Trans Fertility, Pregnancy, & Lactation 101 for Doulas
Intro
I sat down to write this article with the intent of creating a resource to serve both the greater doula community and our clients alike, consolidating the most contemporary existing knowledges from across the spheres of transgender healthcare. This document is meant to be an introduction and roadmap to future research, not an inherently extensive text. For many, portions of this text will be review, yet I hope everyone can come away having learned something new. This text contains four main sections, each covering a unique facet of trangender reproductive healthcare that is often left under-researched or under-discussed. The first section of this text, ‘Medical Transphobia, Transgender Medical Trauma, And The Need for Doulas’ discusses the unique ways that transgender people are uniquely discriminated against or traumatized by medical settings, and how Doulas can have an important role in mitigating that and serving as allies. In ‘Testosterone and Fertility, And Pregnancy as a Man’ I cover the medical and social aspects of fertility and pregnancy as a transgender man. The final two sections, ‘Lactation for Transmasculine Individuals’ and ‘Lactation for Non-Gestational Partners and Transfeminine Individuals’ cover lactation for a variety of gender identities and body types beyond cisgender women who have recently carried a pregnancy. At the end of this text is a list of LGBTQ+ specialized professionals and resources serving the Seattle area and beyond in birthwork related fields such as fertility, lactation, acupuncture, counseling, and more. Sources for each section can be found at the very bottom of the page, sorted by the section that they are referenced by. It is my intention to provide these citations to be used for further research and shared as educational resources, among both doulas and clients alike. Consider this the first edition, a living document that I will continue to renew and expand upon.
A guide to language
A quick refresher on relevant and respectful language:
Assigned Sex At Birth: The gender marker, M or F, that is assigned to a baby at birth based on their visible sex characteristics. Assigned male at birth or assigned female at birth are abbreviated as AMAB and AFAB respectively. Ones assigned sex at birth does not determine gender identity, and may not reflect their current hormonal makeup, reproductive organs, or secondary sex characteristics as an adult. **
Bodyfeeding / Chestfeeding: Gender neutral synonyms for breast feeding. In this text I use the two phrases interchangeably without distinction.
Dysphoria: The distress of feeling an incongruity between ones internal gender identity vs. physical appearance or societal treatment.
Exogenous: Hormones to supplement what is being made by the human body, hormones that come from outside the body eg. taken as medication.
HRT: Hormone replacement therapy, an umbrella term for the variety of hormones taken for gender affirming purposes.
Nonbinary: A gender identity or positionality of being outside the binary of man - woman.
Trans man: A man who was assigned female at birth and transitioned into a man.*
Transmasculine: An umbrella term for transitioning to a more masculine state or identity, but not being inherently or strictly a man.
Trans woman: A woman who was assigned male at birth and transitioned into a woman.*
Transfeminine: An umbrella term for transitioning to a more feminine state or identity, but not being inherently or strictly a woman.
Transsexual: Transgender. An older word that some consider outdated or offensive, while others prefer.
*It’s commonly agreed that the terms “trans man” & “trans woman” as separate words are preferable to the terms “transman” and “transwoman”. In the former, “trans” is the adjective modifying “man” or “woman,” as opposed to combining it into one word which is considered to imply an inherent otherness.
** It’s important to note that in the context of medical care and reproductive health, it is helpful to never assume what reproductive anatomy someone may have based on their appearance or gender marker. Medical transitioning and gender affirming surgeries come in many variations, not to mention intersex individuals who may have anatomy outside what medicine has deemed to be the binary of sex characteristics. Regardless of assigned sex at birth, someone might have for example; both a penis and a vagina, ovaries but no uterus, breasts and testicles, etc.
1. Medical Transphobia, Transgender Medical Trauma, and the Need for Doulas
Trans people, as with other minorities, face unique discrimination and discomforts in medical settings that may affect their comfort in seeking, or ability to access, appropriate healthcare. Many general practice doctors lack a specific, nuanced, and contemporary education on transgender medical care, as its not made a focus in general medical training. Furthermore, in varying locations around the world - including some US states - at points in time transgender people have been required by law to be sterilized before being granted the ability to change their legal sex or other gender marker paperwork. This means that transgender people have not only been ignored by the reproductive medicine field, but also systemically and surgically barred from the ability to grow families biologically. Though laws improve, attitudes and assumptions remain that transgender people don't have the desire, the ability, or the right, to conceive and birth and bodyfeed children.
Some examples of medical transphobia are:
Being asked invasive questions about genitals, sex life, or anatomy unrelated to the treatment being sought; or, clinicians asking invasive questions because they see a transgender client as exotic or something to study
Being misgendered or having anatomy incorrectly referred to; having gender identity denied on the basis of assigned sex at birth or on the basis of present anatomy
Having assumptions made about ones lifestyle on the basis of being LGBTQ+, general social stigmas and discrimination; being denied treatments or sufficient care, discrimination on the basis of their gender identity.
Doctors incorrectly assuming that an unrelated health issues was caused by a patient's gender identity or medical transition; this is colloquially known as “trans broken arm syndrome” or clinically known as gender-related medical misattribution and invasive questioning (GRMMIQ)
Medical transphobia and the related medical trauma can, and does, discourage transgender individuals from seeking medical attention or from sharing everything with their doctors, thus risking insufficient or substandard treatment and care. Medical transphobia leads to a lack of trust in medical providers, which prevents people from seeking out the care they may need. Within the transgender community there is a pervasive lack of trust in medical health care providers, both as a result of communal skepticism, and as a result of individual and personal negative experiences.
In addition to all of these factors, trans men and transmasculine individuals tend to specifically avoid gynecological and reproductive health care. Unique obstacles are raised by gendered healthcare such as this where primarily all resources, language, and knowledge centers around cisgendered and heterosexual women. Transgender individuals seeking this care may find the experience dysphoria inducing, or find that clinicians lack sufficient medical knowledge regarding their anatomy.
So what can we as doulas do to help? Use gender neutral language. Maintain a trauma informed practice that centers consent and bodily autonomy. Stay educated on trangender health, new resources, and case studies. Ask your LGBTQ+ clients how they like to be referred to, what kind of advocacy they need in medical settings; would they like you to correct misgendering from strangers? As a doula, simply being a supportive and familiar presence can mean a world of difference.
2. Testosterone HRT & Fertility, and Pregnancy as a Man
Many transgender men or other transmasculine individuals will take exogenous hormone replacement therapy in the form of testosterone, which causes the developments of masculine secondary sex characteristics such as facial and body hair, a deeper voice, and changes in body shape and genitalia. Although use of HRT testosterone decreases fertility, and often causes the cessation of menstruation, it’s not a contraceptive on its own and it is still very much possible to conceive while using it. In some cases due to lacking a period, or because of weight gain and fat redistribution, being on testosterone may make it harder for an individual to notice that they are pregnant at first. It’s worth noting for transmasculine individuals with transfeminine partners, estrogen HRT and/or testosterone blockers are not sufficient birth control either and they still have the ability to impregnate someone.
However, for those who use testosterone HRT and also wish to carry a pregnancy to term, the standard recommendation is to cease use of testosterone for the course of the pregnancy and until chestfeeding (if desired) is completed. Those seeking to become pregnant should cease testosterone use in anticipation of conception. The U.S. Food and Drug Administration has classified testosterone as a pregnancy category X, the category for drugs that have been linked in studies to fetal risk where the risk outweighs potential benefits. The existing research shows that high testosterone levels in the gestational partner increases the risk of potentially irreversible fetal androgenic effects, including affecting sexual or neurological development later in life. In studies on cisgender women with high endogenous testosterone levels, fetal exposure to androgens correlated to low birth size. However, the existing medical knowledge is limited and focused primarily on cisgendered people. There have been insufficient formal studies on the effects of exogenous testosterone on fetal development, and transgender people suffer from these gaps in medical knowledge.
Ceasing use of HRT can cause a transgender person to go through undesired and unpredicted physical reversions triggering dysphoria, exacerbate pre-existing mental health issues previously treated by the HRT, cause hormonal mood swings or menopausal symptoms. Because of this, consideration and preparation should also be made regarding the potential mental health risks of ceasing testosterone during pregnancy and chestfeeding, especially in comorbidity with the other hormonal changes and mental health risks associated with pregnancy and chestfeeding such as such as postpartum depression or ‘dysphoric milk ejection reflex’.
Even outside of medical contexts, it can be difficult, complicated, and/or uncomfortable socially to be a pregnant man or pregnant nonbinary person. Depending on ones presentation they may face being misgendered as a woman more often, or choose to hide their pregnancy from people to continue passing as their chosen gender or avoid questions. On the other hand, other pregnant men and pregnant transmasculine individuals have reported pregnancy bringing a sense of peace or meaning to anatomy they may otherwise not enjoy.
3. Lactation for Transmasculine Individuals
Following pregnancy and delivery, some transmasculine parents may have the desire to bodyfeed. Unfortunately, this is a subject lacking in existing research and protocols, due to the older beliefs that men and masculine individuals would have no interest in bodyfeeding, or beliefs that aspects of a medical transition would make bodyfeeding impossible. However, I was able to primarily draw from one academic study, the first of its kind to interview 22 transmasculine and nonbinary individuals on their experiences bodyfeeding the children they carried. Though body feeding following a gender affirming chest reconstruction is difficult, uncommon, and still not well researched, it also has a number of successfully reported cases. With the understanding of the myriad health benefits a baby gains from chest feeding and/or consuming human milk, it’s imperative to have the knowledge and resources to support everyone in their journey to bodyfeed.
Unlike a double mastectomy done on cisgender women for cancer treatment or prevention, a gender affirming chest reconstruction leaves behind a small amount of breast tissue to create a fuller pectoral appearance. This breast tissue may still respond to hormonal changes, such as growing during pregnancy. Someone's ability to body feed after masculinizing chest surgery will also be dependent on what type of surgery they had. The most common form is a double incision with free nipple graft, in which all breast tissue, mammary glands and milk ducts are removed and the chest sutured on an incision along the underside of the pectoral. Here the nipple is removed from the nipple stalk and grafted back on. Other forms are periareolar - where breast tissue is removed through a doughnut shaped incision surrounding the areola - or keyhole, where breast tissue is removed through an incision just below the areola. Periareolar and keyhole incision surgeries will have a higher chance of successfully chestfeeding postoperatively because these surgeries leave the nipple stalk connected and in place, as opposed to the double incision surgery where the nipple is fully removed from the body and grafted back onto a new location.
Because masculinizing chest surgery leaves behind some breast tissue, even those who’ve had this surgery before becoming pregnant may experience a re-growth or size increase of their breast tissue during pregnancy. This can be dysphoria inducing for some, and painful or difficult to bind. For those who have not had masculinizing chest surgery, binding can also become uncomfortable or impractical due to changes in body fat distribution or discomfort. It’s important to note that binding while lactating can increase the risk of plugged ducts or mastitis, so individuals who desire to bind while lactating should exert caution, seek resources on safe binding, and watch for early signs of irritation. Another consideration regarding chestfeeding from a postoperative transmasculine chest is that scar tissue and pre-existing tenderness from surgery can also make chestfeeding uncomfortable or untenable.
Most people on testosterone HRT wishing to carry a pregnancy will have to, or be advised to, cease use of testosterone for the duration of the pregnancy and until weaning off bodyfeeding. The cessation of testosterone HRT for trans men and transmasculine individuals can be dysphoria inducing, thus a desire to restart soon after pregnancy is common. This can sometimes conflict with bodyfeeding; both through barriers to prescriptions, and because testosterone can decrease milk production. In one case study of resuming testosterone while still chestfeeding, “[t]o re-start testosterone therapy, Adam consulted with his endocrinologist and his child’s paediatrician. Adam reported that his doctors referred to a study of low-level testosterone use in lactating, cisgender women to assess safety. He stated that his doctors recommended re-starting testosterone therapy and watching the child closely for any signs of early puberty such as body hair. Adam did re-start testosterone therapy when his child was approximately 21 months old. He reported that approximately 15 months after he had re-started testosterone at a standard dose for female-to-male therapy, blood tests showed normal testosterone levels in his child. He did not notice a decrease in his milk supply that coincided with re-starting testosterone.” The study concludes that “[B]ased on the experience of one study participant, others might wish to take testosterone while chestfeeding under the guidance of a physician who can monitor the infant for possible signs of exposure.” (MacDonald) From the National LIbrary of Medicine National Center for Biotechnical Information Drugs and Lactation Database, “[... T]estosterone has low oral bioavailability because of extensive first-pass metabolism, so it appears to not increase serum testosterone levels in breastfed infants. Breastfed infants appear not to be adversely affected by maternal or transgender paternal testosterone therapy.”
Regardless of surgical status, trans men, transmasculine individuals, and gender nonconforming individuals face many shared overarching struggles in their journey of chestfeeding. One significant barrier is the gender dysphoria related to act of chestfeeding; dysphoria in having that part of the body touched or seen by others, dysphoria of medical resources being geared only towards women, dysphoria of being seen as a women due to the act of chestfeeding or the shape of their chest, dysphoria from a changing body or from different hormone levels. Some find pregnancy to be the most dysphoria inducing and enjoyed chestfeeding, others felt the most dysphoric regarding chestfeeding following a tolerable pregnancy, some at the act of weaning; every transgender individual is different in what may be distressing.
Beyond dysphoria, trans men and other transmasculine individuals have to navigate external assumptions, pressures, and lack of knowledge in medical settings and other social spheres. Trans men may feel reluctant to talk to their doctors about their desire to carry a child or to chestfeed because doctors subscribing to binary views of gender roles may view that as contradictory to ones masculinity, and can even deny gender affirming care on those grounds. Trans men desiring to chestfeed face a lack of existing resources both on the effect of testosterone HRT on lactation and breast milk and on lactation after chest masculinizing surgery. They may also face assumptions or pressures, from either medical practitioners or social circles, on which way they will be feeding; assumptions that they will bodyfeed, or assumptions they will be using formula. Due to discomfort speaking of dysphoria inducing subjects, or a desire for privacy, can also make it harder for transmasculine individuals to seek lactation support when it’s needed. The added desire to nurse or chestfeed in a more private place can be a barrier to doing so. However, some men and transmasculine people have reported that the ability to carry a child and/or chestfeed a child eased their dysphoria through giving their chest a somewhat utilitarian sense of purpose.
Because of these things, one of the biggest things that can be done to improve transmasculine chestfeeding success as a care provider is creating a more gender inclusive and gender neutral culture surrounding the topics of chestfeeding. Adopting the use of gender neutral language when applicable, to best respect everyone's identity and how they consider their body. “Chestfeeding” or “bodyfeeding” instead of “breastfeeding”, “parent” instead of “mom,” little changes can make a big difference in making someone feel seen and included versus viscerally distressed. You can offer your pronouns and ask for theirs in turn, you can ask how they like to refer to themselves.
The other biggest thing that doulas can do to support transmasculine people in chestfeeding is having LGBTQ+ and transgender specific resources on hand, such as referrals to specialized lactation consultants or other specialists, links to articles or studies, resources for obtaining donor milk or SNS devices. The knowledge gap of these subjects creates a barrier to accessing care, so simply being educated has a big impact. Resources specific to chestfeeding for trans men can be found through La Leche League, an extensive resource committed to supporting everyone in chestfeeding. There’s also a Facebook page, Birthing and Breastfeeding Transmen and Allies, to share resources and support. Further suggested reading is the book Where’s The Mother? Stories From a Transgender Dad by Trevor Kirczenow, an autobiography detailing a transgender fathers experiences of carrying a child as a man, and chestfeeding after gender affirming chest surgery. For more resources, in addition to any of the sources cited in this text there is a list of educational resources and referrals to transgender specific birthwork practices.
4. Lactation for Non-gestuational Partners and Transfeminine Individuals
All humans, regardless of size of breast tissue or mammary glands, technically have the biological ability to lactate. That means that in some cases even those not pregnant, or even those assigned male at birth, lactation can be induced. The process of inducing lactation known as the Newman-Goldfarb protocol, used by adoptive and other non-gestational mothers, can also be utilized by trans women. This technique is detailed in the book The Ultimate Breastfeeding Book of Answers by Dr. Jack Newman, the doctor who first established and refined this protocol. Simply put, it aims to trick the body into thinking it was pregnant, through a system of gradually increasing doses of galactagogues (medications used to increase milk production) in conjunction with a schedule of pumping. The galactagogues used in the Newman-Goldfarb protocol are firstly birth control and the prescription medication domperidone, and later the herbs fenugreek and blessed thistle are added to the regiment. This specific routine, spanning the course of roughly 6 months, has successfully allowed people who were not pregnant to begin lactating. The details of the protocol schedule and specific medication doses can be found in the links below this section.
There have already been many successful case studies and experiments in inducing lactation in trans women specifically, though the research is still lacking and specialized protocols have yet to be established. In one case study, “[t]o induce lactation, we implemented a hormone-regimen to mimic pregnancy, using estradiol and progesterone, and a galactogogue; domperidone. Our patient started pumping during treatment. Dosage of progesterone and estradiol were significantly decreased approximately one month before childbirth to mimic delivery and pumping was increased. Our patient started lactating and although the production of milk was low, it was sufficient for supplementary feeding and a positive experience for our patient.” (Amesfoort) In another, “Through modification of exogenous hormone therapy, use of domperidone as a galactogogue, breast pumping, and ultimately direct breastfeeding, the participant was able to co-feed her infant for the first 4 months of life.” (Weimer) “After implementing a regimen of domperidone, estradiol, progesterone, and breast pumping, she was able to achieve sufficient breast milk volume to be the sole source of nourishment for her child for 6 weeks.” (Reisman and Goldstein) The details of the regiments used in each case can be found in the full article, linked in the citations at the end of this article.
These are only a few examples of successful cases, but more have been done. In all studies a protocol similar to the established protocol for cisgendered women was modified for transfeminine endocrinology, with a regimen of varying hormonal medications and breast pumping. However, one difference is that transfeminine individuals attempting to induce lactation may require an additional androgen blocker such as spironolactone. A metabolite of spironolactone known as cancrenone is excreted in human milk but has been deemed clinically insignificant and thought to be compatible with breastfeeding by the American Academy of Pediatrics. The women in the aforementioned studies had all been on estrogen HRT for a significant amount of time and had developed mammary tissue. One analysis of the contents of a trans womans breastmilk showed “values of fat, lactose, protein and calorie [...] comparable and even higher than those in term milk produced by cisgender women.” (Amesfoort) This year, the British National Health Service also confirmed that the milk of a trans woman is equal to any other breastmilk, being safe and sufficient. Successful breastfeeding for transfeminine individuals is achievable, and hopefully an area that we will continue to see research and developments in.
It should be noted that the Newman-Goldfarb protocol and other lactation induction regimens call for the prescription medication domperidone, which in the USA is not approved as a galactagogue; the FDA has warned against the use of it as such, citing “potentially adverse side effects.” On the other hand, some of those working in birth-related fields disagree with this decision. From the blog of Lenore Goldfarb, the woman who worked with Dr. Newman to develop the Newman-Goldfarb protocol, Dr. Newman himself argues that the FDA’s decision was based on decades old cases of deaths in chemotherapy patients using high doses of intravenous domperidone, as opposed to the much smaller oral doses used in the Newman-Goldfarb protocol. He argues that “[...] we should do all that is reasonable to maintain and increase the success of woman who are breastfeeding. If this means that, in some cases, we use a drug that, in my experience of using it with thousands of women, is safe, with only minor side effects, we should have that option. Of course, there is no such thing as a drug which never causes side effects, and there are probably very few approved drugs (yes, even approved drugs) out there that haven’t killed someone, but if one weighs the risk against the benefits, domperidone can do much good.” All drugs have potential benefits and side effects; it’s not the place of my text to argue for or against the use of domperidone as a galactagogue, merely to provide information and resources for further learning.
Chestfeeding offers a plethora of health benefits and emotional benefits, for both the baby and the parent. Enabling any parent to be able to chestfeed their child benefits the health of the whole family, and for transfeminine individuals the ability to breastfeed can be a uniquely rewarding and gender affirming act. On the other hand, trans women and other transfeminine individuals may also face social stigmas and discrimination for their decision to chestfeed. Trans women bodyfeeding have made headlines, invoking from the public vitriol born out of a lack of education; those saying a trans woman bodyfeeding their child is a sexual fetish or that the parent is a pedophile for bodyfeeding, those saying that the milk is “full of hormones” or saying that the milk will starve or poison the baby. Trans women may not feel safe to bodyfeed in public, may not feel safe telling certain people about their decision to bodyfeed, or may not know that it is even an option for them.
Seattle Area (And Beyond) Resources & Providers:
Liam Kali - Leading expert in LGBTQ+ fertility and conception, providing consultations and individualized fertility care across the country. Author of the book Queer Conception: The Complete Fertility Guide for Queer and Trans Parents-to-Be.
https://maiamidwifery.com/people/kristin-liam-kali/
Joy McTavish - Lactation consultant with expertise in chestfeeding, inducing lactation, and co-nursing for LGBTQ+ families.
https://soundbeginningsfamily.com/
Patrice Hapke - Practitioner of traditional Chinese medicine including acupuncture, herbal medicine, and moxibustion with a focus on LGBTQ+ health care. Conditions supported include pre-op and post-op care for gender-affirming surgeries and scar healing, gender-inclusive reproductive health conditions, including support for fertility, menstrual health, and sexual health concerns, and more.
https://www.acupunctureforpregnancy.net/lgbtqia-patients
La Leche League - Lactation and bodyfeeding support network
https://llli.org/breastfeeding-info/transgender-non-binary-parents/
Lenore Goldfarb - The blog of the woman who helped develop the Newman-Goldfarb protocol, an extensive blog on information and resources regarding fertility, miscarriage, pregnancy, lactation, and child-rearing https://www.asklenore.info/
Sources
1. Medical Transphobia, Transgender Medical Trauma, and the Need for Doulas
Alpert, Ash B. et al. ‘Transgender People’s Experiences Sharing Information With Clinicians: A Focus Group–Based Qualitative Study.’
https://www.annfammed.org/content/21/5/408
Crawford, Serena. ‘Exploring Transgender People’s Experiences With Health Care.’
https://medicine.yale.edu/news-article/exploring-transgender-peoples-experiences-with-health-care/
Safer, Joshua D. et. al. ‘Barriers to Health Care for Transgender Individuals.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC4802845/
Sbragia, Julia D. and Voterro, Beth. ‘Experiences of Transgender Men in Seeking Gynecological and Reproductive Health Care: a Qualitative Systematic Review.’
https://pubmed.ncbi.nlm.nih.gov/32813436/
Wall, Catherine S J. et. al. ‘Trans Broken Arm Syndrome: A Mixed-Methods Exploration of Gender-Related Medical Misattribution and Invasive Questioning.’
https://pubmed.ncbi.nlm.nih.gov/36736052/
2. Testosterone HRT & Fertility, and Pregnancy as a Man
Amesfoort, J.E. van. et. al. ‘The Barriers and Needs of Transgender Men in Pregnancy and Childbirth: A Qualitative Interview Study.’
https://www.sciencedirect.com/science/article/pii/S0266613823000232
Forest, M G. ‘Role of Androgens in Fetal and Pubertal Development.’
Hahn, Monica. et. al. ‘Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC6814572/
MacDonald, Trevor. et. al. ‘Transmasculine Individuals’ Experiences with Lactation, Chestfeeding, and Gender Identity: a Qualitative Study.’
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0907-y?fref=gc
Makieva, Sophia. et. al. ‘Androgens in Pregnancy: Roles in Parturition.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC4063701/
Thornton, Kimberly GS. et. al. ‘Pregnancy in Transgender Men.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC8412429/
3. Lactation for Transmasculine Individuals
Jackson, Jessica Eve. et. al. ‘Exploring the Healthcare Experiences and Support Needs of Chestfeeding or Breastfeeding for Trans and Non-Binary Parents Based in the United Kingdom.’
https://www.tandfonline.com/doi/full/10.1080/26895269.2023.2265371#d1e638
La Leche League. ‘Support for Transgender & Non-binary Parents.’
https://llli.org/breastfeeding-info/transgender-non-binary-parents/
MacDonald, Trevor. et. al. ‘Transmasculine Individuals’ Experiences with Lactation, Chestfeeding, and Gender Identity: a Qualitative Study.’
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0907-y?fref=gc
National Library of Medicine. ‘Drugs and Lactation Database: Testosterone.’
https://www.ncbi.nlm.nih.gov/books/NBK501721/
Yang, Haibing. et. al. ‘Rates of Breastfeeding or Chestfeeding and Influencing Factors Among Transgender and Gender-Diverse Parents: a Cross Sectional Study.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC9971548/
Heise, Alia M. and Wiessinger, Diane. ‘Dysphoric Milk Ejection Reflex: A Case Report.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC3126760/
4. Lactation for Non-gestuational Partners and Transfeminine Individuals
Amesfoort, Jojanneke E. van. et. al. ‘Lactation Induction in a Transgender Woman: Case Report and Recommendations for Clinical Practice.’
https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-024-00624-1
Canadian Breastfeeding Foundation. ‘The Protocols for Inducing Lactation and Maximizing Milk Production.’
https://www.canadianbreastfeedingfoundation.org/induced/regular_protocol.shtml
International Breastfeeding Institute. ‘Trans Women’s Milk as Good as Breast Milk, Says NHS Trust.’
La Leche League. ‘Support for Transgender & Non-binary Parents.’
https://llli.org/breastfeeding-info/transgender-non-binary-parents/
Moneño, Erlengen. ‘Male Involvement in Infant Nourishment through Breastfeeding.’
Newman, Jack, and Goldfarb, Lenore. ‘Origin of the Protocols - A Word About This Guide.’
Newman, Jack, and Goldfarb, Lenore. ‘Induced Lactation and the Newman-Goldfarb Protocols for Induced Lactation.’
https://www.asklenore.info/breastfeeding/induced-lactation
Newman, Jack, and Goldfarb, Lenore. ‘Introduction to the Protocols for Induced Lactation.’
Newman, Jack. ‘On the FDA and Domperidone.’
Resiman, Tamar and Goldstein, Zil. ‘Case Report: Induced Lactation in a Transgender Woman.’
https://pmc.ncbi.nlm.nih.gov/articles/PMC5779241/
Weimer, Amy K. ‘Lactation Induction in a Transgender Woman: Macronutrient Analysis and Patient Perspectives.’