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Abstract

Human milk feeding has generally been described using a heteronormative and cisnormative paradigm focusing on a mother and child dyad with the child nursing at the mother's breast and the father in a supportive role. However, there has been a paradigm shift that has emerged from the LGBTQI+ community that recognizes dynamic gender identities, gender roles, sexual orientations, and diverse family structures. Social workers can best provide support to people with dynamic and diverse gender roles and a variety of family structures. The purpose of this paper is to provide an overview of social work best practices, including de-sexed and gender-inclusive language, gender-affirming, and trauma-informed care in supporting lactation and infant feeding for LGBTQI+ families. This paper acknowledges and describes terminology that promotes equity and inclusivity in human milk feeding and provides examples of information and anticipatory guidance that social workers can use to protect, promote, and support human milk feeding in the LGBTQI+ community.

Keywords

breastfeeding chestfeeding human milk feeding social work lactation LGBTQI+ healthcare

Human milk is the gold standard for infant feeding, and social workers can use their knowledge, skills, and resources to have meaningful and positive impacts on breastfeeding outcomes. This paper provides an overview of best practices in supporting lactation and infant feeding for lesbian, gay, bisexual, transgender, queer, questioning, intersex, and other people with other diversities in gender identity and sexual orientation (LGBTQI+). Human milk contains anti-bacterial and anti-inflammatory properties and acts as a booster for a child's immature immune system. It is species-specific, easily digested, and meets all the nutritional requirements of infants. Because of the demonstrated health benefits, the American Academy of Pediatrics (Meek & Noble, 2022), the American Academy of Family Physicians (2022), and the WHO (2023) recommend that children be exclusively fed human milk for approximately the first six months of life. During this time, unless otherwise medically indicated, no supplementation with water, cereals, nor infant formula is recommended. At approximately six months of age, the AAP, the AAFP, and WHO/UNICEF recommend that complementary foods be introduced while human milk feeding continues through the child's second birthday and beyond for as long as is mutually desired by the parent and child (AAFP, 2022; Meek & Noble, 2022; WHO, 2023). These feeding policies are universal guidelines that not only cut across socio-economic, ethnic, and racial lines (Angeletti, 2009) but also sexual orientation, gender fluid, and gender non-confirming lines. Thus, social workers have a responsibility to inform and guide LGBTQI+ individuals about their options regarding human milk feeding.

Diversity, Inclusion, and Family Dynamics

Until recently, the topic of lactation and human milk feeding typically adopted a binary, heteronormative, and cisnormative approach, assuming that a cisgender female identified as a woman and mother while a cisgender male identified as a father (Bamberger & Farrow, 2021), without consideration of diverse family dynamics that support anatomic and functional human milk feeding. Most organizations providing support, information, resources, and published research focused on the mother-child dyad, which consisted of cisgender women birthing and breastfeeding children with cisgender males as partners in a supportive role. Additionally, because most published literature on breastfeeding and maternal mortality included subjects that were assumed to be cisgender women, scientific research and data on human milk feeding in the LGBTQI+ community is lacking and the health effects reported in the literature on the mother-infant dyad cannot be generalized to other populations because of chromosomal, hormonal, or other anatomical differences (Bartick et al., 2021). While much of the culture of the childbirth and lactation community is highly gendered and focuses on the mother-infant dyad, members of the LGBTQI+ community need access to lactation support (Ferri et al., 2020). Emerging from the transgender and gender non-conforming communities, there has been a paradigm shift that directly impacts how social workers would approach and support human milk feeding (Dodgson & Bamberger, 2021; Dodgson et al., 2022; Heidari et al., 2016; Lee, 2019; MacDonald, 2019). While there is a scarcity of culturally competent terms and sensitive gendered language, this article tries to acknowledge the varieties, methods, and gender-inclusive terminology in the evolving paradigm shift. The Academy of Breastfeeding Medicine (ABM) affirms that language has power and using unbiased language will contribute to decreasing health inequities (Bartick et al., 2021) with an ever-expanding umbrella group of lesbian, gay, bisexual, trans, queer, intersex, asexual, and two-spirit people (LGBTQIA2S+), and includes a spectrum of individuals who identify as the sexual and gender minority (Bartick et al., 2021; Lee, 2019). In alignment with the ABM, this paper will refer to this umbrella group using the term LGBTQI+ (Bartick et al., 2021).

Sex, gender identity, and sexual orientation are multidimensional concepts that are often misunderstood and even politicized (Soled et al., 2022). Sex is often assigned at birth as male, female, or intersex, and is based on anatomical and physiological traits, such as genitalia, secondary sex characteristics, chromosomes, and hormones (Soled et al., 2022). Gender identity is a person's sense of their own gender (male, female, or other) and while a cisgender person (cis man, cis woman) is someone whose gender identity matches the gender assigned to them at birth, a transgender person's gender identity (trans man, trans woman) does not correspond to their anatomy nor the gender assigned to them at birth. Terms such as assigned female at birth (AFAB) or assigned male at birth (AMAB) can be used in medical documentation (Ferri et al., 2020); however, if a person's identity is fluid or non-binary, they might choose to use they/them as their pronouns, which might reflect their gender identity and not the assigned gender at birth (Wagg & Gray, 2021). Some people who identify as transgender might decide to transition. Transitioning is the social, medical, and legal process to enable a person to assume their affirmed gender identity. Transitioning can include gender-affirming surgeries, including chest or top surgery to alter, augment, or remove mammary tissue which can impact a person's ability to lactate (Ferri et al., 2020). Gender identity is distinct from sexual orientation which refers to the gender(s) of the people to whom they are attracted. Examples of sexual orientations include lesbian, gay, bisexual, queer, homosexual, heterosexual, pansexual, and asexual (Ferri et al., 2020).

There are limited statistics about the number of LGBTQI+ individuals in the United States (Duckett et al., 2019). Recent estimates indicate that the number of individuals who identify as lesbian, gay, bisexual, or transgender (LGBT) has increased to 7.1%, from 3.5% in 2012 when Gallup, an organization that conducts surveys on social, political, and economic issues, first began measuring it (Jones, 2022). While the percentage of Baby Boomers (born between 1946 and 1964) has held steady at approximately 2.6% and Generation X (born between 1965 and 1980) have held steady at a slightly higher rate of 4.2%, reports are indicating a growing LGBT population in younger generations as they reach adulthood (Jones, 2022). For example, 10.5% of Millennials (born between 1981 and 1996) and 20.8% of Generation Z (born between 1997 and 2012) identify as LGBT, with 15% of Generation Z identifying as bisexual (Jones, 2022). However, only the individuals in Generation Z born between 1997 and 2003 had reached adulthood in 2021 when the survey was conducted. If this trend continues, the proportion of adults who identify as LGBT in the United States will continue to increase as the younger individuals in Generation Z and subsequent generations reach adulthood (Jones, 2022). Within the LGBT community, 13.9% identify as lesbian, 20.7% identify as gay, 56.8% identify as bisexual, 10% identify as transgender, and 4.3% identify as other (Jones, 2022). In the United States, it is estimated that between one in three to one in five transgender persons are parents (Meier & Labuski, 2013). Data gathered by the LGBTQ Family Building Survey indicates that 77% of LGBTQ Millennials are either already parents or are considering having children, an increase of 44% over previous generations (Harris & Hopping-Winn, 2019). Additionally, the distinctions between biological sex, gender identity, and the concept that gender roles and identity can be non-binary, non-static, change over time, and be relational have important practice implications for social workers in the support of lactation and human milk feeding (Dodgson & Bamberger, 2021; Griggs et al., 2021; Lee, 2019).

The United Nations (UN) and the World Health Organization (WHO) have called for the end of discrimination against the LGBTQI+ community and the Academy of Breastfeeding Medicine (ABM) has affirmed the importance of language and treatment of members of the LGBTQI+ community in order to reduce health inequalities which contribute to morbidity and mortality among vulnerable populations (Bartick et al., 2021; WHO, 2015). It should be noted that the social acceptance of members of the LGBTQI+ communities varies dramatically. In some geographical regions, it is unsafe or even illegal to self-identify as a marginalized group, and the safety of the client and social worker should be considered of utmost importance (Bamberger & Farrow, 2021). In these cases, social workers should continue to provide services while respecting the safety of the clients (Dodgson et al., 2022) and understanding that children raised in LGBTQI+ families are healthy and well adjusted (Tasker, 2005).

Non-Sexed, Gender-Inclusive Language

Upon meeting an individual or family, social workers should not misgender or make familial assumptions based on hetero and cisnormative standards. Instead, it is best practice for social workers to request names, pronouns, allow clients to self-identify their family structure, and describe their role in the family and then use the same language consistently with them (Bartick et al., 2021; Dodgson et al., 2022; Garguilo-Welch et al., 2023). The ABM recognizes that not all people who give birth and lactate identify as female or mothers and recommends using de-sexed and gender-inclusive language such as the terms lactating person and human milk feeding (Bartick et al., 2021). For example, the cisnormative term “mother” is not exclusively used to define the person who birthed the child. A “mother” may be a grandparent, an adoptive mother, a surrogate who placed the child with another family, a gestational parent who identifies as a trans man or a biological father who identifies as a trans woman. Because of the historical cisnormative associations, someone may be uncomfortable with terms such as “mother.” The client may have their own parenting labels, and the social worker should always follow the client's preferences (Lee, 2019). For example, a trans man who has gestated, given birth, and identifies as a man, may prefer the parenting term “father” and the term “chestfeeding” may be more congruent with his gender identity (Duckett et al., 2019). Chestfeeding is a term used by trans men or masculine-identifying people to describe the act of feeding at the chest (Ferri et al., 2020; MacDonald, 2019; Roosevelt et al., 2021). Social workers can also use gender-neutral terms such as human milk, mammary glands, and lactation which are non-gendered, as well as parent, family, lactating parent, birthing parent, or non-birthing parent, as well as non-binary terms such as birthing people (Wagg & Gray, 2021). The ABM recommends that healthcare workers should always consider the context and audience when selecting the best terminology (Bartick et al., 2021) and use affirming health care that affirms the client's name, pronoun, and role in the family (Ferri et al., 2020). Misgendering, or calling a client by a name, pronoun, or familial role other than that they have affirmed, is hurtful and can interfere with a healthy relationship between the client and social worker. It is recommended that if misgendering does occur, the social worker should acknowledge the mistake but not dwell on the error as that may create more harm (Ferri et al., 2020).

This paradigm shift includes not only “non-traditional” family structures and gender fluidity, but also changes in terminology, including recognizing the limitations of the term “breastfeeding” (Dodgson et al., 2022). Terms such as chestfeed, bodyfeed, human milk feed, or nurse are often preferred by transgender or non-binary individuals (MacDonald, 2019). For example, a transgender man who carries and births his own baby may chestfeed or bodyfeed, and a transgender woman may induce lactation and nurse her baby. By using appropriate terminology that is selected by the client, social workers can assist in minimizing gender incongruence or gender dysphoria. While the term “breastfeeding” is not only poorly defined, it can be uncomfortable to a member of the LGBTQI+ community who is struggling with gender incongruence, which is when a person’s identity does not align with their sex assigned at birth (Ferri et al., 2020; WHO, 2018). If a person's sense of gender is incongruent or not aligned with their physical appearance, this gender incongruence can cause a persistent sense of distress or suffering, referred to as gender dysphoria (Chang & Singh, 2018; Ferri et al., 2020; Lee, 2019; MacDonald, 2019). For example, a trans man may experience gender dysphoria as a result of suspending gender-affirming hormones during pregnancy, birth and lactation, and delaying gender-affirming chest reconstruction or top surgery to breast/chestfeed can prolong gender dysphoria for the client (Ferri et al., 2020). Additionally, experiences of gender dysphoria related to lactation can be extremely varied (MacDonald, 2019). For example, while some trans men report that chestfeeding is a cause of intense dysphoria, other trans men reported that it was the only time that they did not feel chest-related dysphoria (MacDonald et al., 2016). Because there are a variety of options that LGBTQI+ parents and families may use to provide human milk to their child, social workers can request who and how human milk will be provided to the child, and which terminology they prefer (MacDonald, 2019).

Gender-Affirming and Trauma-Informed Care

Because of body dysphoria or experiences of trauma, violence, and institutional discrimination, healthcare workers should be attentive to provide families with privacy during examinations and lactation visits. They can take a “hands-off” approach during lactation visits unless and until permission is provided by the client (Ferri et al., 2020). Additionally, social workers and providers should not assume that a person will want to lactate because they have the anatomy to support the process. Gender-affirming care is sensitive to the experiences of clients and supports them in their decision to continue gender-affirming treatment after the birth, even if that prohibits their ability to lactate (Ferri et al., 2020). Another important consideration for social workers to consider is that there are significant health disparities in the LGBTQI+ community because of past discrimination, stigmatization, and mistreatment by healthcare professionals (Lee, 2019; Roosevelt et al., 2021). Because of this, some members of the LGBTQI+ community may not seek out lactation care, while others may hide their LGBTQI+ status in order to “pass” as cisgender to their healthcare provider (Duckett et al., 2019; Lee, 2019). In a large-scale survey of healthcare professionals at 18 healthcare organizations, 19.4% of clinicians reported that did not feel prepared to meet the clinical needs of patients who identified as lesbian, gay, or bisexual, and 31.8% reported that they did not feel prepared to meet the needs of patients who identified as transgender (Goldhammer et al., 2018). It is important for social workers to understand the challenges faced by members of the LGBTQI+ community as they experience fertility, pregnancy, birth, and lactation, and provide gender-affirming and trauma-informed care for not only their bodies but also their psychological and emotional well-being (Roosevelt et al., 2021).

Implicit Bias and Educational Resources

Social workers should continually strive to identify and consider how implicit bias can influence the mental processes that foster negative internal perceptions toward a particular group and unknowingly affect their judgment or behavior toward others (Berndt Rasmussen, 2020). Implicit bias may be influenced by the environment to which one is exposed, including culture, historical factors, literature, media, and other societal factors. The observed effects identified in multiple meta-analyses suggest that implicit bias correlates to reliably predictable actions of discrimination (Greenwald et al., 2022). Social workers have an ethical responsibility to identify these implicit biases, assess their judgment and behavior, and implement preventative strategies for harm reduction. In order to address disparities and advance equity, social workers can use Transformative Learning Theory (TLT) as a guide. Offered in a safe and supportive learning environment, TLT provides critical reflection, guided discourse, and actions that facilitate behavior changes (Gonzalez et al., 2018) and reduces implicit biases relating to discriminatory outcomes. In order to provide gender-affirming, trauma-informed care and reduce implicit biases in working with the LGBTQI+ community, social workers may need to address their own preconceived ideas, stereotypes, and judgments, and this may require ongoing continuing education at conferences, webinars, and books (Roosevelt et al., 2021). Some examples of these educational opportunities include:

Online Conferences: ◦

Family Equity: LGBTQ+ Training for Professionals online at: https://familyequality.org/lgbtq-training-for-professionals/

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GOLD Learning: LGBTQIA2S Families & Breastfeeding Online Course(s) & Continuing Education online at: https://www.goldlearning.com/ce-library/lectures-by-category/648/LGB

Webinars: ◦

IABLE: Institute for the Advancement of Breastfeeding & Lactation Education online at: https://lacted.org/

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LA Best Babies Network Webinar: Chestfeeding 101: An Overview of Lactation Concerns for Transmasculine and Non-Binary People online at: https://welcomebaby.labestbabies.org/webinar-chestfeeding-101-an-overview-of-lactation-concerns-for-transmasculine-and-non-binary-people/

Books: ◦

Baby Making for Everybody by Ray Rachlin and Marea Goodman (2023)

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Queer Nursing by Liesel Burisch (2021)

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Where's the Mother? Stories from a Transgender Dad by Trevor MacDonald (2016)

Online Resources: ◦

Birth Advocacy Doula Training—Our Favorite Queer and Trans-Centered Resources for Families and Birth Workers online at: https://www.badoulatrainings.org/blog/our-favorite-queer-and-trans-centered-resources-for-families-and-birth-workers

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Happy Milk Lactation Support: https://www.happymilk.us/lgbtqia-resources

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International Lactation Consultant Association (ILCA) Website online at: https://lactationmatters.org/2020/03/01/lgbtqia-families/

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La Leche League International—Support for Transgender and Non-binary Parents online at: https://llli.org/breastfeeding-info/transgender-non-binary-parents/

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Maine State Breastfeeding Coalition Resource Library online at: https://www.mainebreastfeeds.org/resource-library

Human Milk Feeding

Infants born to parents in the LGBTQI+ community have the same feeding options and many of the challenges as children born into cisgender families (Roosevelt et al., 2021). It is important for social workers to recognize that there may be circumstances when the information requested is beyond their level of expertise. In these cases, it is appropriate for the social worker to find additional specialized services and coordinate care with community lactation resources that can provide specialized lactation assistance, emotional support, and guidance from pregnancy through weaning. Depending on the resources needed, a social worker can refer a family to a community-based peer support group (Perez-Escamilla & Sellen, 2015), such as La Leche League, to public health programs such as Women, Infants, and Children (WIC), or to an International Board-Certified Lactation Consultant (IBCLC).

La Leche League International (LLLI) is an organization that provides information and support through face-to-face and online group meetings, web-based and printed materials, and telephone support. LLLI is composed of Leaders who have gone through an accreditation process and lead monthly meetings that discuss a variety of topics, such as the importance of human milk feeding, family dynamics, overcoming challenges, introducing complementary foods, and weaning. The support group setting can also be used to provide support and identify solutions to individual challenges (Perez-Escamilla & Sellen, 2015).

WIC is the acronym for the special supplemental nutrition program which stands for Women, Infants, and Children. The federally funded program utilizes peer counselors and IBCLCs to provide resources for participants. WIC peer counselors offer basic information and coach participants with regular periodic contacts pre and post-delivery. IBCLCs at WIC provide specialized breastfeeding information and support.

If a parent has a medically complicated situation that impacts human milk feeding or is in need of specialized lactation assistance, a social worker can make a referral to an IBCLC who is a healthcare provider who specializes in lactation management (Hurst et al., 2018). Lactation consultants have the education and training to address challenging lactation issues, methods of supplementation, and specific issues within the LGBTQI+ community. Under the Affordable Care Act (ACA), insurance providers are mandated to cover services provided by an IBCLC (Herold & Bonuck, 2016). If a parent is employed at an organization that provides a workplace lactation program, it might offer access to a lactation consultant as part of a workplace lactation program. Based on the specific needs of a family, social workers, and community lactation support volunteers and professionals can educate the members about adaptive approaches to human milk feeding, such as milk expression, a supplemental nursing system (SNS), relactation, induced lactation, co-lactation, milk banks, and milk sharing.

Milk Expression

In cases where a parent is successfully breast/chestfeeding, milk expression may not be necessary. However, there are many situations where milk expression can be used to help achieve breast/chestfeeding goals. For example, if a parent needs to be physically separated from the child, a pump is used to express milk while away. The pumping action and milk removal help to maintain the milk supply, and the milk removed can be used to feed the child by bottle, cup, or supplemental nursing system (SNS). Depending on the family's insurance coverage, the cost of a pump may be covered, and this is an opportunity for the social worker to provide information and assistance prior to delivery or adoption. Because prior authorization is required by some insurance policies, social workers can facilitate the authorization process.

Depending on the parent's needs, there are multiple types of pumps that can be successfully used to express milk including the manual pumps, small portable battery-powered pumps, double electric pumps, and hospital-grade electric pumps (Angeletti, 2009). The manual pump consists of a breast-shield that is placed over the nipple and areola, and a handle or lever that is squeezed to create suction to express human milk into an attached container. The manual pump is beneficial when the need to express milk is infrequent, such as for those who work part-time or have occasional use for a special event. The battery-powered pump uses batteries to power a small, motorized pump that creates suction to extract milk, and is beneficial when there is a need to express, but there is no access to a power source, such as for those who may work outdoors or who may be required to travel as part of their job (Angeletti, 2009). Designed for working parents, the double electric pump is designed for the full-time working parent and those under time constraints. It is the size of a briefcase, easily transported to and from work daily and some models contain an area with cold packs to provide milk storage until a refrigerator is available (Angeletti, 2009). The hospital-grade electric pump is a larger, more efficient, multi-user pump. The sealed motor and mechanical parts protect against cross-contamination of milk from different users, and each person is provided their own tubing and shields. The hospital-grade pump can be used while hospitalized or rented and used at home. For example, in the case where a gestational parent has delivered a baby who is preterm or very ill, the child may be too weak to effectively suckle. In this case, the lactating parent may exclusively express with a hospital-grade pump to induce lactation and express milk that is fed to the child.

Supplemental Nursing System (SNS)

An SNS is a feeding device consisting of a tube that can be taped to a finger or nipple during feeding to provide the child additional supplementation of human milk while providing skin-to-skin contact. An SNS may be used by any client who has a supply of milk lower than the child requires. If the child's needs are not being met by the quantity of human milk that is being produced, it can be supplemented with donor milk or artificial human milk substitute (infant formula) (Ferri et al., 2020; Griggs et al., 2021). The child's growth and the need for supplementation would be determined and closely monitored by a pediatrician or lactation consultant. An SNS can be used for a few days, weeks, or indefinitely depending on the child and parent's lactation plan and goals. Instances when an SNS has been successfully used include latching issues, premature babies, cleft lip or palate, adoption, and babies born with Down Syndrome (Ravichandran, 2022). An SNS can also be used with people who have had breast- or chest-related surgeries, which may include augmentations, reductions, removal of breast tissue for medical reasons, or insufficient glandular tissue (Ravichandran, 2022). For a trans man who has had “top surgery” or a transwoman who has had breast augmentation, the nipple and mammary tissue may be less flexible which could lead to more challenges in the child obtaining a correct latch. In the case of a transman, if the chest is flatter and tighter, the client can be encouraged to try folding or sandwiching the skin with his hands to assist with latching (Griggs et al., 2021; MacDonald, 2019). In both of these cases, the use of a nipple shield can be considered (Ferri et al., 2020). If an SNS is used with a nipple shield, the tube may be used inside or outside of the nipple shield (Ferri et al., 2020). Additionally, an SNS can be used in a family with two lactating parents who are interested in co-feeding the child or with one nonlactating partner who may prefer the skin-to-skin contact of an SNS instead of cup or bottle feeding.

Colactation

Colactating, also referred to as co-nursing, is when two or more people breast/chestfeed a child (Ferri et al., 2020). There are various examples and family dynamics that would support a colactating arrangement and in most cases, one parent is the gestational/birth parent and a non-birth parent, friend, or family member chooses to induce lactation (Griggs et al., 2021). For example, colactation is an option that can be used when a breastfeeding parent works and those who share time caring for a child, such as a parent, extended family member, or friend, breastfeed the child in the parent's absence. While colactation is an option for cisgender lesbian couples, it should be recognized that not all of them will select this option (Griggs et al., 2021). While some non-lactating partners may use non-nutritional suckling for purposes of nurturing and bonding, other partners may not be interested in induced lactation or any form of chest/breastfeeding (Griggs et al., 2021). Additionally, in cases where a lactating parent is uncomfortable with breast/chestfeeding, they may choose to express milk so that the other parent can feed using a bottle, cup, or SNS system.

Relactation and Induced Lactation

Through relactation or induced lactation, it is possible for a family to produce human milk to feed a child who has joined the family through adoption or surrogacy. Relactation is the process by which a person who has given birth and previously produced milk reestablishes a milk supply after having stopped for an extended period of time. If a person has lactated within the last six months, relactation can occur by letting the child suckle at the breast every two hours and can be stimulated with hormones, medications, galactagogues, or herbal remedies (Goldfarb & Newman, 2015). This will increase milk production by approximately one ounce every 24 h. The amount of time needed to reestablish a milk supply may vary and take longer if it has been more than six months since the person has lactated (WHO, 1998). Induced lactation is when a person who has not been pregnant produces milk (Ferri et al., 2020), which makes it possible for adoptive parents, transgender persons, non-birthing women, and individuals assigned male at birth to breast/chestfeed or express their milk for their child (Griggs et al., 2021; Lee, 2018). Gender-affirming healthcare workers should not assume that a person with breasts will know that induced lactation is an option nor that because the client has breasts that they want to induce lactation (Ferri et al., 2020). Information can be shared in a sensitive and affirming manner, allowing the client to determine the best decision for their family. In most cases, induced lactation should be overseen by a lactation consultant and a primary health physician because both herbal and pharmaceutical galactagogues such as fenugreek, domperidone, and metoclopramide (Bazzano et al., 2016) and hormones such as estradiol and progesterone (Jin et al., 2024) can be recommended or prescribed. A transwoman can breast/chestfeed with the use of hormonal treatments that result in breast development (Reisman & Goldstein, 2018). While inducing lactation may be more of a challenge for a transgender person, it generally focuses on hormonal priming of the mammary tissue, the production of the hormone prolactin, and the withdrawal of high doses of estrogen and progesterone during the milk expression phase (Ferri et al., 2020; Reisman & Goldstein, 2018). A recent macronutrient analysis of the milk of a transgender woman that was induced using the Newman-Goldfarb protocols found that there was no significant difference between the protein, fat, lactose, and calorie content of the participant's and that of standard term milk (Weimer, 2023). However, if a client does decide to relactate or induce lactation and suffers from a low milk production, the benefits of skin-to-skin contact for bonding, nurturing, and soothing the child can be discussed as it has been reported to have significant value to many people with a low milk supply (Ferri et al., 2020; Lee, 2019).

Milk Banks and Milk Sharing

Milk banks are an option for families who cannot produce sufficient quantities of human milk to meet their child's nutritional needs. Milk banks dispense human milk that has been donated, and put through a screening, testing, and pasteurization process. For example, milk banks can be suggested by social workers in cases where a young child has been adopted or is being fostered, when a cisgender man is raising a child on his own, or in families with parents that have the desire to increase the volume of human milk available to their infant, such as a ciswoman who has had a single mastectomy, but is still able to successfully breast/chestfeed with one lactating breast (Alianmoghaddam et al., 2016). Although some milk banks can be used as temporary resources, they can become expensive in long-term scenarios and given limited quantities, milk banks may prioritize milk to infants who are hospitalized with critically ill conditions (Martino & Spatz, 2014).

Milk sharing has become popular due to its affordability and accessibility with social media platforms, and milk-sharing communities are popular among LGBTQI+ families (Palmquist & Doehler, 2016). People can connect through social media networks, online forums, and informal groups where human milk is being donated or sold by individuals with a surplus milk supply and/or a desire to help others (Paynter & Goldberg, 2018). Because of the inherent risk involved in receiving human milk from strangers, as well as the possibility of fraud and lack of regulation, milk sharing is not recommended by the American Academy of Pediatrics, the U.S. Food and Drug Administration, the Human Milk Banking Association of North America, and the European Milk Bank Association (Committee on Nutrition, Section on Breastfeeding and Committee on Fetus and Newborn 2017; Ferri et al., 2020; Sriraman et al., 2018). While the ABM does not recommend internet-based human milk sharing, which has been found to have high concentrations of bacteria reflecting poor collection, storage, or shipping practices (Keim et al., 2013), it does acknowledge the risks and benefits of milk sharing and recommends procedures such as the medical screening of the donor and safe milk handling practices be used to maximize safety (Ferri et al., 2020; Sriraman et al., 2018). The ABM recommends that donors be in good health and only use medications or herbal supplements that are compatible with breastfeeding (Sriraman et al., 2018). Additionally, the ABM recommends that donors be screened for HIV, Hepatitis B virus, and HTLV-1 in high prevalence areas, and that donors be excluded if they participate in certain social practices, such as using illegal drugs, marijuana, tobacco products including nicotine gum, patches, e-cigarettes, and alcohol above recommended limits (Sriraman et al., 2018). Additional considerations can include screening for herpes, syphilis, Hepatitis B and C, and tuberculosis in high-risk areas (Ferri et al., 2020). When a family understands the risks and decides to pursue milk sharing, social workers can encourage methods to reduce risks, such as requesting a medical screening of the donor and conducting a home pasteurization process known as the flash heating that removes bacteria and viruses that could be potentially harmful to a child. In the flash heating method, human milk is placed in a heat-resistant glass jar which is then placed in a small pan of water deep enough to come above the level of the milk in the jar. The water is heated on the highest level until it reaches a roiling boil. The water should be closely monitored because the heating process should only last a few minutes to minimize damage to the nutrients in the milk. When the water comes to a boil, the jar of human milk is immediately removed and placed into cool water until it reaches room temperature. Once the human milk has cooled to room temperature, it can be fed to the child, refrigerated, or frozen (Sriraman et al., 2018).

Conclusion

Lactation and human milk feeding must change from from a binary, heteronormative, and cisnormative foundation to one that recognizes the importance of using best practices in supporting sexual and gender-diverse families. Emerging from the transgender and gender non-conforming communities, there has been a paradigm shift that directly impacts how social workers should approach and support lactation and human milk feeding with people with dynamic and diverse gender roles and a variety of family structures. Generally, there is limited knowledge by healthcare professionals, and specifically social workers, for supporting human milk feeding in the LGBTQI+ community. While healthcare professionals advocate for chest/breastfeeding, research indicates that these recommendations are not followed by open discussions of feeding options (Jackson et al., 2022). Population data indicate significant growth in the LGBTQI+ community among younger generations, as well as an increase in their plans to have families. To meet these socio-demographic changes, social workers can actively engage in continuing education opportunities to address their own biases, promote inclusivity, and provide gender-affirming, trauma-informed care that meets the needs of LGBTQI+ families. Best practice includes social workers understanding the importance of de-sexed and gender-inclusive language, offering gender-affirming and trauma-informed care when working with clients in diverse family structures. It is the responsibility of social workers to seek out resources to educate themselves on their own implicit biases so that they can provide the education, support, and resources that ultimately increase children's health, well-being, and survival. Overall, infants born to parents in the LGBTQI+ community have the same feeding options and many of the same challenges as children born into heterosexual and cisgender families. Understanding diverse lactation methods, such as milk expression, supplemental nursing systems, colactation, relactation, induced lactation, milk banks, and milk sharing, can be useful to address the specific lactation challenges of a client in the LGBTQ+ community. Social workers have the opportunity to collaborate with specialized healthcare providers and community support organizations, so should their clients decide to provide human milk feeding, they will be well-informed, well-prepared, and well-supported. Through information and anticipatory guidance, social workers can protect, promote, and support human milk feeding in the LGBTQI+ community.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Michelle Angeletti

Author Biographies

Michelle A. Angeletti is a Professor of Health Services Administration at Florida Gulf Coast University. She focuses her research and service on lactation management with an emphasis on diversity and inclusion. She is a La Leche League Leader, an ACHE Distinguished Service Award recipient and actively leads Health Management Study Abroad programs.

Victoria A. Angeletti is completing her Masters in Social Work and is a Segal AmeriCorps Education Award recipient. She is a dedicated professional with almost a decade of experience in home health and elder care, and her blend of practical experience and academic knowledge support her continuous research in lactation management in the LGBTQI+ community.

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A Paradigm Shift: Implications for Social Worker Provision of LGBTQI+ Information and Support in Human Milk Feeding

Abstract

Keywords

Diversity, Inclusion, and Family Dynamics

Non-Sexed, Gender-Inclusive Language

Gender-Affirming and Trauma-Informed Care

Implicit Bias and Educational Resources

Human Milk Feeding

Milk Expression

Supplemental Nursing System (SNS)

Colactation

Relactation and Induced Lactation

Milk Banks and Milk Sharing

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

Author Biographies

References