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.

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.

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!

Winning the Milk Lottery

In celebration of World Milksharing Week 2012, Diana West, BA, IBCLC, contributes this post about her personal story involving her son’s extreme allergies. Diana experienced internet milk donation before the existence of Facebook-based networks. Her highly informative books, Defining Your Own Success: Breastfeeding After Reduction Surgery and The Breastfeeding Mother’s Guide to Making More Milk have helped many thousands of parents struggling with low milk supply and have great relevance to the milksharing community. She is also the co-author of the bestselling book, The Womanly Art of Breastfeeding, 8th ed. Watch for her upcoming book about sleep and the breastfed baby, co-authored with Diane Wiessinger and Linda Smith, to be published by Ballantine Books in July, 2013.

Through the years, I’ve shared my story about breastfeeding after breast reduction surgery with many people. I didn’t have enough milk for my first son, Alex, but I was proud to be able to provide about 2/3 of his daily needs with my own milk, which I was pumping exclusively because he had a nursing strike at three months that I hadn’t known how to get past. Unfortunately, we had discovered from several scary reactions that he was severely allergic to cow’s milk protein, so we had to use the uber-expensive hydrolysate formulas to take up the slack. The part of the story that most folks don’t know is that he was once the lucky recipient of 700 ounces of human milk that was given to us by a very special mother in New Jersey.

The way this came about was that I saw a posting on a breastfeeding usenet newsgroup – in 1995, usenet newsgroups were the way people connected online using very basic, non-website message boards (pretty primitive, I know! – but it was great at the time). One day when Alex was about six months old, I saw a posting from a mom who had a seven-month-old baby. She wrote that she had accumulated more frozen milk for going back to work than her baby could ever use and she wanted to give it to a mom who didn’t have enough milk and a baby who had a special need for it. She had also undergone extensive infertility treatments in order to conceive her baby, so she had negative test results for just about every communicable disease under the sun to prove that her milk was safe. She clearly expressed that she didn’t want any payment for the milk other than the good feeling that it was going to a mom and baby who really needed it. With my low supply and Alex’s severe cow’s milk allergy, we fit the bill perfectly. The only catch was that the recipient needed to be within driving distance of her home to be able to transport the large quantity of milk inexpensively without thawing. Fortunately, we lived only three hours away.

Hoping against hope and feeling like it was almost too good to be true, I responded to her post as soon as I saw it, telling her our story and how much we would value her milk. I was amazed and elated when she responded just a few minutes later, agreeing that we were the perfect match and choosing us to receive her milk. I felt like we won the lottery. Not only would this help Alex with his allergies tremendously – hydrolysate formula has pre-digested milk proteins that cause fewer allergic reactions, but Alex’s severe eczema was proof that he still reacted to it – it would also save us a lot of money because hydrolysate formula cost about four times the price of regular formula. I was a stay-at-home mom and my husband was just starting out in his IT career, so times were tough and the cost of the special formula was a real stretch for us.

Once it was confirmed that we had “won” the milk, the milk-rich mom and I emailed back and forth to figure out how to get the milk from her location in New Jersey to ours in Maryland. The biggest challenges were figuring out how to keep the hundreds of two and four ounce bags of milk frozen on the three-hour journey home. My husband Brad and I also had to think of a way to store them safely when our only freezer was the small one on top of our fridge that was already jam packed with food. And all the maneuvers had to include our six-month old baby and Brad’s work schedule since we didn’t have family nearby to help out.

The storage problem was solved by deciding to buy the deep freezer we’d always wanted anyway. It was a big expense for us in those days, but we knew it would give us a way to buy food in bulk so it would actually pay for itself in the long run. We solved the journey problem by working out that we could drive there on a Saturday afternoon with baby Alex and lots of toys to entertain him (this was before DVD players and iPads!), pick up the milk bags, put them in several large insulated coolers that we borrowed from friends, stay long enough to visit with the family and thank them properly, and then drive back home fast enough without breaking any speed limits to put the milk in the new deep freezer before it thawed.

As it turned out, on the morning of the trip it took us forever to get the car packed with Alex, his toys, the many coolers, and everything else we needed for a day away from home with a little baby and an exclusively pumping mom. By the time we hit the road, we were running several hours behind, which kept the New Jersey family waiting anxiously for our arrival. The whole family had dressed up and readied their home for our visit, and while they waited and waited for us to get there, the older kids rode their bikes up and down their road looking for our car. We felt like such newbie, inefficient parents to keep them waiting like that, but they were so sweet and welcoming when we finally arrived.

Milk siblings forever.

As a special (but very token) way to thank them, I had made up a purple t-shirt for Alex that said “Milk Brother” and one for her baby that said “Milk Sister,” based on the Islamic teachings that children who share a mother’s milk are considered siblings and not allowed to marry. (Neither of us is Muslim, but we liked the tradition.) The mom loved the shirts. We put them on the babies and let them crawl around each other in her back yard while we snapped pictures. Then both families went out to a nice dinner and basked in the good feelings of their altruism and our deep gratefulness. Afterward, we loaded all the milk into the insulated coolers and started the urgent (but not speeding!) drive home. We made it back in good time and got all the milk safely into its new home in the deep freezer.

I don’t remember how long the milk lasted, but because he was so severely allergic to cow’s milk and many other foods, Alex needed milk and formula until he was nearly two. So we stretched those 700 ounces out as long as we could and always felt so happy each time we could use human milk instead of the expensive and horrible smelling hydrolysate formula. Eventually, the deep freezer bought just for the milk became more and more empty and we began filling it up with frozen vegetables and other foods. Alex is now almost 17 years old, and shaving and driving if you can believe it (and very embarrassed that I’m blogging about this). The milk and his need for it are long gone, but we still have the deep freezer and we’ll always have the warm and wonderful memory of a mother in New Jersey who shared her milk bounty to help our baby.

Yoga for Breastfeeding

I practiced yoga throughout my pregnancy, including headstand.

Half-moon pose helped alleviate back pain as well as nausea.

Did you know that yoga can have a beneficial impact on breastfeeding? While tight or ill-fitting bras (not that as a post-surgery transgender man I have anything to do with those, ha!) can damage breast tissue and inhibit the flow of milk, yoga can improve circulation in the chest and help the body to produce more milk. At least Diana West says so anecdotally in her book Making More Milk, and so does Geeta Iyengar in her impressive, enormous, virtually biblical, Iyengar Yoga for Motherhood - from personal experience, I agree with them both. I finally went again to a yoga class this week after an absence of almost a year (time well spent constantly breastfeeding Jacob - I just never felt like leaving him for long enough to go to a class).

I am far from an expert, but I did practice Iyengar Yoga for a few years before having Jacob. The Iyengar method is careful, thoughtful, and thorough. Geeta's book includes meticulous descriptions of poses to be done, and not to be done, in each trimester. Some sequences are said to alleviate pregnancy-related headaches, others are for treating nausea, others for dizziness, still others counteract high blood pressure. And, again in my personal experience, they work.

I began my yoga studies before I transitioned. I wanted to try a different physical activity in my new hometown of Winnipeg that I could do completely away from my new work colleagues. At the end of my second class I left the Yoga North studio only to see a man from my job, whose face was only vaguely familiar to me, rushing in just in time for the next session. Ugh! I came here to get away from you, I thought. Then I married him three years later. But that's a story for another time.

I kept going to the yoga studio despite Ian's presence there. At the end of my first year, I was ready to transition to male. I thought about quitting yoga - I wasn't sure I'd be at home in either the men's or the women's change room. A large and varying population of clients attend the studio, some of whom I know reasonably well and some I don't. I talked to the instructor, Drew, about my plan to transition, and he didn't see any problem at all. He didn't want me to stop attending class and said I should simply use the men's change room. He told the other instructors about my situation so that no one would be confused. When a number of my fellow students learned of my decision, they gave me a congratulatory card and a fancy razor, an incredibly kind though useless gesture since I maintained a terrible scruffiness and pretty much never shaved (and still don't). I felt completely welcome.

A few years later, in my second trimester of pregnancy, my back and hips started to ache. I didn't go to yoga because this time I really didn't believe there was any way I could stomach being seen in my unusual (for a man, anyway) state by the other students who ranged from friends and acquaintances to complete strangers. Ian mentioned my shyness to Drew, who immediately came up with a plan to teach me one on one. In the months that followed we worked together once a week right up until Jacob was born.

I am certain that these classes saved me from much discomfort during the pregnancy and helped me get through the hard work of a long labour. They also put more food in Jacob's belly. I worked with another instructor, Lisa, on creating space and lift in my chest. In addition to being an experienced teacher who has studied frequently in India with the Iyengar family, Lisa has practiced yoga through two of her own pregnancies. On days that I worked with her, I was able to express twice as much colostrum as usual. I diligently saved the precious liquid in syringes and stored it in the freezer in anticipation of Jacob's birth, fully aware that milk production would be an issue for me due to my chest surgery. Thank you Geeta, Lisa, and Drew for helping me to feed my baby in his early days some of the best food in the world.