Gender-affirming approach to infant feeding

Gender-affirming approach to infant feeding

Transgender, Two-Spirit A term used within some Indigenous communities to reflect complex Indigenous understandings of gender and sexuality and the long history of sexual and gender diversity in Indigenous cultures. Two-Spirit encompasses sexual, gender, cultural and spiritual identity. It may refer to cross-gender, multi-gender or non-binary gender roles, non-heterosexual identities, and a range of cultural identities, roles and practices embodied by Two-Spirit peoples. Some people also use "2-Spirit" or "2S." (Source: Battered Women’s Support Services) , and non-binary Umbrella term referring to people whose gender does not fall within the binary gender system of woman/girl or man/boy. Some individuals identify as non-binary while others may use terms such as gender non-conforming, genderqueer, or agender. Non-binary people may or may not conform to societal expectations for their gender expression and gender role, and they may or may not seek gender-affirming medical or surgical care. (TTNB) people become parents in many ways, including pregnancy, adoption, surrogacy, and blended or chosen family creation. TTNB people’s infant feeding choices should not be assumed based on gender, family structure, or health history [1,2]. Infant feeding discussions need to include personal values, goals, beliefs, relevant medical or surgical history, mental health history, and available support systems [2,3].  

Discussing infant feeding early in the caring relationship (in early pregnancy or family planning stages) allows ample time for development of trust, decision making, and collaborative care planning Process that a person, their health care providers, family and other supporters undertake in planning to reach their gender-affirming care goals. .

To provide care spaces that are safer for Indigenous TTNB people, we must first recognize the long-standing and ongoing Indigenous-specific racism within political and healthcare institutions that continues to perpetuate and reinforce disconnection from community, language, and culture. Through residential schools, Indian hospitals, child welfare practices, birth evacuation policies, and other government policies and practices, settler colonialism continues to impact Indigenous parents, children, and families [4–7]. The intergenerational repercussions of residential schools have separated families from community, language, and culture and dispossessed Indigenous peoples of their land and traditional food in ways that continue to influence infant feeding practices [8].  

It is essential to recognize that the ongoing harms of colonization exist alongside Indigenous strength and resilience. Indigenous communities are rich in knowledge, language, and culture, including traditions around birth and parenting that are unique to each nation and community. Showing up authentically in caring relationships and honoring Indigenous ways of knowing will contribute to culturally safer care for Indigenous TTNB people.  

For some Indigenous people, the journey of growing a family and feeding an infant may lead to an increased desire for connection to Indigenous ways of knowing and culture. For those who have had disconnections from their communities, resources such as Indigenous friendship centres and community centres are valuable for supporting this connection.  

Language is ever changing and, while we have made every effort to be inclusive, we recognize that some people will not feel represented by the terms we have chosen to use. Care should be individualized by using a client’s preferred terms when supporting them with feeding.  

Bodyfeeding: an inclusive term for feeding an infant human milk from the body, with or without supplemental feeding equipment. While it primarily refers to feeding an infant human milk from the body, it can also include methods such as feeding with a supplemental feeding system, cup, bottle, syringe, or finger feeding, as these approaches maintain close contact with a caregiver’s body.  

A note on language

Trans Care BC uses the term “bodyfeeding” as an inclusive way to describe feeding an infant from the body, ensuring that the language reflects diverse genders and experiences. When selecting this language, we found that members of the Two-Spirit A term used within some Indigenous communities to reflect complex Indigenous understandings of gender and sexuality and the long history of sexual and gender diversity in Indigenous cultures. Two-Spirit encompasses sexual, gender, cultural and spiritual identity. It may refer to cross-gender, multi-gender or non-binary gender roles, non-heterosexual identities, and a range of cultural identities, roles and practices embodied by Two-Spirit peoples. Some people also use "2-Spirit" or "2S." (Source: Battered Women’s Support Services) , transgender and non-binary Umbrella term referring to people whose gender does not fall within the binary gender system of woman/girl or man/boy. Some individuals identify as non-binary while others may use terms such as gender non-conforming, genderqueer, or agender. Non-binary people may or may not conform to societal expectations for their gender expression and gender role, and they may or may not seek gender-affirming medical or surgical care. (TTNB) communities were already using “bodyfeeding” as an anatomy-neutral term. It aligned well with our writing style and met the needs of TTNB parents and their support networks. 

While “bodyfeeding” is appropriate for our audiences, it is not yet a mainstream term and, in many cases, using inclusive additive language (e.g., “breastfeeding or chestfeeding”) may be more suitable [9]. Other inclusive language for infant feeding includes (but is not limited to) breast/chest feeding, chestfeeding, nursing, human milk feeding, and lactation. We encourage you to consider your practice context and use the terminology that aligns with your client’s needs. 

As language develops and evolves, the terms used in our resources may become outdated or misaligned with community needs. In all instances, care should be individualized by using a client’s preferred terms when supporting them with infant feeding.  

The experience of gender incongruence A mismatch between a person's gender and the sex they were assigned at birth. or dysphoria is unique for every client. Gender incongruence “describes a person’s marked and persistent experience of an incompatibility between that person’s gender identity A person's deeply held, internal sense of themself as male, female, a blend of both or neither. (Source: GenderSpectrum.org) and the gender expected of them based on their birth-assigned sex” [10]. Gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) , used by the American Psychiatric Association as a diagnostic label, refers to the distress or discomfort that may be experienced due to the difference between gender assigned at birth and experience of gender [10].

Infant feeding and the body

Pregnancy and bodyfeeding are physical experiences that may bring up feelings of gender incongruence or dysphoria and internalized racism [2,11–16]. This may be due to the physical and emotional changes that occur during pregnancy or may be due to being misgendered during healthcare experiences and social interactions [17].  

During pregnancy and infant feeding, clients may be navigating grief, joy, loneliness, connection, ambivalence, and many other emotions. Some TTNB people feel that pregnancy is an affirming experience, gaining appreciation for a body that has, prior to pregnancy, felt alien, and others see pregnancy as a means to an end [2,18,19]. For many trans women, bodyfeeding after lactation induction is a gender-affirming experience [20,21]. Some people experience discomfort in their bodies that impacts their relationship with bodyfeeding, an experience that may be rooted in racism and sexualization of certain body types. The cultural shifts that have led to the sexualization of Indigenous bodies may make it uncomfortable to bodyfeed in some environments [15].  

Work to create safety in clinical visits through non-judgmental and relational care and provide space for clients to share their emotions without attempting to solve them. This safe space can provide an opportunity for clients to discuss how they are experiencing the physical and emotional shifts that come with pregnancy and/or infant feeding.  

For more information on a gender-affirming approach to care, see Trans Care BC’s Gender-Affirming Relational Practice Course.  

Misgendering

Many TTNB people share that being misgendered (assumed to be a gender that does not align with your own gender) during pregnancy worsens gender dysphoria [2,17]. TTNB people who are pregnant or bodyfeeding often carry the weight of educating their care providers, correcting their language, or choosing when to disclose or not disclose their gender as they navigate gendered care spaces [13,14,16]. This can lead to clients choosing to self-isolate to avoid social interactions and care environments [11,22].  

Language and support

Gender-affirming infant feeding support requires providers to be familiar with and use the language chosen by clients and their families. This includes names, pronouns, infant feeding language, and parenting terms. Ensure documentation is up to date and clearly communicates this information to the care team. When referring to external services, clearly communicate client’s name and pronouns on requisitions and referrals to decrease the chance of clients being misgendered and having a negative healthcare experience. In some cases, a letter or phone call may be necessary to advocate for clients.  

Always gain client’s consent before documenting and sharing their chosen name and pronouns.  

For more information on language and charting practices, see Clark et al. (2022). Gender and sex data practices within electronic health records in a primary care setting: A use case approach.

Making mistakes

If you make a mistake, acknowledge it, apologize, and move on. Do not expect the client or family to do the emotional labour of continually correcting your language and recognize that repeated mistakes create unsafe care environments and can exacerbate gender dysphoria Distress resulting from a difference between a person’s gender and their sex assigned at birth, associated gender role, and/or primary and secondary sex characteristics. (Source: WPATH) . Use this as an opportunity to learn and reflect on your practice, continually seeking to be more inclusive in your language and approach to care.  

For more information, see Trans Care BC’s document Making Mistakes and Correcting Them.  

Provider selection

Self-reflection and awareness are essential when caring for TTNB clients. You may not be the best care provider for a client based on their preferences, care needs, and your model of care. Community interviews done by Trans Care BC showed that TTNB people feel safest when cared for by TTNB or queer A reclaimed term for non-heterosexual or non-cisgender people. "Queer" provides convenient shorthand for "LGBT2Q+", and is also used by some people to describe their personal identities. providers and TTNB Indigenous clients prefer Indigenous providers, even if they are not TTNB [22].  

Recognize how your lived experience impacts the care you provide and, where appropriate, initiate a conversation about provider options that fit clients’ care needs. If a client expresses a desire to have a care provider who is TTNB or queer, continue to provide care while supporting them to find available providers in the community.

Build a knowledge base

Providing gender-affirming relational care may be a new practice for you as a provider. Do not expect clients to address these knowledge deficits. Recognize your own biases and knowledge gaps with self-reflection and humility. Anticipate questions that are outside of your knowledge base and be prepared to address them directly. Differentiate between “I don’t know but I will find out” and “science doesn’t know” and provide a clear follow-up plan for how you will find this information [1].  

Trans Care BC education and practice support tools  

For questions related to specific clinical situations, clinicians may use eCase or call the RACE Line A phone consultation line for primary care providers, staffed by physicians who are experts in trans health care. at 604-696-2131 or toll free at 1-877-696-2131 and request the “Transgender Health'' option to consult an experienced provider.  

ECHO Trans Care BC is an advanced medical education course for health care providers interested in learning more about gender-affirming medical care. For more information, see the Project ECHO page.  

Lactation consultants  

International Board-Certified Lactation Consultants (IBCLCs) are experts in supporting clients with infant feeding concerns. We recommend consulting an IBCLC at any point in the infant feeding journey when low milk supply is anticipated, the feeding plan is complex, or if there are feeding concerns beyond your scope of practice. IBCLCs who are registered midwives are covered by the provincial medical services plan (MSP The Medical Services Plan (MSP) is a B.C. government health plan that pays for physician services and referred services that are considered medically necessary, such as specialists (surgeon, psychiatrist, etc.), diagnostic x-rays, or laboratory services, for all BC residents. Some residents qualify for premium assistance for physiotherapy, chiropractic, naturopathy, massage therapy and acupuncture. ) during pregnancy and up to 6 weeks postpartum. In some communities, IBCLCs who are registered nurses or other medical professionals are funded through a hospital or public health clinic. If not covered by MSP, registered nurses and other medical professionals who are lactation consultants may be covered by extended benefit plans. Clients may also choose to pay out of pocket for a private-pay lactation consultant.

Resources

Build a repository of resources and have a list of safer and more inclusive providers for when referrals are needed for TTNB clients. This list may include fertility clinics, midwives, nurse practitioners, general practitioners, obstetricians, doulas, lactation consultants, and mental health workers or support groups.  

The Trans Care BC Health Navigation team can help you find local providers who provide gender-affirming care Processes through which a health care system cares for and supports an individual while recognizing and acknowledging their gender and expression. .

Informed feeding decisions

Informed feeding decisions are based in empathetic, two-way communication between provider and client, recognizing that both bring knowledge and expertise to the relationship [24]. Parents are empowered to make an informed feeding decision when they have information about feeding options and an opportunity to express their own values, preferences, and family circumstances. Providers support informed feeding decisions by respecting clients’ circumstances and providing information that is contextual, evidence-informed, and objective [24].

For more information, see Alberta Health Services Informed Feeding Decision Definition and Approach for Infant and Child Feeding.

Socio-ecological context 

Infant feeding decisions are highly personal and occur within the larger context of family, home life, society, and culture [24,25]. Feeding decisions should not be assumed based on gender, family structure, or health history [1,2]. 

Context may be influenced by previous interactions with healthcare providers, access to gender-affirming care Processes through which a health care system cares for and supports an individual while recognizing and acknowledging their gender and expression. , support systems, socioeconomic status, disability, race, cultural beliefs and practices, and community resources. The best way to learn about a client's context is to engage in relational practice and get to know your client and their support people.

Download the Socio-Ecological Model in the Infant Feeding Context

Infant feeding flowchart

Just as there are many ways to grow a family, there are many ways to feed an infant. The following decision support tool can be used alongside informed feeding discussions to guide care and practice.  

This flowchart outlines common feeding variations to emphasize the many ways to feed an infant. It is important to understand that not all families fit into these categories, as all families are unique in their composition and feeding choices.

Infant Feeding Flowchart

Bodyfeeding after pregnancy

When a person has been pregnant and plans to feed their infant any amount of milk from their body. Client may have a history of chest surgery or be planning to co-feed with one or more other people.

For more information, see Bodyfeeding: History of Upper Surgery.

Co-feeding

Bodyfeeding will be shared between two or more people. One person may or may not have been pregnant, and one or more people is usually inducing lactation.  

For more information, see Co-feeding.

Lactation induction

The process of establishing a milk supply in someone who is not pregnant or in the immediate postpartum period. People may induce lactation to provide donor milk, bodyfeed after a partner has given birth, or to provide human milk when growing their family through adoption or surrogacy.  

Trans Care BC content in development. For more information, see the Academy of Breastfeeding Medicine’s Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients.  

Lactation suppression

Using medications or non-pharmacological treatments to prevent lactogenesis or to stop milk production.  

For more information, see Lactation Suppression.  

Formula feeding

Formula used as a primary feeding option or in combination with other feeding methods.  

For more information about infant formula, see Perinatal Services BC’s Infant Formula: What You Need to Know.  

Feeding with donor milk

Donor milk is human milk that does not come from a parent and is usually obtained through formal milk banks or informal community connections. It may be used as a primary feeding option or in combination with other feeding methods.  

For more information, see Perinatal Services BC’s Information for Families: Informal (Peer-to-Peer) Milk Sharing.

The client resource Deciding How to Feed Your Baby can be used alongside these discussion questions.  

Initiate a conversation

  • Have you thought about how you are going to feed your infant?
  • What questions do you have about feeding your infant?  
  • Would you like me to review infant feeding options?

Explore feeding priorities  

  • What is important to you when you consider infant feeding?
  • What do you value as a parent / family? How might this affect your infant feeding choices?

Consider the context

  • Who will be involved with feeding your infant? Consider co-feeding, induced lactation, and chosen family.
  • What factors will impact your decision on how to feed your infant?  
  • Have you heard stories from others that may impact your decision?
  • Are there any external factors that may impact your infant feeding decision? Consider work, school, housing, and / or community
  • Is cost a concern when deciding how to feed your infant?

Indigenous and cultural considerations (Healy, 2017)  

  • Are there any cultural and traditional practices that would be helpful for you?
  • Would you like an Elder or trusted loved one to be part of this visit or future visits?  

Integrate infant feeding history

  • If you have fed an infant before, what was this experience like? In an ideal world, would you like to have the same experience or a different one?
  • Are there factors that made infant feeding easy or difficult for you?

Tailored information and support

  • What do you want to know more about when it comes to infant feeding?
  • How can I support you in achieving your infant feeding goals?
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Current versionJanuary 14, 2025
AuthorsCaitlin Botkin Nurse Educator, Trans Care BC; Registered Midwife (non-practicing) 
Rowan McNiven Gladman Registered Midwife, IBCLC 
ContributorsKatia Mordak  Registered Midwife, IBCLC; Member of the Penelakut Tribe