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Transgender women, breastfeeding and drug regimens

Impact Ethics by Martha Paynter 15 March 2018

The recent publication of a case report of induced lactation in a transgender woman, and reactions to it, are cause for critical examination of myths surrounding drug use in lactation and the impulse to restrict transgender bodies. “We need to make sure it is pure and hormone free,” a critic says of the human milk produced by the transgender woman patient, who used medications to induce lactation (domperidone) and to block testosterone production (spironolactone). Yet, human milk is not “pure” or “hormone free.”

The pituitary hormones prolactin and oxytocin are responsible for milk production and “let down” from the breast/chest. The bioactive ingredients of human milk include dozens of endogenous hormones. Hormonal contraception (progestin alone or combined with estrogen) is commonly-used for pregnancy prevention in the postpartum period. Historically, concern with use of hormonal contraception during lactation lay more with potential reduction of milk supply than on adverse effect of transfer to the infant. A recent systematic review found no evidence of negative impact of combined oral contraceptives by lactating people on infant health, growth or development when initiated after six weeks postpartum.  Hormonal oral contraceptives are considered safe and are widely used during lactation.

In fact, most drugs are compatible with breastfeeding/chestfeeding. Misunderstanding about the safety of most drugs, which are shared by clinicians, the public and lactating parents, contributes to poor breastfeeding/chestfeeding rates.

The World Health Organization recommends exclusive breastfeeding/chestfeeding for the first six months of life because of clear benefits to infant health and well-being. Yet in Canada, only 26% of infants are exclusively breastfed/chestfed for the first six months.

Breastfeeding/chestfeeding parents are routinely misinformed about drug risks and advised to stop breastfeeding/chestfeeding for surgery, viral and bacterial illnesses, pain relief, and other therapies. Most drugs pass into milk but do so in such trace amounts they are unlikely to adversely affect infants. Adverse effects must be weighed against the risks of milk substitutes, of which the public is also routinely unaware.  An increasingly relevant example is that breastfeeding/chestfeeding is recommended among parents in pharmacological opioid dependence treatment programs, as trace opioid is less damaging to their vulnerable infants than formula preparations.

Notably, a greater threat to the illusive “purity” of human milk is not medication, but pollution.  Researchers first found DDT in human milk in 1951, and we now have almost seventy years of evidence of widespread contamination of human milk with bisphenol A, polybrominated diphenyl ethers, hexachlorobenzene, and cyclodiene pesticides. Despite these findings, breastfeeding/chestfeeding remains the best food for infants. Efforts to improve human milk “purity” should focus on environmental regulation and restriction of polluting industries, not individual parents whose medication regimens are usually compatible with lactation.

The myth of breastfeeding/chestfeeding as “pure” creates stigma for people who experience challenges with lactation and reinforces structural barriers to support. Lactation is not always easy or “natural.” People of colour, people with disabilities, chronic illnesses, who identify as LGBTQ+, or adopt a child, may face considerable barriers to breastfeeding/chestfeeding success. Such individuals should receive priority access to lactation consultants, peer support groups, equipment, and herbal and pharmacological galactologues (supply-promoters).

Exclusive breastfeeding/chestfeeding promotes infant immune, gastrointestinal, and metabolic health, and cognitive and emotional development. There is also research demonstrating benefits of breastfeeding/chestfeeding to parental health, including reduction in chronic disease burden and protection from postpartum depression. It is a public health imperative to improve breastfeeding/chestfeeding exclusivity and duration. Supporting lactation in transgender women will not change poor national breastfeeding/chestfeeding rates, but it will a significantly demonstrate clinical progress towards equity.

As infant feeding is a key consideration in perinatal health services for new families, care and support must be inclusive of transgender parents. Trevor MacDonald is a leading voice in this arena, studying the lactation experiences of transmasculine men. He calls for clinician attention to the effects of chest masculinization surgery and binding practices on chestfeeding and gender dysphoria. An inclusive society overcomes barriers to participation so that all people can experience belonging, value and contribution. Social inclusion is also a public health imperative. Isolation and discrimination have real and profound negative impacts on health.

A Hastings Centre columnist argues it is unethical to “experiment” on the infants of transgender women by supporting their breastfeeding/chestfeeding when we lack certainty of the quality of their milk and of the impact of their drug regimens. However, domperidone, promoted by breastfeeding specialist Dr. Jack Newman, is widely used in Canada for lactation induction among cisgender women. Dr. Thomas Hale and Hilary Rowe, authors of the “bible” of drug-lactation interactions, Medications and Mothers’ Milk, categorize spironolactone as “probably compatible” and calculated infant doses as too low to be clinically relevant. Domperidone and spironolactone should not be impediments to extending breastfeeding/chestfeeding experience to transgender women, but rather clinical tools to advance social inclusion for transgender parents and symbolic concrete steps towards increased infant access to human milk.

Martha Paynter is a Ph.D. student in the School of Nursing at Dalhousie University and a Registered Postpartum Nurse at the IWK Health Centre.