Exploring language among gender nonconforming individuals and nontraditional partners

 June is notoriously known as Pride Month, but October features other observances that bring awareness to a variety of health issues and topics that impact LGBTQIA youth. October 11 was National Coming Out Day, October 20 was International Pronouns Day and last week, individuals and organizations recognized Intersex Awareness Day

In Breastfeeding Priorities: Safe Sleep, Bias, Gender Equitable Norms, and Paid Leave— Q&A with Internationally and Nationally Recognized Breastfeeding Expert, Lori Feldman Winter, MD, MPH, NICHQ poses the questions: How can we acknowledge the need to be inclusive of all types of parents and caregivers?  How do we promote gender-equitable social norms to better support breastfeeding?”

Photo by Karolina Grabowska

Feldman Winter offers, “… We need to ask, ‘how do we better support breastfeeding among gender nonconforming individuals and nontraditional partners?’ so we don’t alienate anyone when it comes to breastfeeding. It starts with being more inclusive and acknowledging that the benefits of breastfeeding aren’t all tied to the concept of the ‘breast’ itself. Breastfeeding is a complex compilation of systems including biological benefits from skin-to-skin touching and nurturing; nutrients from human milk that can be breast- or bottle-fed; and benefits that come directly from the flora on a lactating/nursing breast.

There are multiple ways to look at breastfeeding and understand its benefits, Feldman Winter continues. 

For instance “a chest that may not be able to produce milk can still nurture babies through the benefits of skin-to-skin contact,” she’s quoted in the NICHQ piece. “People who don’t produce breastmilk can still provide human milk through donor milk and bottle feeding. Transgender men and gender nonconforming parents and caregivers may still breastfeed safely if they choose to, and may prefer the term chestfeeding over breastfeeding because it respects their identity. All kinds of arrangements can be made to truly provide an equitable support system. As clinicians and scientists, we need to keep an open mind as we look at breastfeeding and explore how to optimize the health and well-being of all babies and families.” 

The authors of Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language present their thoughts about the risks of using desexed language in perinatal care.

Photo credit: PNW Production

The authors acknowledge that “Desexing the language of female reproduction has been done with a view to being sensitive to individual needs and as beneficial, kind, and inclusive.” 

They go on, “Yet, this kindness has delivered unintended consequences that have serious implications for women and children. These include: decreasing overall inclusivity; dehumanizing; including people who should be excluded; being imprecise, inaccurate or misleading; and disembodying and undermining breastfeeding. In addition, avoidance of the term ‘mother’ in its sexed sense, risks reducing recognition and the right to protection of the mother-infant dyad.”  

As part of this discussion, NICHQ has released statements in regard to the use of its language.

Photo by Mikhail Nilov

Heidi Brooks, Chief Operating Officer at NICHQ writes,  “NICHQ is not abandoning the traditional use of the terms ‘mother’ and ‘maternal.’ We are embracing the inclusive language of ‘birthing person/people’ across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects. This evolution is another aspect of NICHQ’s commitment to equity in all forms, including race, nationality, gender identity, sexual orientation, and ability.” 

The Academy of Breastfeeding Medicine (ABM) put out its Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients in May 2020 to help guide lactation care providers through items like language, creating a respectful health care environment, through the effects of transition-related health care on pregnancy and breast/chestfeeding, fertility options, induced lactation and colactation and milk sharing, as well as put out a call out for future research to better inform practice.

Photo courtesy of Glenis Decuir

Check out past Our Milky Way coverage on LGBTQIA health

Uplifting transgender and non binary parents 

On becoming transliterate 

Working to close the gaps in LGBTQ care 

Blurring the binary 

Skin to skin image goes viral 

Wives co-breastfeed son for two-and-a-half years

Explore youth.gov’s page for other past and upcoming events celebrating Sexual Orientation and Gender Identity, Expression, and Well-Being.

22 more actions in 2022

 In our third installment of 22 in 2022, we bring you 22 MORE Actions in 2022, because there is always work to do. 

Source: United States Breastfeeding Committee

22 in 2022 was inspired by Life Kit’s 22 Tips for 2022, and we hope it provides inspiration for you to forge forward with this important work.

  1. Learn about the Girls’ Bill of Rights. Empowered women start with empowered girls. 
  2. Watch a film centered around maternal child health like  A Doula Story, The Milky Way breastfeeding documentary, Chocolate Milk, Zero Weeks, Legacy Power Voice: Movements in Black Midwifery or register to play Factuality
  3. Identify and network with an individual or organization with a mission that intersects with maternal child health. This shouldn’t be a challenge… “All roads lead to breastfeeding!” (A popular adage at Healthy Children Project.)  Often, we find ourselves preaching to the choir, shouting in an echo chamber, whatever you want to call it. It’s time to reach beyond our normal audience. 
  4. Follow Dr. Magdelena Whoolery on social media to stay up to date on strategies that combat the multi-billion dollar artificial baby milk industry. 
  5. Sign on to USBC’s organizational letter in support of the DEMAND Act of 2022.
  6. Congratulate, encourage or simply smile at a mother. 
  7. Explore White Ribbon Alliance’s work around respectful care. You can start by watching this poignant webinar Healthcare Professionals Honoring Women’s Demands for Respectful Care
  8. Read The First Food System: The importance of breastfeeding in global food systems discussions.
  9. Read Lactation in quarantine: The (in)visibility of human milk feeding during the COVID-19 pandemic in the United States
  10. Sign this petition to stop unethical formula research on babies. 
  11. Check out the updated Center for WorkLife Law’s Winning New Rights for Lactating Workers: An Advocate’s Toolkit
  12. Register for a free PQI Innovation webinar.
  13. Read the revised Academy of Breastfeeding Medicine (ABM) Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads here
  14. Gear up for World Breastfeeding Week 2022 and National Breastfeeding Month. 
  15. Check out this NIH project Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project which seeks a deeper understanding of human milk biology to address ongoing and emerging questions about infant feeding practices.  
  16. Learn about the Melanated Mammary Atlas.
  17. Consider becoming a ROSE community transformer or share the opportunity with someone who may be interested. 
  18. Get familiar with WHO’s recent report How the marketing of formula milk influences our decisions on infant feeding and disseminate the corresponding infographics
  19. Sensitize journalists and the media to stimulate public debate on the links between breastfeeding and the climate crisis as suggested by the World Alliance for Breastfeeding Action (WABA).
  20. Get to know how breastfeeding and proper nutrition fits into the Sustainable Development Goals (SDGs)
  21. Access one of the National Institute for Children’s Health Quality’s (NICHQ) webinars on breastfeeding, infant health, early childhood or health equity here
  22. Engage with the PUMP Act Toolkit! This is crucial, time-sensitive work that will make a huge difference for families across our nation.

Read our original list of 22 Actions here and our celebration of unsung sheroes/heroes here

Physicians as breastfeeding supporters

Photo retrieved from: https://tobacco.stanford.edu/cigarette/img0079/

“More doctors smoke camels than any other cigarette,” claims the ad from 1950. Today, it’s preposterous to imagine that any physician would align themselves with the tobacco industry. Starting  in the 1920s and continuing well into the 1950s though, tobacco companies used doctors to help them sell their products. Stanford’s Research into the Impact of Tobacco Advertising has a collection of over 1,000 advertisements that feature doctors endorsing tobacco products. 

In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7) 

Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12) 

 

Pervasive industry influence for generations

Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.”  Formula milk companies exploit this relationship of trust. (WHO, p. 12)

Source: United States Breastfeeding Committee

BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13) 

The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients. 

Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence

Curious consumers can search their doctors’ names through ProPublica’s Dollars for Docs project to learn about gifts they have accepted. 

 

Mechanical culture 

Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.

Source: United States Breastfeeding Committee (USBC)

“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.” 

[As a side, Attorney Leah Margulies recently shared in Protecting Breastfeeding in the United States: Time for Action on The Code that formula companies provide architectural designs to maternity care facilities in a deliberate attempt to separate dyads.] 

The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.  

We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.

 

Inadequate education 

How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollins pointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary. 

A cross-sectional study in the UK suggests that UK medical schools are not adequately preparing students to support breastfeeding patients.  

Source: United States Breastfeeding Committee

Samantha A Chuisano and  Olivia S Anderson’s findings in Assessing Application-Based Breastfeeding Education for Physicians and Nurses: A Scoping Review “… align with existing literature in finding a dearth of high-quality studies assessing breastfeeding education among physicians and nurses. The variability in teaching and evaluation methods indicates a lack of standardization in breastfeeding education between institutions.”

Elizabeth Esselmont and colleagues’ piece Residents’ breastfeeding knowledge, comfort, practices, and perceptions: results of the Breastfeeding Resident Education Study (BRESt) concludes: “Pediatric residents in Canada recognize that they play an important role in supporting breastfeeding. Most residents lack the knowledge and training to manage breastfeeding difficulties but are motivated to learn more about breastfeeding. Pediatric program directors recognize the lack of breastfeeding education.” 

 

A collection of physicians’ stories 

Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities. 

Source: United States Breastfeeding Committee (Photo by Sara D. Davis)

Some of those stories are linked below: 

Sarah Jacobitz-Kizzier, MD, MS, in Resident physician advances breastfeeding support,  shares that her lactation education in medical school included a one hour lecture about the anatomy of the breast and a brief discussion in physiology about lactogenesis.

“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.

Physician calls for peer breastfeeding support features the work of Colette Wiseman, MD, CLC. 

In Breastfeeding in the healthiest county in Virginia, Janine A. Rethy, MD, MPH, FAAP, FABM, IBCLC, a general pediatrician in Loudoun County, Va. describes her dedication to improving breastfeeding outcomes. In it, she shares a resource she and her colleagues created –the Breastfeeding Support Implementation Guide for the Outpatient Setting which includes information on how to bill insurance for lactation services.

Skin to skin in the OR showcases Rebecca Rudesill’s, MD, CLC quest for more breastfeeding education. 

Kristina Lehman’s, MD, CLC work is featured in Internist looks to augment breastfeeding education

James Thomas Dean III, DO and Assistant Professor of Pediatrics at the University of Texas San Antonio Dr. Perla N. Soni, MD share their perspectives in Lack of breastfeeding education in med school harms families

Alison Stuebe, MD, MSc tackles big topics in OB/GYN sheds light on breastfeeding culture.

We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. ​​With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.

“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.  

Elizabeth Sahlie’s, MD, FAAP and Jesanna Cooper’s, MD work is featured in Birmingham Mother-to-mother support helps moms reach feeding goals. Cooper says that before she became a mother, she had no idea that her medical training and education had been so lacking.

“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”

Other stories and models for care 

Lori Feldman-Winter’s, et al  Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.

 As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.

 

Further reading and resources

Physicians, Formula Companies, and Advertising: A Historical Perspective

Inspire Health, CHAMPS,  and the University of Mississippi Medical Center’s Breastfeeding, Human Medicine,  Interprofessional Education training   

CDC Physician Breastfeeding Education  

What Every Physician Needs to Know About Breastfeeding from the W.K. Kellogg Foundation

The Institute for the Advancement of Breastfeeding & Lactation Education (IABLE) is a nonprofit membership organization whose mission is to optimize the promotion and support of breastfeeding for families in the outpatient sector. IABLE is dedicated to building Breastfeeding Knowledgeable Medical Systems and Communities. 

Academy of Breastfeeding Medicine (ABM) Breastfeeding-friendly Physicians protocol 

 

Physician group position papers and recommendations on breastfeeding 

American Academy of Pediatrics (AAP)

American Academy of Family Physicians (AAFP)

The American College of Obstetrics and Gynecology (ACOG) 

Suggested Covid-19 resources for pregnancy and lactation

Lactation care and breastfeeding support are always essential, but perhaps even more so during crises like the one we’re facing today, dazed by social isolation.

Photo by Sasha Freemind on Unsplash

Like many states responding to the Covid-19 pandemic, The Academy of Lactation Policy and Practice (ALPP) is required to comply with Massachusetts Governor Baker’s emergency order and stop in-person operations. Healthy Children Project, Inc. has also been required to halt in-person operations, including the Lactation Counselor Training Courses (LCTC) for the time being. ALPP is continuing to process Certified Lactation Counselor (CLC) recertification requests remotely.  

Despite the current situation, the spirit of CLCs shines. In the CLC Facebook Group, lactation care providers are engaging in conversations about telemedicine, HIPAA compliance, and protective equipment and how to best serve families amidst the unknown. 

ALPP Executive Director Ellie MacGregor, MPH, CLC mentions that there are other important exchanges happening in  ALPP’s Community of Practice portal like current research and practice recommendations.

“We’re doing our best to share all of the evidence-based information although it’s changing every day,” MacGregor says.  

Photo by Luiza Braun on Unsplash

Healthy Children Project’s Cindy Turner-Maffei, MA, ALC, IBCLC has compiled resources for maternal child health care providers to reference when helping their clients navigate life during a pandemic. 

General Statements and Resources

For formula-feeding families

For expectant parents 

  •  Ready Set Baby curriculum produced by The Connecticut Department of Public Health (CT-DPH) in partnership with the Carolina Global Breastfeeding Institute (CGBI)

For personal sanity 

  • The meditation app, Ten Percent Happier, has made a set of meditations entitled “Coronavirus Sanity Guide” available to the general public.  In addition, they are making their full app available at no charge to healthcare workers who are responding to the virus outbreak. They invite health workers to email them for instructions at care@tenpercent.com. 
  • Yale’s Dr. Laurie Santos will host a Coursera Live Q&A event featuring ways to cope and process our emotions during the Covid-19 pandemic.
Photo by Greg Rakozy on Unsplash

Going forward, the United States Breastfeeding Committee (USBC) and MomsRising are inviting health care providers, pregnant and breastfeeding families, and all public health stakeholders to share how the pandemic is impacting the infant feeding experience. MomsRising points out that with the situation constantly evolving, personal experiences can make an impact on decision-making and help elected leaders understand how to best meet the needs of families.