As the world rang in a new year on Jan. 1, two medical professionals quietly announced they had made what was once an impossible dream a clinical reality. Thanks to the work on induced lactation in transgender women by Dr. Tamar Reisman and nurse practitioner and program manager Zil Goldstein at the Mt. Sinai Center for Transgender Medicine and Surgery, a transgender mother was not only able to breastfeed her child, but to be the baby’s exclusive food source for its first six weeks of life. This is incredible news for families. As Reisman tells Romper by email, creating a standard of care that supports breastfeeding in transgender mothers is key to " building happy, healthy, transgender families."
While trans women have experimented for years with methods to induce lactation, usually using drugs like domperidone on a DIY basis, Reisman and Goldstein’s case report, published in Transgender Health, is the first time medical professionals have worked toward the same goal and published their results in a medical journal.
To Madeleine Bair, an undergraduate at UCLA and a trans woman, that’s not surprising.
“But I find that studies like this are the exception to the rule. So, most trans health care ends up being crowdsourced from other trans people,” she says. “We educate each other so we can empower each other to take back our own medical agency.”
Because of the barriers to health care access often faced by trans people, members of the community have thus far had to rely on their own resources and wits to get the therapies they need.
"I have had to practice DIY HRT regimens in the past, because access for me was limited due to poverty and lack of insurance," Bair says. "Many people who want HRT can't get it for reasons such as class issues, mental health issues, and physical health issues."
Reisman explains that in the past, "gender-affirming care has taken place underground," and, in terms of research fields, "transgender endocrinology" is a fairly young sub-specialty. The changing cultural and legal landscape, she says, means that academics are beginning to work in the field. The result will be "more evidenced-based data to help guide medical decision-making and increased standardization of care."
When medical providers and trans people work together and share their knowledge, the results can be remarkable, as Reisman and Goldstein have shown.
Beyond the obvious importance of inducing medically significant lactation — enough to feed a baby — their case study is notable for two other reasons.
First, their patient was on a dosage regimen of hormone replacement therapy (HRT), ranging from feminizing hormones to anti-androgens typical of most trans women in the United States who have not undergone certain surgical procedures. Second, while their patient had been on HRT since 2011, she had not undergone any gender-related surgeries such as breast augmentation or a vaginoplasty, which involves the surgical construction of a vagina and vulva.
Because not every trans woman wants to undergo surgical intervention (nor, if she wants to do so, can she always access these procedures for medical or cost reasons), the fact that certain surgeries aren’t a prerequisite for success under the Reisman/Goldstein method means the technique could have a wide application if their results can be replicated.
Moreover, the benefits of breastfeeding to both parent and child, from lower rates of breast cancer in women who breastfeed, to a stronger infant immune system, and stronger parent-child bonding, have been well documented. While every mother may not choose to breastfeed, there’s much to be said for making sure those who want to are physically able to do so.
To make that happen, Riesman and Goldstein put their patient on 10 milligrams of domperidone and asked her to take it three times per day. While domperidone was originally developed to treat gastric issues, it has been used around the world to increase lactation, often without the approval of government regulators.
Using drugs for off-label purposes is common in transgender medicine, with spironolactone — which was originally developed to treat hypertension — being a prime example. Many trans women take spironolactone because one of its side effects can be the development of breast tissue and because as a diuretic, it’s useful for helping to keep testosterone levels down.
In addition to the domperidone, Reisman and Goldstein asked their patient to use her breast pump for five minutes on each breast three times per day.
At a follow-up visit a month later, the patient could produce milk droplets. Reisman and Goldstein doubled her dose of domperidone, raised her progesterone dose by four times (to 400 milligrams a day) increased her estradiol prescription sixfold (from 2 milligrams twice per day to 12 milligrams twice per day) and kept her on the breast pump.
By her next monthly visit, their patient could produce 8 ounces of milk a day. Reisman and Goldstein then slashed her estradiol to “low dose” level and cut her progesterone to 100 milligrams per day.
Once their patient’s partner had their baby, their patient breastfed the child for its first six weeks of life. Although she was concerned about a reduction in her milk supply after that period and began to supplement her breast milk with formula, the woman continued to breastfeed her child until it was about six months old.
Reisman and Goldstein are frank that more research needs to be done in this area, particularly on the question of whether the use of domperidone is necessary for the technique to be replicated. The drug has been banned for almost 14 years in the United States by the FDA because of the agency’s concern about potential lethal side effects if it is taken intravenously. While Reisman and Goldstein’s patient took her dose orally, the FDA is reportedly still worried about the possible effects of domperidone on infants, since the drug is passed through breast milk.
Even if a trans woman is willing to assume these health risks, there are currently legal hurdles to consider. Thanks to the FDA, it’s illegal to import domperidone into the U.S. and federal officials actively attempt to seize inbound shipments of it, though — as Reisman and Goldstein’s patient showed — they’re not always successful.
Because of this barrier to acquiring the drug, removing it from the mix could make the Reisman/Goldstein technique more accessible if it’s possible to achieve similar results as those in the case study solely through adjustments to the patient’s HRT levels and breast pumping.
Bair appreciates Reisman and Goldstein’s willingness to think outside the box.
“Current HRT regimens are decades old and often insufficient, so most of us end up having to either educate our medical providers or self-medicate because it's so rare to find someone who is willing to try something new” she says. “I don't know that I would practice the technique now, but if I had a baby I most definitely would.”
Check out Romper's new video series, Bearing The Motherload, where disagreeing parents from different sides of an issue sit down with a mediator and talk about how to support (and not judge) each other’s parenting perspectives. New episodes air Mondays on Facebook.