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Bioethics Forum Essay

Breastfeeding and Transgender Women

A transgender woman has successfully breastfed a baby. This case has been hailed as a “breakthrough” for transgender families. I will argue that being transgender is only peripherally relevant, and the potential risks to infants are unjustified.

The woman, whose name and hometown were not given, had been taking hormonal medications since 2011 as part of her transgender treatment. In 2017, when her partner was in her fifth month of pregnancy, she approached her health care providers (a doctor and a nurse practitioner at Mount Sinai Hospital in New York) about the possibility of her being able to breast-feed the child, since her partner did not want to.

Her providers prescribed progesterone and estradiol, hormones that occur normally in pregnant women and are used in induced lactation protocols. (Induced lactation refers to the initiation of lactation in women who have adopted a baby and others who have not borne a child but want to breast-feed.) The couple’s health care providers also suggested using domperidone, an antinausea drug used in induced lactation protocols in Canada , but banned in the United States because it has been associated with cardiac arrest and sudden death. The couple obtained the drug on their own in Canada and their providers advised them on the dosage. After three months of treatment, the woman was producing eight ounces of milk per day. She was able to exclusively breast-feed the infant for six weeks, when bottle-feeding was added to ensure that the child was getting enough milk. According to a pediatrician, the baby’s development in growth, feeding, and bowel habits was normal. The baby is now six months old, and apparently healthy.

Although the woman in the experiment was transgender, induced lactation could be used by other new parents, such as a woman who adopts and wants to breast-feed,  and a lesbian woman who wants to breastfeed the child her partner has birthed. Some men have attempted to breastfeed, and a Sri Lankan man reportedly breast-fed his two infant daughters after his wife died in childbirth.

So, is this something that should be encouraged?

Supporters say yes, pointing to the advantages of breast milk over formula. The World Health Organization recommends that a child breast-feed for at least two years. The American Academy of Family Physicians, like the American Academy of Pediatrics, “recommends that all babies, with rare exceptions, be exclusively breastfed for approximately six months and continue breastfeeding with appropriate complementary foods for at least one year.”

Breast-feeding is particularly important in developing countries where formula is expensive and clean water is not always available. In the 1970s, Nestle was accused of getting third world mothers hooked on formula . Some women, unable to afford formula, have diluted the powder to make it go further, causing malnutrition in their babies. Given that human milk has evolved specifically for human babies, it is almost always preferable that women who can breast-feed should do so.

The cost-effectiveness of breast milk is obviously not relevant to the question of induced lactation. However, breast milk has other advantages, including healthier immune systems in infants, better mother-baby bonding, higher IQs in children, and a possible reduced risk of obesity. Certainly, these advantages provide reasons for society to encourage nursing.

But are the advantages so great that breast-feeding must be regarded as a maternal responsibility? If a woman decides not to breast-feed, will she be sacrificing IQ points? The studies have shown that breast-fed babies have, on average, higher IQs than bottle-fed babies. But this may be because breast-feeding is associated with socioeconomic status. We don’t know if breast milk affects IQ, or if the increase stems from the privileged backgrounds breastfed babies are more likely to have.

Even if “breast is best” for women who have given birth (and this is not always the case; the Centers for Disease Control and Prevention recommends that women who are HIV-positive, for example, not breast-feed), we do not know that the breast milk from induced lactation is equivalent to breast milk produced by women who have given birth. This being the case, one wonders why the transgender couple’s health care providers did not encourage the birth mother to take on the responsibility of breast-feeding.

Of particular concern in this case is that the woman continued to take another drug, spironolactone, in addition to the drugs to induce lactation. Spironolactone, used in trans female patients to suppress endogenous testosterone, and therefore masculine appearance, is excreted in human milk, and no one knows what the risks to infants are. Even if her health care providers believed that she could safely nurse a child, it is hard to fathom why they supported her continuing to take an unrelated drug with unknown risks to the baby.

It is understandable that transgender women, like adoptive mothers, might want to have the experience of nursing a child they will raise. It is also understandable that some men might want to breast-feed. But before induced lactation is promoted and encouraged, we would need to know a lot more about the safety of the hormonal regimens for infants. However, is there an ethical way to find out? Given that there is a safe alternative to feeding infants whose mothers cannot or will not breast-feed, namely, bottle-feeding, how could a clinical trial to determine the safety and nutritional value of breast milk from induced lactation be justified? Surely the well-being of children should take precedence over the desire to breast-feed.

Bonnie Steinbock, a Hastings Center Fellow, is a professor of bioethics at Clarkson University and Icahn School of Medicine at Mount Sinai.

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  1. Professor Steinbock has an excellent point regarding the need to carefully assess potential risks to infants from hormone suppressing drugs that may be contained in breastmilk. However, this risk seems to be similar to the risk breastfed infants might face from common drugs taken to address mental illness or many other conditions of the person breastfeeding. While hormone suppressing drug risks merit study and should not be discounted, they also should not be overstated or treated differently from other drug risks. Moreover, the benefits to an infant of breastfeeding are not merely the nutritional value of the breast milk itself but also the close and frequent skin to skin contact that appears to correlate with better health and development outcomes. A clinical trial studying transgender breast-feeding could be justified not only based on the desire of the parents but also on the well-being of the child.

  2. I, too, have wondered about medications taken by the lactating person that may be passed to the baby via breastmilk. Many have been shown to be safe to use while breastfeeding. While I have not looked for specific research on spironolactone compatibility with breastfeeding, a quick search on Micromedex indicates that infant risk is minimal and it is compatible with breastfeeding. Also, a quick aside about breastfeeding for those who are HIV positive: the guidelines to not breastfeed are U.S. guidelines; WHO guidelines encourage breastfeeding if the person nursing and/or the infant feeding is on a stable regimen of antiretroviral medication (because the benefit of breastfeeding is very high — particularly in low resource countries/settings — and the chance of disease transmission is very low).

    So, actually, what I wonder about more is the composition of this milk and how it compares to the breastmilk of cis women who are producing it naturally (not through induced lactation). Does the milk contain as many antibodies and oligosaccharides and other beneficial components? Do the components of milk (such as protein ratios of whey vs casein) change and adapt as the baby grows in response to what the baby needs developmentally? How does it compare to formula? Seeing as induced lactation has been done in adoptive parents and/or lesbian partners, it’s possible some of this research has been done for cis women, and I am curious to know more about it. It would have been great if this documented case of the trans woman breastfeeding had looked into the composition of her breastmilk.

  3. Hold on … dumb question … why not just take a sample of the milk and answer all your questions? maybe talk to women about their experiences of lactating and how it brings them closer to their children.

    Also … this whole thing seems to be a round about way of saying “herpa derpa trans people scary protect the children” so … yeah nah.

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