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Chestfeeding and Lactation Care for LGBTQ+ Families (Lesbian, Gay, Bisexual, Transgender, Queer, Plus)


Key Points

  • LGBTQ+families may have unique experiences in providing human milk for their infants.

  • LGBTQ+individuals may face particular barriers related to their ability to provide human milk for their infants related to discriminatory policies, restricted donor milk regulations, or anatomic/functional limitations.

  • Appropriate care for LGBTQ+families includes the use of both respectful and affirming language and background knowledge of the physiologic impacts of any past or current treatments on milk production.

  • As with all families, lactation providers should be careful to provide appropriate information, while not making assumptions or judging parental decisions.

Social science evidence clearly shows that the children of LGBTQ+families thrive on par with children living in different-sex families. 1 Assessments of well-being span cognitive and psychological development, mental health, and adolescent risk-taking behavior, among others. 2 In the United States, where there exist policies related to nondiscrimination, 35% of US LGBTQ+families have children. 3 Internationally, many countries have LGBTQ+-inclusive social norms and policies; however, there are still countries where “homosexual activity” continues to be illegal 4 and many others where same-sex couple adoption is highly restricted. LGBTQ+couples in these countries may have significantly less access to family building opportunities. Box 20.1 lists organizations that provide guidance and information on gender-affirming care.

Box 20.1
Groups and Organizations That Support Gender-Affirming Care

  • Equaldex: The Collaborative LGBT Rights Knowledge Base. Includes maps and lists of laws applying to LGBT persons around the world. Access at: http://www.equaldex.com .

  • Transcend Legal: Medical organization statements. List of medical and nursing groups along with their statements of nondiscrimination and the promotion of safe and affirming care for gender nonconforming patients. Access at: https://transcendlegal.org/medical-organization-statements .

  • World Professional Association for Transgender Health: International, interdisciplinary, professional association devoted to understanding and treatment of gender identity disorders. Access at: http://www.wpath.org .

  • UCSF Transgender Care. Website for the Transgender Care Clinic at University of California San Francisco. Includes evidence, terminology, environment guidance and clinical guidance for appropriate care. Access at: https://transcare.ucsf.edu/ .

  • National LGBT Health Education Center. A program of the Fenway Institute. Their mission is to advance health equity for LGBTQIA+ people, address and eliminate health disparities, and optimize access to cost-effective health care for the LGBTQIA+community. They provide distance learning, videos, and printed educational health materials. Access at: https://www.lgbthealtheducation.org/publication/lgbt-glossary/ .

Family development in LGBTQ+couples may take many forms and can include adoption and assisted reproductive technologies. The infant children of LGBTQ+ families may be at risk for health disparities from birth in the form of reduced access to human milk. 5 Children raised in LGBTQ+ families thrive on par with children raised in heterosexual, cisgender families. 2 , 6 However, given the range of anatomy and fertility that may exist within LGBTQ+families, they may be unable to offer a parent’s human milk to their children. Because current donor milk policies prioritize medically high-risk infants, babies in LGBTQ+families may also lack access to donor milk (see Chapter 22 for information on expanding donor milk availability). It is therefore critical for providers to both understand how to support and counsel families about their options with respect to lactation and to compassionately approach any constraints they may face.

Providers should not assume that all parents will desire to lactate because they have the anatomy or hormones to do so. As with any family, human milk feeding may not be a parental goal; in LGBTQ+ families, specifically, parents may be taking turns gestating, birthing, and lactating or may have histories of medical treatment that will make lactating, breastfeeding, or chestfeeding uncomfortable or impossible. As with all families, lactation providers should be careful to provide appropriate information while not making assumptions or judging parental decisions. 5 , 7 , 8 , 9

The Academy of Breastfeeding Medicine (ABM) has a protocol for the care of lactating patients who identify as LGBTQ+, which is available on their website. 10 To best care for patients, it is important to understand some basic terminology used within the LGBTQ+ community. Box 20.2 is a list of definitions helpful in this context.

Box 20.2
Definitions Related to LGBTQ+ Health 10

Definitions: Several sources have defined terms related to LGBTQ+ health. Here, we reference the University of California San Francisco Transgender Care & Treatment Guidelines 17 and the National LGBT Health Education Center’s glossary of terms. 18 However, it is important to note that terminology is fluid and community-specific. In countries speaking languages other than English, these terms may have adaptations or may be irrelevant entirely. Consulting with members of LGBTQ+ advocacy communities in such areas, where possible, may be helpful to ensure that language is respectful and inclusive.

  • LGTBQ+: A term for people who identify as lesbian (L), gay (G), bisexual (B), transgender (T), queer (Q) or questioning (Q) and people with other diversities in sexual orientation and gender identity (+). There are a variety of these terms internationally with their own acronyms. This term is meant to be inclusive.

    • Lesbian (adj., noun): A sexual orientation that describes a woman who is emotionally and sexually attracted to other women.

    • Gay (adj.): A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender. It can be used regardless of gender identity, but is more commonly used to describe men.

    • Bisexual (adj.): A sexual orientation that describes a person who is emotionally and sexually attracted to people of their own gender and people of other genders.

    • Transgender (adj.): Describes a person whose gender identity and assigned sex at birth do not correspond. Also used as an umbrella term to include gender identities outside of male and female. Sometimes abbreviated as trans.

    • Queer (adj.): An umbrella term used by some to describe people whose sexual orientation or gender identity are outside of societal norms. Some people view the term queer as more fluid and inclusive than traditional categories for sexual orientation and gender identity. Because of its history as a derogatory term, the term queer is not embraced or used by all members of the LGBT community.

    • Questioning (adj.): Describes individuals who are unsure about or are exploring their own sexual orientation and/or gender identity.

    • “+”/Plus: The plus sign represents the ever-growing list of terms people use to describe their sexual orientation or gender identity. There are many different variations of the LGBTQ+ acronym, and the “+” acknowledges that it is not possible to list every term people currently use.

  • Affirming care: Refers to care that supports a patient’s gender identity and must include inclusive terminology, practices, insurance coverage, and knowledgeable providers.

  • Affirmed pronouns and name: Pronouns and name that are chosen by the individual and therefore best represent the person’s gender identity. People in the LGBTQ+ community may have changed their name and gender, informally or legally, to those that affirm their true gender identity.

  • Assigned Female at Birth, Assigned Male at Birth: These terms refer to gender assignment at birth medically and socially, generally based on genital anatomy. These terms may be abbreviated (AFAB, AMAB) to communicate birth anatomy in medical documentation.

  • Cisgender: Someone whose gender identity aligns with the gender assigned to them at birth. For example, someone who was assigned female at birth who identifies as a woman.

  • Chestfeeding: A term used by many masculine-identified trans people to describe the act of feeding their baby from their chest, regardless of whether they have had chest/top surgery (to alter or remove mammary tissue). 19

  • Co-lactation: When more than one parent breastfeeds/chestfeeds their child.

  • Gender-affirming surgery: Surgeries specific to transgender people include feminizing and masculinizing procedures that align secondary sexual characteristics with a person’s gender identity. These may include facial, voice, genital, and hair removal/addition procedures.

  • Gender-expansive, genderqueer, nonbinary: All different terms for a broad category of gender identities in which the individual identifies outside of a binary concept of gender (binary meaning “male” and “female”). This can mean identifying as both feminine and masculine or as neither.

  • Gender identity: Persons’ innate sense of their own gender. It does not necessarily correspond to anatomy, sex assigned at birth, or how someone expresses self. Examples include but are not limited to cis woman, cis man, trans man, trans woman, nonbinary, gender expansive, and gender fluid. Not the same as sexual orientation (see later).

  • Gender incongruence, formerly “gender dysphoria” or “gender identity disorder”: Incongruence between an individual’s experienced or expressed gender and assigned sex. *

    * World Health Organization. International Classification of Diseases. 11th ed. Geneva, Switzerland: WHO; 2018.

    Dysphoria refers particularly to suffering as a consequence of this incongruence.

  • Heteronormative/cisnormative: The assumption and/or preference of individuals and institutions that everyone is heterosexual and cisgender. This leads to invisibility and stigmatization of people in the LGBTQ+ community.

  • Transition: The process and time during which persons assume their affirmed gender expression, which may or may not include legal, medical, or surgical components.

  • Sexual orientation: The aspect of someone’s identity, which refers to the gender(s) of the people to whom they are attracted. Examples include but are not limited to homosexual, lesbian, gay, heterosexual, bisexual, asexual, and pansexual.

Creating a Respectful Health Care Environment

There are many opportunities for health care systems, hospitals, and clinics to provide affirming care to LGBTQ+ individuals. Increasing the amount of LGTBQ+ training for health care providers and building inclusive systems and documentation can minimize provider and staff mistakes surrounding an individual’s gender or sexual orientation. Examples of inclusive practices include updated intake forms with more options for affirmed gender, affirmed pronouns, and partnership status; single-stall, all-gender restrooms; and gestation and lactation spaces that include all parents, not just those identified as mothers. Coupling training and inclusive practices with displaying signs or statements of inclusivity is a subtle but impactful way to welcome individuals with diverse genders, sexual orientations, and families. 11 , 12 Patient confidentiality is another cornerstone to LGBTQ+ care, because many patients may not be “out” to all of their health care providers, 13 and even a patient’s family and friends may not be aware of the patient’s gender identity and/or sexual orientation. This information is privileged within provider-patient relationships, and it is critical that providers ask patients about when, how, and why they might disclose their gender and sexuality. Although not a comprehensive list, other considerations include the following:

  • An individual’s appearance may not match gender identity. Do not assume that a female-appearing individual identifies as female or is interested in breast/chestfeeding. 14

  • Ensure that people are addressed by their affirmed names and pronouns. To know the patient’s preference, one needs to ask. For example: “I’d like to address you respectfully, what name and pronouns should I use?”

  • Names and pronouns are but one aspect of a parent’s experience, and patients may also use different terms for parenting (mom/mama/mum, dad/father, parent, etc.) and lactation (chestfeeding, lactation, breastfeeding, etc.). We recommend ensuring that patients have the opportunity to identify at the beginning of a patient care visit which words they would like to use.

  • Calling a patient by a name, pronoun, or parenting term other than the patient’s affirmed name/pronoun, is generally referred to as misgendering and is hurtful to the patient. If intentional, misgendering damages the patient–provider relationship; if unintentional, it is an opportunity for providers to acknowledge the mistake, correct it, and continue with the visit using affirming language. 15 Acknowledging the mistake and apologizing is key, but prolonged attention on the mistake may take the focus off of providing appropriate and affirming health care.

Physiology of Lactation in Special Circumstances

Because of the development of mammary tissue and its hormone responsiveness in critical windows, timing of gender-affirming treatments or practices (e.g., chest binding) may or may not affect the ability to lactate. Following are some examples of hormonal treatments, surgeries, and practices and how they may affect lactation. Because of a dearth of clinical studies on LGBTQ+ human milk feeding, many of these effects are theoretical.

Transmen (Assigned Female at Birth, Affirmed Male)

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