants)

The next sentence is very, very special: “LLL Leaders have breastfed a baby for at least nine months and have demonstrated a commitment to the philosophy of La Leche League.” Gendered terms such as woman and mother are nowhere to be found. If you’ve spent any time on LLL web sites or working with LLL, you will know that this is rare, and very probably done on purpose.

At the end of its press release, LLLC states that it has updated its own policies to be consistent with LLLI’s recently made change, and to be “in keeping with the Canadian Charter of Human Rights and Freedoms and the Canadian Human Rights Act.” It is still not affirmed specifically that people who do not identify as women may apply to be Leaders, but I’m going to hope that this is (at least part of?) what they mean!

I was unable to find a related press release on LLL International’s site.

YAY, La Leche League!!! (I think)


Wednesday, 1 January 2014

Resolution: Tackle Inner Transphobia


The hardest part about nursing my child as a trans person is that doing so forces me to come out to anyone who sees it happening.  If I nurse in public, people come up to me and ask what I’m doing. I guess they think that because I’m doing it where they can see it, this means that I am willing and available for questioning. It doesn’t occur to them that Jacob and I are nursing because we need to, because he has hurt himself or is very tired and I need to calm him down. If I nurse in front of a guest in my home, I feel obligated to explain a bit of our backstory.

Those of you who follow me on Facebook might have noticed that I’m rather dog-obsessed these days. We have a rowdy ten-month-old puppy that was having major behavior problems until he recently was diagnosed with a thyroid condition. I hired a professional trainer to come to our home and work with us. Of course, she could only come during Jacob’s usual nap-time, when he nurses a fair bit.

The trainer began her evaluation and then Jacob woke up crying. I brought him into the living room, and as I sat down to nurse him, I said something horribly awkward like, “Uh, we’re a bit of an unusual family. Ummm… I’m transgender. I was born female but took testosterone. Anyway, so I birthed him myself and I still nurse him.”

The trainer was wonderful about it. She said, “Oh, that’s fine. Now I want to show you how to teach Tadoo to accept a muzzle.”

Unfortunately, I found this trainer difficult for unrelated reasons, and located another one who was a better match for us in terms of our doggy issues. She, too, was only able to work with us at a time when Jacob was exhausted and badly needed to nurse. I could choose to either nurse him, or not hear a word the trainer was saying to us due to continuous crying. I said another explanatory spiel and started to nurse him in front of her.

The trainer said, “Oh, I’ve seen everything, don’t worry. I used to work as a nurse. A guy [sic] I used to work with was trans [a trans woman].  He [sic] and I got along really well.”

Then came the questions.

“How much milk do you make?”

Fairly innocuous. I didn’t mind to answer that. I explained that since I had chest surgery, I don’t have a full supply.

“Oh! I thought you’d gone the other way. I don’t know as much about female to male.”

Then she said something like, “When are you going to go all the way?” or maybe it was, “when are you going to complete your transition?”

Ian, my partner, told her that bottom surgery wouldn’t be very good for our hopes of having another child. I mumbled something about the risks of such a major surgery and then tried to get her back onto the topic of dog training.

There was so much in what she’d said that made me uncomfortable. I personally knew the woman that she had worked with, and I knew she would be horrified at the trainer’s use of male pronouns for her. Further, I don’t think of my transition as incomplete, but there would be no way to explain that in brief to someone who believes that gender is firmly binary.

There was something eerily familiar to me about her questioning. After her visit I remembered that medical professionals have asked me those sorts of questions, and she was indeed a retired nurse. In a clinical setting such questions are difficult because I can’t tell whether the practitioner needs to know the answers to take care of my health concerns, or if they are simply being curious (and inappropriate).  I feel like I am supposed to respond fully.

Why did I feel that I had to tell my dog trainer I am trans before nursing my child in front of her? It certainly doesn’t help normalize what I’m doing. If it is normal, then why do I need to explain it?

Coming out to her started a conversation that I didn’t want to have and led to her asking questions that made me uncomfortable. My intention was to share this as one piece of information and to get it out of the way, but that was not what happened. That said, I don’t believe that coming out to someone should give that person a right to ask intrusive questions. If a new acquaintance tells me, for instance, that she is a single mother, I do not respond by asking her, “What happened to your husband? Did he pass away, or did he leave you, or did you split up?”

My New Year’s Resolution: I am going to stop doing preemptive explaining in this sort of situation. I am going to do what I need to do, what is best for my child, and if someone is curious or confused about it, I will hand them a card with my blog on it, where I have laid everything out. I want to be an advocate and an educator, but I don’t need to continually open myself up to personal questioning in my day-to-day life. I will be brave and strong, and I will let go of my inner transphobia, embracing my own normalcy.

The trainer was excellent with our dog, by the way, and we have been making great progress.

Friday, 6 December 2013

A Transgender Patient in the ER: 12 Hours

I try to keep this blog as positive as I can, because I feel that this is the best way to move forward to greater understanding and tolerance in general. By nature I am an optimistic person and I prefer to highlight what is going well. Yet life is not always rainbows and butterflies. Sometimes we must tell our sorrowful stories in addition to those of gratitude and joy.

Trigger warning: This post is about a pregnancy loss.

We got our positive pregnancy test on Thanksgiving Sunday (Canadian). We had been in our new home just a few weeks at that point, and decided it was meant to be. We moved to this beautiful forested property with a cute red barn, and of course we were newly pregnant!

We told some family and close friends. I had a little nausea but nothing as bad as with our first. Now I remember reading a few years ago that the more sick you feel, the less likely you are to miscarry. Vomiting is a particularly good sign.

Last week we had our first meeting with our midwife, at around 10 weeks’ gestation, and discussed having a home birth outside the city limits. We talked about the logistics of a potential hospital transfer as well as how quickly the midwife could get from her home to ours.

I told her that in terms of care, the biggest deal for me is pelvic exams and how much I hate them. I don’t think anybody enjoys them, but for a lot of trans people they are particularly excruciating. The midwife accepted this well and said that only under rare circumstances would she really insist on doing one – if there was a huge amount of bleeding or if the baby’s heart rate suddenly tanked. That sounded fine by me. We left the appointment feeling happy. The pregnancy seemed much more real, and we told more family and friends.

A few evenings later I noticed some light bleeding. It wasn’t much, but I had been feeling poorly all day and wanted to go to the hospital. I just really wanted to go. We didn’t yet have our midwife’s pager number, so I wasn’t able to talk to her about what I should do. I drove myself into town and left Ian and Jacob on their own for the first time overnight.

The intake nurse asked me what was going on. Here. We. Go. “I am transgender. I was born female and transitioned to male.” I paused and looked at her. “Is that ok? Do you understand that?”

She nodded.

I once saw a walk-in clinic doctor about a urinary tract infection and erroneously assumed that he knew what ‘transgender’ meant. Then I realized part way through the visit that he was utterly confused about what I have ‘down there’. Ever since, I’ve spoken more slowly and spelled out my situation clearly. I always stop for a moment and give the care provider time to absorb what I’ve said. Then I ask as gently as I can if they are ok and if they know what I’m talking about. I try to leave space for the person to admit that they don’t have a clue.

I told the intake nurse that I was pregnant, experiencing bleeding and feeling unwell. She gave me a paper wrist bracelet and told me to wait.

After a couple of hours, I got moved to an exam room, where I waited another three hours without speaking to anyone.

A nurse came in and asked why I was at the hospital. I started again from the beginning – transgender, born female, pregnant, 10 weeks, light bleeding, one previous healthy pregnancy, no testosterone for years. She said a doctor would see me in a while.

Another nurse came in later to check my vitals. She, too, asked why I was in the hospital. I went through the same spiel, and she, like the others, was professional and respectful.

A student doctor came in and asked what was going on.

“Ummm… Do you know the background at all?” Did I really have to come out as transgender to each of these people, one at a time?

“Well, yes, I do know the backstory a bit.”

“So, you know I’m transgender?”

“Yes.”

“Are you ok with that?” I asked him.

“Yes. I did a bit of research, but I think I am caught up.”

Cool! He looked in the chart ahead of time, realized he was unfamiliar with transgender folks, and decided to look us up. Then, within a few minutes of doing some reading, he was able to use the correct pronouns and have a frank discussion about my medical problem. THANK YOU, whoever you are. YOU will be an awesome doctor when you are all grown up.

He asked me lots of questions, including checking several times that I had not been taking testosterone recently. I confirmed that I haven’t taken T since well before conceiving my toddler.

He asked if I’d had any surgery, so I told him about my top surgery from a few years ago. He seemed genuinely interested to learn what that was all about – what the procedure was like and how it differs from a double mastectomy.

“Have you had anything done on the… bottom? Anything that we should know about?”

“No.” Thank you for asking politely rather than making assumptions because you find this embarrassing to talk about.

The teaching doctor came in and said something like, “So I understand you are pregnant.”

Thank you for signaling to me that I don’t have to start by discussing my genitals at birth with you.

We talked about what was going on, and the doctor said he would order an ultrasound. He thought everything was probably fine given it was very little bleeding, but he wanted to be sure.

I was moved to a waiting area in the hallway near the nurses’ station. I saw a doctor arrive in his coat and scarf, coffee in hand. He was wearing a pair of black Blundstones, the same kind of boots that I use for riding horses. They seemed incongruous to me in a hospital, but I suppose they must be much more comfortable than traditional dress shoes. Another doctor asked him how he was, and he replied that he'd spent two hours cleaning up vomit in the middle of the night – his kid had been sick. Still, he and the new nurses coming in for the day looked much more cheery than the night shift had.

 The student doctor came up to me and said that they would be discussing my case with the next set of doctors coming in. “So you might hear us talking about you.”

I watched and listened to it all. Not a single wrong pronoun, no poorly-covered laughs, no unnecessary discussion of my body or my transition. In comparison, the last time I had to go to the hospital for something, I heard the doctors and nurses laughing about me in the hallway, not even trying to be discreet.

The doctor in the Blundstones sat down next to me and said I would need a Winrow shot because my blood type is Rh negative and I’d had some bleeding. “It will not only protect this pregnancy, but all future pregnancies as well.”

Thank you for understanding that this pregnancy was planned and wanted. Thank you for accepting that I deserve the right to have children as much as anyone else.

I called Ian. I was anxious to hear how he and Jacob did overnight.

“We saw FOX!” Jacob said over the phone.

Jacob had been very brave and did not cry at all, even though he woke up in the middle of the night a few hours after I left. He also did not want to lie down in bed. Ian held him for the rest of the night in the rocking chair by our front window. At one point Ian looked out and saw a fox standing there, very near the house. He woke Jacob so that he could see it, too.

I was relieved to hear Jacob sounding so happy. I said I would call back when I had some information.

Finally they were ready for me to have the ultrasound. The technician put goo on my belly and started taking pictures.

“Are you sure the baby isn’t 5 weeks instead of 10?”

I knew this was bad. I was sure about our dates. He wasn’t finding a 10-week-old fetus.

He said we needed to do a vaginal ultrasound. I told him I was not so comfortable with that procedure. He said he didn’t like doing them either but it was important to find out what was going on with the baby, and he couldn’t get a good enough picture otherwise. He asked if it would help to have another person in the room, male or female. I said no. Thank you for asking. Thank you for considering it from my perspective, and helping me make my own choice.

It wasn’t as bad as I thought it was going to be, except for that the room was very cold for someone wearing a paper gown. The technician said that I should go and talk to the emergency room doctor, who would get the ultrasound pictures soon.

A half hour later, the Blundstone doctor told me, “I don’t have all the pictures yet on the computer, but I can see what they wrote on the file. It looks like a healthy 6 week fetus. You probably just have the dates wrong. It happens all the time.”

I had trouble holding back tears. “I don’t see how I could have the dates wrong. We were trying for this, so it’s not like I wasn’t paying attention. I don’t see how this is possible.”

The doctor said he would wait for the images to be on his computer, and he would look closely at them.

Another 30 minutes later he took me aside to a separate room.

“You were right about the dates. The fetus stopped growing at 6 weeks. I’m so sorry. We almost never know why this happens. I’m going to call for an OBGYN consult. This happened 4 weeks ago but you have only had very light bleeding. Have you heard of a D&C before?”

I had. Vaguely. “I’ve heard it is really unpleasant.”

“Yeah. I’m sorry. There might be an alternative. There’s a medication you might be able to take instead. It depends on certain factors. We’ll see what the OBGYN recommends.”

I called Ian and told him. I felt like I was stabbing him, giving him such painful news. I’ve never heard his voice sound so broken the way it did that day. He and Jacob got picked up by a friend and came to the hospital while I waited for the OBGYN.

The doctor and student who came to talk to me were profoundly sympathetic and kind. They discussed the risks and benefits of both the D&C and taking the medication, and left the choice up to me. I chose the medication. Jacob and Ian came in and I got some amazing, big hugs. Jacob nursed a ton while the various doctors and nurses gave him adoring looks.

The doctor said, “We usually give this medication as a vaginal injection, but we looked it up and found that you can also take it in pill form. So we can give you a prescription for it and you can take it at home when you are ready.”

Wow. They get it. I don’t have to say anything. YES, a trans guy will likely prefer a pill. Why that isn’t normally available for cis women as well, I have no idea. I am only grateful on this day.

They told me what to expect and how to contact them if I had any questions. On my way out I thanked every nurse and doctor I saw. I caught Dr. Blundstone in between tasks and I said, “Every single person here has been so respectful and understanding. I really appreciate it. I’ve had some pretty bad experiences in the past…”

“You will have them again. You know that. But I’m glad that people were good this time. I think things are changing. We are getting much more education about trans health care in med school and it is making such a difference.”

Ian, Jacob and I ate sushi with our friend and her son in the hospital lobby. We picked up the prescription and some heavy pads and then went home. I was exhausted from staying overnight in the hospital and decided to wait until the following day to take the medication. That was another process to go through. We all needed to rest and have time together first. We had to somehow catch up to the realization that for the past four weeks, while we were planning and dreaming about a new family member, our baby was already gone.

Sunday, 29 September 2013

Good News From La Leche League

This past Spring I wrote to LLL Canada and LLL International asking if I could create some resources for Leaders who might need to work with transgender parents. I received an enthusiastic response from an LLLC board member! We decided that I would write some tip sheets based on what was already on my blog.

The tip sheets are now available in the Leaders' area of the LLLC web site. Leaders can go to Leader Resources - PL Department - Information Sheets to find the "Tip Sheet for Assisting Transgender Parents." It comes in three parts – a general information sheet, one specific to trans men, and one specific to trans women.

LLL International also asked permission to use the sheets, which I happily gave. Hopefully Leaders around the world will be able to view the sheets very soon.

A version of these information sheets is available on my blog.

Hooray for La Leche League training its volunteers to be trans friendly and knowledgable!!! On a personal note, I'm delighted to be contributing meaningfully to the organization :)

Friday, 20 September 2013

Update: Tips for Assisting Trans Folk with Lactation

I know what you're thinking: Long time no blog, right?

Well, I'm getting back to it :)

Here's a much-needed update to my old post on assisting trans folk with lactation. It comes in three parts: 1) general info for health care providers working with trans individuals 2) assisting trans men 3) assisting trans women. Enjoy, and please tell me if you have suggestions!

http://www.milkjunkies.net/2012/03/tips-for-transgender-breastfeeders-and.html

Tuesday, 2 July 2013

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.