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Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative… MacDonald, Trevor; Noel-Weiss, Joy; West, Diana; Walks, Michelle; Biener, MaryLynne; Kibbe, Alanna; Myler, Elizabeth May 16, 2016

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RESEARCH ARTICLE Open AccessTransmasculine individuals’ experienceswith lactation, chestfeeding, and genderidentity: a qualitative studyTrevor MacDonald1*, Joy Noel-Weiss2, Diana West3, Michelle Walks4, MaryLynne Biener5, Alanna Kibbe6and Elizabeth Myler7AbstractBackground: Transmasculine individuals are people who were assigned as female at birth, but identify on the maleside of the gender spectrum. They might choose to use and engage their bodies to be pregnant, birth a baby, andchestfeed. This study asked an open research question, “What are the experiences of transmasculine individualswith pregnancy, birthing, and feeding their newborns?”Methods: Participants who self-identified as transmasculine and had experienced or were experiencing pregnancy,birth, and infant feeding were recruited through the internet and interviewed. Interviews were transcribed verbatim.We used interpretive description methodology to analyze the data. Our analysis was guided by our awareness ofconcepts and history important to the transgender community.Results: Out of 22 participants, 16 chose to chestfeed for some period of time, four participants did not attemptchestfeeding, and two had not reached the point of infant feeding (i.e., were still pregnant or had a miscarriage).Nine of the 22 study participants had chest masculinization surgery before conceiving their babies. Six participantshad the surgery after their children were born, five desired the surgery in the future, and two did not want it at all.Chest care, lactation, and chestfeeding in the context of being a transgender person are reported in this paper. Theparticipants’ experiences of gender dysphoria, chest masculinization surgery before pregnancy or after weaning,accessing lactation care as a transmasculine person, and the question of restarting testosterone emerged as data.We present the participants’ experiences in a chronological pattern with the categories of before pregnancy,pregnancy, postpartum (6 weeks post birth), and later stage (beyond 6 weeks).Conclusions: The majority of participants chose to chestfeed while some did not due to physical or mental healthreasons. Care providers should communicate an understanding of gender dysphoria and transgender identities inorder to build patient trust and provide competent care. Further, health care providers need to be knowledgeableabout lactation and chest care following chest masculinization surgery and during binding, regardless of thechosen feeding method and through all stages: before pregnancy, during pregnancy, postpartum, and afterward.Keywords: Breastfeeding, Chestfeeding, Chest masculinization surgery, FtM, Gender dysphoria, Lactation, Topsurgery, Trans, Transgender, Transmasculine* Correspondence: milkjunkies@ymail.com1Community advocate, Winnipeg, MB, CanadaFull list of author information is available at the end of the article© 2016 MacDonald et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.MacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 DOI 10.1186/s12884-016-0907-yBackgroundIntroduction and purposeTransmasculine individuals are people who were assignedas female at birth, but identify on the male side of the gen-der spectrum. Their anatomical birth sex does not matchtheir inner sense of gender identity. This incongruity maybe a source of gender dysphoria, the experience of distressor anxiety regarding one’s gender and body. To transition isto make a change in one’s public gender identity, whereasone’s inner gender identity may have been the same sincebirth. Transitioning may encompass changes in name andclothing choices; using testosterone; or having surgical pro-cedures related to the chest or reproductive organs. Thegender binary is the assumption that there are two distinctand opposite genders, rather than a gender spectrum [1, 2].Taking testosterone results in changes to secondarysex characteristics such as increased muscle mass, fat re-distribution, growth of facial hair, male-pattern baldness,and deepening of the voice, and it usually causes thecessation of menses [3–5], though some transmasculineindividuals may become pregnant while taking testoster-one [5]. For some individuals, some of these body changesare permanent [3, 4]. Cessation of testosterone therapycan result in the return of menses and fertility [3].Some transmasculine individuals choose to engagetheir bodies to carry a pregnancy and birth a baby. Theyalso make choices about how they will feed their newborns.Whether they have taken steps to transition medically orsurgically and whether or not they choose to chestfeed theirbabies, these individuals may require assistance from lacta-tion professionals.We asked the question, “What are the experiences oftransmasculine individuals with pregnancy, birthing, andfeeding their newborns?” We interviewed 22 individualswho self-identified as transmasculine and who had expe-rienced pregnancy, birth, and infant feeding, or werecurrently experiencing pregnancy and planning for birthand infant feeding. Based on findings from the researchstudy, the purposes of this paper are: 1) to describetransmasculine individuals’ experiences with their chests,lactation, and chestfeeding; 2) to inform transmasculineindividuals who might want to chestfeed their babies;and 3) to guide health care professionals (e.g., lactationconsultants, midwives, nurses, physicians, and surgeons)who provide breast and chest care. We report our re-search findings regarding pregnancy and birth in aseparate paper.Inclusive languageLanguage, both written and spoken, has power. Wordscan heal or wound, uplift or disparage. During the inter-views, participants expressed the importance of wordsrelated to gender. Being described with words such asshe, her, mom, mum, mother, breasts, or breastfeedingcould be distressing for a parent who self-identifies dif-ferently. A finding of this paper is that health care pro-viders (HPCs) and others may inadvertently cause harmand intensify feelings of gender dysphoria by misgender-ing transmasculine patients. Conversely, care providerscan affirm a patient’s gender identity by gendering themcorrectly, and thus alleviate distress related to genderdysphoria. To uphold the importance of using respectfuland appropriate language, inclusive and gender-neutralterms are used in this work. In order to be inclusive ofall gender identities, we use the pronouns they, them,and their to refer to an individual when appropriate, asopposed to limiting these pronouns to plural use.Of the 22 participants, 20 participants said they pre-ferred male pronouns and two preferred neutral pro-nouns or both “he” and “she.” All participants referredto their upper front torso as their chest and avoided theterm breasts. However, two participants spoke of theirbreasts when they described what it was like to breast-feed their babies much earlier in their lives, before theyhad come out as transgender. In general, in this paper,the term chest is used to refer to the upper front torso,which includes the nipples and surrounding skin, mam-mary tissue, and fatty tissue.Study participants used a range of terminology to dis-cuss feeding their babies from their chests. Six used theterm breastfeeding, four spoke of nursing, three pre-ferred to say chestfeeding, two used both breastfeedingand nursing, two said it did not matter, one used feedingand nursing, and one used feeding and mammal feeding.In this paper, the term chestfeeding is used to refer totransmasculine or gender non-conforming individualsand the act of feeding a baby or child at the chest withor without a supplementing tube. We use breastfeedingwith regard to research or settings that are not inclusiveof transgender or gender non-conforming individuals.Breastfeeding is not exclusive to cisgender women (i.e.,women whose gender identity and gender expressionconform to the gender that is typically associated withtheir birth-assigned sex) who gave birth and are lactat-ing. Transmasculine individuals also lactate and chest-feed babies they have birthed. Individuals sometimesinduce lactation or relactate to feed babies and childrenthey did not birth. In some cases, a supplementing tubeprovides nourishment while breastfeeding or chestfeed-ing. A supplementer could be used by women, transmas-culine individuals, or gender non-conforming personswho have given birth, are lactating, and need to supple-ment, or by individuals who chose to relactate or inducelactation to breastfeed or chestfeed a baby or child.Literature reviewWhen it comes to building knowledge about health care,transgender issues are often folded into discussions aboutMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 2 of 17gay, lesbian, and bisexual health rather than treated separ-ately [6–8]. The research literature from the past 10 yearsspecific to transgender health consists primarily of generalhealth needs assessments and research studies [9–11].However, physicians and nurses have begun to contributewith wide-ranging topics such as identifying physician-side barriers to providing healthcare for transgenderpatients; curriculum recommendations for health carestudents; and analyses about gendered language, theinvisibility of transgender diversity, and transgender pa-tients’ avoidance of emergency care [12–17].There are a few journal articles about transgendermen and gynecological care [18, 19]. Dutton and Fennieinterviewed six transgender men to determine theirgynecological needs [19]. In their qualitative study,breasts were identified as causing significant discomfortrelating to gender dysphoria [19]. Dutton and Fennierecommended that clinicians should encourage clientsto asexualize the breasts [19], although it is unclear howthis strategy might be implemented.There are commentaries and research about trans-gender individuals’ experiences of pregnancy and birth[20–22], yet we found little in the academic literaturespecifically about transmasculine individuals and chest-feeding, with the exception of two papers published in2015. Farrow wrote a commentary about lactation sup-port and the lesbian, gay, bisexual, transgender, queer,questioning, and intersex community that includedtransgender men and infant feeding [23]. Wolfe-Roubatisand Spatz presented three cases and summarized strat-egies to provide support for transgender men who are lac-tating [24]. While commentaries and practical suggestionsbring the topic to the attention of health care providers,there is a lack of research about transmasculine individ-uals’ experiences with chestfeeding. With this paper, weaim to begin to establish a body of knowledge about trans-masculine individuals and their experiences of lactationand chestfeeding.MethodsStudy designBecause of the current lack of research on this topic, wechose a broad research question: “What are the experiencesof transmasculine individuals with pregnancy, birth, andinfant feeding?” We used a qualitative methodology todesign this study and interpretive description methodologyto analyze the data. According to Thorne et al., “interpretivedescription acknowledges the constructed and contextualnature of human experience that at the same time allowsfor shared realities” [25] (p. 172). We wanted to learn aboutthe study participants’ choices and experiences with infantfeeding. The research was designed as semi-structured in-terviews with a goal of describing and interpreting patternsand themes that emerged from the data.RecruitmentInclusion criteria for the main study specified individualswho self-identified as transmasculine regardless of stageof transition. Participants were required to have experi-enced or to be currently experiencing pregnancy andbirth, and there was no requirement regarding type of in-fant feeding. Inclusion was not restricted by geography,but all interviews were conducted in English.We recruited a convenience sample of participantsmostly through the internet. A letter and a poster wereused to recruit participants. The letter was posted to theFacebook page, “Birthing and Breast or ChestfeedingTrans People and Allies,” (formerly “Birthing and Breast-feeding Transmen and Allies”) managed by the firstauthor (TMD). The poster was circulated through email.Data collectionTMD used a questionnaire to collect demographic anddescriptive information about participants before eachinterview. He then used a semi-structured interviewguide that included a list of open-ended questions andprompts. The questionnaire used to collect demograph-ics information and the semi-structured question guideused as a basis for interviews are included in Additionalfile 1. Interviews were conducted by Skype or telephone.To allow for personal preference and to ensure conveni-ence, safety, privacy, and confidentiality, each participantchose the time of their interview and whether it wouldbe a telephone call or a Skype call with cameras. All in-terviews were audiotaped using a digital recorder, andthen transcribed verbatim, de-identified, and shared withthe team to consider themes that emerged as the inter-views were conducted. Interviews continued until it wasdetermined we had a wide variety of experiences withconsistent, common topics.Data analysisThe transcribed interviews were uploaded to NVivo 10and JN-W, MW, and TMD coded data. We used a com-bination of line-by-line coding and overall analyses toidentify associations, patterns, and relationships. Thesesteps were guided by qualitative description analysesmethods [26–28]. All interviews were coded by at leasttwo researchers. Each used their own topics and thentopics were merged. The topics that emerged from thedata about infant feeding were well-defined and prac-tical. After the topics had been identified from the inter-views, we reversed the process and the sets of approvedquotes were recoded under the topics to ensure we hadnot missed any key topics.Methodologically, we based our analysis on interpret-ive description analysis. Thorne, Reimer Kirkham, andO’Flynn-Magee state, “Interpretive description departsfrom traditional qualitative descriptive approaches inMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 3 of 17that it assumes nurse investigators are rarely satisfiedwith description alone and are always exploring mean-ings and explanations that may yield application implica-tions” [29] (p. 6). We wanted an analysis that wouldprovide a rich description while at the same time givingus an interpretation that would lead to recommenda-tions for transmasculine individuals considering preg-nancy or chestfeeding and for HCPs who work withtransgender patients and clients.ResultsDescription of the participantsWe had a sample of 22 participants ranging in age from24 to 50 years. Nineteen spoke English as a first language,and three cited both English and French or another lan-guage as their first languages. Fifteen were living with apartner at the time of their interview, and 17 participantshad a family income of over $40,000 CAD per year. Everystudy participant had at least some college-level education,and 13 participants had graduate degrees. Participants werelocated in North America, Europe, and Australia.For ethnicity, we used an open question and invitedparticipants to use their own descriptive words. Thirty-nine different words were used by the 22 participants todescribe their ethnicity. Among the 22 participants, 11used a single word, six used two words, four used threewords, and one participant used four words to describeethnicity. Thirteen participants used race as a means ofidentifying ethnicity: ten White or Caucasian; two Black;and one non-Hispanic. Nationality was cited 22 timeswith five participants combining two or more terms todescribe themselves: Aboriginal, Albanian, American (2),British, Canadian (2), Cajun, Cree, Creole, Czech, English(2), European (2), French, German, Greek, Irish, Italian,Ukrainian, and Welsh. Three used Jewish and one used acountry, Australia, to describe their background.We did not ask specifically about disabilities in ourdemographics questionnaire, but during interviews, twoparticipants mentioned that they were disabled or had apartner or close friend with a disability who was involvedin their pregnancy and birth.Twenty study participants had carried babies to termat the time of their interviews. Fourteen participants hadone child. Eight participants reported on the initial ques-tionnaire that they had experienced miscarriage andduring interviews two participants mentioned that theyhad an abortion. Two participants mentioned duringinterviews that their pregnancies were not planned. Preg-nancy lengths and birth weights were unremarkable: birthsoccurred between 36 and 42 weeks gestation and birthweights ranged from 2722 to 4308 g. Seven participants re-ported experiencing postpartum depression, of whom threeparticipants received a medical diagnosis. Thirteen partici-pants reported no symptoms of postpartum depression andtwo had not reached the postpartum stage. Nine partici-pants had taken testosterone before they conceived, eighthad started taking it for the first time after their childrenwere born, and five had never taken it.Sixteen study participants chose to chestfeed for someperiod of time, four participants did not attempt chest-feeding, and two had not reached the point of infantfeeding (i.e., they were still pregnant or had a miscarriage).Nine of the 22 study participants had chest masculinizationsurgery before conceiving their babies. Six participants hadchest masculinization surgery after their children wereborn, five desired the surgery in the future, and two did notwant it at all.Participants’ experiencesWe present the participants’ experiences in a chrono-logical pattern with the categories of before pregnancy,prenatal, postpartum (6 weeks post birth), and laterstage (after 6 weeks postpartum). This format followsthe narrative flow of the interviews and provides a richdescription of the participants’ stories.Before pregnancyParticipants cited chest-related gender dysphoria as driv-ing an urgent need for chest masculinization surgery. Ina certain context, gender dysphoria refers to a medicaldiagnosis from the DSM-5 of an individual who displays“a marked incongruence between one’s experienced/expressed gender and assigned gender” [30] 302.85 (F64.1)and experiences discomfort as a result. In this paper, weuse the term gender dysphoria to denote transgender indi-viduals’ lived experiences of distress about their bodies asthey describe these experiences.Chest masculinization surgery, also known as top surgeryor male chest-contouring surgery, refers to a procedure toremove mammary tissue and create a masculine chest. It isnot the same as a breast reduction where the goal is to pro-duce smaller but still recognizably female-shaped breasts. Italso differs from a mastectomy performed to prevent ortreat cancer. Chest masculinization surgery does not nor-mally involve removal of all mammary tissue since doing sowould result in a sunken-looking chest.Whether or not a participant had chest masculinizationsurgery before conceiving and the type of chestmasculinization surgery were main factors that af-fected decisions and experiences around lactation andfeeding. Out of the nine study participants who hadchest masculinization surgery prior to their first preg-nancies, five participants reported that they knew atthe time of surgery that they eventually wanted tohave children; four participants said they had not con-sidered pregnancy or lactation at the time of surgery.Although surgical techniques and their names varied,the techniques as they were reported by participantsMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 4 of 17could be grouped into two categories: a) surgeries thatinvolved two broad incisions underneath the mammarytissue and temporary removal and subsequent reposi-tioning of the nipples using nipple grafts (often called“double incision with nipple grafts”) and; b) surgeriesthat removed mammary tissue while preserving thenipple pedicles. Five participants had the “double inci-sion” style surgery with nipple grafts. Three participantshad surgeries that preserved the nipple pedicles: one hada “keyhole” or “purse-string” type procedure where inci-sions bordered the areolae and the nipples were notmoved; one had a double incision style surgery but thenipples were not re-positioned; and one had a proceduresimilar to the double incision but a pedicle flap was usedto avoid the need for nipple grafts and to maintain intactnipple stalks. One participant did not discuss the type ofsurgery he had.Participants were asked about their decisions regard-ing chest masculinization surgery. Reasons for havingthe surgery included chest-related gender dysphoria andbeing identified as female due to having a female-appearingchest. Participants also cited ongoing discomfort from bind-ing, a term used to describe the practice of flattening thechest with material such as bandage wrappings or tight,stretchy garments. In all cases, chest masculinizationsurgery seemed to provide immense relief from theseexperiences. Two participants mentioned that the dra-matic lessening of gender dysphoria brought about bychest masculinization surgery facilitated the choice tobecome pregnant, and these participants noted that thelevel of gender dysphoria during pregnancy would havebeen unbearable if they had female-appearing mam-mary tissue.I should know [the type of chest masculinizationsurgery] and I don’t. That tells you how much I waspaying attention. I was like just get them off me, I don’tcare what you do. Just get them off me. [Cory, whoinitially could not recall the surgical technique used forhis chest masculinization surgery but later in theinterview determined on the basis of his scars that itmust have been the double incision]It [chest masculinization surgery] was the thing thatmade it possible for me to get pregnant… and I’dnever been so depressed in that time that I tried toget pregnant without top surgery… I literally hadnightmares of cutting my chest off with scissors… Iassumed that I couldn’t [chestfeed]. I mean it washard because it was one of the first things my mom hadsaid to me after I told her about the surgery—“Well,you’re never going to be able to feed your babies andthat’s terrible.” And I was like, “Maybe I don’t wannafeed my babies that way.” It was a point of defensivenesswith me that I could still have a relationship withmy child without feeding them from my chest.[Felix, double incision surgery]I don’t think that I could have navigated this entireprocess [pregnancy] without having had top surgery.[Oren]Participants did not discuss future infant feedingchoices with their surgeons in consultations prior tosurgery, and no surgeon brought up the topic. Partici-pants believed that their surgeons subscribed to abinary view of gender, and that pregnancy and chest-feeding would not fit with their surgeons’ ideas ofwhat a “true” transgender man would want to do. Toreveal that they were considering future pregnanciesor chestfeeding might delay or jeopardize their chanceto have chest masculinization surgery.I didn’t want to wait. I was on a waiting list ofwhere to get it covered and I didn’t want to waitanymore ’cause I’d been binding for 6 years…Iwent to this plastic surgeon dude and he hadn’tdone a lot of trans surgeries but we paid for it…He was just like, “Oh yeah, you’re the guy trappedin a girl’s body, and now your body matches howyou feel inside.” And I was like, “Uh, yeah, sure,thanks, I’ll take my new chest now and go.” [Kai]The “born in the wrong body” or “trapped in thewrong body” narrative is a simplistic depiction of trans-gender people that is commonly found in media stories[31]. Proponents of this narrative give the impressionthat transgender people want to change all aspects ofthemselves to conform absolutely to the opposite trad-itional gender role and physical sex from what they wereassigned at birth, an assumption that would logically ex-clude transmasculine bodies from the realm of preg-nancy and lactation.Four study participants specifically mentioned in inter-views that they felt unable to discuss future pregnancy orlactation with their surgeon before chest masculinizationsurgery due to the surgeon’s belief in the gender binary orthe “trapped in the wrong body” narrative. One of theseparticipants explained that he postponed asking necessaryhealth-related questions until after surgery because he wasunsure of his surgeon’s views about gender identity.To get top surgery you kind of have to talk aboutit as if you never want to get pregnant, right, tothe surgeon. You can’t be wiggly about that so Idon’t know… I don’t think there was a way to talkto him about getting surgery without having aconventional narrative about it. [Felix]MacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 5 of 17After surgery, because again I didn’t know what his[the surgeon’s] thought processes were about genderidentity, afterwards I called him up and I asked him.I wasn’t really thinking about nursing, but more theworry of are they going to grow back if I get pregnant.[Oren]Four participants were certain they would not be ableto chestfeed for physical reasons because they hadchosen chest masculinization surgery. They cited phys-ical pain, inability to make milk, and lack of tissue tolatch to as a result of surgery as factors that would makechestfeeding impossible.I had top surgery a few years ago, so I chose then thatif I ever wanted to have a child I wouldn’t be able tobreastfeed. So I have a masculine chest and a formula,bottle-feeding baby…my choice around top surgerywas one around which I felt incredibly disconnectedto my chest, so much so that I literally had no sensationat all. [Dagan]I think the biggest issues [with chestfeeding a babyafter chest masculinization surgery] may be physicalas opposed to psychological. After surgery it took mychest about a year to get sensation back and it’s kindof hit or miss. There are times when somebodytouches it and it kind of makes me nauseous…There’sthis fine line between I can feel it and it hurts, so Idon’t know. [Kennedy]On the other hand, seven participants explained thatthey knew well before conception that they wanted tochestfeed their babies. They had family members whobreastfed or they had learned about how human milkprovides optimal nutrition and how chestfeeding is away to build a secure attachment between baby and par-ent. Five participants mentioned that they delayed chestmasculinization surgery in part or wholly because oftheir commitment to chestfeeding.It [breastfeeding] is the absolute, well, first my motherdid. Um, and with the information that was available atthe time, it was the best thing to do for your baby.[Nick, came out and transitioned after weaning]My partner used to go out with a midwife. Hergirlfriend was learning to be a midwife while theywere together…So, she learned a lot of stuff aroundchestfeeding. I was really surprised to learn all thethings about, the kind of stuff like how your body cansense what is in the room and what your baby needsantibodies to and your body can bump it up andproduce it in the milk. That to me, when I heardthose kind of things, it was just incredible that yourbody could do that kind of thing. [Peter]I always, I wanted it [chest masculinization surgery],since transitioning, but because of being able to feedmy kids, I might have waited or I might not have[speculating because surgery was not financiallypossible]. [Vince]PrenatalDuring pregnancy, participants noticed and coped withchest changes and planned for infant feeding. A wide rangeof experiences were reported in terms of mammary tissuegrowth as well as related gender dysphoria. Six of the par-ticipants who had previous chest masculinization surgeryfound that their chest tissue was growing back someamount or even to pre-surgery size. Those who had nothad surgery experienced predictable chest growth.Out of nine participants who had previous chestmasculinization surgery, two reported no change to theirchest tissue during pregnancy. Both participants had thedouble incision surgery with nipple grafts. Three partici-pants reported minor chest tissue changes: two haddouble incision surgery with nipple grafts and one haddouble incision surgery with a pedicle flap. One partici-pant who had double incision surgery with nipple graftsreported some degree of chest tissue changes. Two partici-pants stated they experienced significant chest changesduring pregnancy and that their chest tissue had grownback to its pre-surgical size. One of these participants hadliposuction and keyhole surgery and the other had doubleincision surgery without repositioning of the nipples.I was under the complete understanding that it waspermanent, that it was not ever going to grow back,so actually it was quite the opposite—the fact that itdid grow back [during pregnancy] was really…I wouldhave done a lot better if I had been warned that thatwas possible that that would happen. [Emmett,previous chest masculinization surgery, doubleincision with no nipple grafts or re-positioning]The experience of gender dysphoria was a commontheme during pregnancy due to body changes, but it wasnot experienced by all participants, and no two storieswere the same. While participants identified many bodilysources of gender dysphoria including changing hormones,widening hips, and reduced facial hair, breast or chest-related gender dysphoria was cited frequently. Some partici-pants described gender dysphoria as being simply abouttheir own relationship with their body.I kind of feel like the whole pregnancy and certainlybirth and now feeding him it’s like I feel like I don’tMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 6 of 17really have a body. It’s not my own. I’m not sure ifthat’s a good or a bad thing but it just feels like I don’treally own this body currently. So I guess to kind ofanswer your question more, because it’s really hard, Idon’t really feel like myself, when I look at myself Idon’t look like myself and it was like prior to beingpregnant and having him I did a certain amount ofbinding to my chest and that’s been really difficult tonot do that anymore and I feel very floppy all over theplace. [Julian]Nine study participants stated that they did notexperience an increase in gender dysphoria related tobody changes during pregnancy, but they did experi-ence distress when others misgendered them as aresult of their pregnancies or body changes. Partici-pants described situations where growth of chest tissueaffected how their gender was perceived by others,which then triggered their own gender dysphoria. Hav-ing prominent chest tissue seemed to result in individ-uals being identified by others as female more oftenthan other typically female secondary sex characteris-tics, including a pregnant belly. Participants noted thattheir pregnant bellies were frequently identified as fat,male bellies, and were generally easier to disguise withclothing than chests were.My gender identity is still male [during pregnancy]but it’s hard really because I believe my gender is alsopart me and part society. So I think it’s, I’m both, andso if society is not seeing it then I don’t really considermyself there all the way, because I think it’s kind of atwo-way street there…Identity is not something that isseparate from my family or my community. [Emmett,previous chest masculinization surgery, experiencedsignificant reversal of body changes during pregnancyincluding reduced facial hair, higher-pitched voice, andre-growth of chest]I was pregnant, I was like seriously pregnant, andthen they [nurse at clinic] called me but, of course,they call the female name [participant’s legal namewas female at the time] and we get up and we walkover and the nurse hands the [specimen] cup to myfemale partner, who doesn’t look pregnant at all,she’s like very tall and thin, and then says “Oh, here,I need this sample, and your husband can wait overthere,” and is like waving me off, this short, fat man,and it’s like wait, no, it’s my husband that’s actuallypregnant. [Daniel]Four participants who had not had chest masculinizationsurgery mentioned that they had practiced chest bindingbefore they conceived their babies, but no participantreported being able to bind during pregnancy. Thosewho tried binding found it too painful or inadequate tocontinue, which also contributed to chest-related gen-der dysphoria. One participant who did have previouschest masculinization surgery attempted binding be-cause his mammary tissue increased during pregnancybut he stated that the practice was ineffective for him.So there was some swelling and I got binders again,which I had gotten rid of years before, and just foldedthem up so they would be over my belly, but in theend I stopped using it because it didn’t feel like—itwasn’t enough. [Felix, previous chest surgery, doubleincision with nipple grafts]I stopped binding pretty early because it was also verytender. I didn’t go back [to binding] until I wasfinished feeding my kids…between pregnancies I wentback to it but, but yeah, I mean that’s pretty muchhow I coped. I just tried to let go of my usual way ofdoing things. I think that was another step towardsnot passing as much and sort of, I don’t know,realizing that I was going to have to make somecompromises from the way that I would prefer to dothings because of the choice that I had made. [Vince,no chest masculinization surgery]The temporary nature of pregnancy and chestfeedingcame up often during interviews as a means of copingwith chest-related gender dysphoria. Participants an-ticipated an eventual end to pregnancy and lactation,and planned for future chest masculinization surgeryor surgical revisions. Revision surgery is commonlyperformed at a minimum of 6 months after chestmasculinization surgery to ameliorate the appearanceof scars, remove excess tissue, improve symmetry, andadjust nipple and areolar dimensions [32]. Utility andpurpose were also important as transmasculine indi-viduals reminded themselves that body parts normallyassociated only with distress would soon provide nu-trition for their babies.At the time I was just like it’s OK, now is notforever. I’ve always wanted a revision and I never gotone so the way I got myself through it [pregnancywith mammary tissue growing back] is I was just likeit’s OK because I was planning on getting therevision anyways. [Kai, previous liposuction andkeyhole surgery]I just really felt like I’d been stuck in this body, I’d hatedit my whole life and here was just this one amazing thingthat my chest could do that you know I sort of felt likethat’s maybe the reason why I had been given this body.MacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 7 of 17So I just felt like it was something that I wanted to do.[Peter, no previous chest masculinization surgery]With the breasts, it was like what do I have these foranyway. The functional aspect of it to me, that madethe most sense to me. I guess on some bizarre level Ijust wanted to feel like there was some reason I havethis body. I guess having, being equipped with a bodythat was female, it seemed like that was a reasonablething to do, was to use the breasts to feed the baby.[Daniel, no previous chest masculinization surgery]Post-surgical participants assessed their chests forchanges during their pregnancies to try to determine ifchestfeeding would be realistic. They had concernsabout milk production and the ability to latch a baby toa chest with little tissue.My first indication that I was pregnant, even on themiscarriage, was that my breasts were tender, mynipples were tender. Or at least on my right side Iwas. My left side—both of my nipples were madefrom one nipple—and so the one on my right side ismore I guess whole, or has more integrity than theleft, so the one on the left I never had much happenbut the one on the right I did. And then I actually hada little bit of swelling I think. There was no permanentchange but I definitely had sensitivity so much so that Ireally thought I might be able to produce a little bit ofmilk. [Cory, previous double incision with nipple grafts]I am pretty sure that, well, my chest tissue hasn’t grownback. It grew back right at the start of the pregnancy asmall amount just here and then it stopped. I’m prettysure that, I’ve done some reading, and I’m worriedabout the baby being able to latch on, there beingenough tissue to latch on. [Travis, previous doubleincision chest masculinization surgery]During their pregnancies, participants planned aheadfor infant feeding and sought information and support fortheir choices. All study participants who had not had pre-vious chest masculinization surgery chose to chestfeedtheir infants, and seven participants described it as a sim-ple decision due to what they considered health benefitsand the utility of chestfeeding. Four participants also men-tioned bonding and attachment parenting as reasons tochestfeed their babies. Participants cited aspects of theiridentities and circumstances other than identifying astransmasculine when they described how they arrived attheir decisions. They discussed racialized communities,parenting and breastfeeding groups, urban versus ruralsettings, and other family members’ infant feeding choicesas contributing significantly in terms of their decision.I always knew I would breastfeed. I had known thatthere are a lot of benefits to breastfeeding. It wasn’t evena choice, I just knew. I was fortunate that I could.[Alex, came out and transitioned after weaning his child]We happen to live in a place where there are all thesehippies and we shop at a co-op, and everyone isbreastfeeding like crazy. There’s a store that sells clothdiapers up my street. We just happened to move intothe most progressive area ever. When I meet peoplethey recognize that I’m transgender without me evensaying anything half the time…Here, you’re muchmore likely to hear about breastfeeding or at least seeit…We talk about—in the black community, incities—there can be this overwhelming feeling that it’snot socially acceptable. I’ve heard people say that,“We don’t do that because that is what slaves did.”[Adam, multiracial family]One of the most supportive communities I foundduring my pregnancy was the La Leche Leaguecommunity, which my midwife was heavily involvedin. And she got me connected to a lot of other peopleand they were just so accepting and warm andgracious…I also really wanted that relationship withmy child. I wanted that connection, you know, ofholding my child, my own child, to my chest, beingconnected in that way and being able to offer that notjust nourishing but nurturing aspect. [Cory, previousdouble incision with nipple grafts]I did read up a lot about nursing for example. I don’tknow how it’s like now, I think North America ingeneral has become a bit more breastfeeding friendly,but you know 15 years ago it was just starting to comeback into the public landscape and there was still a lotof push against it. That’s where I did take chargebecause I wanted to inform myself because I knew Iwas going to face some resistance possibly from familymembers or health care providers. [Gabby, experiencedpregnancy before coming out or transitioning]Six participants mentioned that they experienced signifi-cant pressure from health care providers, friends, or familyto chestfeed their babies. Two participants reported thattheir decisions about chestfeeding affected their legal cus-tody rights as parents. When midwives and doulas wereexplicitly pro-chestfeeding and seemed obviously pleasedthat their clients did choose to chestfeed, participants de-scribed a greater sense of anxiety and pressure to succeed.My lawyer very strongly suggested that I do it becauseit’s a very….If you’re breastfeeding the child they[social services] are less likely to take it away fromMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 8 of 17you. So she [lawyer] very much pushed, “You have tobreastfeed—you have to prove that you’re breastfeeding.If possible do it in front of the social workers when theycome around.” I was just, like, I’d really rather not. Iplanned on pumping and then giving the child thebreast milk but not actually full on doing it. But I hadto. [Ben, no previous chest surgery]Because I’m not a mom…and I wasn’t breastfeedingor chestfeeding, for me, there wasn’t any assumptionthat this kid needed to be with me. The idea was youcould separate him from me earlier on [in order toshare custody], but all the hormones from givingbirth, all the other connections are still there, and itwas incredibly painful. [Felix, double incision surgery]People who know that I’ve had—I call it a doublemastectomy to them because that’s the easiest—andthey see my chest, they see everything and then theyask me about breastfeeding. Midwives and doulas, likethat’s a big thing. And I’m like I don’t have anybreasts. It’s not even that I have a little bit of tissue. Ihave nothing, it’s not there. The nipples were removedand put back. I really don’t think that that’s going tohappen. [Oren]I’ve sort of run into health workers who are trying tobe respectful saying, “So how do you want to feed?”But then as soon as I say I’m going to nurse they’relike, “Oh, good,” which then puts me in a positionthat like if I ever want to change my mind I knowthey’re going to be disappointed in me or whatever itis, like it puts the pressure on. [Lee]PostpartumThe postpartum period involved a variety of lactation andchest-related challenges and experiences. Seven of the 16participants who initiated chestfeeding reported that theyexperienced gender dysphoria while chestfeeding. Five ofthese individuals found means of coping with genderdysphoria such as making use of layered clothing or think-ing in terms of the utility of chestfeeding. For two of theparticipants, intense and overwhelming gender dysphoriawas cited as a main reason for why they could not con-tinue chestfeeding. As during the prenatal period, genderdysphoria did not always have to do solely with the indi-vidual’s body and what it was doing, but also how the bodywas being seen and gendered by others.I was huge, like, it grew like everything came in, sothat was dysphoric and I didn’t know what to do withit. I was producing a ton of milk. I mean I could havenursed her fine you know but I just…I didn’t haveanything ready socially, either. I didn’t have any zip-upbinders. I had no way to stop the milk from leakingthrough my chest. I had no appropriate clothes for, maleclothes for nursing. I didn’t have any of it so and it wasjust too much to organize on too little sleep. [Emmett,previous double incision without nipple grafts]I was like, “He needs to eat!” It’s like these two thingswarring inside of me. One, I’m transgender, but two, I’ma really big proponent of attachment parenting. I thinkthat it’s awesome. I think that breastfeeding andbabywearing and family bed and all that stuff really help.[Adam, began coming out and transitioning beforepregnancy, presented during pregnancy as female]I would sometimes go, OK, I’m supposed to be likebaby’s so sweet, and we’re bonding, and I was like,whatever, eat. [Henry, came out to himself and othersand transitioned after chestfeeding was finished]Um, even with the nursing I don’t think I’m going todo extended. Like, I might last a couple months butyou know I’m going to want to be back ontestosterone and because I present as female duringthe pregnancy and I can only live my life as beingseen as female for so long. [Emmett, planning for anadditional future pregnancy]Privacy during chestfeeding was often important toparticipants. Two participants mentioned in interviewsthat the need to chestfeed without anyone witnessing,judging, or gendering the process conflicted with theirability to seek chestfeeding support and help.I spent a lot of time in the room by myself forprobably the first 3 months. Every time I needed tofeed her I would just go away and do it because I justdidn’t feel like I could do it in front of other people.[Peter, no previous chest masculinization surgery;presented as female to all health care providers excepthis doula]So I tried [to chestfeed] a few times but I had this likeintense privacy about it. Like I didn’t want anyone toknow, I didn’t want anyone to see and it just didn’twork out with bringing her home and the in-laws andeverything. [Emmett]I was feeling really inadequate because I had chestsurgery and stuff and so anytime she wouldn’t latch Iwould get really upset. I was really heavily dependenton him [husband] and for a while I wouldn’t try to gether to latch if he wasn’t there…I decided not to [gethelp from a care provider] because it was so hard thatI just couldn’t… I knew that I couldn’t deal if someoneMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 9 of 17ended up being, “Well, of course, she’s not latching.” Ipictured the worst and I couldn’t do it. You just, you areputting your trust, and you just never know. [Kai,previous keyhole chest masculinization surgery; did notplan to chestfeed; learned how to use a supplementerfrom reading a blog post]Out of the 16 participants who initiated chestfeeding,nine reported that they did not experience any genderdysphoria as a result of the act of chestfeeding. Fourparticipants mentioned in interviews that they werecomfortable chestfeeding their babies in public spaces.Again, the participants cited the utility of lactation tofulfill the needs of their babies. One participant expressedthe belief that chestfeeding in public is an important, posi-tive act from a social and political perspective.In the beginning, I was really worried about how thatwas going to work, like if I was going to be OK with it[chestfeeding]. I have a tendency to cover up inmultiple layers and don’t really reveal myself inpublic. I was really worried about feeding him inpublic and around friends and family but I think whatwas kind of interesting to me was that once she wasborn it just kind of became this thing I needed to do.[Julian, no previous chest masculinization surgery]I actually really liked it [chestfeeding]. Again, I saw itas a physical process that my body was able to do.Like with the pregnancy, I didn’t gender it. I was likeOK, my body can do this, and it actually feels goodand I know that my baby is getting something out ofit. It was really relaxing. It was nice. [Gabby, came outand transitioned after chestfeeding was finished]I was happy to be able to use ’em you know. I alwayssaid it sure would be nice to take ’em off and put ’emon a shelf you know. For me it was great to be able touse ’em for their intended purpose. [Nick, came outand transitioned after weaning]Sometimes I kind of covered up. I really liked to wear abutton down shirt with an undershirt underneath it andthen I could button my shirt down a certain amount andthen pull up my undershirt a little bit like an A-shirt…Ido think that it’s something [chestfeeding in public] thatpeople should be doing, or that there should be morepublic space for feeding kids generally and so I waswilling to put myself out there a little bit because it’ssomething that I feel strongly about on a social andpolitical level. So, yeah, sometimes I’d get looks but Ididn’t really get many comments and people didn’treally make gendered comments to me about feedingmy kids. Yeah, because I think at that point I wasn’treally passing at all. [Vince, no previous chestmasculinization surgery]Some participants had to cope with physical challengesin the postpartum period that were specifically related tomedical aspects of their transition. Two participants whohad previous chest masculinization surgery experiencedengorgement and early signs of mastitis for which theyand their health care providers were ill-prepared. One par-ticipant who had previous double incision surgery withnipple grafts described his struggle to latch his baby.It’s a good thing I had a doula because my OB/GYNdidn’t say anything about like you need to work—Iassumed there wouldn’t be anything to dry up. Butactually I did and I almost got mastitis. I started to getsick. I had a lot of pain and I started to get red,streaky hot spots. That’s the mastitis thing. And Istarted to get a fever. And they, my friend who’s adoula just came and brought all these cabbages anddid all this stuff. And I had to get a night doula to getBenadryl some nights too because the, all the otherstuff just wasn’t working fast enough. [Felix, previousdouble incision with nipple grafts; chose before thebirth to bottlefeed]With the follow-up check with the pediatrician, I haddeveloped this mass you know on the left side thatwas really scary. It was rock hard it was like about thisbig and I didn’t know what it meant or if it was safe,or what the deal was. So we asked at the doctor andthe midwives and we had them check it at the clinicwhen we took the baby when she was like a week oldand they said like well then they recommended notnursing. [Emmett]I only got him to latch on once for like 10 s and itwas glorious. I was like, oh my God, at least I got tofeel that at least—I got to experience that little bit andI’ll never forget it but beyond that he never would…Because it was my midwife [who was providingassistance with latching], because it was her, and wehad such a good relationship, it was great. I mean itwas, you know, she so obviously had my best interestsat heart and she cared for me personally and for mybaby and for our family in general so I felt very open;I wasn’t scared or nervous. I would have beenprobably with anybody else. [Cory, previous doubleincision with nipple grafts]Two study participants who had planned not to chest-feed due to lack of chest tissue, as well as anticipatedgender dysphoria, reversed these decisions after theirbabies were born.MacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 10 of 17After she was born, you know she had kind of likecrawled up on my chest and I felt the instinct to nurseher which I had really like I mean I had planned somuch against it that I had, they had the medication onhand to make the milk dry up…[Emmett, previouschest masculinization surgery]She was born on a Sunday, yeah, I would say it was aWednesday when they [mammary glands] got all likepuffy. Yeah and I hadn’t tried to see if anything—likeit hadn’t occurred to me before that if I couldsqueeze them and see if…It was my midwife whocame over and told me to do that…We were using abottle and that’s kind of, yeah. It wasn’t until Irealized I was producing milk that I was like, oh myGod, I want to feed my baby this way and I reallywant to make this work…[Kai, previous liposuctionand keyhole surgery]Participants commented about how lactation-relatedcare could be made transgender-competent. Some par-ticipants reported that they felt respected as transgenderpatients by individual perinatal providers and that theydid not need to educate their providers in terms of lan-guage or identity. Two study participants described beingtouched on their chest without consent, an experiencethat caused distress during an already challenging time.Participants suggested a need for health care providers tocommunicate respect for different feeding choices otherthan chestfeeding, and that providers should neitherassume a desire to chestfeed nor push for it.At one point I was trying to get her to latch and shehad just latched when the nurse came in and she waslike “Oh, oh, I’ll leave you guys,” and then she cameback a bit later and was like, “I’ll talk you throughbreastfeeding and help you,” and she used “dad” thewhole time and “chest.” And I never asked her to dothat. She just she was like, “Yeah, you wanna have heron dad’s chest,” and that was the language she used soI thought that was pretty cool. [Kai, previous liposuctionand keyhole surgery]About the nurses, one challenging thing after birthwas there’s this huge push to like get the baby latchedon and work on feeding and that was challengingbecause people didn’t really ask if they could grab mybreast. You know, they would just grab and manipulate,and um that was pretty alarming. [Julian, no previouschest masculinization surgery, presented as female tocare providers]I think there’s a real push towards breast is best, whichI think is great for a lot of reasons, but I’d also want tosee health workers have in mind that there are a varietyof reasons why people might not nurse and that a lot ofthose reasons are valid and that gender issues might bea valid reason not to nurse. [Lee]Study participants discussed their use of donor milk.Seven participants used donor milk or said they wereconsidering using it, and one donated to babies in need.One of these participants mentioned that he receiveddonor milk through a care provider, while another citeda lack of information from health care providers regard-ing donor milk. One participant recounted that his careproviders did not provide adequate information aboutbottle-feeding. Only one study participant used an at-chest supplementer to feed his baby. Two participantsdescribed how they bonded with their babies throughclose bottle-feeding.I guess I do have a little bit of a regret. I did have anSNS [supplementer] system that I had in the cabinetfor months before my son was born and, in the end,I didn’t even try it. I don’t know why. I think I hadput so much effort into trying to produce a little bitof my own milk, and going so far as having blistersfrom pumping and all that. I had that little weirdgadget as I saw it, and I just couldn’t see, you know,if I’m not producing any of my own milk, I justdidn’t see using that. [Cory, previous double incisionwith nipple grafts]I’ve felt like I could get more information [aboutinfant feeding and using a supplementer] fromother trans guys, so with them [health careproviders] I focus on the pregnancy and the birthand get me through this. I just don’t want to addanything else to it…I was interested in thesupplemental system, like at-the-chest sort ofthing, but there was way too much going on toreally try. I was really like, I don’t, just put thebottle in his mouth…I was trying to learn a lot ofthings, cloth diapering, it’s a lot. [Oren, previousdouble incision chest masculinization surgery]I didn’t know anything about people having donormilk through milk shares locally or anything likethat. I would have been scrambling. That’s anotherthing that trans people should be made aware ofabout during their prenatal care, that that’s availableand how to educate about that. I don’t know ifdoctors would talk about that. If it’s too much of aliability to talk about it because of the aspect whereyou are responsible for screening people and makingdecisions where you think milk could be contaminatedor not. [Adam, speculating about what he would haveMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 11 of 17done if he did not have a full milk supply]When she has a regular feed like from a bottle she takesabout six ounces but when she takes it from me, uh theamount that she takes from me, ’cause you know I use abottle with the tube [homemade supplementer], sheusually only takes about four. So my guess is in eachfeed she’s getting about one to two ounces. [Kai,previous liposuction and keyhole surgery]We get the closeness with the bottles. Even now whenbaby has her feedings, she’s so particular about it. Youknow, we have to go into the bed, or the quiet placeand she has to cuddle, and you know in fact we oftencall it nursing anyway because it’s not my chest butit’s still the same action from me. [Emmett]Along with the physical need for donor milk due tochest masculinization surgery or gender dysphoria, therewere social aspects to milk sharing as well. Just as oneparticipant made a decision about chestfeeding in thecontext of his multiracial family and broader commu-nity, another participant discussed milk sharing from hisperspective as a black, transgender person. The partici-pant reported deciding to come out as gay but not astransgender to his milk donors, and he wryly noted hisexperience as a black, gay parent receiving milk frommany white donors.I went on to Human Milk 4 Human Babies and I saidwe were two gay guys—I didn’t mention I wastrans—and women were throwing themselves at us,like they got progressive points for giving the gaydudes breast milk…[Partner’s] mom bought us a chestfreezer for Christmas ’cause she was tired of usputting milk in hers. He’s loving it, he’s fat, and I’mhappy. Everybody’s getting sick, and he’s had a cold,but that’s pretty much it. I always say he’s got theantibodies of like 18 different white women so he’sgood to go. [Oren, Black]Later stageThree participants chestfed for under 6 months, 11 partici-pants chestfed for more than 1 year, and two participantswere in the early postpartum period at the time of their in-terviews and were still chestfeeding. As chestfeeding wenton, participants had to make choices about how to balancefeeding their babies with gender dysphoria, mental health,and the need to transition.Two study participants considered binding their chestswhile they were still chestfeeding but explained that theywere unable to do so successfully due to discomfort anda fear of causing mastitis. However, one participant(pseudonym “Adam”) did practice binding and alsotook testosterone while he was chestfeeding, and hereported these as positive choices. Prior to his preg-nancy, Adam had not had chest masculinization sur-gery and had taken testosterone for under 1 year. Henoted that binding and taking testosterone allowedhim to present as male and also chestfeed his childinto toddlerhood. Both his gender presentation andchestfeeding past infancy were important to this par-ticipant. Adam identified the way hormones made himfeel as a source of gender dysphoria. He also cited theway others perceived him based on his appearance asa trigger of gender dysphoria.I didn’t want to force wean him at all. It was justgetting to a point where I—I mean it’s such anebulous feeling, it’s difficult to describe but it’s likeyou just feel inside what your hormonal dysphoriais, if you have dysphoria around your hormones,and you just know, this is where it’s going to bereally bad now, from now on, I’m going to bemiserable. [Adam]In general with transition, I find that when youtry to ask people to respect your name andpronouns and who you are, but if you don’t havefacial hair and your features are really such thatthey are going to read you as a woman all thetime, it’s really hard for me to get people to takeit seriously, and even when they were actingrespectful toward me it was like they were doingit to please me but they didn’t really see me theway that I am and it just started to bother memore and more. I was trying to keep my chin upand be really optimistic and I think I succeededwith that for a long time but it was just like youknow what, enough is enough. [Adam]Adam began binding with caution when his babywas approximately 10 months old. He would bind forshort periods of time (i.e., an hour or less) and payclose attention to sensations of fullness or discomfortin his chest. He gradually increased the duration ofbinding sessions and did not experience any problemssuch as mastitis.The binding that I use, it’s made of really flexible, elasticmaterial so it shifts around. It’s got this zipper…It doesn’thave Velcro, it doesn’t have much compression. It’s reallygood for nursing. At first I didn’t like it ’cause it wasshort and it reminded me of a bra and I thought I’drather have something like an undershirt but for nursingit’s perfect because I can just unzip it discreetly in apublic place and feed him and then zip it up. Peopledon’t necessarily realize that he’s eating…He knows howMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 12 of 17to unzip my binder. He’s just sort of like, “It’s time forme to eat.” [Adam]To re-start testosterone therapy, Adam consulted withhis endocrinologist and his child’s paediatrician. Adamreported that his doctors referred to a study of low-leveltestosterone use in lactating, cisgender women to assesssafety [33]. He stated that his doctors recommended re-starting testosterone therapy and watching the childclosely for any signs of early puberty such as body hair.Adam did re-start testosterone therapy when his childwas approximately 21 months old. He reported that ap-proximately 15 months after he had re-started testoster-one at a standard dose for female-to-male therapy, bloodtests showed normal testosterone levels in his child. Hedid not notice a decrease in his milk supply that coin-cided with re-starting testosterone.I think that getting top surgery and just starting toreally feel just this tangible feeling to how much timeI have to wait because it was going to be 6 monthsafter he weaned [before surgeon would advise havingchest masculinization surgery] and knowing that hecould nurse for a long, long time. That actually reallydrove me with the testosterone decision because it’sgoing to be a while before I can do something else torelieve things. But between binding and testosterone,that puts me in a really good place with things.[Adam]Participants described a wide range of thoughts andfeelings about getting chest masculinization surgeryafter weaning was finished. One participant used thesurgery as a reward for reaching his personal chestfeed-ing goals. Six participants described getting chestmasculinization surgery as a simple decision once theirmammary tissue was no longer being used to nourishtheir children.In my mind it [chest masculinization surgery] was like areward. I felt like if I could at least chestfeed her for thefirst year then it meant that I could get top surgery, soit was something that I used as like a bit of a, I guess agoal, or something to work towards. [Peter]I want it [chest masculinization surgery] to happen assoon as possible. Because I pretty much I have thefeeling that the breasts were good only for feeding mybabies. Otherwise I don’t need them at all…Here I gooften at the nude beach and when I am walking thereI often I am just crossing my arms so that peoplecouldn’t see the breasts just like a habit or I don’tknow because I don’t care if they look at me on thebottom, I, it doesn’t matter but the breasts somehow Ifeel like they don’t belong there. [Ron]They were used for their intended purpose. No, I washappy to get rid of them. [Nick]I feel glad that we’re not planning, like I’m not planningto carry another kid, so I don’t feel like it’s this either ordecision [to have chest masculinization surgery or tochestfeed] for my child. So, which I know, definitelyknow guys who are making that sort of either ordecision for kids that they intend to carry. So I’m reallyglad I don’t have to do that. [Henry, had chestmasculinization surgery after weaning was finished]Three participants mentioned that they never experi-enced gender dysphoria while chestfeeding but did ex-perience intense gender dysphoria soon after weaning.For these participants, having mammary tissue and usingit to feed did not seem to be problematic. However,when their chests were no longer a source of nourish-ment and others identified these individuals as femalebecause of their chests, intense social gender dysphoriawas triggered. One participant did not feel a need forsurgery and opted to bind after weaning.You know it [breastfeeding] was absolutely the besttime of my life, even now… As soon as I was donebreastfeeding within about a month my dysphoriacame back to the point where I couldn’t handle it…It[choosing chest masculinization surgery] was a toughdecision for me because I did have such emotionalties because of my experience with my son and thefact that I did want more kids and I always wanted tobreastfeed my kids. But, because I was so largechested I knew that this was something I had to do.Because I already had a full beard, I was passing asmale. I couldn’t live with the chest I had and I alsocouldn’t bind…They [chest] were so large. Andthrough the summer it was just too much. I couldn’teat with the binder on. It was causing other healthproblems. So I made the decision I had to make eventhough my chest dysphoria was never terrible. So Iwent for surgery. [Alex]I did not [experience gender dysphoria whilechestfeeding]. No, mm mm. I was and still am, I meanI’ve just had top surgery, but my, my chest was not ahuge source of body dysphoria for me. It wassomething that, if we lived in a different world thatwas more accepting of just different identities anddifferent bodies I’m not sure that I would have gottentop surgery. But since you know it’s this sort of thingwhere people are going to question my identity as aman because of my chest and I wanted to be able toMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 13 of 17go to the pool or whatever and take off my shirt. LikeI really like to swim and I felt really vulnerablewhenever I would go swimming, like everyone isseeing me as a woman when I go swimming. In thesuits that I have to wear, even though I wear a t-shirtor whatever, I just felt like, yeah, I just felt like sovulnerable like everyone sees a woman right now sothat was where that decision came in to get topsurgery and it’s been fantastic. [Andrew]I was very conflicted about potential top surgery, and inthe end I’ve decided not to get it but for other reasons.At first I was like I don’t know if I could ever do thatbecause yeah I fed my baby with these…That concernkind of eventually faded because I nurture him in otherways now. I don’t want to put myself throughunnecessary surgery anymore. I’m OK with them beingthere. I’ve found some comfortable binders, and I’mlike you know what, that’s fine. [Gabby]DiscussionIt is apparent from the findings that health care providersworking with transgender clients require a nuanced under-standing of gender dysphoria that goes beyond the familiar“trapped in the wrong body” narrative. Media depictions ofgender dysphoria have treated it as a condition to be curedby medical transitioning and by conforming to societal ex-pectations of traditional gender roles [31]. This strategymay be best for some transgender individuals, but not forall [31]. Participants in this study did not necessarily equatelactation and chestfeeding with femininity, and for thosewho did, they sometimes opted to chestfeed while findingways to cope with gender dysphoria if they experienced it.The experiences of transmasculine individuals reportedhere show that chest-related gender dysphoria frequentlyled to chest masculinization surgery and affected feedingchoices. Some individuals cited others’ gendered percep-tions of their chests and chestfeeding choices, as well ascare providers’ physical touching of their chest withoutpermission, as triggers of gender dysphoria. Dutton andFennie [19] also found that having prominent mammarytissue was a particularly intense source of gender dys-phoria in the transgender men they interviewed. Forothers in our study, there were ways to cope with the dys-phoria and reasons such as infant nutrition that made itworthwhile to chestfeed. In another variation, some trans-gender individuals in our study reported that the act ofchestfeeding seemed to mitigate their gender dysphoriabecause of its utility.The issue of gendered language was raised frequentlyby the participants and it has been addressed by otherauthors [15, 24]. In addition to preferred pronouns, oneshould consider using masculine or gender-neutrallanguage such as “chestfeeding,” “parent,” and “parental”instead of “breastfeeding,” “mum,” and “maternity.” InNorth America, “nursing” could substitute for “breast-feeding.” Providers need to be aware that the act ofbreastfeeding or chestfeeding is not necessarily per-ceived as feminine by their transmasculine clients.From the interviews, we see a distinction between gen-der dysphoria rooted in the individual’s feelings abouttheir body versus gender dysphoria triggered by socialinteractions. This distinction has important implicationsfor health care providers. It means that care providersand others are capable of causing gender dysphoria in apatient by misgendering them. Conversely, care providerscan affirm a patient’s gender identity through appropriatelanguage, respectful touch, and other intentional actions,and thus alleviate distress associated with gender dysphoria.Care providers should use the pronouns and genderedlanguage that patients have stated they prefer, ratherthan making assumptions based on a patient’s appear-ance or behaviour. In other words, in order to avoid trig-gering gender dysphoria, HCPs must believe the patientwhen gender identity is disclosed to them and they mustdemonstrate respect by using appropriate language. Asone participant stated and others reiterated in variousways, gender identity is a “two-way street” that involvesdeclaring one’s gender to others, but also having one’sfelt gender reflected back to one by others, includinghealth care providers. Care providers could increasetheir language awareness and competence by practicingthe use of gender-neutral language outside of clinicalsettings and prior to meeting their first transgender cli-ents. We suggest that the ability to use appropriate lan-guage is an important skill to be developed, especially inpregnancy and childbirth settings where the norm is touse feminine pronouns and descriptors.In the academic and medical literature, it is commonlyreported that deepening of the voice and growth of bodyand facial hair, as a result of testosterone treatment, areirreversible in transmasculine individuals [3, 5, 18]. Incontrast, we have found this to be true for some, yet forothers these secondary sex changes are fully reversibleupon the cessation of testosterone treatment. Healthcare providers should understand that a transgender in-dividual’s gender presentation can revert unpredictablyas a result of ceasing testosterone therapy, and that bodychanges can be distressing for an individual whose gen-der expression has previously been more masculine.Bauer et al. report that transgender persons frequentlyavoid using emergency department services because ofprevious negative experiences or fear of negative experi-ences due to their transgender status [17]. We found asimilar phenomenon with study participants’ perceptionsof their care providers’ assumptions becoming a barrierto accessing care. Surgeons were viewed as gatekeepersto chest masculinization surgery who would not beMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 14 of 17accepting of future plans for pregnancy or chestfeedingin a transmasculine client. As a result, participants didnot obtain information that they required. Two partici-pants avoided asking for lactation help because they hadstrong needs for privacy during chestfeeding or becausethey perceived that care providers observing them wouldmisgender them or negatively judge their past choicesregarding chest masculinization surgery.To mitigate problems, we suggest that care providersgive clients cues early on in the provider-patient rela-tionship to demonstrate that they have a flexible under-standing of gender and gender roles in infant feedingand parenting. Surgeons should state in a pre-operativeconsultation that they are aware that some transmascu-line individuals choose to become pregnant or chestfeedafter chest masculinization surgery, thereby opening anopportunity for discussion. Transmasculine individualsconsidering the surgery need information about the pos-sibility of mammary tissue regrowth in the case of preg-nancy. Lactation consultants could mention that theyunderstand that transmasculine clients experience arange of gender dysphoria over chests and chestfeedingor sometimes no dysphoria at all, and then ask the indi-vidual how they can best be supported in their plans. Iftouching might trigger gender dysphoria in a client, acare provider could employ hands-off techniques todemonstrate positioning for chestfeeding or the use of asupplementer.We learned from the participants that HCPs must beeducated about chest care for transmasculine individualsduring pregnancy and postpartum. Chest binding duringpregnancy will likely be uncomfortable and ineffectivebeginning early on in gestation and continuing through-out pregnancy. Transmasculine people who have hadchest masculinization surgery need to be aware thatmammary tissue may or may not grow during preg-nancy. Chestfeeding, if desired, may be possible if thereis enough tissue for a comfortable latch. Some transmascu-line individuals do produce milk after chest masculinizationsurgery, although at-chest supplementation and donor milkor formula is likely to be required. They should be giventhe tools to successfully establish a chestfeeding relation-ship, especially around the use of at-chest supplementers.The study identified a need for HCPs to provide an-ticipatory guidance to transmasculine individuals regard-ing postpartum chest health and lactation. Transgenderpatients should be taught to recognize engorgement,plugged ducts, and mastitis, whether or not they intendto chestfeed their babies, regardless of their history ofchest masculinization surgery. Some participants lackedinformation about engorgement and mastitis because ofthe incorrect assumption that someone who had chestmasculinization surgery would not experience lactogen-esis II following birth.HCPs should be knowledgeable about potential prob-lems that can be caused by constriction of mammarytissue (e.g., constriction from bras or baby carriers canlead to pugged ducts or mastitis) because transmasculinepatients might have questions about how to safely chestbind during lactation. In order to cope with gender dys-phoria, transmasculine individuals who are chestfeedingmight begin binding with caution for short periods aftertheir milk supply has stabilized. Based on the experienceof one study participant, others might wish to take tes-tosterone while chestfeeding under the guidance of aphysician who can monitor the infant for possible signsof exposure.The study finds strength in its roots in the transgendercommunity. It benefits from the leadership of a trans-gender man who birthed and chestfed two children anda research team that includes clinicians who work withtransgender and queer clients and patients. The inclu-sion of participants who transitioned before havingchildren as well as those who transitioned afterwardsprovides a rich understanding of the many ways thattransgender individuals experience pregnancy, birth, andinfant feeding.The key limitation for this study is about transferability.We do not know whether the convenience sample we re-cruited reflects the general population of transmasculineindividuals experiencing pregnancies. All of the study par-ticipants were university educated, and the majority werefinancially secure and in a committed relationship.Further studies on this topic should attempt to in-clude more low-income individuals and those with lessformal education, and they should also aim to betterunderstand geographical considerations. Future re-search could try to determine the effect of differenttypes of chest masculinization surgery on lactation. Asa possible trend to investigate, we did note that thetwo participants with previous chest masculinizationsurgery who had significant mammary tissue re-growthand some amount of lactation following birth both hadsurgeries that preserved the nipple stalks instead of surger-ies involving nipple grafts. The experiences and needs oftransmasculine individuals who had unplanned pregnanciescould be an important topic for future research.ConclusionsThe information gathered in this study sheds light on awide range of transmasculine individuals’ experienceswith lactation and infant feeding. Study participantsshared stories that were personal and nuanced. There isno single experience that is the transgender experienceof infant feeding. It is apparent that transmasculine indi-viduals who give birth sometimes choose to chestfeed,even when they have had previous chest surgery, whileothers do not chestfeed their babies for physical andMacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 15 of 17mental health reasons. Care providers should communi-cate an understanding of gender dysphoria and trans-gender identities in order to build patient trust andprovide transgender-competent care. Further, HCPs needto be knowledgeable about lactation and chest care duringbinding and following chest masculinization surgery, re-gardless of the chosen feeding method, through all stages:before pregnancy, pregnancy, and post birth.Ethics and consent to participateThis study was approved by the Health Sciences and Sci-ence Research Ethics Board at the University of Ottawa,Ontario, Canada. The approval is based on the Tri-CouncilPolicy Statement: Ethical Conduct for Research InvolvingHumans (2nd edition). Participants provided informed con-sent in writing or verbally on a digital recording after hav-ing opportunities to ask questions about the research.Consent to publishThe original transcribed interviews (one each for 18participants and two each for four participants who com-pleted follow-up interviews) were formatted into separatequotes with extraneous information removed. We kept allquotes directly related to the research question andremoved any details that might identify any participant.Names were replaced with pseudonyms approved by theparticipants. When participant quotes include discussionsof race, we identify the racial background of the partici-pant using terms they approved. A set of quotes was sentto each participant for final approval, and permission topublish was obtained in writing.Availability of data and materialsAdditional file 1: Demographics and question guide. Thisfile contains the questionnaire used to collect demograph-ics information and the semi-structured question guideused as a basis for interviews.Data from the study other than the quotes alreadyincluded will not be shared in order to protect participants’anonymity.Additional fileAdditional file 1: Demographics and question guide. This file containsthe questionnaire used to collect demographics information and thesemi-structured question guide used as a basis for interviews. (PDF 66 kb)AbbreviationsHCP: health care professional.Competing interestsTMD manages a Facebook page from which study participants wererecruited. Potential participants were aware of TMD’s involvement in boththe research study and the Facebook page.Authors’ contributionsTMD and DW conceptualized the study. TMD, JN-W, MW, DW, MLB, AK, andEM collaborated to design the study and write the research proposal. TMDcollected all data. TMD, JN-W, and MW analyzed the data and MLB, AK, andEM assisted with further interpretation of the results. TMD and JN-W draftedthe manuscript and DW, MW, MLB, AK, and EM revised it critically. All authorsread and approved the final manuscript.Authors’ informationTMD BA (Hon) is a transgender man from Manitoba who birthed both hischildren at home and nurses them. In 2011, he began a blog that is popularwith both transgender individuals and health care providers looking forinformation on transgender reproduction and infant feeding. Trevor startedthe first online support group for transgender individuals interested in birthand breast/chestfeeding. He wrote tip sheets published by La Leche LeagueCanada and has presented lectures on gender and reproduction innumerous conferences, seminars, and university courses. Trevor is the authorof Where's the Mother? Stories from a Transgender Dad.JN-W RN IBCLC PhD is an experienced nurse and lactation consultant whohas worked with families in hospital and community settings. JN-W is anassociate professor at the University of Ottawa and the focus of her researchprogram is breastfeeding and human lactation.DW BA IBCLC is a lactation consultant in private practice and La LecheLeague Leader, author of Defining Your Own Success: Breastfeeding afterBreast Reduction Surgery, and co-author of Sweet Sleep: Nighttime andNaptime Strategies for the Breastfeeding Family, the 8th edition of TheWomanly Art of Breastfeeding, The Breastfeeding Mother’s Guide to MakingMore Milk, Breastfeeding after Breast and Nipple Procedures, and ILCA’sClinician’s Breastfeeding Triage Tool. She is the Director of Media Relationsfor La Leche League International and a member of the editorial reviewboard of Clinical Lactation.MW PhD is a Sessional Instructor at the University of British Columbia(Okanagan campus). She teaches Cultural Anthropology, Sociology, andGender Studies at three universities in BC. Her research and teaching focuson medical anthropology, queer reproduction, feminist anthropology,mothering, and qualitative social research methods.MLB IBCLC is a lactation consultant who works both as a clinician and facultyat the Newman Breastfeeding Clinic/International Breastfeeding Centre. MaryLynne Biener teaches counselling skills to aspiring lactation consultants andworked as a crisis counsellor for many years prior to becoming an IBCLC.AK RM is a practicing midwife at Seventh Generation Midwives Toronto(SGMT), and the former Head Midwife at Sunnybrook Health Sciences Centrein Toronto, Ontario. She has been involved in queer and trans reproductivehealth work since 1992, and aspires to make reproductive health andbirthing environments safe for all clients and their families. She activelyengages in an anti-oppression framework for the teaching, interprofessionalwork, and clinical care she provides.EM BSN, RN, IBCLC is an experienced RN/IBCLC in maternal/child healthcaresince 1999. She is enrolled in Georgetown University’s School of Nursing andHealth Sciences Family Nurse Practitioner Program. Beth owns and operatesa busy private practice in New Jersey where she works with complexbreastfeeding dyads, trains intern lactation consultants, and speaks nationallyand internationally on topics related to lactation and human milk.AcknowledgementsWe gratefully acknowledge the generous contributions of the parents whocontributed to this work.FundingThis study was funded by the Canadian Institutes of Health Research—Gender,Sex & Health Research Integration and Innovation (funding number 134042).The funding body did not play any role in study design, collection of data,interpretation of results, or drafting the manuscript.Author details1Community advocate, Winnipeg, MB, Canada. 2School of Nursing, Universityof Ottawa, Ottawa, ON, Canada. 3Diana West Lactation Services, Long Valley,NJ, USA. 4Community, Culture, & Global Studies, University of BritishColumbia, Kelowna, BC, Canada. 5The Newman Breastfeeding Clinic, Toronto,ON, Canada. 6Seventh Generation Midwives Toronto, Sunnybrook HealthMacDonald et al. 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Int J Pharm Compd. 2009;13(4):314–7.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:MacDonald et al. BMC Pregnancy and Childbirth  (2016) 16:106 Page 17 of 17


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