ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients
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BREASTFEEDING MEDICINE
Volume 15, Number 5, 2020 ABM Protocol
ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2020.29152.rlf
ABM Clinical Protocol #33:
Lactation Care for Lesbian, Gay, Bisexual, Transgender,
Queer, Questioning, Plus Patients
Rita Lynne Ferri,1 Casey Braitsch Rosen-Carole,1–3 Jason Jackson,1,2 Elizabeth Carreno-Rijo,1,2
Katherine Blumoff Greenberg,1–3 and the Academy of Breastfeeding Medicine
Abstract
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A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing
common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for
the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as
standards of medical care. Variations in treatment may be appropriate according to the needs of an individual
patient.
Definitions B Transgender (adj.): Describes a person whose gen-
der identity and assigned sex at birth do not corre-
Several sources have defined terms related to LGBTQ+
spond. Also used as an umbrella term to include
health. In this study, we reference the University of Cali-
gender identities outside of male and female.
fornia San Francisco Transgender Care and Treatment
Sometimes abbreviated as trans.
Guidelines1 and the National LGBT Health Education Cen-
B Queer (adj.): An umbrella term used by some to
ter’s glossary of terms.2 However, it is important to note that
describe people whose sexual orientation or gender
terminology is fluid and community specific. In countries
identity is outside of societal norms. Some people
speaking languages other than English, these terms may have
view the term queer as more fluid and inclusive than
adaptations, or may be irrelevant entirely. Consulting with
traditional categories for sexual orientation and
members of LGBTQ+ advocacy communities in such areas,
gender identity. Owing to its history as a derogatory
where possible, may be helpful to ensure that language is
term, the term queer is not embraced or used by all
respectful and inclusive.
members of the LGBT community.
LGTBQI+: A term for people who identify as lesbian B Questioning (adj.): Describes an individual who is
(L), gay (G), bisexual (B), transgender (T), queer (Q), unsure about or is exploring their own sexual ori-
questioning (Q), and people with other diversities in entation and/or gender identity.
sexual orientation and gender identity (+). There are a B ‘‘+’’/Plus: The plus sign represents the ever-
variety of these terms internationally with their own growing list of terms people use to describe their
acronyms. This term is meant to be inclusive. sexual orientation or gender identity. There are
B Lesbian (adj., noun): A sexual orientation that de- many different variations of the LGBTQ+ acronym,
scribes a woman who is emotionally and sexually and the ‘‘+’’ acknowledges that it is not possible to
attracted to other women. list every term people currently use.
B Gay (adj.): A sexual orientation that describes a Affirming care: Refers to care that supports a patient’s
person who is emotionally and sexually attracted to gender identity, and must include inclusive terminol-
people of their own gender. It can be used regard- ogy, practices, insurance coverage, and knowledgeable
less of gender identity but is more commonly used providers.
to describe men. Affirmed pronouns and name: Pronouns and name that
B Bisexual (adj.): A sexual orientation that describes are chosen by the individual and, therefore, best rep-
a person who is emotionally and sexually attracted to resent their gender identity. People in the LGBTQ+
people of their own gender and people of other genders. community may have changed their name and gender,
1
University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
Departments of 2Pediatrics and 3Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester,
New York, USA.
284ABM PROTOCOL 285
informally or legally, to those that affirm their true and stigma, including in medical interactions.6,7 Their med-
gender identity. ical care is often inadequate, ranging from a failure of health
Assigned female at birth, assigned male at birth: These care professionals to recognize their unique needs (e.g., in
terms refer to gender assignment at birth medically and sexual and reproductive health care), to the enforced use of
socially, generally based on genital anatomy. These heteronormative procedures (e.g., registering a trans man as a
terms may be abbreviated (AFAB, AMAB) to com- woman in their medical record).6 In many regions of the
municate birth anatomy in medical documentation. world, families who had been unable to raise children be-
Cisgender: Someone whose gender identity aligns with cause of their gender identity and/or sexual orientation now
the gender assigned to them at birth. For example, have the opportunity to become parents. This is largely due to
someone who was AFAB who identifies as a woman. the liberalization of adoption policies, along with advances in
Chestfeeding: A term used by many masculine- fertility management, surrogacy, and transition-related health
identified trans people to describe the act of feeding care for transgender individuals. Pregnant people and parents
their baby from their chest, regardless of whether they who identify as LGBTQ+, therefore, need access to nontra-
have had chest/top surgery (to alter or remove mam- ditional lactation supports that may be unfamiliar to health
mary tissue).3 care providers. In particular, barriers to lactating LGBTQ+
Colactation: When more than one parent breast/ individuals include confronting highly gendered assumptions
chestfeeds their child. in the world of childbirth, effects of transition (e.g., hor-
Gender-affirming surgery: Surgeries specific to trans- monal, surgical), impacts of induced lactation, colactation,
gender people include feminizing and masculinizing and hospital considerations. The Academy of Breastfeeding
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procedures that align secondary sexual characteris- Medicine (ABM) seeks to provide guidance to those caring
tics with a person’s gender identity. These may in- for individuals who identify as LGBTQ+.
clude facial, voice, genital, and hair removal/addition
procedures. Background and the Importance of Language
Gender-expansive, genderqueer, nonbinary: All differ-
When concerned about discrimination in health care set-
ent terms for a broad category of gender identities in
tings, patients frequently do not self-disclose their LGBTQ+
which the individual identifies outside of a binary con-
identities.6,8 Transgender patients, in particular, have a his-
cept of gender (binary meaning ‘‘male’’ and ‘‘female’’).
tory of experiencing discrimination and even violence in
This can mean identifying as both feminine and mas-
health care settings.9 In one U.S.-based study, one-third of
culine, or as neither.
transgender individuals reported having at least one negative
Gender identity: A person’s innate sense of their own
health care experience. In the same study, nearly one-third of
gender. It does not necessarily correspond to anatomy,
individuals reported that none of their health care providers
sex assigned at birth, or how someone expresses them-
knew their gender status.6 This has implications for delayed
selves. Examples include, but are not limited to, cis
diagnosis and treatment, such as the possibility of a missed
woman, cis man, trans man, trans woman, nonbinary,
ovarian torsion or tumor in a transgender man or undiagnosed
gender expansive, and gender ‘‘fluid’’ (as opposed to
prostatic disease in a transgender woman.10,11 At its most se-
‘‘fixed’’). Not the same as sexual orientation (see
vere, discrimination by health care providers has led to
hereunder).
patient deaths from potentially treatable illnesses due to the
Gender incongruence, formerly ‘‘gender dysphoria’’ or
refusal of providers to care for transgender individuals.12,13
‘‘gender identity disorder’’: Incongruence between an
Although the terms introduced previously may be unfa-
individual’s experienced or expressed gender and their
miliar to some providers, recognizing and affirming patients’
assigned sex.4 Dysphoria refers particularly to suffering
names, pronouns, and family members are a cornerstone
as a consequence of this incongruence.
of providing affirming care for patients who identify as
Heteronormative/cisnormative: the assumption and/or
LGBTQ+. Traditionally, health professional education has
preference of individuals and institutions that every-
contained little to no content related to caring for patients
one is heterosexual and cisgender. This leads to invis-
who may be LGBTQ+ identified. As a result, LGBTQ+
ibility and stigmatization of people in the LGBTQ+
communities have been marginalized in health care systems
community.
and settings. Experiences of stigma and discrimination, both
Transition: The process and time during which a person
in and outside of health care contexts, have led to both severe
assumes their affirmed gender expression that may or
psychological pain and disparate health outcomes. This is
may not include legal, medical, or surgical components.
most extreme in areas of sexual, reproductive, and mental
Sexual orientation: The aspect of someone’s identity
health. Affirming health care, including using affirming
that refers to the gender(s) of the people to whom they
names and pronouns, and recognizing individual patients’
are attracted. Examples include, but are not limited to,
families and communities, can help to mitigate the effects of
homosexual, lesbian, gay, heterosexual, bisexual, asex-
stigma and improve health.14
ual, and pansexual.
General Considerations
Purpose Outward appearance may not match gender identity.
Children raised by LGBTQ+ parents are well adjusted and Do not assume that a female-appearing individual iden-
healthy, and in such families children thrive.5 Despite this, tifies as female, or is interested in breast/chestfeeding.15
people who are transgender and/or whose sexual orientation Ensure that people are addressed by their affirmed
is not heterosexual frequently experience misunderstanding names and pronouns. To know, one needs to ask.286 ABM PROTOCOL
B Introductions to a patient can include a provider’s - displaying affirmed, rather than legal, names and gender
own pronouns, which may make the patient feel on documentation such as printed schedules and patient
more at ease sharing their own. (e.g., ‘‘My name is wristbands,
Dr. X, I use she/her pronouns.’’ - avoiding gendered prefixes and pronouns when some-
B Predominantly masculine pronouns = he/him/his/ one’s gender is unknown (e.g., use a patient’s given first
himself and last name, or another nongendered culturally spe-
B Predominantly feminine pronouns = she/her/hers/ cific form instead of Mr./Ms. X).
herself
B Gender-neutral pronouns = they/them/theirs/them- Effects of Transition-Related Health Care
selves; Ze/Zir (Hir)/Zirs (Hirs)/Zirself (Hirself). on Pregnancy and Breast/Chestfeeding
Patients may also use different terms for parenting
(mom/mum, dad/father, parent, etc.) and lactation Transgender and gender expansive individuals may seek
(breastfeeding, chestfeeding, lactation, etc.). It is most out gender-affirming medical and/or surgical treatment to
respectful to ensure that patients have the opportunity help align their physical appearance to their gender iden-
to identify which words they would like to use for their tity. These therapies can begin in early adolescence for the
visit at the beginning of the visit. purpose of pubertal suppression. Hormone therapy for
Misgendering, or calling a patient by a name, pronoun, transgender individuals is typically either masculinizing or
or parenting term other than their affirmed name/ feminizing.
pronoun, is hurtful to the patient. When done inten- Pubertal suppression and timing of gender-affirming
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tionally, it may sever the patient/provider relation- treatments: gonadotropin releasing hormone agonist
ship and put the patient’s health at risk. When done (GNRHa) therapy may be used in carefully selected early
unintentionally, it is recommended to acknowledge the adolescents to temporarily halt the development of sec-
mistake, correct the pronoun, and continue with the ondary sexual characteristics to lessen gender dysphoria
visit using the correct pronouns and name. It is best that and allow time for decisions to be made concerning
the mistake be acknowledged so that the individual gender-affirming treatments. The use of GNRHa pauses
feels respected, but prolonged attention on the mistake the development of irreversible secondary sexual charac-
may take the focus off of providing appropriate and teristics, but also prevents maturation of primary oocytes
affirming health care. and spermatogonia.19 For adolescents who move from
GNRHa therapy on to cross-gender hormones, no current
Creating a Respectful Health Care Environment studies address the possibility of future fertility.
For transgender people who want to preserve their
There are many opportunities for health care systems,
fertility and/or breast/chestfeeding capability, deciding
hospitals, and clinics to provide affirming care to LGBTQ+
when to start gender-affirming treatment can be diffi-
individuals. Provider and staff mistakes surrounding an in-
cult. For example, delaying gender-affirming female-
dividual’s gender or sexual orientation can be minimized
to-male chest reconstruction (‘‘top’’ surgery) for a trans
with increased training and by having inclusive systems and
man until after the completion of breast/chestfeeding
documentation. For example, intake forms should be updated
may prolong his distressing gender dysphoria for many
to include more options for gender, pronouns, and sexual
years.3 In addition to the risk of continued gender
orientation. ‘‘Male’’ and ‘‘female’’ assigned bathrooms may
dysphoria, another challenge is the lack of data on the
pose a problem for gender-expansive or transgender people.
effects of postpubertal hormone therapy on fertility,
It may force an individual to use a bathroom that is less ac-
including the thresholds for causing infertility.19,20
cessible or unsafe, instead of using one that aligns with their
Fertility preservation is a growing field, and new
gender identity. Some countries have laws that prevent
methods are being investigated.19 Various forms of
transgender people from using bathrooms that align with their
fertility preservation exist (i.e., testicular sperm ex-
gender identity, which poses a safety and violence risk for
traction and banking, oocyte harvesting and banking,
transgender people.16 Having gender-neutral bathrooms
and ovarian tissue cryoprecipitation) and should be
(or single-user) mitigates these concerns and is an important
discussed with individuals before starting therapies that
aspect of respectful care. Displaying signs or statements
may affect fertility.19,21,22
of inclusivity is a subtle, but impactful way to acknowledge Feminizing treatments and practices: Hormone therapy
individuals with gender and sexual diversities.17,18 Patient
for trans women and transfeminine people typically
confidentiality is another cornerstone to LGBTQ+ care, as
includes an estrogen and antiandrogen (such as spir-
family and friends of a patient may not be aware of their
onolactone), and may also include a progestin. Estrogen
gender identity and/or sexual orientation. Disclosing this in-
therapy will induce breast tissue development.21,23,24
formation may compromise the patient’s safety. It is, there-
There is one case report and many anecdotal reports
fore, important to ask the patient how much you can disclose if
of trans women inducing lactation (see Induced Lacta-
you need to talk to other people in their lives. Although not a
tion and Colactation section) and producing human milk.
comprehensive list, other considerations include:
Breast augmentation in trans women may mask inade-
- consideration of the name of the clinic or organization quate mammary tissue development or result in pressure
in which people seek care (avoiding gendered terms atrophy of remaining tissue. It may also increase the risk
such as ‘‘women’s,’’ ‘‘maternal,’’ and ‘‘moms’’ in favor of engorgement during induced lactation.
of more inclusive terms such as ‘‘parent,’’ ‘‘prenatal,’’ Masculinizing treatments and practices: Testosterone
‘‘pregnancy,’’ ‘‘reproductive,’’ or ‘‘lactation’’), therapy for transgender men or transmasculine peopleABM PROTOCOL 287
suppresses endogenous estrogen production that can re- B conceive through penetrative (penis in vagina)
sult in atrophy of estrogen-responsive breast tissues.25 intercourse, intrauterine insemination, or in vitro
Trans men who are gestational parents generally must fertilization;
suspend testosterone therapy during pregnancy. This B use sperm donation (formal or informal); or
suspension may be continued in the postpartum period B use egg donation from a partner or donated egg.
if lactation is desired. In addition, trans men may
practice chest binding (using a tight compressive gar- Induced Lactation and Colactation
ment or bandage to flatten the appearance of the chest).
Some LGBTQ+ parents may desire to induce lactation,
This may result in compression atrophy, worsen en-
which is to start the production of milk in the absence of a
gorgement, or lower milk supply. Finally, trans men
pregnancy. There are many anecdotal reports and one case
who have undergone ‘‘top’’ surgery may or may not
report of a trans woman (AMAB, on hormone replacement
have the ability to lactate. Surgical techniques for
therapy) successfully inducing lactation.33 Regarding in-
‘‘top’’ surgery vary widely from a bilateral total mas-
duced lactation in LGBTQ+ parents, we recommend the
tectomy with resection of the nipple areolar complex
following based on our experience and the limited published
(NAC) to utilization of reduction pattern techniques
information:
with preservation of the NAC on an intact neurovas-
cular pedicle. These techniques can result in differences Do not assume that a person with breasts will know
in residual mammary parenchyma among individuals. that inducing lactation is an option, nor that they will
Furthermore, if the nipple is completely removed and desire to induce lactation. Rather, provide information
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reattached, the ductal anatomy is less likely to regen- on its possibilities and ask open-ended questions,
erate and allow for lactation, as opposed to when it is such as, ‘‘What are your thoughts about feeding your
preserved.26 Modern NAC tattooing techniques may child’’ and ‘‘What have you considered about inducing
give the appearance of a native NAC, but the results are lactation?’’
cosmetic only. Counsel the family about stress and maintaining mental
Gender dysphoria as a result of lactation care: Any health and relationships.34 Inducing lactation can be
treatment that alters the hormonal milieu of trans pa- difficult and takes time and effort, which may increase
tients may increase their gender dysphoria. This may be a family’s stress level.35 In addition, there is no pub-
added to any suffering they experienced as a result of lished research on the frequency of success. Parental
fertility and pregnancy care. For instance, when a trans stress has neurodevelopmental consequences for their
man gestates, he will have hormonal changes from children, and any benefit of human milk must be
suspending testosterone therapy and from the preg- weighed against this risk.36
nancy itself, which may be stressful, and he may have There exists no standard guidance on inducing lactation
negative emotions related to his chest changes. Being for any patient population. Different methods have
sensitive to the experiences of patients means sup- been used for inducing lactation, including visualiza-
porting them in their decision to resume gender- tion/meditation, expression by hand or pump, feeding
affirming hormonal treatments after birth, including at the breast/chest, and combinations of oral contra-
decisions not to lactate. ceptive use followed by hormone withdrawal combined
with galactogogues and expression (see ABM Protocol
Fertility Options #9 ‘‘Use of Galactogogues in Initiating or Augment-
ing Maternal Milk Production, Second Revision
Reproductive options for LGBTQ+ individuals vary de-
201837).33,35,38
pending on the personal preferences of the individuals in- Inducing lactation may present more of a challenge for
volved, their and their partner’s gonads and reproductive
transgender individuals. In these cases, one can gen-
organs, past or current therapies that may affect fertility,
erally refer to three components: hormonal priming of
access to reproductive endocrinology and infertility special-
the mammary tissue, prolactin promotion, and hormone
ists, finances/insurance coverage, and local legislation.27,28
withdrawal with expression.
Fertility and child-bearing goals vary greatly from individual
B Priming: Hormonal priming of the mammary tissue
to individual, so assumptions must be avoided.29–31 Although
in nongestating people AFAB generally involves a
these can be sensitive topics and providers may be uncom-
combined oral contraceptive with estrogen and
fortable with their own knowledge, it is important to provide
progesterone (e.g., ethinyl estradiol and norgesti-
information on the possibilities and be informed about local
mate), taken continuously for months without a
resources and legal restrictions. Patients may be hesitant to
menstruation phase (placebo pills). Patients AMAB
bring up their goals or questions out of fear of discrimination
who have transitioned will likely already have a
or violence.6,29 As a result, parents and infants may suffer
medication regimen including estrogen, progester-
poor outcomes during this vulnerable time.
one, and an androgen blocker (often spironolactone)
If neither partner has child-bearing potential or nei- if they have not had a bilateral orchiectomy. De-
ther partner desires to carry a pregnancy, their options pending on the length of treatment, patients will
include surrogacy (formal or informal, with sperm or egg have growth of mammary tissue. When patients
from one or both partners or from a donor) or adoption.32 desire to induce lactation, it has been assumed that
If at least one partner has child-bearing potential (i.e., the hormonal milieu of pregnancy should be ap-
has a uterus and appropriate hormonal milieu) and proximated for a similar period of time as in in-
desires to carry a pregnancy, they may: duced lactation with nongestating people AFAB, or288 ABM PROTOCOL
3 to 6 months. Doses of estrogen and progesterone 1. Discuss expectations and goals
may be increased gradually as tolerated to 8–12 mg Inform parents that colactation experiences are
estrogen and 400 mg progesterone daily during the unlikely to decrease the workload for the gesta-
stimulation phase as in the Reisman case report.33 tional parent. This may be a misconception about
Risks, especially of blood clots with high doses of colactation.
estrogen, should be discussed. Laboratory testing Other duties (including chores, work/income, and
for serum levels has been done but may or may not infant care) should be discussed and any family/
be useful in guiding therapy. A more useful guide community resources available should be identi-
may be a patient’s symptoms of breast/chest chan- fied, especially for the first 2 weeks after birth.
ges. At this phase, many providers will recommend Discuss parental goals for colactating. Some spe-
stimulation of the nipples and areolae and gentle cific questions for parents to consider are: who will
hand expression one to three times per day. do skin-to-skin at birth, who will feed and when,
B Prolactin promotion: Prolactin promotion is gener- and how will multiple milk supplies be maintained?
ally achieved with galactogogues and may be used Appendix A1 offers a sample colactation plan that
during the hormonal stimulation phase (above) or can be adapted for individual parents and may be
the expression phase (below). Traditional induced created and shared with providers before birth.
lactation protocols use these medications through- 2. Support milk production and infant health
out the induced lactation process, although this is All lactating parents will need to maintain a milk
not evidence based. Domperidone has the strongest supply by feeding or expressing milk.
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evidence for successful lactation promotion, and the Support milk production in all lactating parents
only published case report of successful induced with removal of milk six to eight times per day
lactation is in a transgender woman who used this and galactogogues, as detailed in ABM Protocol
medication.33 It is not FDA approved for use in the #9.37
United States. Metoclopramide or herbal galacto- When possible, consider prioritization of colos-
gogues may also be attempted. Cost, risks, and side trum feeding with the gestational parent, given
effects of some treatments may limit a patient’s the individuality of colostrum for the neonate.
ability to take these in the long term. Colostrum is produced in the birth parent starting
B Expression: In general, withdrawal of the high doses in the second trimester of pregnancy.39
of estrogen and progesterone during the expression Situations of adoption or surrogacy may be complicated
phase should occur a month before a child will by a birth taking place in a different area than the parents’
need to be fed. A patient may resume their original home, at an unfamiliar hospital, or one with inadequate lac-
estrogen and progesterone dosages. Alternatively, as tation support for LGBTQ+ individuals. The breastfeeding
in the Reisman case report,33 estrogen may be medicine provider can serve as an important mediator in this
lowered even further (0.025 mg estradiol patch). interaction. In particular, before birth:
Side effects of lowering estrogen to this level must
be considered if a patient has been well maintained Consider testing for transmissible infections when in-
at higher levels previously. During this phase, ducing lactation or a nongestational parent desires to
consistent hand expression and pumping are begun, give their milk. These laboratories are routinely re-
and should be gradually increased to 5–10 minutes commended in prenatal care and, as such, serve to guide
6–8 times per day. Flange fitting and pump teaching both pregnancy and lactation management. In addition, a
should be done by a trained professional. Pumping birth hospital may require that a parent have screening
without expressing milk may be uncomfortable, and laboratories before allowing their milk to be provided.
lubricants can be used in the flanges (such as lan- The following may be considered: HIV, syphilis, hepa-
olin, coconut oil, or lubrication sprays specific for titis B and C (to provide counseling in the instance of
pumping) to decrease friction. If milk is not being bleeding nipples/blood in the milk), and tuberculosis in
used, it can be frozen in capped syringes. high-risk areas. Cytomegalovirus testing of gestational
B If a child is being put to breast/chest during the parents and/or human milk is performed in some neo-
expression phase, without or before a full supply is natal intensive care units (NICUs) and may be consid-
created, a supplemental feeding tube at the breast/ ered, especially for infants born atABM PROTOCOL 289
With patient consent, contact the lactation consultant or the tissue is not flexible and cannot be pulled into a
breastfeeding support person(s) at the birth hospital; standard shield.
this is likely to encourage accurate pronoun and name B Positioning of infants for trans men who have had
use, discuss milk status of the parent providing milk, ‘‘top’’ surgery may also be higher on the parent’s
and discuss assistance for feeding at the breast/chest if body, as there will generally be no pendulousness to
this is desired by the parent (i.e., supplemental feeding the chest. Additional pillows may be needed.
tubes at the breast/chest, supplementation, etc.) B For any patient with latch difficulties, another ap-
proach is to form the breast/chest tissue with hands
to encourage infant latch. As with any patient, a
Birth, Birth Plans, and Breast/Chestfeeding hands-off or hand-over-hand approach is most ef-
fective for teaching and preferred by most patients.
The birth experience for LGBTQ+ parents may be socially
B For patients with low milk supply, a supplemental
complex if the birth facility is not prepared to work with
feeding tube attached to a bottle, syringe, or specific
families with gender and sexual diversities. In addition,
supplemental device with human milk or artificial
families may have experienced discrimination, substandard
human milk substitute (infant formula) may be ap-
care, and/or trauma in the health care setting.6–8,41 In these
plied to provide nutrition to the infant at the same
cases, the lactation support team has the unique opportunity
time as stimulation and milk transfer from the par-
to be prepared, respectful, and kind.
ent. The end of the feeding tube should reach the
Regardless of a family’s prior experience, families with nipple tip, and the tube may be secured by tape to
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LGBTQ+ members should be provided appropriate the chest wall. Such a tube may be used inside or
standard care to promote human milk feeding, includ- outside of a nipple shield. There is no published
ing prenatal education, skin-to-skin immediately after evidence on the best methods of use for these
birth, rooming in, feeding on demand, and appropriate devices.
follow-up (see ABM Clinical Protocol #5).42 Standard
guidance on exclusive breastfeeding may need to be
altered based on the expected production of a non- Additional Considerations in the Hospital and NICU
gestational parent and whether milk will be provided LGBTQ+ families face special challenges in the intensive
by a gestational parent. For instance, full production is care unit setting. First, there is extensive staff, which extends
not usually achievable in induced lactation, or after beyond the primary team of providers and nurses. This, with
‘‘top’’ surgery. Therefore, parents should be encour- frequent changes of staff, makes it more difficult to ensure all
aged to provide as much human milk as possible, and staff involved are aware of familial relationships and af-
be educated on the indications for supplementation, firmed pronouns/names. Furthermore, many NICUs are in
types and methods of supplementation, and need for educational facilities, exposing LGBTQ+ parents to medical
close follow-up. students, residents, and fellows with varying levels of train-
If two or more family members plan to breast/
ing in culturally competent health care. Based on preliminary
chestfeed: qualitative research with LGBTQ+ parents, interactions with
B Cocreate a plan surrounding feeding preferences
staff play a major role in the overall parental experience.
B Determine which parent will do skin-to-skin and
These interactions begin with reception and continue
who will feed in the hospital, with support of all through discharge.* As already described but accentuated by
milk supplies (Appendix A1). multipatient rooms, loss of privacy may add another barrier to
B All lactating parents should have medications and
breast/chestfeeding for parents with gender dysphoria or
health conditions reviewed for any possible impacts histories of trauma or abuse.
on lactation or infant health. In addition, LGBTQ+ families face the same barriers as
Privacy may be a concern. Providers and lactation
others attempting to breast/chestfeed in the NICU, including
consultants should be aware that some transgender and the reliance on breast pumps to initiate and maintain supply,
gender-expansive patients may have body dysphoria, difficulty establishing skin-to-skin due to equipment needed
surgical scars, or experiences of trauma, abuse, and vi- for the infant (i.e., endotracheal tubes, mechanical ventila-
olence. Privacy during examination, feeding, and latch tors, and central lines), difficulty feeding a premature infant
assistance may be very important to the family and with poor feeding cues and oromotor skills, and the many
should be respected. Also, a hands-off approach for competing interests of living with a hospitalized child
lactation assistance should be considered if preferred by (financial, family, support, emotional, employment, trans-
the family. portation, etc.).
Latch considerations include working with the areo-
The following may be helpful for families identifying as
lar/chest contour, flexibility of the chest/breast, posi- LGBTQ+ in the NICU, as well as any institutional setting:
tioning, and assistive devices:
B For trans men who have had ‘‘top’’ surgery, or trans Ensure that check-in forms use inclusive language (e.g.,
women who have had breast augmentation, the fields for ‘‘parent 1, parent 2,’’ instead of ‘‘mother,
mammary tissue may be less flexible and areolae father’’).
may be flat. If latch is desired and the infant is not
able to latch, a nipple shield may be considered.
Some nipple shields have a nipple similar to a bottle *Jackson J, Dadiz R. (2020). LGBTQI Parent Experience with
nipple, which may further aid in latch, especially if Newborn Nutrition. Unpublished raw data.290 ABM PROTOCOL
Ensure that leadership emphasizes the need for inclu- Culture’’ available at: https://www.goldlearning
sive and respectful language at all times. This will often .com/lecture/221.
include the need for prior training, clear hand-off be- Professional organizations:
tween shifts involving different caregivers, and the lack B World Professional Association for Transgender
of tolerance for any disrespectful behavior. Health.
Use skills of introduction, asking pronouns, asking for B La Leche League International, https://www.llli.org/
which words the family would like to use for parenting, breastfeeding-info/transgender-non-binary-parents/.
feeding, etc., and ensuring that these preferences are Group meetings:
clearly passed off between caregivers so that the burden B Peer support is an important predictor of a par-
of repetitive education is not placed on families. ent’s success attaining their personal breastfeeding
Ensure that parental concerns are addressed and that all goals.48 Trans parents and other LGBTQ+ families
parents are included in medical decision-making.8,41 may already feel isolated, especially if they do not
know other LGBTQ+ families.28
Donor Milk and Informal Milk Sharing
Multiple sources confirm donor human milk is a safe and Future Research
effective source of nutrition for the extremely preterm, very Significant research gaps exist in this field. In the future, it
low birth weight, or medically complex infant.43,44 Un- is unlikely that grouping sexual orientation and gender
fortunately, in many countries, donor milk is not available, is identity will provide appropriate research or practical guid-
only available for high-risk infants, or is prohibitively ex-
Downloaded by 68.102.24.202 from www.liebertpub.com at 05/14/20. For personal use only.
ance. It is, therefore, suggested that future research examine
pensive. Thus, LGBTQ+ families are at a disadvantage when LGBTQ+ community subgroups. Specifically, investigation
they are unable to produce their own human milk. Because of is needed into milk production in parents who have under-
this, informal milk sharing communities are popular among gone gender-affirming surgeries and those who have induced
LGBTQ+ parents.45 The American Academy of Pediatrics lactation. Given that this is a new and growing field and the
(AAP) does not endorse the use of informal milk sharing due history of neglect and discrimination in the LGBTQ+ com-
to the inability to assess risk.43 The ABM, however, ac- munity, community-based participatory research and quali-
knowledges the risks and benefits of informal milk sharing, tative studies informing future research and support should be
and suggests medical screening of the donor and safe milk strongly considered.
handling practices to maximize safety.46 Both the AAP
and ABM recommend against Internet-based human milk
sharing. Disclosure Statement
C.B.R.-C. is a consultant for May & Meadow, a biotech
Supports start-up. No competing financial interests exist for the
remaining authors.
Few but growing numbers of resource exist to support
LGBTQ+ families and their health care providers during
pregnancy and lactation. Unfortunately, resources on par- Funding Information
enting and lactation remain hetero- and cisnormative with an
explicit maternal focus when discussing breastfeeding and No funding was received for the creation of this protocol.
lactation. They do not tend to discuss or include other types of
families and parents. LGBTQ+ parents have described a References
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working group session on fertility preservation for indi- gogues in initiating or augmenting maternal milk produc-
viduals with gender and sex diversity. Transgender Health tion, second revision 2018. Breastfeed Med 2018;13:307–
2016;1:99–107. 314.
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43. Committee on Nutrition; Section on Breastfeeding; The Academy of Breastfeeding Medicine
Committee on Fetus and Newborn. Donor human milk Protocol Committee:
for the high-risk infant: Preparation, safety, and usage Michal Young, MD, FABM, Chairperson
options in the United States. Pediatrics 2017;139:pii: Larry Noble, MD, FABM, Translations Chairperson
e20163440. Melissa Bartick, MD, MSc, FABM
44. Coutsoudis I, Adhikari M, Nair N, et al. Feasibility and Sarah Calhoun, MD
safety of setting up a donor breastmilk bank in a neonatal Monica V. Carceles-Fraguas, MD, IBCLC, FABM
prem unit in a resource limited setting: An observational, Megan Elliott-Rudder, MD
longitudinal cohort study. BMC Public Health 2011;11: Lori Feldman-Winter, MD, MPH
356. Laura Rachael Kair, MD, FABM
45. Palmquist AE, Doehler K. Human milk sharing practices in
Susan Lappin, MD
the U.S. Matern Child Nutr. 2016;12:278–290.
Ilse Larson, MD
46. Sriraman NK, Evans AE, Lawrence R, et al. Academy of
Breastfeeding Medicine’s 2017 position statement on in- Ruth A. Lawrence, MD, FABM
formal breast milk sharing for the term healthy infant. Yvonne Lefort, MD, FABM
Breastfeed Med 2018;13:2–4. Kathleen A. Marinelli, MD, FABM
47. Lev AI, Dean G, DeFilippis L, et al. Dykes and tykes: A Nicole Marshall, MD, MCR
virtual lesbian parenting community. J Lesbian Stud 2005; Katrina Mitchell, MD, FABM
9:81–94. Catherine Murak, MD
48. Shakya P, Kunieda MK, Koyama M, et al. Effectiveness of Eliza Myers, MD
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community-based peer support for mothers to improve their Monica Pina, MD
breastfeeding practices: A systematic review and meta- Sarah Reece-Stremtan, MD
analysis. PLoS One 2017;12:e0177434. Susan Rothenberg, MD, IBCLC, FABM
Tricia Schmidt, MD
ABM protocols expire 5 years from the date of publication. Tomoko Seo, MD, FABM
Content of this protocol is up-to-date at the time of publication. Christina Smillie, MD, FAAP, IBCLC, FABM
Evidence-based revisions are made within 5 years or sooner if Natasha Sriraman, MD
there are significant changes in the evidence. Elizabeth K. Stehel, MD
Gina Weissman, DMD, RN, IBCLC, FABM
Rita Lynne Ferri, BA, lead author Nancy Wight, MD
Casey Braitsch Rosen-Carole, MD, MPH, MEd Adora Wonodi, MD
Jason Jackson, DO Deena Zimmerman, MD, MPH, IBCLC
Elizabeth Carreno-Rijo, MD, MPH
Katherine Blumoff Greenberg, MD For correspondence: abm@bfmed.org
Appendix A1. Colactation Feeding Plan
(Please note, this feeding plan is filled out by the gesta- ROUTINE (CHECK ALL THAT APPLY):
tional parent. In a hospital or institution, this would be the
, Skin-to-skin: please place our baby skin-to-skin on
patient who would give their consent for health care choices,
my chest after delivery. Please do checkups and pro-
in most cases. It assumes a two-person parenting relationship,
cedures on our baby while they are skin-to-skin, when
which may not be applicable. It may, therefore, need to be
possible.
adapted to specific circumstances.)
, Emergency Cesarean: if I am unable to hold the baby
Date: _________/___________/____________
skin-to-skin at birth, please allow my (partner status)
Colactation Infant Feeding Plan __________________, (name)_______________
My name is__________________________________and _________ to do so and latch for the first time.
my goal is to cofeed my baby with my (partner status) , Exclusive breastfeeding: our goal is to exclusively
______________ (name) _________________________ breastfeed our baby. Please do not give my baby any
_________________. formula before speaking to us about it.
, No bottles or pacifiers: please do not give pacifiers or
The benefits of human milk feeding are very important to us
bottles without speaking with us first.
and our baby. We would like to have our guidelines supported
, Feed on cue: please help me to learn the signs that my
as long as it is medically safe. We also would like to ensure
baby is hungry and feed my baby when they are ready
that my milk supply is well established, while supporting
to eat.
_____________________ in learning how to nurse and bond
, Rooming in: please help our baby and I stay in our
with our new baby. Because of this, some things in our feeding
room together 24 hours per day.
plan are the same as other peoples, and some are different.
(Appendix follows /)ABM PROTOCOL 293
FOR COLACTATION (CHECK ALL THAT APPLY): ___________, (name)________________________ is
not making milk, a supplemental nursing system will
, At the time of delivery, my (partner status)____ need to be used. In all cases, baby’s weight will need
___________, (name)______________________ is to be closely monitored.
making _________mL per day of milk. , Please provide my (partner status)______
, Initial skin-to-skin and latch will be done by ____________, (name)______________________
______________________, if we are medically able. help with a supplemental nursing system while in the
, If I am not available after birth to do skin-to-skin hospital.
and latch, please allow my ___________, , After we go home, we would like to _________
(name)____________________ to do so and latch for __________________________________
the first time. , ____________________________________________
, After the first latch, we would like _________ _________________________________.
_______ to primarily feed the baby at the breast. This plan has been discussed with my provider: ________
, After the first latch, we would like to both feed at the ____________________
breast. We know that if we do this, whoever is not My baby’s provider/pediatrician will be: ___________
feeding at the breast will need to hand express or pump _______________________
milk, and this may result in a decreased milk supply.
We also understand that if my (partner status)_______ , Discuss with baby’s provider/pediatrician
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