Enabling breastfeeding through the lens of gender affirmation

By Amy Weimer, MD, FACP, FAAP (she/her)

In my work as a primary care provider with expertise in gender-affirming health care, I recently had the gratifying opportunity to help my patient, a transgender woman, in her goal of breastfeeding her newborn baby. The patient felt it “would be a wonderful, personal experience, and it would be a great help for my partner,” who was carrying the pregnancy.

As family structures continue to diversify and fertility services become more accessible, a growing number of people are becoming parents without carrying a pregnancy. As a parent, the ability to nourish an infant with one’s own milk has many benefits – including bonding with the infant, providing optimal nutrition, and promoting better health in the nursing parent and infant. For some transgender and gender-diverse (TGD) people it may also have a profound effect on one’s gender experience.

The patient had been on estrogen-based hormone therapy for many years. To promote milk production, she was treated with a modification of her hormone therapy, additional medication (domperidone) to stimulate milk production, and mechanical breast pumping. She started the process about four months prior to the infant’s due date, and by one month prior to the due date was successfully producing five ounces of milk daily. After the infant was born, she co-fed with her partner, providing a combination of direct breastfeeding and expressed milk, which she continued until the infant was four months old. Details of the medication management, laboratory assessment, and outcomes are presented in a single accessible table.

Though it seemed intuitive that her milk would have typical characteristics for human milk, no prior publications addressed nutrient content of milk produced by a person on estrogen-based gender-affirming hormone therapy. Her milk was analyzed at the Human Milk Institute, and found to be robust in macronutrients – fat, lactose, protein and calories.

The patient describes her experience with this process as follows: “I found it both an emotionally fulfilling experience as well as a pragmatic one. I continue to feel heartened that I was able to do this for baby and have such a connection with her during her earliest days. It’s something that so many women do and definitely felt special to me. I was moved to learn that my breastmilk had good nutritional qualities, that I actually had fed her, even in a supplemental role. And it was also really convenient to be able to feed baby during the early weeks and months, especially at night, to make our routine smoother and make sure my partner could sleep better between the scheduled feedings.”

This patient experienced some common challenges faced by many lactating parents, including navigating insurance coverage for her breast pump, and finding time to pump with adequate frequency. However, there are additional, unique barriers that TGD people may experience when seeking to breast- or chest-feed. Access to medical care and social acceptance of sexual and gender minority (SGM) identities vary widely across the world, and many SGM individuals who may desire lactation support face insurmountable barriers as a result. Though this patient benefitted from receiving care in a state with explicit protections for gender-affirming medical care, expanding legislation which attacks the rights of TGD people across the United States increasingly threatens access to medically necessary care known to improve health outcomes. Additionally, it is well described that many clinical care providers have a lack of knowledge about caring for TGD people, which may result in non-affirming language or an inability to provide services.

This article serves to provide a clinical approach to inducing lactation for TGD people on estrogen-based hormone therapy, to reassure that such milk should adequately sustain infant growth, and to underscore the importance of this experience on a personal level.

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Article Details
Lactation Induction in a Transgender Woman: Macronutrient Analysis and Patient Perspectives
Amy K. Weimer, MD
First published online May 3, 2023
DOI: 10.1177/08903344231170559
Journal of Human Lactation

About the Author

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Amy Weimer, MD, FACP, FAAP (she/her) has served as the medical director for the UCLA Gender Health Program since its inception in 2016, wherein she provides primary care and hormone management for patients of all ages. Dr. Weimer is a dynamic educator, delivering lectures, case-based learning sessions, and direct preceptorship and mentorship to medical students, residents and other faculty, as well as broader audiences in the community. Her research interests involve patient-centered research on experiences within the health care setting; understanding and meeting patient goals; and optimizing effectiveness of gender-affirming hormone treatment.