ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients

Definitions

Several sources have defined terms related to LGBTQ+ health. In this study, we reference the University of California San Francisco Transgender Care and Treatment Guidelines and the National LGBT Health Education Center’s glossary of terms. 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.

• LGTBQI+: A term for people who identify as lesbian (L), gay (G), bisexual (B), transgender (T), queer (Q), 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 is outside of societal norms. Some people view the term queer as more fluid and inclusive than traditional categories for sexual orientation and gender identity. Owing to its history as a derogatory term, the term queer is not embraced or used by all members of the LGBT community.

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

  • “+” /Plus : The plus sign represents the evergrowing 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 their 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 AFAB 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).

• Colactation: When more than one parent breast/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: A person’s innate sense of their own gender. It does not necessarily correspond to anatomy, sex assigned at birth, or how someone expresses themselves. Examples include, but are not limited to, cis woman, cis man, trans man, trans woman, nonbinary, gender-expansive, and gender “fluid” (as opposed to “fixed”). Not the same as sexual orientation.

• Gender incongruence, formerly “gender dysphoria” or “gender identity disorder”: Incongruence between an individual’s experienced or expressed gender and their assigned sex. 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 a person assumes their affirmed gender expression that may or may not include legal, medical, or surgical components.

• Sexual orientation: The aspect of someone’s identity that 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.

Purpose

Children raised by LGBTQ+ parents are well adjusted and healthy, and in such families children thrive. Despite this, people who are transgender and/or whose sexual orientation is not heterosexual frequently experience misunderstanding and stigma, including in medical interactions. Their medical care is often inadequate, ranging from a failure of health care professionals to recognize their unique needs (e.g., in sexual and reproductive health care), to the enforced use of heteronormative procedures (e.g., registering a trans man as a woman in their medical record). In many regions of the world, families who had been unable to raise children because of their gender identity and/or sexual orientation now have the opportunity to become parents. This is largely due to the liberalization of adoption policies, along with advances in fertility management, surrogacy, and transition-related health care for transgender individuals. Pregnant people and parents who identify as LGBTQ+, therefore, need access to non-traditional lactation supports that may be unfamiliar to health care providers. In particular, barriers to lactating LGBTQ+ individuals include confronting highly gendered assumptions in the world of childbirth, effects of transition (e.g., hormonal, surgical), impacts of induced lactation, colactation, and hospital considerations. The Academy of Breastfeeding Medicine (ABM) seeks to provide guidance to those caring for individuals who identify as LGBTQ+.

Background and the Importance of Language

When concerned about discrimination in health care settings, patients frequently do not self-disclose their LGBTQ+ identities. Transgender patients, in particular, have a history of experiencing discrimination and even violence in health care settings. In one U.S.-based study, one-third of transgender individuals reported having at least one negative health care experience. In the same study, nearly one-third of individuals reported that none of their health care providers knew their gender status. This has implications for delayed diagnosis and treatment, such as the possibility of a missed ovarian torsion or tumor in a transgender man or undiagnosed prostatic disease in a transgender woman. At its most severe, discrimination by health care providers has led to patient deaths from potentially treatable illnesses due to the refusal of providers to care for transgender individuals. Although the terms introduced previously may be unfamiliar to some providers, recognizing and affirming patients’ names, pronouns, and family members are a cornerstone of providing affirming care for patients who identify as LGBTQ+. Traditionally, health professional education has contained little to no content related to caring for patients who may be LGBTQ+ identified. As a result, LGBTQ+ communities have been marginalized in health care systems and settings. Experiences of stigma and discrimination, both in and outside of health care contexts, have led to both severe psychological pain and disparate health outcomes. This is most extreme in areas of sexual, reproductive, and mental health. Affirming health care, including using affirming names and pronouns, and recognizing individual patients’ families and communities, can help to mitigate the effects of stigma and improve health.

General Considerations

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

• Ensure that people are addressed by their affirmed names and pronouns. To know, one needs to ask.

  • Introductions to a patient can include a provider’s own pronouns, which may make the patient feel more at ease sharing their own. (e.g., “My name is Dr. X, I use she/her pronouns.”)

  • Predominantly masculine pronouns=he/him/his/ himself.

  • Predominantly feminine pronouns=she/her/hers/herself.

  • Gender-neutral pronouns=they/them/theirs/themselves; Ze/Zir (Hir)/Zirs (Hirs)/Zirself (Hirself).

• Patients may also use different terms for parenting (mom/mum, dad/father, parent, etc.) and lactation (breastfeeding, chestfeeding, lactation, etc.). It is most respectful to ensure that patients have the opportunity to identify which words they would like to use for their visit at the beginning of the visit.

• Misgendering, or calling a patient by a name, pronoun, or parenting term other than their affirmed name/pronoun, is hurtful to the patient. When done intentionally, it may sever the patient/provider relationship and put the patient’s health at risk. When done unintentionally, it is recommended to acknowledge the mistake, correct the pronoun, and continue with the visit using the correct pronouns and name. It is best that the mistake be acknowledged so that the individual feels respected, but prolonged attention on the mistake may take the focus off of providing appropriate and affirming health care.

Creating a Respectful Health Care Environment

There are many opportunities for health care systems, hospitals, and clinics to provide affirming care to LGBTQ+ individuals. Provider and staff mistakes surrounding an individual’s gender or sexual orientation can be minimized with increased training and by having inclusive systems and documentation. For example, intake forms should be updated to include more options for gender, pronouns, and sexual orientation. “Male” and “female” assigned bathrooms may pose a problem for gender-expansive or transgender people. It may force an individual to use a bathroom that is less accessible or unsafe, instead of using one that aligns with their gender identity. Some countries have laws that prevent transgender people from using bathrooms that align with their gender identity, which poses a safety and violence risk for transgender people. Having gender-neutral bathrooms (or single-user) mitigates these concerns and is an important aspect of respectful care. Displaying signs or statements of inclusivity is a subtle, but impactful way to acknowledge individuals with gender and sexual diversities. Patient confidentiality is another cornerstone to LGBTQ+ care, as family and friends of a patient may not be aware of their gender identity and/or sexual orientation. Disclosing this information may compromise the patient’s safety. It is, therefore, important to ask the patient how much you can disclose if you need to talk to other people in their lives. Although not a comprehensive list, other considerations include:

• consideration of the name of the clinic or organization in which people seek care (avoiding gendered terms such as “women’s,” “maternal,” and “moms” in favour of more inclusive terms such as “parent,” “prenatal,” “pregnancy,” “reproductive,” or “lactation”),

• displaying affirmed, rather than legal, names and gender on documentation such as printed schedules and patient wristbands,

• avoiding gendered prefixes and pronouns when someone’s gender is unknown (e.g., use a patient’s given first and last name, or another nongendered culturally specific form instead of Mr./Ms. X).