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.

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 :)

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

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.

Trans Women and Breastfeeding: A Personal Interview

Update: Read my interview with Jenna, another trans woman, here. Read my interview with health care providers who have assisted trans women with lactation here.

So far, this blog has exclusively addressed issues faced by transmasculine folks. I started writing it from my personal experience, and I am transmasculine. However, I've received several questions from trans women who are interested in breastfeeding. After doing some Google searches, I realized that just as there is little to no information for trans men on this topic, there is not much written for trans women. In particular, I haven't found any personal accounts or interviews. I will try to do my part to fill a little bit of this gap. This is part one of a mini-series on trans women and lactation. Enjoy!

Trans women, individuals who were assigned male at birth but identify and live as women, CAN breastfeed. It is possible, and totally awesome! Health care providers, volunteer breastfeeding counsellors, and trans women themselves need to learn this important, empowering fact.

Over the last few weeks, I spoke a couple of times with a trans woman and mother, who we'll call Sarah, to better understand how she became a parent and successfully induced lactation. Sarah's baby is now more than a year old and they still enjoy a wonderful breastfeeding relationship. I'll give a bit of background here on conception and then launch into our lactation interview.

Sarah and her wife are both genetic parents to their baby. Sarah explained to me that many doctors, endocrinologists and trans women erroneously believe that after taking antiandrogens and hormone replacement therapy for a relatively short period of time (depending on who you're talking to, they may say something between six months and two years), a trans woman will be permanently infertile, despite not having had 'bottom surgery'. This is to say that even if she halts her hormone therapy, it is claimed that she will not be able to produce viable gametes. Sarah believes this claim is based not on science, but on a widespread lack of understanding of trans women’s bodies and many healthcare professionals’ lack of interest in helping them preserve their fertility.

Despite having taken hormone replacement therapy and antiandrogens for 5 years, Sarah was still able to produce what she calls ‘baby-making ingredients’ following a six-month cessation of her medication. Trans women hoping to help make a little munchkin should note that it takes about three months for their gametes to grow and mature. In addition, this genetic material is very sensitive to heat and needs to develop away from the body, below core body temperature. A trans woman who usually ‘tucks’ will need to change how she dresses for a while to regain her fertility.

Sarah banked her gametes, a choice she believes all trans women should be offered. Another five years later, when she and her wife decided to conceive, Sarah went off her hormones once again to obtain a fresh DNA contribution if possible. She was again successful, after a total of ten years on hormones and antiandrogens. The couple was able to conceive at home, an option that was far less expensive than using the previously banked material at a clinic.

They chose to have a homebirth because they wanted to avoid unnecessary medical interventions. As a lesbian couple, they were also worried about their relationship being questioned by hospital employees.

SARAH: We had the most incredible midwife for the birth. When we first met her, we explained our situation, and she used the term "non-gestational mom," which I’d never heard before. I loved that when confronted with a situation that had been confusing for so many doctors and nurses, she had a perfect, descriptive word for my relationship to my baby, right on the tip of her tongue and didn’t stumble over whether to use ‘non-biological’ or ‘donor’ or something else inappropriate. I'm one of the two genetic moms of my baby, but I'm the non-gestational mom.

ME: So you didn't have to educate your midwife at all about trans issues. That's awesome! What steps did you take to induce lactation? Which health care providers did you approach for help?

SARAH: I didn't know where to start. I looked through my health insurance booklet for an endocrinologist. There was a section that said "reproductive endocrinologist," which sounded just right. I called a couple of different offices until I got someone to call me back.

I said to the nurse, "Here's what I'm looking for. I know that this doctor doesn't have any experience with this, because NO ONE has any experience with it. I'm not looking for her to know what's going on, but I have an idea what I want to do, and I think I know what I need. I just want somebody to work with me."

When I saw the doctor, she said, "I think this is very unlikely to work, but I'm happy to help you try."

I didn't feel like she added that much to the process, other than prescribing the hormones I needed.

ME: When did you first think that you might breastfeed?

SARAH: We definitely thought about it before we got pregnant. It had been a vague part of our plan. I was inspired by the book, Confessions of the Other Mother: Non-Biological Lesbian Moms Tell All. As an aside, I really don’t like this use of the word ‘non-biological,’ referring to both parents and trans people. Just because we transitioned, or just because someone's not genetically linked to their child, that doesn’t mean we’re made of styrofoam. We’re flesh and blood, we have real live bodies that are ours, and that hold and love our children. There is no such thing as a non-biological person. But reading the book was really worthwhile, and one of the things that struck me was the difference in a mom's experience when she had not had a breastfeeding relationship with her baby. I wanted our roles in caring for our baby to be defined as little as possible by who gave birth to him, and for us to be able to give the same kind of comfort to him. As we started reading more, I got pretty attached to the idea of breastfeeding and really hoped it would work out.

ME: What medications did you take to induce lactation?

SARAH: People sometimes say that birth control pills ‘simulate pregnancy.’ Another effect of this medication is to stimulate the development of breast tissue. If you haven't been through a normal female puberty and haven't had progestins in your system, birth control pills are necessary to help build milk ducts and glandular tissue. Estrogen increases during pregnancy, and then after birth it drops sharply.

I modified the Newman/Goldfarb protocol for induced lactation a bit, since I was already taking hormones. I started replacing my usual estrogen with birth control pills (Nortrel 1/35, each pill contains 1mg of a progestin and 0.035mg of synthetic estradiol) about six months before our baby's birth. Closer to the due date, I added half my regular dose of estrogen, and then stopped taking it after the birth. Two weeks after the birth I started pumping and taking domperidone. [Note: Domperidone is a drug generally used to control nausea, but has the side effect of increasing lactation output, often quite dramatically. Domperidone for breastfeeding support is an off-label use of the drug. It can be difficult to obtain for that purpose in some countries such as the US. In others, it is much more commonly available.]

ME: We know that breastfeeding works via a supply and demand system. If the baby does not take enough milk from the gestational mother, her body will produce less milk as a result. If the baby nurses more and demands more milk, the gestational mom will produce more. In the early weeks, the amount that a baby nurses and draws milk helps to determine the gestational mother's milk supply later on. Having the baby nurse from you, Sarah, would also increase your supply, since a healthy baby is more efficient than a breast pump at removing milk from the breast. What did you do after your baby was born? How did you protect your wife's milk supply while bringing in your own?

SARAH: We wanted my wife to breastfeed him exclusively for about the first 4-6 weeks so that she could establish her supply. I pumped during that time. After about the third day of pumping, I started to produce some milk. It was weird, because I was used to pumping and pumping and not getting anything. I looked down that day and there were tiny milky droplets, and they were firm, almost like wax. I kept pumping, and I kept getting that weird consistency, and then the next day, it was softer. It got thinner until it was just milk. I didn't expect it to come in like that - it didn’t come in all at once like my wife’s milk did after she gave birth. It came gradually and it took days before the first drop fell into the pump bottle. But it looked like milk, smelled like milk, and tasted like melted ice cream. You could put it in your coffee or whatever!

ME: How was your experience of latching your baby in the beginning?

SARAH: It probably helped that it wasn't his first attempt. He pretty well knew what he was doing. He’d been nursing on my wife since he was five minutes old. I did find that, especially when I was very full of milk, my breasts were not really soft enough to go into his mouth. Some lactation consultants recommend making a sandwich to help smush your breast into the baby's mouth, and I had to do that. When he was little, I don't think he could get my breast far back enough in his mouth to trigger the sucking reflex without quite a bit of help from me. But after a few months I didn’t have to do that anymore. My wife and I both had more issues with nursing early on than we do now, because when babies are so small, you can't really get very much [breast tissue] in and you have to hold their head at just the right angle.

ME: Yeah, it gets so much easier as they get bigger and stronger. How did you and your wife share nursing duties?

SARAH: When I started nursing, my milk came in quite slowly, so it didn't seem to have any effect on my wife's supply. I would pump every time he nursed on her, and at first, she would try to pump every time he nursed on me. That way we wouldn't be hurting each other's supply. After a couple of months, we stopped pumping. We were sharing nursing and had a freezer full of milk - we decided to just let it be. Neither of us had enough milk to keep him happy all day long, but we both stayed home from work for quite a while so it worked out well.

ME: How was the experience of co-nursing overall?

SARAH: The breastfeeding relationship with my son is so amazing, it's more wonderful than I ever imagined. I feel so connected to him, and he is so bright and independent and I think part of that is having such secure attachments to both his moms. Plus, it's incredibly convenient. I think all parents who can manage to do it should try. In the early months we got twice as much sleep because we were cosleeping and he just rolled back and forth between us to nurse when he needed to. ["Or half as much sleep", Sarah's wife joked.] Either of us could take him out for an afternoon without worrying about bottles or getting him back home in time for a feed.

Then when our baby was about six weeks old, my wife had to go to the hospital for surgery. She was there for almost a week.

ME: Wow, how lucky that you were both nursing then!

SARAH: It was really, really lucky. We didn’t get good breastfeeding support from the hospital. We had doctors insisting she not breastfeed because of medications when our midwife and lactation consultant knew it was fine. They gave us no support with pumping. I think that for a lot of moms a situation like that could have been the end of the breastfeeding relationship, and it was a huge help that we were both able to nurse him.

ME: Do you have any idea how much milk you ended up producing?

SARAH: It's changed over time. I'm working outside the home now. I was pumping at work for the first four months, but he’s nursing less now and I’ve stopped needing to pump. Our baby is eating solid foods really well now. He still loves nursing and when he comes home he really wants a feed. Back when we were full on breastfeeding exclusively all the time... when I woke up in the morning if I hadn't nursed a lot overnight, I could pump and get 4 ounces.

ME: That's amazing! Lots of gestational moms have trouble pumping that much.

SARAH: Yeah, I had a lot of milk! I didn’t expect inducing lactation to work so well. When my wife was in the hospital and he was nursing on me all the time, I did have quite a bit of pain. We sorted that out with our midwife who realized I probably had low-grade thrush, which makes everything very painful. At first, I thought, "It must just hurt to breastfeed this much." I found out that it wasn't normal and we fixed it.

ME: Are you still taking domperidone now?

SARAH: I tried to wean off domperidone. The dose you have to take to induce lactation is quite high. I slowly reduced my dosage. I found though that if I took less than four 10 mg tablets per day, then my supply really suffered. The protocols for induced lactation say that if you take domperidone, you will probably need to take it until you wean. It's not quite the same self-regulating supply and demand system as experienced by a gestational parent. Also, I'm taking half of my pre-breastfeeding dose of estrogen, which is not recommended while nursing because it can have a negative effect on milk supply. It is considered safe for the baby though.

As well, I'm currently taking one combination birth control pill that is mostly a progestin. A lot of literature says that progestin is not advised for trans women because there is supposedly 'no benefit' to it: it doesn’t increase breast size over estrogen alone. But that is not why I take it. When I was preparing to induce lactation [and taking progestins], my moods were so fantastic. I felt much more calm and loving, and I just really liked how I felt in myself. So, I decided after being just on estrogen for a while that I wanted to go back to having a progestin as well.

ME: Did you try to get help with lactation from any other care providers besides your midwife and endocrinologist?

SARAH: I wrote to La Leche League through their web site where you can send a message to a local volunteer. I asked if they knew anything about what we were trying to do. The response I got back was from somebody saying I didn't have real breasts so I obviously couldn't breastfeed. It was from somebody definitely not educated about trans issues. I think this is actually quite commonplace among health care providers, too. I don’t know what goes on in some people’s heads about trans women - I guess they think we all strap on rubber boobs or something? Yet some feel qualified to give medical advice in spite of their total lack of knowledge.

ME: People also focus so much on the amount of milk that is made and not on the relationship. So what if you didn't produce a drop of milk?

SARAH: Yeah, exactly. People should be supported to breastfeed however they can do it. I think it's a shame that so many people don't think about trans people's bodies being capable of breastfeeding, and that they don't consider and value the breastfeeding relationship. They think it's just about gestational moms and that no one else can do it. That presents two problems: how they think about breastfeeding, and how they think about trans people as well. Health care providers need to be more flexible and help trans people have more control over our own healthcare. We deserve to have the same choices that most other people have when it comes to our fertility and to caring for our children.

Big thank you to Sarah for sharing her thoughts and experiences with us! Read the next post in this series on trans women and lactation - I spoke with lactation consultant, Mary Lynne Biener, and Dr. Jack Newman from the International Breastfeeding Centre in Toronto, and with Diana West, IBCLC.

Read my interview with Jenna, another trans woman who breastfed her baby.

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The Gay, Breastfeeding HOCKEY Dad?

Last week we celebrated our son's second birthday! We've been breastfeeding for two years.

Jacob is still dedicated to 'nay-nay.' He asks to nurse frequently throughout the day, always nurses to sleep for his nap, and still breastfeeds many times during the night.

His other main passion is hockey! We play hockey every day, inside and out, we read hockey books, and watch hockey videos on YouTube.

How did the gay, breastfeeding dad end up with such a hockey-loving son, you ask? A few months ago, we took Jacob swimming at a sports complex that also had a hockey rink. On a whim, we wandered in to watch the game that was going on, and our kid has been hooked ever since. That day, he watched the big kids playing and hitting the boards. He eagerly called out, "Owee! Crash!" and immediately learned the words 'hockey,' 'puck,' 'net,' and 'goal.' He sobbed in anguish, toddler-style, when the game was over and it was time to go home.

Another word my son shouts during hockey games is 'nay-nay.' When he sees a player take a hard fall, he insists the guy should nurse. It's what makes sense to him. I've nursed Jacob several times when we're both wearing skates and parkas following owees of his own on the ice at our community club.

I have a feeling that both hockey and nursing will be with us to stay for quite a while, and I'm curious to see how that will play out. These days, I get approving smiles from the macho hockey dads who see us at the ice rink. "He just loves it!" I tell them. They respond with, "It's good to start 'em young! Good on ya." We do some skating on our own and then usually find a place to nurse for a bit to recover from the cold. So far no one's noticed.

I'm trying to imagine nursing Jacob in a year or two amongst the other hockey dads after he's cut his lip in an 'owee crash.' I can't quite picture it yet, but I'm sure we'll find our way, and hopefully make some friends in the process.

 

Queering Arizona's Toilets

The Arizona state legislature is considering passing a bill that would prohibit a person from using a restroom that is not associated with the sex listed on his or her birth certificate. A large part of me feels like this is too stupid to bother blogging about. Another part of me can't stop laughing. My serious side is extremely concerned by the fact that, if this bill was to actually pass, transgender men and women in Arizona would likely face an increase in violence.

Perhaps a visual would help. Below is a photo of Buck Angel, a transgender man. Representative John Kavanagh, the genius behind this piece of legislation, is insisting that men like Buck should use the women's restroom.

Buck Angel

The basics of the proposed legislation is this: if you go to the "wrong" potty and get caught, you could be jailed for six months. The idea is ridiculous for a number of obvious reasons. Who will police and enforce this law? Will people have to show their birth certificates (not just their driver's licenses, even!) before they can pee? Yes, we could joke quite a bit here about the "potty police".

The terrifying aspect of this bill is that it would force already vulnerable trans women to use men's restrooms. As Ida Hammer from the Trans Women's Anti-Violence Project points out, violence against trans people is almost always committed against trans women. In 2009, 50% of lesbian, gay, bisexual, transgender, queer and HIV-affected (LGBTQH) murder victims were trans women. However, trans people only make up 1% of the LGBTQH population. Obligating trans women to use men's washrooms is asking for trouble - this forces them to out themselves and highlight their transgender identity in order to pee.

It is evident that Representative Kavanagh has no knowledge of the transgender community. He reportedly stated that "this law simply restores the law of society: Men are men and women are women." I believe that he thinks all transgender people are trans women in the midst of transition or who do not pass easily.

Kavanagh wants these women, the intended target of his legislation, to use men's facilities, presumably because he thinks that they look like men and are "actually" men. What he doesn't realize is that there are many trans women and lots of trans men who no one would ever suspect as being trans. For example, if I walked into a women's bathroom today (under Kavanagh's proposed law, I would have to - my birth certificate says female), I'm sure the women there would be rather surprised. The effects of testosterone therapy (facial hair, male pattern baldness, thickened vocal chords resulting in a deep voice, etc) are extremely powerful for most trans guys, who virtually always pass as male. Even though I stopped taking testosterone a couple of years ago to have a baby, I still pass (and identify) as male at all times.

Kavanagh's bill would result in queering washrooms, not straightening them out. Trans men who are indistinguishable from cisgender (non-trans) men would have to use women's bathrooms. Hence, Kavanagh wants Buck Angel in the ladies' room. In a certain way, I think this could be great! If trans men were to obey such a law, the general public would suddenly realize just how many trans people there really are and how "normal" we look (not to mention that we all have to pee, just like everyone else). It's hilarious to think that Kavanagh's bill would inadvertently turn restrooms into mixed gender spaces. I've often thought that doing away with gender-segregated restrooms would be nice.

Using a Supplementer Long-Term

I've been thinking about this post for ages and was finally inspired to sit down and write it when someone asked me for advice on the matter. So, thank you for the question!

On demand, supplemented nursing sessions with a newborn or young baby seemed obvious enough. When Jacob was hungry, we fed him. When he wanted more, we gave him more. I almost always used supplement during our nursing sessions.

When we introduced solid foods, we assumed that food would take the place of some of the donated breast milk we were continually struggling to find. To our surprise and dismay, it didn't seem to work that way. Jacob took a long time to really get good at eating solids, and even once he did, he never seemed to want any less milk. I sometimes tried to nurse him without using supplement, but he strongly preferred the fast flow that he was used to. Some people suggested not using supplement at night, yet I found that if I didn't he would get increasingly frustrated until he was wide awake. If I used the supplement, I could get him back down to sleep much more easily in the middle of the night (not that it has ever been easy, per se...).

I casually asked friends what they thought I should do, and several pointed out that if a parent with normal milk making capacity nurses frequently, he or she will continue to produce plenty of milk even as the child gets older. In contrast, a La Leche League Leader explained that as the baby gets older, the parent's milk supply naturally decreases. Others noted that babies who were bottlefed typically still get, even as toddlers, a large bottle of milk before going to bed and another one for nap time.

Around the time I was trying to figure out how to proceed, I saw a post in my parenting group from a mom of a 14 month old baby. She was newly pregnant, and her milk supply had disappeared. Her 14 month old still badly wanted to nurse, but this was painful for the mom. They went through a challenging weaning process and the mom started giving bottles of donated breast milk. Her child needed both the milk and the nursing relationship, but it was not possible for her to give. They did the best they could under the circumstances.

I know of another parent who, like myself, is breastfeeding after having had chest surgery. She makes enough milk to have the occasional let-down, but does not have a full supply. Her toddler is two and a half years old and nurses a lot AND gets a significant amount of milk in bottles. Early on, they used a supplementer, but they eventually got to a point where the child no longer wanted it. Their nursing relationship is still very strong.

In another example, the parent of a friend of mine used a supplementer due to her diagnosis of insufficient glandular tissue (IGT), and continued nursing until her child was three. As a toddler, the child would ask for "big milk" when she wanted to nurse using the supplementer, and "little milk" when she wanted to bare nurse. Given the variety of stories I'd heard, I decided to just keep doing what we were doing, since it seemed to work okay for both of us. We switched to putting cow's milk in the supplementer when we could no longer get donated human milk, with no apparent ill effects.

The issue came up again last fall when Diana West came to Winnipeg for a conference. She is the author of Defining Your Own Success: Breastfeeding After Reduction Surgery, and, of course, she is an expert on at-breast supplementation. She stayed with us for a few nights, and was shocked to see just how much supplement we prepared to take to bed with us in the evenings. I felt so busted! If I remember correctly, the much-admired breastfeeding authority said that Jacob doesn't need much milk at this point - it is the nursing relationship that he wants and needs. She reminded me that he was getting some milk from me. She also enthused about how much easier my life would become if I no longer needed to carry supplement around on outings or take it with me to bed at night.

I tried harder this time to wean ourselves from our crutch, but with the same result as before. If I didn't use the supplement, Jacob would quickly get frustrated. The universal and incredibly irritating toddler habit of nipple twiddling got infinitely worse (not surprisingly, this is something babies do to try to get a let-down!), and I again couldn't get him back to sleep at night. To add to the troubles, nursing without much coming out was quite uncomfortable for me, too. Jacob will be two in April, and this is where things stand: we still use lots of supplement at night, during naps, and to re-connect at other points during the day. Sometimes we go on outings without it and I nurse him as needed, but often I take it along for back-up, and then don't end up using it.

As Jacob's vocabulary increases, he is beginning to express how he would like to nurse. He says "nay-nay" for nursing, but also "milk" when he wants to use the supplementer. Sometimes he pleads with me "up!" and "fridge!", until I get up and grab the supplement from the fridge. Other times I ask him if he wants me to get the extra milk and he shakes his head "no" while he is latched on. Ultimately, Diana and everyone else said that we have to do what works for us, and I couldn't agree more. We'll let you know as we go.

Trans Kids and Reproductive Choices

Trans kids today have new options for transition. Few people even know about these possibilities, although awareness is increasing. In my own pre-teen years, I noticed that my girlfriends were starting to change, and I felt different from them. In my private, inner thoughts, I believed I should be a gay boy, but that seemed so very far from what was possible in reality that I wondered from time to time if I was crazy. I didn't know about the existence of transgender people until I was an older teenager, and even then, I had no idea that trans kids could access any kind of specialized medical help.

Photo: Visit Cape May (Creative Commons)

Hormone blockers have long been used to delay the development of secondary sex characteristics in children experiencing precocious puberty. More recently, paediatricians have started prescribing them for trans kids. This prevents a female-to-male (FtM) trans boy from growing unwanted breasts and experiencing other pubescent changes. In the case of a male-to-female (MtF) trans girl, the blockers halt all the powerful effects of testosterone, including deepening of the voice and changing of the face shape. At age 16 or 18, depending on who you're talking to, patients can begin taking synthetic hormones so that they will develop the secondary sex characteristics of their intended gender, or they can take nothing and develop according to their genetics.

The effects of the hormone blockers are completely reversible. Nevertheless, if an FtM teenager takes them and then takes testosterone as a young adult, his female sexual organs will not mature. I don't know if they would ever mature if he stopped taking the testosterone some years later. Testosterone use in FtM trans guys who transitioned after puberty can cause female sex organs to atrophy, and may also result in polycystic ovary syndrome (PCOS), which can lead to permanent infertility. I haven't been able to find good information concerning its effect on individuals who used hormone blockers and never produced natal hormones.

If I'd known about hormone blockers and the possibility of transitioning earlier in my life, would I have done so? I don't know. I didn't have the social supports necessary for transition at that time. It's hard to separate such a support system from an individual's emotional readiness. I wonder if I may have been much happier earlier in my life if I'd been able to transition as a teenager. I don't know if the choice would have been as clear for me at age 12 or 14 as it was at 23.

If you had asked me when I was ten years old if I thought I would ever want to birth a baby, or even adopt one, I would have for sure said no. At age twenty and even twenty-four, I would have still said no. Nobody asked me. When discussing transition, I don't remember being asked by my therapist, family doctor or endocrinologist if I thought I ever would want to have kids. My surgeon definitely didn't talk to me about future breastfeeding. I'm guessing that most trans people and their health care providers assume that infertility is the price we pay for transitioning. Recently, some people have accused me of wanting to "have it all" - meaning the correct gender identity and my child. Well, isn't that what most others can enjoy?

I didn't contemplate having a relationship and a family until after I'd taken testosterone and had top surgery. I wasn't content enough before that to have any inkling of what I really wanted in that regard. Now, my son and my husband are the most precious parts of my life.

Do I think that trans kids shouldn't take hormone blockers so that they can maintain their reproductive potential? Do I think they shouldn't transition at a young age? No and no. Each individual has to make his or her own decision. Others can guess at how badly someone needs to transition and when, but only the person contemplating transition can really know. Some trans kids suffer from such severe gender dysphoria that they are depressed and even suicidal. These children often feel that they need to transition as soon as possible. Others, like I was, can kind of manage by keeping very busy and not being terribly self-aware - they might not need to transition as urgently.

Sometimes I wish that I could wake up in the morning with a physiologically male body, but I would never trade my baby for anything. Most of the time, I enjoy traveling my unique path. I am comfortable enough with my male-sounding voice, my beard, and my flat chest. The parts of me that I don't love so much are what helped to make the family I love so deeply. This is my conundrum.

Malunggay: Breast Milk Super Vegetable

For those of us whose jeans are noticeably tighter as a result of endless holiday feasts, this is a post about an Asian super vegetable, called malunggay, that happens to be great for breast milk production. Ian and I need this more than most right now because we just returned from a trip visiting (and eating heartily with) Jacob's grandparents, after celebrating Christmas at numerous indulgent gatherings with our friends here in Winnipeg. It has all added up to way more meat, baked goods, and candy than we care to admit. We came home vowing to exercise more, eat healthier, and to avoid buying anything other than fresh produce since our pantry is overflowing with slimming foods like lentils and beans (nice that these foods have already been purchased - flying across the country was wonderful, but pricey).

Cooking malunggay into a curry

I first heard about malunggay when my dear friend and the very fancy author Diana West came to Winnipeg to speak at the Baby Friendly Conference in the fall. As a lactation consultant, she says that malunggay is her number one go-to food for increasing milk production. It is native to the foothills of the Himalaya and is sometimes called moringa, horseradish tree, benzolive tree, kelor, marango, mlonge, moonga, nébéday, saijhan, sajna or Ben oil tree. India is the largest producer of Malunggay, although it is also grown in the Philippines, Thailand, Taiwan, Malaysia, Africa, and Central and South America. Cultivation is in early stages in Hawaii for the US market.

Malunggay grows as a slender tree, with all its parts, including bark, stems, roots and leaves, being edible. The most nutritious part of the plant is the leaves, which contain, gram per gram, "SEVEN times the vitamin C in oranges, FOUR times the Calcium in milk, FOUR times the vitamin A in carrots, TWO times the protein in milk and THREE times the Potassium in bananas." A double blind study suggested that consuming malunggay leaves has a considerable positive impact on breast milk production.

Malunggay helps increase milk production

A number of companies include malunggay in capsules meant to increase one's milk supply, but I prefer to buy it fresh. I have found the leaves at several local Asian markets. I simply asked, "malunggay?" and got pointed in the right direction by someone who knew. The leaves are very versatile ingredients - they are wonderful in soup, but also delicate enough to be added fresh as a garnish to salads. One of the most traditional dishes that includes malunggay leaves is sour Thai curry.

Wish us luck with our New Year's resolution and let me know if you come up with your own great malunggay recipes. I'd love to hear them!