This information is free for personal use. Any trans folk are welcome to print it out and give a copy to their health care provider! However, if you wish to publish any part of it or quote this material in a presentation you must obtain formal permission. Thanks!
I'm not a health care professional and this blog entry does not constitute or replace medical advice. Please consult your doctor if you need medical advice.
**** This blog post has been updated and now comes in three parts: 1) general information 2) assisting trans men 3) assisting trans women
Transgender/transsexual/genderfluid Tip Sheet – General Information
Prepared by Trevor MacDonald
This tip sheet provides some key details you should be aware of when offering reproductive/lactation support to transgender, transsexual, or genderfluid individuals. Keep in mind that in most ways, medically and otherwise, trans people are just like everyone else. There is a list of key terms and their definitions at the end of this sheet.
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. Gender expression has to do with how an individual presents their gender to others within a given cultural context. For example, within western culture the colour pink has gone from being a traditional boys' colour to one for girls in only a few generations.
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. 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.
It may be essential to ask questions regarding an individual's gender identity or history of medical transition in order to provide adequate care. However, only ask those questions that are relevant. Do not ask questions solely out of curiosity.
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 prefer, simply ask in a respectful manner. If you make a mistake, apologize promptly and move on. Some people prefer 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, or transvestite.
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." (similar to how it is best to say "He is a black person", rather than "He is a black")
A person is transgender, not transgendered. It is never necessary to add the suffix 'ed' to transgender.
*Note that these definitions explain how the following terms are generally understood. However, individuals within the trans community may define them differently or may self-identify outside of these labels.
cisgender: someone whose gender identity matches their assigned birth sex (they are not transgender)
FtM: female-to-male trans person
MtF: male-to-female trans person
gender binary: The notion 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.
gender identity: a person's inner sense of their gender.
intersex: a condition in which an individual is born with reproductive and/or sexual anatomy that does not fit the usual male or female definition.
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.
Tip sheet for assisting trans men
Trans men are individuals who were born with anatomy typical of females 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.
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, rather than 'breastfeeding'. Trans men may refer to themselves as 'dad', 'papa', or another term, rather than 'mom'. Don't make assumptions. Remember that if you are unsure, it is best to ask about which names and pronouns an individual prefers to be used. If you make a mistake, apologize promptly and move on.
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 such as deepening of the voice, growth of facial hair, and male pattern baldness.
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. However, most of his male secondary sex characteristics will remain. For example, once testosterone has stimulated the growth of hair follicles in a person's face, those follicles will stay there and hair will keep growing unless extensive electrolysis treatments are undertaken (a common element of male-to-female individuals' transitions).
Although very 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.
Testosterone use during the period of lactation would likely interfere with the hormones required to produce milk and achieve let-down.
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 nor preserving milk ducts. 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 in terms of future breastfeeding and milk production.
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.
Some trans men who give birth do not want to chestfeed at all, in some cases for reasons to do with mental health. Others do, and opt to postpone desired top surgery so that they will be able to produce a full milk supply. Others who have had top surgery may still wish to develop a nursing relationship and may do so using an at-chest (at-breast) supplementer.
Gender Dysphoria and Chestfeeding
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.
Supporting the Decision NOT to Nurse
Support an individual who has chosen not to chestfeed by sharing how he can quickly reduce his 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.
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.
Supporting the Decision TO Nurse
Be respectful when providing ‘hand-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 particularly at risk due to struggling with gender dysphoria in addition to the usual challenges of giving birth and caring for a newborn.
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 a 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 the 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.
Encourage the trans breastfeeding parent to attend group meetings and 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.
Other Support and Resources
The community of trans individuals interested in birth and various infant feeding methods is growing fast. At this time, the only online support group is the Facebook-based Birthing and Breastfeeding Transmen and Allies, with over 500members worldwide. The group includes many interested and supportive lactation consultants and LLL Leaders.
Toronto's LGBT Parenting Network runs a weekend course once every few years for transmasculine individuals considering pregnancy.
Diana West's book, Defining Your Own Success: Breastfeeding After Reduction Surgery, contains information relevant to trans men who have had top surgery. Also see her web site, bfar.org.
Tip sheet for assisting trans women
Trans women are individuals who were born with anatomy typical of males 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.
Trans women may induce lactation by following the Newman-Goldfarb protocol. A physician would need to 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. Some trans women have successfully taken a decreased dose of their usual estrogen while lactating. Any medications, such as anti-androgens or estrogens, should be carefully considered for safety during lactation on an individual basis.
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 women 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 as important as the nursing relationship itself. An at-breast supplementer may be used to support a nursing relationship.
Encourage the trans breastfeeding parent to attend group meetings and ensure 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.
Resources and Further Information
"Trans Women and Breastfeeding: A Personal Interview" by Trevor MacDonald, available at http://www.milkjunkies.net/2013/05/trans-women-and-breastfeeding-personal.html.
"Trans Women and Breastfeeding: The Health Care Provider" by Trevor MacDonald, available at http://www.milkjunkies.net/2013/07/trans-women-and-breastfeeding-health.html
Facebook-based Birthing and Breastfeeding Transmen and Allies group welcomes trans women interested in nursing their infants.
Diana West's book, Defining Your Own Success: Breastfeeding After Reduction Surgery, contains information relevant to trans women who have had breast surgery. Also see her web site, bfar.org.