554928
research-article2014
JHLXXX10.1177/0890334414554928Journal of Human LactationFarrow
Commentary
Lactation Support and the LGBTQI
Community
Alice Farrow1
Keywords
barriers, bisexual, breastfeeding, chestfeeding, cisnormative, disclosure, discrimination, gay, gender identity, health disparities,
heteronormative, intersex, lactation support, lesbian, queer, questioning, sexual orientation, support, transgender
Although it is recognized that diverse members of the les-
bian, gay, bisexual, transgender, queer, questioning, and
intersex (LGBTQI) community face significant barriers to
accessing appropriate health care,1,2 very little has been writ-
ten and little research has been done on access to lactation
support for this community. Heteronormative and cisnorma-
tive assumptions are predominant in the language (including
images) in mainstream breastfeeding literature and the lan-
guage used by providers. This would appear to be a signifi-
cant barrier to accessing lactation support by LGBTQI
parents, as well as limiting the adequacy of that support,
forming a barrier to a positive working environment for
LGBTQI providers who are vital to the process of change
toward LGBTQI inclusion in the field.
Heteronormativity is “the mundane production of hetero-
sexuality as the normal, natural, taken-for-granted sexual-
ity,” which leads to social exclusion or marginalization of
nonheterosexuals.3 Heteronormativity can easily be seen in
breastfeeding literature and practice as the assumption that
families are made up of a man, a woman, and a child or chil-
dren. Cisnormativity is the assumption that everyone is cis-
gender or cissexual (ie, “people who are not transsexual and
who have only ever experienced their subconscious and
physical sexes as being aligned”).4 Cisnormativity is mani-
fested in institutional erasure and practices that “exclude or
ignore the possibility of providing service to trans clients,”5
such as the predominant use, within the lactation profession,
of female gendered language when referring to breastfeeding
parents.
Each letter of the acronym LGBTQI represents a diverse
group of people with different needs and issues. Readers may
be familiar with other variations of this acronym in the form
of LGB, LGBT, or LGBTQ. The author has chosen the form
LGBTQI (as it encompasses the diverse acronyms used in
the studies referenced) when speaking of the community
generally, and abbreviated forms of this acronym when refer-
ring to a smaller grouping of identities. The letters contained
in LGBTQI do not represent all gender identities and sexual
or affection orientations, knowledge of which is in rapid evo-
lution, especially within popular culture; social media has
recently recognized this by allowing account holders to
Downloaded from jhl.sagepub.com by guest on June 11, 2016
Journal of Human Lactation
2015, Vol. 31(1) 26­–28
© The Author(s) 2014
Reprints and permissions:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0890334414554928
jhl.sagepub.com
identify in dozens of ways6 or to not identify at all. Acronyms,
therefore, can be problematic and limiting as descriptors of
this community and should be held under scrutiny for their
accuracy and usefulness.
Advocacy and research have visibly focused on the white
Caucasian lesbian and gay communities, which are not rep-
resentative of LGBTQI people worldwide. English language
terms and acronyms are not inclusive of the terms used in
other cultures such as the Native American Two Spirit people
and the Indian Hjira. Sexual orientation and gender are only
1 facet of an intersectional identity, and some LGBTQI peo-
ple belong to more than 1 minority group and therefore are
subject to intersectional discrimination. Members of the
LGBTQI community experience acceptance and equality
diversely according to culture, religion, country or region of
residence, sex, gender, and sexual or affection orientation.
Health research shows that LGBTQI people have limited
access to health care due to factors such as poverty, home-
lessness, gender-specific care and services, ineligibility for
health insurance coverage due to marriage discrimination
laws, fear of violence, refusal of care, substandard care with-
out consideration of noncisgender heteronormative needs,
and derogatory or moralistic comments from providers.1,2
Transgender health care is problematized by the implication
that transsexualism is a disorder.1 Resultant reluctance to
seek care, including routine checks and specialist referrals
due to the stress of disclosure of sexual orientation and/or
gender identity to health care providers, widens gaps in
health disparity for this community.2,7 Studies have found
that all members of the LGBTQ community are affected by
heteronormative and gendered language and invisibility,5,8-10
but transgender and bisexual individuals experience more
invisibility and erasure within society and the health care
system than other members of the LGBT community,2,5,11
1
The Open University, Milton Keynes, UK
Date submitted: August 4, 2014; Date accepted: September 19, 2014.
Corresponding Author:
Alice Farrow, Via Francesco Catel 25, 00152 Rome, Italy.
Email: alice.farrow@hotmail.com
Farrow 27
and transgender people are particularly affected by institu-
tional barriers such as gender-specific health insurance cov-
erage and care.1,2
Although there is little mention of LGBTQI parents in
breastfeeding literature, the author has heard positive first-
hand accounts of breastfeeding support from individual
LGBTQ parents who also note the absence of culturally
competent breastfeeding resources, the lack of representa-
tion of nonheteronormative families (in areas such as intake
forms and images representing parents and families), as well
as a lack of specific information and research for their spe-
cific breastfeeding or chestfeeding concerns or difficulties,
leaving these parents to do their own research for the infor-
mation required. The lactation profession has shown interest
in LGBTQ issues and a desire to be inclusive through
changes in policy,12 recognition of women as partners and
coparents,13,14 an increase in LGBTQ inclusive breastfeeding
materials and provider education,15-18 as well as discussion of
LGBTQ inclusion at an institutional level.19
Much of the research, resources, and commentary on lac-
tation and the LGBTQI community have come from LGBTQI
providers and parents themselves, yet the contribution of
members of this community may be limited due to fear of
disclosure; LGBTQI providers and parents may not be “out”
(express publicly their sexual or affection orientation or fam-
ily composition) or may live in “stealth” (not disclose their
transgender status) by choice or out of fear of discrimination.
The author has had, as well as received personal communica-
tions from other LGBTQ lactation providers who report,
negative experiences such as unsolicited comments and
openly expressed provider opinions on LGBTQI people as
parents, and judgment on conception, feeding decisions, and
the imaginary “gay lifestyle,” which are harmful and
unfounded.
Whereas many parenting and breastfeeding challenges
are common to heterosexual and same-sex or queer families,
the LGBTQI community have specific parenting and infant
feeding concerns, such as co-nursing and induced lactation;
chestfeeding, breastfeeding, nursing, or feeding (preferred
terms may vary) after chest reduction (top-surgery in trans-
gender men); breastfeeding after breast augmentation (trans-
gender women); the use of testosterone while chestfeeding;
and pregnancy and lactation’s effects on gender dysphoria
(which “occurs when an individual feels discomfort due to
parts of their body that do not match their gender identity”).15
LGBTQI parents are also at risk of mental health issues, due
to minority stress and social stigma.20 Fear of the implica-
tions and repercussions of disclosure, the legal difficulties
involved in validating family composition, health disparities,
institutional discrimination, and lack of social, family, and
professional support are factors that can increase the difficul-
ties intrinsic to the transition to parenthood.
Research into health outcomes of the LGBTQI commu-
nity indicate lower physical and mental health outcomes2,7 of
youth and adult members of this community, but also the
Downloaded from jhl.sagepub.com by guest on June 11, 2016
effects of social stigma on the children of same-sex attracted
parents.21 Public health research may not include informa-
tion on sexual identity and gender identity. Health concerns
of lesbian and bisexual women include multiple risk factors
for breast and reproductive cancers, such as nulliparity, alco-
hol consumption, smoking, obesity, and stress,2,22,23 yet accu-
rate data on specific concerns, such as the presumed
prevalence and incidence of breast cancer in the lesbian and
bisexual women’s community, are lacking due to the type of
demographic data collected by cancer agencies.23 There is
also limited published literature on breast cancer and the
transgender population.24 Not breastfeeding is known to be a
risk factor in these cancers, but there has been little research
done on the breastfeeding rates of lesbian and bisexual
women and transgender men and women.
The recent Australian Study of Child Health in Same-Sex
Families (ACHESS)21 found high breastfeeding rates, simi-
lar to those of the general population within their cohort,
which was limited to a group of parents with an above-aver-
age income and education who may well have had fewer bar-
riers to health care access and infant feeding support, along
with the ability to access private lactation care. Although
breastfeeding is known to be fundamental for the infant’s
short- and long-term health and an important factor in the
health of the lactating parent or parents, and breastfeeding
objectives emphasize the role of breastfeeding in improving
population health,25 the United States’ Surgeon General’s
Call to Action to Support Breastfeeding26 does not mention
nonheteronormative families in any way. Advocacy for
LGBTQI inclusion in public health research focusing on
breastfeeding may need to come from the profession itself.
The United States’ Healthy People 2020 Objectives27
have called for LGBT parenting issues throughout the life
course to be evaluated and addressed in the 2010-2020
decade. Since breastfeeding is known to be an important fac-
tor in the health of infants and the lactating parent or parents,
improving access to breastfeeding support, individuating
barriers to and the efficacy of that support, and studying
LGBTQI parents and breastfeeding rates should therefore be
considered priorities within the field of lactation.
LGBTQI parents and their families should not be consid-
ered a “separate chapter” in breastfeeding literature; LGBTQI
parents have the same lactation and family adjustment chal-
lenges as the heterosexual mothers currently served by main-
stream breastfeeding support, as well as unique challenges
(currently under- or un-researched). Increasing LGBTQI
awareness and competency within the breastfeeding field
and the use of inclusive nongendered language in intake
forms and parent literature are immediate ways of increasing
access to breastfeeding support for LGBTQI families.
LGBTQI health and lactation providers have unique
insights into the complexities of the issues faced by LGBTQI
families. Therefore, they should be consulted and involved in
discussions of the institutional barriers within this field as
well as supported as key researchers and education providers
28 Journal of Human Lactation 31(1)
for the development and implementation of culturally com-
petent resources and policies.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
References
1. Harvey VL, Housel TH, eds. Health Care Disparities and the
LGBT Population. Plymouth, UK: Lexington Books; 2014.
2. Committee on Lesbian, Gay, Bisexual, and Transgender Health
Issues and Research Gaps and Opportunities. The Health of
Lesbian, Gay, Bisexual, and Transgender People: Building a
Foundation for Better Understanding. Washington, DC: Board
on the Health of Select Populations, Institute of Medicine of
The National Academies; 2011.
3. Kitzinger C. Heteronormativity in action: reproducing the
heterosexual nuclear family in after-hours medical calls. Soc
Probl. 2005;52(4):477-498.
4. Serrano J. Whipping Girl: A Transsexual Woman on Sexism and the
Scapegoating of Femininity. Emeryville, CA: Seal Press; 2007.
5. Bauer GR, Hammond R, Travers R, Kaay M, Hohenadel KM,
Boyce M. “I don’t think this is theoretical; this is our lives”:
how erasure impacts health care for transgender people. J
Assoc Nurses AIDS Care. 2009;20(5):348-361.
6. Barker M. 57 Genders (and none for me)? Reflections on the
new Facebook gender categories. Rewriting the rules [blog].
http://rewritingtherules.wordpress.com/2014/02/15/57-gen-
ders-and-none-for-me-reflections-on-the-new-facebook-
gender-categories/. Published February 15, 2014. Accessed
September 16, 2014.
7. Leonard W, Pitts M, Mitchell A, et al. Private Lives 2: The
Second National Survey of the Health and Wellbeing of Gay,
Lesbian, Bisexual and Transgender (GLBT) Australians.
Melbourne: La Trobe University, The Australian Research
Centre in Sex, Health & Society; 2012.
8. Hagen B, Paz Galupo M. Trans* individuals’ experiences of
gendered language with health care providers: recommenda-
tions for practitioners. Int J Transgend. 2014;15(1):16-34.
9. Bjorkman M, Malterud K. Lesbian women’s experiences with
health care: a qualitative study. Scand J Prim Health Care.
2009;27(4):238-243.
10. Rosenstreich G, Comfort J, Martin P. Primary health care and
equity: the case of lesbian, gay, bisexual, trans and intersex
Australians. Aust J Prim Health. 2011;17(4):302-308.
11. Barker M, Richards C, Jones R, et al. The Bisexuality Report.
Milton Keynes, UK: Open University, Centre for Citizenship,
Downloaded from jhl.sagepub.com by guest on June 11, 2016
Identities, and Governance and Faculty of Health and Social
Care; 2014.
12. West D. LLLI updates breastfeeding counsellor eligibility crite-
ria [press release]. http://www.llli.org/llli_updates_breastfeed-
ing_counsellor_eligibility_criteria_21_april_2014. Published
April 21, 2014. Accessed September 17, 2014.
13. Wiessinger D, West D, Pitman T. The Womanly Art of
Breastfeeding. 8th ed. London, UK: Pinter & Martin Ltd; 2010.
14. Farrow A. When two women share parenting. Breastfeeding
Today. 2014;23:16-18.
15. MacDonald T. Tips for transgender breastfeeders and their lac-
tation educators. http://www.milkjunkies.net/2012/03/tips-for-
transgender-breastfeeders-and.html. Published May 5, 2012.
Accessed September 17, 2014.
16. Simpson J. LGBTQ parents and lactation—an exploration in
LGBTQ culture. GOLD Lactation Online Conference; May 8,
2014. http://www.goldlactation.com/conference/presentations/78
17. MacDonald T. How health care providers and other birth work-
ers can support trans* clients through pregnancy, birth, and
infant feeding. YoniFest, Québec; August 2, 2014.
18. Dobrich C. Lesbian couples and breastfeeding. Liquid Gold,
Australian Breastfeeding Association National Conference,
Melbourne; August 3, 2014.
19. Carothers C. 2014 Lactation summit: addressing inequities
within the lactation consultant profession. Clinical Lactation.
2014;5(3):86-89.
20. Meyer IH. Prejudice, social stress, and mental health in lesbian,
gay, and bisexual populations: conceptual issues and research
evidence. Psychol Bull. 2003;129(5):674-697.
21. Crouch SR, Waters E, McNair R, Power J, Davis E. Parent-
reported measures of child health and wellbeing in same-sex
parent families: a cross-sectional survey. BMC Public Health.
2014;14:635.
22. Meads C, Moore D. Breast cancer in lesbians and bisexual
women: systematic review of incidence, prevalence and risk
studies. BMC Public Health. 2013;13(1):1.
23. Cochran SD, Mays VM. Risk of breast cancer mortality among
women cohabiting with same sex partners: findings from the
National Health Interview Survey, 1997-2003. J Womens
Health. 2012;21(5):528-533.
24. Pattison ST, McLaren BR. Triple negative breast cancer
in a male-to-female transsexual. Intern Med J. 2013;43(2):
203-205.
25. Centers for Disease Control and Prevention. Breastfeeding report
card: United States/2014. http://www.cdc.gov/breastfeeding/
pdf/2014breastfeedingreportcard.pdf. Accessed September 29,
2014.
26. US Department of Health and Human Services. The Surgeon
General’s Call to Action to Support Breastfeeding. Rockville,
MD: US Dept of Health and Human Services; 2011.
27. US Department of Health and Human Services. Healthy People
2020: Lesbian, Gay, Bisexual, and Transgender Health.
Rockville, MD: US Dept of Health and Human Services; 2010.