The Ugly Truth of Male Breastfeeding
Is a transwoman nursing really about feeding the infant, or is it about feeding the dysphoria? In this detailed piece, Talia analyzes the literature on artificially-induced male breastfeeding to see if it is safe and healthy for the infant.
Illustration by Cynthia (@PTElephant).
Here's another debunking adventure into the world of safety and considerations in male breastfeeding. This adventure was spurred on by the ongoing claims made by a transwoman on Twitter who claims that transwomen are just as capable, if not better, than females when it comes to breastfeeding infants.
Today, we will analyze their prepared and cited argument to determine if transwomen breastfeeding is truly better than females breastfeeding. We’ll cover three categories:
Milk production volume
Adequate nutrition
Medication effects
The argument begins with two studies with the comment that "Two Peer-Reviewed case studies of induced lactation in trans women. Each case involved moderate quantities of milk production, and the childrens' health was observed to be developmentally appropriate."
What about milk production volume?
Case Study One
The first article cited is a single case study.[1] It should be noted that single case studies are not adequate for efficacy population-wide.
This article has issues, but documents that a transwoman was able to lactate by using a combination of stimulation and medication.
The first problem is that this transwoman was able to produce 8oz of milk per day. For reference, a newborn will drink between 4-6oz a day for the first 2 days of life. By day 3, an infant will drink up to twice that much. By 2 weeks of age, the infant will drink between 2-3 oz per feeding with 8-12 feedings a day. The 6 oz each day will nowhere near cut it, which is why by the time the infant was 6 weeks old, they were supplementing feeding with formula and eventually switching to formula being the primary source of nutrition.[2]
But, on top of that, the primary medication used to induce prolactin levels is called domperidone, which was determined not to be safe for infants or children because of lack of efficacy. This was also done after reports of cardiotoxicity at pediatric doses. This report highlights the significant risk for populations with reduced liver function and electrolyte instability, of which infants fall under both categories.[3]
In addition, the FDA recommended against using domperidone for breastfeeding in 2004 because the medication is excreted in breast milk, causing unknown risk in infants.[4]
Case Study Two
The second case study mirrors what was seen in the first: lactation was induced by altering progesterone and estrogen levels and using domperidone to increase lactation. Even given more lenient dosing, the transwoman was only able to produce 3-5 oz per day. Again, this is nowhere near what would be nutritionally required.[5]
What about adequate nutrition?
The goal behind the next section of citations is to demonstrate that a transwoman can produce adequate nutrition to an infant via breastfeeding.
Study One
The first study cited in this section involves measuring the nutrients from a 47 year old transwoman who wished to support breastfeeding of their child in addition to the mother's breastfeeding. Similar to the previous cases, this transwoman was only able to produce approximately 150 mL or about 5 oz per day. The expressed milk was analyzed for four nutrients: protein, lactose, fat, and calories. These values were then compared to average values of breastfeeding women between 2 and 3 months after birth.[6]
The results of the analysis were that the milk produced was within a reasonable range of the standard numbers with the exception of one: fat. The average fat for breastfeeding women was 3.4 g/dL. The amounts collected from the transwoman's samples ranged from 4.1-6.2 g/dL. The amount of fat in milk that the infant receives is important for the growth and development of the infant, however too much fat can also result in health problems early in life including obesity and diabetes.[7]
It should be noted that the mother in this case also breast-fed the infant in question, so despite the poor volume, the infant was never malnourished.
In addition, the study states its own limitations that the nutrient measurements may be over or under represented as the collection was over an estimated 24 hour period.
Perhaps the most concerning part of the study is that it included a statement from the transwoman about how affirming the act of breastfeeding was and the emotional and bonding benefits for the transwoman. While bonding to the infant is important, such bonds can be achieved through skin to skin contact and does not require breastfeeding.
Study Two
The second study in this section was a comparison of nutritional values of milk from the gestating female parent and a non-gestating female parent. Lactation was induced in the non-gestating parent via stimulation and hormone changes. The nutrition between the two groups was found to be identical. This shouldn't be surprising as both groups are female.[8]
Study Three
The last study that was offered compared the nutritional components of breast secretions of a male with galactorrhea. The study was not specific about the particular disorder causing the 27 year old male to lactate, but indicated an enlarged pituitary fossa. The most common cause of such an enlargement is a tumor.[9]
There are quite a few issues with this study. The first is that it was published in 1981. A 40+ year old study isn't the best science we have available. The second issue is that the amount of secretions was not documented, only the macronutrients, so there is no way to tell if such secretions would be sufficient to feed an infant.
The third issue is that the milk that was being compared against included the averages of nutrition from 52 women from varying timings from pre-partum to up to 12 months postpartum. The nutritional value of milk varies depending on the age and needs of the infant. With such a large and varied sample size, the standard deviation of the nutritional values were so wide that most any nutritional value could be included in the normal range. For instance, the nutritional potassium levels from breastfeeding mothers was an average of 13.4 mM ± 20.3 mM. So, the male secretions could have had 0 potassium and still have been within the standard deviation of the breastfeeding mothers. It is fair to say that the conclusions of this study should not be used to determine nutritional success of transwomen.
From all these studies, we can say that the nutritional value of breastmilk was only ever proven in females. The studies involving males are consistent in low milk supply and inconsistent when it comes to nutritional value.
What about the effects of the drugs used to induce lactation?
The next few citations include information packets on the medication domperidone.[10] Something to note is that this pamphlet states the maximum dose to be used to increase lactation is 10 mg three times a day. In the second study linked in this list, the transwoman had to increase the dose of domperidone to 30 mg three times a day. That is 3 times the maximum dosage for the medication. In addition, the pamphlet states that no known impacts to health of mother or infant were documented for the 10 mg dose. None of these studies in the pamphlet included male participants.
The next cited page is another information page on domperidone, which continues to state that side effects for the infant are not well known or tested, but that the vast majority of mothers receive little to no benefit from the use of the medication to increase lactation. This means that the risk is not worth the benefit for breastfeeding mothers.[11]
Next, we cover three medications that transwomen use and their safety for infants who are breastfeeding. The first is spironolactone. In the citation provided, it states that the use of spironolactone is acceptable, and shows the levels seen in applicable case studies.[12] Of these case studies, there was only one transwoman, and the dose was at 100 mg per day in 2 doses. However, many transwomen can take a maximum of 400 mg per day.[13] Additionally, the article states that there has been no published information about the use of spironolactone in infants via breastfeeding. In other words, it is a big unknown given the potential varying doses.
The next medication on the list is estradiol. The linked citation states that serum concentrations of maternal estradiol and serum infant estradiol levels were not connected.[14] However, many cases that involved the use of estradiol resulted in the inability to provide sufficient nutrition to the infant without supplemental nutrition sources. This is because in females who breastfeed, estrogen levels are naturally lowered while prolactin levels rise. When a mother stops breastfeeding, her prolactin levels decrease and her estrogen levels rise, allowing her to start her menstrual cycle again.[15] So, although it may be a safe hormone to have while breastfeeding, it is naturally antagonistic to the hormonal process that allows for lactation to occur.
The third medication on the list is progesterone.[16] The cited page gives an overview of progesterone and the impact on nursing women and infants, which is minimal. However, the dose given to these women was via birth control medications or devices producing a dose of approximately 10 mg per day. The starting dose of progesterone recommended for transwomen can be as high as 100-200 mg per day.[17]
In the first case study, the progesterone levels of the transwoman was up to at least 400 mg per day. That is 40 times greater than the dose being given to the mothers in the efficacy studies using birth control. No studies have evaluated the safety and efficacy at such a dose.
Conclusion
Given all the available data on the amount of milk produced as well as the lack of studies on the safety of these medications at such high doses, it is safe to say there is no sufficient evidence to prove transwomen can safely breastfeed an infant. Transwomen cannot produce enough to give adequate nutrition and the unknown dangers to the infant from the medications is not worth the risk.
But even further, it is concerning that it was of great importance that breastfeeding was affirming for the transwoman. Breastfeeding is about providing nutrition and immunity benefits to the infant. It should be concerning to everyone that affirmation is addressed at all. Given the risk to the infant, the ethical question must be asked: is a transwoman nursing really about feeding the infant, or is it about feeding the dysphoria?
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[1] Reisman, T., Goldstein, Z. (2018). Case report: induced lactation in a transgender woman. Transgender Health, 3(1), 24-26.
[2] (2023). How much and how often to feed infant formula. Centers for Disease Control.
[3] (2019). Domperidone: no longer approved for use in children due to a lack of efficacy. Federal Agency for Medicines and Health Products.
[4] (2004). FDA talk paper: FDA warns against women using unapproved drug, domperidone, to increase milk production. Food and Drug Administration.
[5] Wamboldt, R., Shuster, S., Sidhu, B. (2021). Lactation induction in a transgender woman wanting to breastfeed: case report. The Journal of Clinical Endocrinology & Metabolism, 106(5).
[6] Weimer, A. (2023). Lactation induction in a transgender woman: macronutrient analysis and patient perspectives. Journal of Human Lactation, 0(0).
[7] Martin, C., Ling, P., Blackburn, G. (2016). Review of infant feeding: key features of breast milk and infant formula. Nutrients, 8(5), 279.
[8] Perrin, M., Wilson, E., Chetwynd, E., Fogleman, A. (2014). A pilot study on the protein composition of induced nonpuerperal human milk. Journal of Human Lactation, 31(1), 166-71.
[9] Kulski, J., Hartmann, P. (1981). Composition of breast fluid of a man with galactorrhea and hyperprolactinemia. The Journal of Clinical Endocrinology and Metabolism, 52(3), 581-2.
[10] Jones, W. (2019). Domperidone and breastfeeding. The Breastfeeding Network.
[11] (2006). Domperidone. Drugs and lactation database (LactMed) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development. [Updated 2023 May 15].
[12] (2006). Spironolactone. Drugs and lactation database (LactMed) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development. [Updated 2022 Jul 18].
[13] Tomlins, L. (2019). Prescribing for transgender patients. Australian Prescriber, 42(1), 10-13.
[14] (2006). Estradiol. Drugs and lactation database (LactMed) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development. [Updated 2021 Mar 17].
[15] (2023). Sex, hormones and breastfeeding. La Leche League Canada.
[16] (2006). Progesterone. Drugs and lactation database (LactMed) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development. [Updated 2022 May 15].
[17] (2021). Feminising hormones. Health & Gender Affirmation in NSW, Trans Hub.
