Supporting Trans Clients: An Assignment

This was originally an assignment in a midwifery course. I've shared my thoughts here in hopes it helps other birth workers serve all birthing people with dignity and thoughtfulness. To read the original format of the assignment and/or references, click here.

Case Study 1

A male trans client who has had top surgery (double mastectomy) comes to you with the following questions about chestfeeding:

Can you help me understand the process of chestfeeding and what I can expect?

“Chestfeeding can look many different ways, depending on your goals, what you’re comfortable with, and who is supporting you. I want to start by talking about what your thoughts are on feeding a baby and I’d love to hear what you would like the experience of chestfeeding to be like for you, baby, and any partners involved.” This is how I would start the conversation, because I want to get a feel for where the client’s values lie and what they already know about chestfeeding. This is the same process I go through when beginning the breastfeeding conversation.

As far as what to expect: “I don’t have a lot of first-hand experience with chestfeeding, but I do know that some people enjoy the experience while others feel really uncomfortable and know it’s not for them early on. I think it’s safe to say you might feel awkward at first, because this is true of anyone who feeds a baby from their body and it will be a unique experience for everyone because we each relate to our bodies so differently. I also think it’s good to start thinking about what it would mean to you if you plan to chestfeed, but decide in the moment it’s not for you, and vice versa. I always suggest my clients give some time and thought to what would happen if Plan A in any scenario doesn’t end up working out for whatever reason. That way you have a backup in your mind, which may lessen any sense of guilt, frustration, or sadness related to the experience or it may help you process through these feelings if they do come up.”

2. Do you recommend trying to chestfeed even if I may not produce milk?

“There are many potential benefits to chestfeeding other than the milk you might produce, if that’s what you’re asking. But the decision to try chestfeeding is your own and only you can say whether it makes sense for your mind, body, and family. Would you like some research on skin-to-skin, hormones involved in the process, and/or alternative options?”

3. If so, do you have any recommendations for coping with gender dysphoria if it arises while I feed my baby?

“I think the first step in coping with any challenge that arises is recognizing it’s a possibility, and you’re already there just by asking this question. What possible feelings do you think might come up for you if you chestfeed your baby? How do you cope with challenges in the way you see your body now, during pregnancy? Do you have mental health or counseling support already set up now? If so, how would you feel about sharing your plans to chestfeed and getting some feedback on how it might trigger dysphoria in you?” (I’m assuming this is a pregnant client, but if it was the partner of a client who birthed, I would still ask the question but remove the during pregnancy portion.)

4. What support will you offer to me until feeding gets well underway?

“I’ll arm you with referrals to appropriate providers, such as an IBCLC, who can help you assess what’s working and what isn’t about chestfeeding. In the initial hours and day after birth, I will be available personally to help initiate baby’s latch, bonding, and skin-to-skin and then we can go from there. I’ll check in with you about how you’re feeling about the process, whether it makes sense for you, etc. There are also tools that many of my clients utilize, such as a SNS, to help facilitate the process of feeding at the chest while also ensuring baby is getting enough nutrition. I think it could be beneficial to have some helpful tools on hand so that when you see an IBCLC they can guide you to using aids, if needed, quickly for the best results.”

5. Do you have any recommendations for herbs or supplements that might help me produce milk?

“There are many items available, like lactation cookies/treats, herbs like fenugreek, and even foods that can help you produce milk. I don’t recommend using any of these before checking in with an IBCLC to assess what’s going on if you are struggling. Often, we think it’s a supply issue when the baby’s actually in need of extra support. I’ve always got these extra supply-building things on hand if the need does arise, but I think seeing what happens before adding anything to the mix would be helpful to get a baseline.”

6. Do you know of any resources for donor milk in our area?

“There are multiple helpful Facebook groups where many clients have found donors in the past. Human Milk for Human Babies is a particularly active page. Let me send you the link.”

7. Can you explain how lactation assist devices work and which types do you recommend?

“I can’t recommend one device over another at this point, because we just don’t know what you or baby will need until they arrive. I know of a couple different types of SNS setups that may be helpful. I also have experience helping families syringe feed or cup feed in addition to what takes place at the chest. And, of course, there’s a ever-popular nipple shield that I wouldn’t necessarily recommend investing in until you chat with an IBCLC post-birth.”

8. Do you know of any trans friendly experienced lactation consultants?

“Yup! I’ve got a couple referrals and can help you reach out for support if you’d like.”

9. Do you know of any trans friendly LLL groups?

“Unfortunately, I don’t think there are any specifically designated or known as trans friendly in our county. However, I know of an independent breastfeeding, bottlefeeding, and chestfeeding support group nearby that is geared toward promoting and including people of color and LGBTQIA+ families.”

10. Do you know of any trans friendly parenting groups?

This question is just super sad to me at the moment. There are zero groups open to trans folks in my county. LA county and San Diego county have a couple each, but we’re stuck in this pit of hetero/cis happenings where everything is a “mommy” group and doesn’t make space even for male hetero partners to join. I hope to one day have a space open for inclusive classes, meetups, and just a safe central space for families to explore and network so that the answer can always be yes to questions like this.

Case Study 2

Colin (age 32) and his partner, Jeff (age 36) come to you for their initial visit. Colin conceived unexpectedly while using testosterone. He transitioned 8.5 years ago and has been taking Testosterone Cypionate since he began his transition. He has been taking 60mg injections weekly for about two years. He initially took 80mg injections weekly. Colin had chest surgery 6 years ago. He has not had bottom surgery. His partner, Jeff is a cisgender male. They have been together for ten years. They are excited about the pregnancy. Colin discontinued testosterone as soon as he discovered the pregnancy at 7 weeks 4 days. He is currently 11 weeks 2 days pregnant and you find strong FHT in the 150s.

1. Do you anticipate any concerns for the baby due to exposure to testosterone for the first 5 weeks following conception?

Unfortunately, I really don’t know a lot about the specific levels of various hormones required at various stages of pregnancy yet. I know from the provided readings that testosterone discontinuation prior to pregnancy or embryo retrieval is ideal, but the fact that Colin discontinued so early on would make me feel hopeful that the pregnancy wouldn’t be affected much. The basic fact that he became pregnant even while on testosterone and has carried through almost all of the first trimester indicates to me that the baby is going to do well overall.

2. How will you approach Colin’s care over the next several months?

I would personally want to monitor a little more frequently than the average low risk person who hasn’t had testosterone to minimize risk of fetal loss and ensure growth is on par. I’d also want to be in close conversation about this family’s needs and wants surrounding birth and what their support network is like. Unexpected pregnancies can be challenging for anyone and if their support system was also not expecting to support this couple through becoming parents (or becoming biological parents), it could come as a shock. I could imagine family members being confused about what it means for Colin as a man. All this could add to his stress in pregnancy, which I’d like to minimize wherever possible.

3. What needs may Colin have that are unique?

Hypertension, placenta abruption, & preterm labor have been reported as possibilities in those who have been on testosterone prior to pregnancy, but not enough studies have been done to specify management or treatment variations based on these potentials. What does seem possible just from what I understand to be true about trans folks is that a trans man may not want or feel comfortable having a vaginal birth. Some trans men have plans to remove reproductive organs at some point or surgically match their genitalia to their gender identities, indicating that explicit connection to processes involved with these organs may be triggering and unwanted. So, I’d want to chat about their thoughts on the type of birth they believe would meet their needs. And, of course, part of informed consent for this family would be educating them on local hospitals as birthplace options. I know I would be referring to LA hospitals specifically for this trans client if I was practicing in my county at the time.

4. What questions might you ask to ascertain what Colin and Jeff need?

1. “How do you envision my role as your midwife?”

2. “Do you intend to share about your pregnancy publicly or to your family? If so, do you anticipate your support circle being supportive?”

3. “Do you have concerns specifically related to your pregnancy at this time?”

4. “What reading or education have you done around pregnancy, birth, and recovery for your body?”

5. “Do you have peers who have experienced birth as trans folks that you can reach out to?”

5. What resources might you use to educate yourself about Colin’s pregnancy, labor, birth, and postpartum care?

I would seek out more research articles like the 2016 one provided in class and would also want to take the time to read up about other trans folks’ experiences in births from first-hand accounts wherever possible. I think I’d also want to seek out other trans birth workers for thoughts, feedback about my approach, and maybe even communication guidance to ensure that I was considering the many layers of lived experience my client has.

Amanda Cagle is a professional doula, educator, and student midwife located in Orange County, CA who offers comprehensive services to growing families and birth professionals alike. Amanda can be reached via email at yourbirthteam@gmail.com or through www.yourbirthteam.com.