Lactation induction for transgender women and transfeminine people in health care: a scoping review

Bertollo, Leandro Pedro Goloni; Campos, Liliana Alice da Silva; Suzuki, Thaiane Almeida; Chao, Meily Soares; Santos, Vanessa Cunha dos; Amorim, Ana Paula Andreotti; Germani, Ana Claudia Camargo Gonçalves

doi:10.1590/1413-81232024294.18232023

Leandro Pedro Goloni Bertollo

study design

analysis and interpretation of results

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0000-0001-5973-9035

Liliana Alice da Silva Campos

study design

analysis and interpretation of results

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0000-0002-1690-4923

Thaiane Almeida Suzuki

study design

analysis and interpretation of results

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0009-0009-7124-5797

Meily Soares Chao

analysis and interpretation of the results

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0009-0009-5229-7807

Vanessa Cunha dos Santos

analysis and interpretation of the results

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0009-0000-7907-6101

Ana Paula Andreotti Amorim

study design

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0000-0002-7307-4647

Ana Claudia Camargo Gonçalves Germani

study design

writing

approving the final version

Faculdade de Medicina, Universidade de São Paulo. Av. Dr. Arnaldo 455. 05403-000 São Paulo SP Brasil. bertolloleandro@gmail.com

https://orcid.org/0000-0002-7409-915X

Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Article title and authors	Publication year	Country	Type of study	Main contribution
Case report: Induced lactation in a transgender woman (Reisman & Goldstein)¹⁵15 Reisman T, Goldstein Z. Case report: induced lactation in a transgender woman. Transgend Health 2018; 3(1):24-26.	2018	US	Case report	Case report of a 30-year old transgender woman who wanted to breastfeed her child since her pregnant partner did not have the intention to breastfeed. The authors created a protocol mimicking nonpuerperal lactation induction for cisgender women, lowering estradiol dosage to a very low dose such as in delivery. The patient was able to breastfeed her baby exclusively for six weeks. The case had a nine month follow up, and the patient was still breastfeeding complementing with formula when the baby was 6 months old, when the article was published.
Induced lactation in a transgendered female partner (Sperling & Robinson)³⁰30 Sperling D, Robinson L. Induced lactation in a transgendered female partner. J Obstet Gynecol Neonatal Nurs 2018; 47(3):S61.	2018	US	Case report (congress abstract)	Poster presentation abstract that mentions the case of a trans woman who breastfed her biological child in tandem with her partner, who delivered the baby.
Trans woman breastfeeds baby (Hamzelou)²¹21 Hamzelou J. Trans woman breastfeeds baby. New Sci 2018; 237(3166):13.	2018	not described	News	News about the Reisman and Goldstein’s case report. The news article also presents opinions on the matter, including statements that more studies are needed before the practice can be recommended.
Breastfeeding in the transgender; recent advances (Madu)²²22 Madu AE. Breastfeeding in the transgender; recent advances. Obstet Gynecol Int J 2018; 9(5):368.	2018	UK	Opinion article	The article raises concerns and criticisms about the applicability of the protocol used in the Reisman and Goldstein’s case report and conducting the practice itself before more studies are done.
A review of breast development in cisgender women and implications for transgender women (Reisman et al..)²⁴24 Reisman T, Goldstein Z, Safer JD. A review of breast development in cisgender women and implications for transgender women. Endocr Pract 2019; 25(12):1338-1345.	2019	US	Review	Review article focusing on describing the hormonal pathways required for breast development in cisgender women and reviewing the current available literature describing breast growth and breast cancer risk in transgender women. Describes a basic framework of regimens to induce non-puerperal lactation and within their argument regarding the similarity of breast tissue between cisgender and transgender women, states that their case report mimicking this framework was successful in inducing lactation in a trans woman.
Trans* pregnancy and lactation: A literature review from a nursing perspective (García-Acosta et al..)²⁵25 García-Acosta JM, San Juan-Valdivia RM, Fernández-Martínez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* pregnancy and lactation: a literature review from a nursing perspective. Int J Environ Res Public Health 2019; 17(1):44.	2019	Spain	Systematic review	Review article describing pregnancy and lactation care for transgender men and women, as well as barriers in healthcare for this population. It describes the usual hormone therapy used by transgender women and their breast tissue development. The rationale for lactation induction for non-birthing cisgender women is presented, as well as the interventions modified by Reisman and Goldstein for a transgender woman.
Queering lactation: Contributions of queer theory to lactation support for LGBTQIA2S+ individuals and families (Lee)²⁷27 Lee R. Queering lactation: contributions of queer theory to lactation support for LGBTQIA2S+ individuals and families. J Hum Lact 2019; 35(2):233-238.	2019	Canada	Original perspective	Opinion article exploring the perspective of queer theory to support lactation for LGBTQIA+ Individuals and Families. The article examines how queer and feminist theories, despite the tensions between them, can each support a lactation practice outside of binary gender roles. It cites the possibility of inducing lactation for transgender women, as in the Reisman and Goldstein’s case report.
Lactation care for transgender and non- binary patients: Empowering clients and avoiding aversives (MacDonald)⁶6 MacDonald TK. Lactation care for transgender and non-binary patients: empowering clients and avoiding aversives. J Hum Lact 2019; 35(2):223-226.	2019	Canada	Insights into practice and policy	Insights into the care of transgender and non-binary people focusing on creating care providers undergoing specific training for care in this population and then signaling patients that they have done so, as this could reduce some of the uncertainty and fear that frequently causes these patients to avoid or delay seeking care. It cites briefly the possibility of lactation induction for transgender women, as described by Reisman and Goldstein.
Lactation can be successfully induced in transgender women while maintaining gender-congruent serum hormone levels (Moravek & Pasque)¹⁶16 Moravek MB, Pasque KB. Lactation can be successfully induced in transgender women while maintaining gender-congruent serum hormone levels. Reprod Sci 2019; 26(S1):136A.	2019	US	Case report (congress abstract)	Scientific congress abstract of a case report of inducing lactation in a transgender woman without interrupting her gender-congruent hormone therapy.A 34-year-old transgender woman wanting to breastfeed her baby conceived by her cisgender partner used an adapted model from the protocol created by Newman-Goldfarb for inducing lactation for adoptive mothers, without interrupting or significantly reducing her previous hormone therapy with estradiol and spironolactone. Both mothers were able to breastfeed, with a six month follow-up.
Medication and facilitation of transgender women’s lactation (Paynter)²³23 Paynter MJ. Medication and facilitation of transgender women's lactation. J Hum Lact 2019; 35(2):239-243.	2019	Canada	Insights into practice and policy	Opinion article responding to concerns and negative reactions in the media regarding the lactation induction in trans people following the publication of the Reisman and Goldstein’s case report. The article provides evidence for the examination of safety concerns raised by the use of drugs for lactation induction and focuses on deconstructing potential biases and prejudices on the matter. The article also discusses the importance of health professional support to provide adequate care and break through stigmas that transgender people face.
ABM clinical protocol #33: Lactation care for lesbian, gay, bisexual, transgender, queer, questioning, plus patients (Ferri et al..)¹1 Ferri RL, Rosen-Carole CB, Jackson J, Carreno-Rijo E, Greenberg KB. ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients. Breastfeed Med 2020; 15(5):284-293.	2020	US	Clinical protocol	Clinical protocol for reproductive and lactation care for LGBTQIA+ families, suggesting respectful terms and how to create an adequate health care environment for this population. Briefly describes hormonal therapies used for body transformations in the transgender population and discusses possibilities on fertility, lactation and support for LGBTQIA+ families. Regarding the lactation process for trans women, the article suggests interventions such as the case report by Reisman and Goldstein and includes other unreferenced interventions.
Maternal health in the transgender population (Patel & Sweeney)²⁶26 Patel S, Sweeney LB. Maternal Health in the Transgender Population. J Womens Health 2021; 30(2):253-259.	2020	US	Narrative review	Review article that describes a wide range of care for transgender people regarding fertility, contraception, pregnancy and lactation. The article cites the possibility of inducing lactation for transgender women, describing the case report by Reisman and Goldstein.
Knowledge and practice of induction of lactation in trans women among professionals working in trans health (Trautner et al..)³3 Trautner E, McCool-Myers M, Joyner AB. Knowledge and practice of induction of lactation in trans women among professionals working in trans health. Int Breastfeed J 2020; 15(1):63.	2020	US	Cross-sectional study	Cross-sectional study that interviewed participants of the World Professional Association for Transgender Health (WPATH) symposium. Eligible participants had professional experience serving the transgender population. A third of respondents reported having known a trans woman who wanted to induce lactation, and one in five reported knowledge of providers or clinics that were able to help trans women breastfeed. Only one in four respondents reported current knowledge of an appropriate protocol for inducing lactation in trans women.
Lactation induction in a transgender woman wanting to breastfeed: Case report (Wamboldt et al..)⁷7 Wamboldt R, Shuster S, Sidhu BS. Lactation induction in a transgender woman wanting to breastfeed: case report. J Clin Endocrinol Metab 2021; 106(5):e2047-e2052.	2021	Canada	Case report	Case report describing lactation induction in a transwoman who wanted to breastfeed her 11-month old baby, who had already evolved from exclusive breastfeeding (from her partner) to solid complementary feeding. Lactation induction was successful for the patient’s goals (bond, maintenance of human milk after her partner returned to work, breast development), and the case presented a follow up of nine months. A protocol for lactation induction was created by the authors based on cisgender nonpuerperal women lactation induction.
Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. (Rodriguez-Wallberg et al..)²⁸28 Rodriguez-Wallberg K, Obedin-Maliver J, Taylor B, Van Mello N, Tilleman K, Nahata L. Reproductive health in transgender and gender diverse individuals: a narrative review to guide clinical care and international guidelines. Int J Transgend Health 2022; 24(1):7-25.	2022	USA	Narrative review	Narrative review that summarizes the current findings in literature on reproductive healthcare issues in transgender people. The study mentions the possibility of inducing lactation in transgender women based on two successfully published case reports that used a combination of estrogen, progesterone, domperidone and breast pumping.
The breast in the transgender woman. Systematic review (Gonzalez Marino)²⁹29 González Mariño MA. La mama en la mujer transgénero. Revisión sistemática. Rev Obstet Ginecol Venez 2022; 82(3):373-382.	2022	venezuela	Systematic review	Systematic review about the technical particularities of the breast in transgender women in use of hormone therapy. The article mentions the possibility of breastfeeding using lactation induction techniques.
Perinatal considerations for care of transgender and nonbinary people: A narrative review. (McCracken et al.)³³33 McCracken M, DeHaan G, Obedin-Maliver J. Perinatal considerations for care of transgender and nonbinary people: a narrative review. Curr Opin Gynecol Obstet 2022; 34(2):62-68.	2022	USA	Narrative review	Narrative review about pregnancy related care of transgender and nonbinary individuals during the antepartum, intrapartum and postpartum periods. It briefly discusses the benefits and importance of the possibility of breastfeeding for this population.
Chestfeeding and Lactation Care for LGBTQ+ Families (Lesbian, Gay, Bisexual, Transgender, Queer, Plus). (Rosen-Carole and Greenberg)³⁴34 Rosen-Carole C, Greenberg KB. Chestfeeding and lactation care for LGBTQ+ families (lesbian, gay, bisexual, transgender, queer, plus). In: Lawrence RA, Lawrence RM, editors. Breastfeeding: a guide for the medical profession. Amsterdam: Elsevier; 2021. p. 646-650.	2022	USA	Book chapter	Book chapter about care on chestfeeding and lactation focusing on the LGBTQ+ population. It mentions the Reismen and Goldstein report as an example of a well succeeded case of lactation induction in a transwoman.
Inducing lactation in a transgender woman without galactogogues: a case report. (Elkin et al.)¹⁸18 Elkin B, Duran A, Rauwerdink K, Goldsmith ES. Inducing lactation in a transgender woman without galactogogues: a case report. J Gen Intern Med 2023; 38(2):S628-S629.	2023	USA	Case report (meeting abstract)	Meeting abstract of a case report of a 36 years-old transgender woman wanting to breastfeed her child, carried and delivered by her partner, a transgender man that wished to return to testosterone use shortly after delivery. The protocol involved mimicking physiological levels of estrogen and progesterone during pregnancy and after birth. Galactogogues weren’t included due to FDA recommendations against domperidone and the patients concerns of side effects. The patient was able to lactate, but it wasn’t described the duration of the follow-up.
Lactation Induction in a Transgender Woman: Macronutrient Analysis and Patient Perspectives (Weimer)¹⁷17 Weimer AK. Lactation induction in a transgender woman: macronutrient analysis and patient perspectives. J Hum Lact 2023; 39(3):488-494.	2023	USA	Case report	Case report of a 46 years-old transgender woman who underwent successful induction of lactation in order to breastfeed her infant, who was gestated by her partner. The protocol used included modification of exogenous hormone therapy, use of domperidone as a galactogogue, breast pumping, and ultimately direct breastfeeding as mechanical stimulation. The participant was able to co-feed her infant for the first 4 months of life. The report provided a detailed description and timeline of the lactation induction process, results of the participant’s milk analysis showing robust macronutrient content and description of the participant’s experience in her own words.
Domperidone (no authors listed)³⁵35 Drugs and Lactation Database (LactMed). Domperidone [Internet]. [cited 2023 oct 13]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501371/ https://www.ncbi.nlm.nih.gov/books/NBK50...	2023	not described	Drug review	Review describing the usage and effects of domperidone as a galactogogue aiming lactation induction and the increase of milk supply for people wanting to breastfeed. It mentions the cases of Reisman and Goldstein, Weimer and Wamboldt to exemplify cases of lactation induction in transgender women. It provides a thorough analysis of domperidone’s excretion through breast ducts and describes the discussion on the established dosage for each result and the side effects during the use and after discontinuing domperidone.

Article title	Previous hormone treatment	Context	Hormonal interventions			Intervention by galactogogue	Mechanical intervention	Outcomes
			Estrogen	Progesterone	Anti androgenic
Case report: Induced lactation in a transgender woman¹⁵15 Reisman T, Goldstein Z. Case report: induced lactation in a transgender woman. Transgend Health 2018; 3(1):24-26.	Prior hormone treatment for six years for body transformation. At the beginning of the interventions*, she was using: - Spironolactone 50 mg po bid; -Estradiol 2 mg po bid; - Micronized progesterone 100 mg po bid	A 30-year-old transgender woman whose partner conceived the child but had no intention of breastfeeding. Therapy started three and a half months before delivery with the intention of being their baby’s main food source.	-Time 0: Estradiol 4 mg/day -Time 1: Increase to 8 mg/day -Time 2: Increase to 12 mg/day -Time 3**: Reduction to 0.025mg/day	-Time 0* : Micronized Progesterone 100mg 2x/day -Time 1: Micronized Progesterone 200 mg/day -Time 2: Increase to 400 mg/day -Time 3***: Reduction to 100 mg/day	Spironolactone 50mg twice a day throughout the process	-Time 0: Introduction of Domperidone 10 mg po tid -Time 1*: Increase to 20 mg po qid	-Time 0: Breast pump 5 minutes per breast 3x/day -Time 1*: Increase to frequency of 6x/day	-Time 1: Production of a few drops of milk -Time 3**: Production of eight ounces per day After birth, there is no mention of the volume produced, but it was sufficient for exclusive breastfeeding up to six weeks of age with good development of the child. After this period, breastfeeding was supplemented with milk formula.
Lactation can be successfully induced in transgender women while maintaining gender-congruent serum hormone levels.¹⁶16 Moravek MB, Pasque KB. Lactation can be successfully induced in transgender women while maintaining gender-congruent serum hormone levels. Reprod Sci 2019; 26(S1):136A.	Prior hormone treatment for 15 years for body transformation. At the beginning of the interventions, she was using: -Estradiol 6 mg/day -Spironolactone 100mg twice a day	A 34-year-old transgender woman with a cisgender partner who conceived the child, with a desire to co-breastfeed. Therapy started before delivery, at a time not described by the report.	Previous use of 6 mg estradiol/day. Reduced to 2 mg/day five weeks before birth. Increase to 3 mg/day two months after birth due to facial hair growth.	Medroxyprogesterone 1.25mg/day was discontinued five weeks before delivery. It does not report how long it was used, since it does not define a start date for the intervention.	Previous use of spironolactone 100mg twice a day. Reduction to 50 mg twice a day just before delivery. Return to initial dose two months after birth due to facial hair growth.	Domperidone 10 mg po qid introduced one month after the start of the intervention	Pumping started five weeks before delivery, without mentioning pumping technique, frequency or time. She kept pumping after the child was born	Production of two to three ounces of milk every 3 hours just before delivery. After birth, the child was co-breastfed by the two mothers for more than six months.
Induced lactation in a transgendered female partner³⁰30 Sperling D, Robinson L. Induced lactation in a transgendered female partner. J Obstet Gynecol Neonatal Nurs 2018; 47(3):S61.	Prior hormone treatment for 1 year before the intervention. No details about prescription.	Transgender woman with a desire to co-breastfeed her biological child with a cisgender partner who conceived their baby.	Not reported	Not reported	Not reported	Not reported	Not reported	Co-breastfeeding obtained with satisfaction by the family, without details on volume or time of milk production.
Lactation induction in a transgender woman wanting to breastfeed: Case report⁷7 Wamboldt R, Shuster S, Sidhu BS. Lactation induction in a transgender woman wanting to breastfeed: case report. J Clin Endocrinol Metab 2021; 106(5):e2047-e2052.	Prior hormone treatment for 9 years with spironolactone and estradiol for body transformation. At the beginning of the interventions, she was using: - Spironolactone 100mg po bid; -Estradiol 5mg/day -Progesterone 100 mg/day; (started a few months before the initial visit)	A 38-year-old transgender woman with a cisgender partner who was already breastfeeding the couple’s 11-month-old biological baby at the beginning of the interventions. Therapy was started with the aim of co-breastfeeding after the partner returned to work with nutritional motivation, for bonding with the child and breast development.	Initially, the patient preferred not to abruptly reduce the estrogen dose, however, she retrospectively reported having tried the abrupt reduction without supervision, without further details described in the text.	-Previous use: Progesterone 100 mg/day -First visit: Increase to 200 mg/day She returned to initial dose after verifying little variation in laboratory tests, but not specifying when it had occurred.	Spironolactone 100mg twice a day throughout the process	-Started Domperidone 10 mg 3x/day on first visit -After 8 weeks, increased to 30 mg 3x/day due to reduced milk production -After 6 months, 20 mg 3x/day -After 9 months, reported not having used it continuously	-Previous use: Manual pumping 3-4x/day for 5 minutes duration for 4 months -First visit: Guided to use electric pump, however, manual pumping was maintained 3 times during the day and 1 time at night for 5 minutes on each side	Prior to the start of follow-up, it was possible to accumulate a few drops of milk per day after 4 months of manual pumping. After 1 month of follow-up: Production of 3-5 ounces of milk per day. After 6 months: reduction to 1 teaspoon daily
Lactation Induction in a Transgender Woman: Macronutrient Analysis and Patient Perspectives.¹⁷17 Weimer AK. Lactation induction in a transgender woman: macronutrient analysis and patient perspectives. J Hum Lact 2023; 39(3):488-494.	Prior hormone treatment for 19 years with estradiol and for 13 years with spironolactone before orchiectomy. At the beginning of the interventions she was using: - Sublingual estradiol 2mg/day (paused 4 months prior to the report to preserve sperm viability)	A 46 years-old transgender woman with a cisgender woman partner with a due date 4 months in the future that wanted to breastfeed to support her partner during the early postpartum months and as a personal experience as well.	Days before due date (DD): - DD-121: 2mg twice daily; - DD-107: 4mg twice daily; - DD-34 until DD+128: 25mcg/d transdermal	Days before due date (DD): - DD-107: 100mg once daily; - DD-94 until D-34: 200mg once daily	Not used due to prior orchiectomy	Use of domperidone. Days before due date (DD): - DD-107: 10mg four times daily; - DD-94: 20mg four times daily; - DD+27 until DD+128: 20mg three times daily	6 weeks prior to the due date the protocol initiated a regimen of pumping with a goal of six 15-min sessions per day.	During the first 14 days after delivery the participant produced approximately 150ml per day over five pumping sessions. After this first period, she started directly breastfeeding the infant once to twice daily for 4 months, until she desired to stop breastfeeding, weaned off the domperidone and resumed her previous dose of estradiol. The stored milk supply lasted two more months following the stop of the interventions.
Inducing lactation in a transgender woman without galactogogues: a case report.¹⁸18 Elkin B, Duran A, Rauwerdink K, Goldsmith ES. Inducing lactation in a transgender woman without galactogogues: a case report. J Gen Intern Med 2023; 38(2):S628-S629.	Prior hormone treatment without further details of duration or previous regimens. At the beginning of the interventions she was using: - 17-beta estradiol 4mg/day	A 36 years-old transgender woman who was planning on having a child with her partner, a transgender man, who wished to return to testosterone use shortly after delivery. Her goals included sufficient milk production to allow bonding, even if not the sole source of infant nutrition.	Initially, estrogen dose was increased to mimic physiological levels during pregnancy starting 377 days prior to the due date and it was reduced shortly before delivery to mimic physiological levels after birth. No details were described about the dose or the exact duration of usage.	Initially, progesterone was introduced in a dose high enough to mimic physiological levels during pregnancy starting 377 days prior to the due date and it was reduced shortly before delivery to mimic physiological levels after birth. No details were described about the dose or the exact duration of usage.	Not used due to prior orchiectomy	Not used due to the FDA recommendations against domperidone and due to the patients concerns of side effects with other galactogogues.	The protocol involved physical nipple stimulation using a breast pump. No details about the frequency, duration or when it was initiated were described.	The participant started seeing the first drops of milk 40-50 days after beginning nipple stimulation and the report states that the participant was able to lactate, allowing bonding with her baby. No details were described about the frequency, duration or if there was milk enough for storing.

[1] Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva

Brasil

Brasil

Lactation induction for transgender women and transfeminine people in health care: a scoping review

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Abstract