Abstract

This article tried, from an intersectional standpoint, to grasp the challenges experienced by health professionals and service users of human milk banks in provision of care for transgender men chestfeeding. This exploratory, descriptive qualitative study drew on interviews of six human milk bank staff, who had previously assisted trans men in relation to chestfeeding and two bisexual trans men, who chestfed. The data was treated by thematic analysis, supported by Atlas.ti software, version 9.0. Lacunas in the educational, institutional and management spheres, associated with personal and social issues, reproduce a pre-conceived normative model and disregard the special demands of providing chestfeeding care for the trans population. Cisheteronormativity and “professional supremacy” operate in personal, social and institutional respects to segregate transgender men in lactation support services. Intersectional analysis of these challenges affords an overall view of segregative factors and enables public policies to be introduced to promote social justice.

Key words:
Transgender; Lactation; Health service access barriers; Milk banks; Intersectional framework

Introduction

Society is made up of families in a plurality of formations. Families of people who are Gay, Lesbian, Bisexual, Transgender, Queer, Intersex, Asexual, Pansexual and other variations of gender identity and sexual-affective orientation (LGBTQIAP+) are a kind of arrangement that deviates from cisheterosexual norms. Given this variation in family constitution, emerging forms of parenthood, which can happen by way of natural pregnancy, adoption or assisted reproduction techniques, are involving parents in a constant movement of resignification of identities, gender relations and social norms¹1 Lee R. Queering lactantion: Contiributions of Queer Theory to Lactation Support for LGBTQIA2S+ Individuals and Families. J Hum Lact 2019; 35(2):233-238..

Just as with the right to family and parenthood, there are reproductive rights, which demand support for children’s nutrition and suitable food and raises the issue of breastfeeding a manner of exercising those rights¹1 Lee R. Queering lactantion: Contiributions of Queer Theory to Lactation Support for LGBTQIA2S+ Individuals and Families. J Hum Lact 2019; 35(2):233-238..

Breastfeeding, a practice encouraged worldwide, offers advantages well substantiated in the literature, as well as reducing infant morbidity and mortality. The Brazilian network of human milk banks (HMB) acts strategically in this process, as a reference point in promoting and supporting breastfeeding and offering guidance for nursing mothers and human milk processing²2 Fonseca RMS, Milagres LC, Franceschini SCC, Henriques BD. O papel do banco de leite humano na promoção da saúde materno infantil: uma revisão sistemática. Cien Saude Colet 2021; 26(1):309-318..

Human milk banks in Brazil cite promotion of women’s and children’s health as a guiding principle and act as an important component in efforts to reduce maternal and neonatal mortality. Accordingly, breastfeeding at human milk banks is regarded as a female act, contributing to the invisibility of this reproductive right of trans men, who can breastfeed²2 Fonseca RMS, Milagres LC, Franceschini SCC, Henriques BD. O papel do banco de leite humano na promoção da saúde materno infantil: uma revisão sistemática. Cien Saude Colet 2021; 26(1):309-318..

The transgender population faces numerous obstacles in accessing health services marred by prejudice and marginalisation and resting on cisheteronormativity. Patterns of behaviour and social expectations shape the stance from which professionals tend to perform their activities and involve interconnected personal, social, cultural and historical issues³3 Lacerda JAG, Bigliardi AM. A política nacional de saúde integral LGBT aplicada no NASF-AB. Rev Contraponto 2021; 8(1):141-161..

In that light, intersectionality offers an analytical framework that encompasses and connects the component elements which result in this population’s being segregated in various health services⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021.. The social actors involved in the breastfeeding support process require qualified listening to reveal the challenges that have marred care for nursing transgender men. This study is unique in exploring the obstacles to this interaction in breastfeeding care in Brazilian scenarios, with a view to informing efforts to address the inequities.

Given the above, this study endeavoured, in the light of intersectionality, to understand the challenges posed by the experiences of HMB users and health professionals in care for transgender men in relation to chestfeeding.

Methodology

This exploratory, descriptive, qualitative study involved health professionals from three public HMBs in the State of Pernambuco, who had previously assisted trans men in relation to chestfeeding, with actions to promote, protect and support chestfeeding and carry out human milk collection activities.

The health professionals were selected initially following contact with the managers of Pernambuco’s nine public HMBs. Face-to-face visits were made to all shifts so as to include all professionals in these sectors, to present the study and ascertain their interest in participating. The respective managers were asked to message their work groups via WhatsApp, every two weeks for six weeks, to remind teams of the possibility of participating in the study.

The convenience sampling concluded when two weeks passed with no further responses from potential volunteers. Data collection, based operationally on exhaustion-saturation⁵5 Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saude Publica 2008; 24(1):17-27., ended with six health professionals included. Professionals absent during the data collection period were excluded.

Trans men who had chestfed their babies for at least 1 month in the last 5 years were selected by “snowball” sampling, the first participant being nominated by a specialised LGBT care service. The researcher contacted this trans man via WhatsApp to provide information about the research and, through him, it was possible to nominate another participant, totalling two bisexual trans men. A third trans man withdrew from participating in the research, citing personal reasons.

The interview scripts were used for each group of participants to consider the challenges in caring for trans men in breastfeeding support services. Each participant was interviewed once, between August and October 2022. Interviews lasted an average of 30 minutes and, with the prior authorisation of the participants, were recorded and transcribed. Each transcription was then validated by the respective interviewee. After responding to a questionnaire to record their socio-demographic characteristics, participants were interviewed and their physical characteristics were recorded in a field notebook, along with those of the HMB environment.

The health professionals were interviewed in person, in private rooms at their workplace. One trans man was interviewed online via Google Meet and the other, in person, in a private setting in a shopping centre in the Recife metropolitan region, Pernambuco.

With a view to anonymity, participating health professional were designated as PS, followed by an ordinal number, in order of interview, plus the letter M or F, depending on their sex at birth, and another ordinal number for their age (example PS1-M40). The same logic was applied to the trans participants: the term USS signifying health service user, plus the letter M, as they all described themselves as trans men (example USS2-M32). The mention of the health professionals’ biological sex was justified by a lack of knowledge, on the part of some of them, of the meaning of gender identity.

The analysis was carried out in pairs following the thematic analysis proposed by Braun and Clarke⁶6 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2):77-101., for each segment of group of participants, following the six steps and using Atlas.ti (version 9.0) software as a support tool (Figure 1).

The interviews began after a declaration of free and informed consent was read, explained and formally consented to, in person or virtually. The study was approved by the research ethics committee of the Universidade Federal de Pernambuco under Ethical Appreciation Presentation Certificate No. 58300022.1.0000.5208 and conducted in accordance with the topics of the Consolidated Criteria for Reporting Qualitative Research (COREQ)⁷7 Souza VRS, Marziale MHP, Silva GTR, Nascimento PL. Tradução e validação para a língua portuguesa e avaliação do guia COREQ. Acta Paul Enferm 2021; 34:eAPE02631..

Results

The presentation of chestfeeding experiences with HMB professionals and trans users of health services were preceded by participant characterisation data.

The health professionals’ ages ranged from 25 to 60 years, a mean of 43 years. Mean length of professional experience was 18.5 years, of which mean time working with the HMB was 10.8 years, ranging from 18 months to 18 years. Four professionals were born in Pernambuco, one in Santa Catarina and another in Ceará. All self-declared themselves to be heterosexual. Two declared they were cisgender; the others did not know the meaning of gender identity and could not self-declare. Four reported their biological sex as female and two, as male. All had higher education; two were coordinators, three, nursing technicians and one, a nursing auxiliary. The four women were married, one male participant was single and one reported ‘living together’. One professional worked in the HMB1, two, in HMB2 and three, in HMB3.

All reported assisting only one trans person in relation to chestfeeding. One of them mentioned prior training in assisting the public in view of gender diversity and sought further training after the initial session. None of the participants’ training or undergraduate courses addressed the subject of gender and sexuality. During visits to the HMB facilities, there were publicity materials encouraging breastfeeding by cisgender women and photographs of family formations with cisheterosexual parents, but no references to the LGBTQIAP+ population.

The transgender men who were SUS national health service users, were of mean age 32.5 years. They had facial hair, short hair and used loose clothing during the interview. Both were bisexual, white and had suffered embarrassments in health services because of their gender identity. At time of interview, none had undergone breast surgery or procedures. Other sexuality-related characteristics and socio-demographic markets are described in Chart 1.

Analysis of the interviews and field diary resulted in three thematic categories: I - Trans men in the HMB? Who are they?; II - Personal/social challenges in assistance for trans men in an HMB; and III - Institutional/management challenges in assistance for trans men in an HMB.

Trans men in the HMB? Who are they?

The first thematic category related to the professionals’ impressions of the presence of trans men in the HMB environment. It revealed that, in that contact, there were doubts as to sexuality-related terms and in the notion that body-modification surgeries were necessary in order to be a trans person. Although they had assisted only trans men, the professionals used female adjectives in their reports:

The sensation of strangeness was present in the professionals’ accounts of when they realised that a man would like to chestfeed. The perception was that the chestfeeding would not take long, surprising the HMB staff.

Personal/social challenges in assisting trans men at a HMB

In this category, what emerged were personal and social challenges in assisting trans men in lactation support services.

Reports from other colleagues of previous negative experiences in the hospital environment raised fears of dealing with trans men in the HMB environment and fear of committing transphobia. One [female] professional felt oppressed in entering dialogue with the user:

Professionals reported their perceptions of trans men during chestfeeding-related care. They told of apparent embarrassment, neediness and misgivings about the attitudes of professionals and other women in the HMB environment. These perceptions aroused empathy and a wish to minimise discomfort during their stay at the hospital and the HMB:

Personal elements may have hampered interaction between professionals and users. The professionals’ religiosity and upbringing within normative social expectations are recognised to be possible obstacles, while there are efforts to redefine their worldview on gender issues:

One professional mentioned the possibility that care would be more inclusive if the trans person verbalised information about their sexuality, their family structure and their expectations regarding breastfeeding to the HMB team:

Transphobia was present in the public environments, in the public’s acts of extreme curiosity, staring, unauthorised photographing and filming of chestfeeding trans men:

Despite the advantages, chestfeeding can be a difficult path to take and is sometimes romanticised as something perfect and exclusively the responsibility of the ‘mother’, to the exclusion of the father figure. The trans men reported difficulties including pain and engorgement, which are conditions encountered by cis women:

In this category, breaking with a romanticised idea, there is a consensus between users and professionals as to the difficulties in the act of breastfeeding. Fear was felt by the groups of participants and affected the dialogue between them. The PSs expressed fear of acting with prejudice and reported a variety of USS attitudes, ranging from shyness to harshness. Fear was also reported by the USSs, who perceived a vulnerability to exposure to violence, because of the act of breastfeeding.

The PS acknowledged the influence of religion and normative cultural standards in shaping relationships between professionals and trans men in the chestfeeding process.

Institutional/management challenges in assisting trans men at the HMB

Both trans men wanted to chestfeed. One of them attended a public HMB and reported having been asked by a professional how a man could chestfeed. The other trans man was seen by a private consultant, who saw lesbian women and had a better idea of inclusiveness, and he commented on health professionals’ lack of knowledge of gender-inclusive terms:

The trans man perceived the HMB as feminine, with a tendency to use feminine terms when addressing users and corrections by users as to names suited to their gender identity. The apparel for expression was a cause of discomfort and endeavours were made to be inclusive by listening to the user to minimise anguish:

The lack of professional preparedness associated with the HMB team’s scant contact with trans people meant they knew little about chestfeeding in the trans population and, consequently, could not share that experience with their peers. All participants saw only one trans man at their respective services.

Aggravating this situation, professionals point to difficulties in accessing scientific studies on chestfeeding in trans men. The doubts arose as to whether pregnancy could occur while testosterone was being used. One professional discussed the lack of care protocols for this population from higher authorities:

One trans man noted gaps in knowledge about the chestfeeding pathway, mainly about the safety of testosterone during lactation:

Professionals’ excessively curious attitude to trans men’s intimacy and sexuality can cause embarrassment. There is concern about the possibility of trans men’s experiencing transphobia for chestfeeding:

In this category, both groups of participants were agreed regarding knowledge gaps, lack of scientific studies and protocols that result in obstacles to inclusive care. That situation meant the USS needed to act as an educator in the HMB environment.

The HMB professionals’ reports showed their experiences and challenges they faced in offering safe, discerning care to trans men in the chestfeeding process. Trans men reported experiences regarding the specificities of chestfeeding and the challenges they faced in specialised lactation services. Grounding the study on the principles of intersectionality afforded a better understanding of the inequalities and discrimination suffered as a result of established social paradigms of power. The discussion that follows is based on the consolidated reports, as proposed in Figure 2.

Discussion

This qualitative study endeavoured, in the light of intersectionality, to understand challenges in the experiences of human milk bank users and staffs in the provision of assistance to transgender men in relation to chestfeeding.

The central ideas of intersectionality - social inequality, intersectional power relations, the social context, relationality, complexity and social justice - act as analytical and problem-solving tools, with a view to assimilating the social, structural and institutional reasons that associate to marginalise care for the LGBT population and to proposing public policies to favour social change⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021.. Overall, the findings of this study show the need to break with breastfeeding-related paradigms shaped by cisheteronormativity.

The structure of educational institutions in Brazil reflects the scant attention given to the subject of sexuality and affects health professionals’ knowledge in care for the trans population. A 2021 survey in São Paulo State revealed the existence of 264 nursing courses. Course educational plans for 19 of these were available for analysis; only nine featured curricular syllabuses with subjects relating to the health of the trans population, and approaches to the subject were limited⁸8 Santana AVS, Melo LF, Santos AL, Machado GM, Jesus LLR, Teixeira RMP, Lima GCBB, Reis NROG, Santos DMS, Barros FD, Martins MCV, Galloti FCM. Approach to trans population in Nursing education. Res Soc Dev 2022; 11(9):1-11..

The manner in which the trans population is approached in undergraduate nursing courses is insufficient and too superficial to guarantee competent, comprehensive care for this group. It is also importance that capacity be built in teaching staffs to break with cisheteronormative paradigms in the educational sphere, and practical experience with this population is important in order to develop greater understanding of gender issues⁹9 Gentil AGB, Padilha MI, Bellaguarda MLR, Caravaca-Morera J. Unveiling undergraduate nursing students' knowledge about trans people. Texto Contexto Enferm 2023; 2:e2022015032..

The health of the trans population is rarely described in courses in interdisciplinary health areas, such as Medicine¹⁰10 Visgueira FLL, Chaves SRS, Batista LIV, Nunes MDS. Análise do conhecimento de estudantes de medicina acerca da identidade de gênero. Rev Bras Educ Med 2021; 45(4):e192. and Nutrition¹¹11 Rizzieri LB, Silva DL. A saúde LGBTQ+ no curso de Nutrição: a importância da pluralidade da população na ementa curricular. Rev Interdiscip Saude Educ 2022; 3(2):8-21.. This is a substantial obstacle to health access, as lack of knowledge about the specifics of this population, such as failure to use social names or gender-inclusive terms and the presumption of gender identity based on appearance, can cause trans people to abstain from seeking health care when they anticipate the possibility of transphobia¹²12 Matsuno E, Bricker NL, Savarese E, Mohr Jr R, Balsam KF. "The default is just going to be getting misgendered": Minority stress experiences among nonbinary adults. Psychol Sex Orientat Gend Divers [periódico na internet]. 2022 [acessado 2023 maio 6]. Disponível em: https://doi.org/10.1037/sgd0000607.
https://doi.org/10.1037/sgd0000607... .

Cisheteronormativity is evident in the educational sphere, in that it assumes that everyone is heterosexual and cisgender. The social inequality resulting from this thinking and from gaps in education constitutes one of the pillars for intersectional analysis⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021. and results in a lack of equal access to health services.

Given that not all the trans men reported problems with chestfeeding itself, it is worth considering the mental repercussions resulting from stigma in environments regarded as “feminine” and lack of professional preparedness to work with the trans population¹³13 Rodriguez-Wallberg K, Obedin-Maliver J, Taylor B, Van Mello N, Tilleman K, Nahata L. Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. Int J Transgend Health 2022; 24(1):7-25.. Overlaid on this is also the hierarchical power of professional knowledge, a tool based on the public health paradigm, which prioritises the advantages of human milk for children’s health, without valuing the desires and feelings that permeate the act of breast-/chest-feeding¹⁴14 Kalil IR, Aguiar AC. Amamentar hoje é pensar no futuro: o lugar da mulher nos discursos de promoção ao aleitamento materno contemporâneos. Rev Bras Pesq Saude 2019; 21(2):29-39..

Cisheteronormativity and the biomedical model of care constitute power structures that intersect in producing inequities and influence individual attitudes in society⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021.. Horizontal dialogue between health professionals and users permits mutual learning, bonding and sharing of life experiences¹⁵15 Oliveira I, Romanini M. (Re)escrevendo roteiros (in)visíveis: a trajetória de mulheres transgênero nas políticas públicas de saúde. Saude Soc 2020; 29(1):e170961., and is an important factor in breaking with the power structure of the hierarchy of professional knowledge and of cisheteronormativity itself, by applying continued professional development policies in health care.

The perpetrators and locations of violence suffered by trans bodies can differ. Although a Chilean study found that transphobic attitudes occurred more prevalently among strangers, in a sample of 101 people, 16.67% of trans people suffered prejudice from health professionals and 13.3% reported violence in health centres. Participants in the study reported here said that discrimination seemed to begin when there was recognition that the person was part of the LGBT+ population, with the fear of suffering prejudice greatest among the trans population¹⁶16 Ortega Quezada IR, Pujol-Cols L, Lazzaro-Salazar M. General health and perceived/feared discrimination in the LGBT+ community. Texto Contexto Enferm 2022; 31:e20220130..

In a Brazilian study¹⁷17 Schio NA, Drum AJS. Atendimento médico na transexualidade: uma abordagem interseccional, competências e desafios. In: Viana ACA, Bertotti BM, Gitirana JHS, Kreuz LRC, Costa TC, organizadores. Pesquisa, Gênero & Diversidade: Memórias do III Encontro de Pesquisa por/de/sobre mulheres. Curitiba: Editora Íthala; 2020. p. 181-196., when other identity markers, such as blackness and disabilities, occurred in association with transgenderism, the percentage of adverse experiences among the trans population in health services increased. Economic inequalities are also segregative factors in the trans population’s access to health services¹⁷17 Schio NA, Drum AJS. Atendimento médico na transexualidade: uma abordagem interseccional, competências e desafios. In: Viana ACA, Bertotti BM, Gitirana JHS, Kreuz LRC, Costa TC, organizadores. Pesquisa, Gênero & Diversidade: Memórias do III Encontro de Pesquisa por/de/sobre mulheres. Curitiba: Editora Íthala; 2020. p. 181-196. and may be related to the obstacles encountered by the participants in this study, both of whom were SUS users earning less than 4 minimum wages. The importance of intersectional relationality between different markers of segregation is explained, which reinforce one another in intensifying disparities⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021..

The fear of violence can be seen explicitly when users avoid discussing their gender identity and other sexuality constructs with health professionals. That blockage can result in failure to include the non-pregnant partner in the chestfeeding process and to provide information to allow the family to decide how best to feed their child. These possible manners include relactation, translactation, partner-induced lactation, colactation and use of formula milk, if necessary¹⁸18 Ferri RL, Rosen-Carole CB, Jackson J, Carreno-Rijo E, Greenberg KB, Academy of Breastfeeding Medicine. ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients. Breastfeed Med 2020; 15(5):284-293.^,1919 Rosen-Carole C, Greenberg KB. Chestfeeding and lactation care for LGBTQ+ families (lesbian, gay, bisexual, transgender, queer, plus). In: Lawrence RA, Lawrence RM, editors. Breastfeeding. 9ª ed. Philadelphia: Elsevier; 2022. p. 646-650..

Even when desiring inclusive care, HMB staff’s the speech is notable for using female names when referring to trans men. “Her”, “mother” and “breast milk” were used, which constituted “unwitting” micro-aggressions on the part of professionals that brought discomfort to the USSs in this study. It is more inclusive to use appropriate pronouns and avoid ingrained terms, such as breastfeeding for chestfeeding or lactation, and it is important for users to mention the terms they would like used to refer to them as parents¹⁸18 Ferri RL, Rosen-Carole CB, Jackson J, Carreno-Rijo E, Greenberg KB, Academy of Breastfeeding Medicine. ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients. Breastfeed Med 2020; 15(5):284-293.^,1919 Rosen-Carole C, Greenberg KB. Chestfeeding and lactation care for LGBTQ+ families (lesbian, gay, bisexual, transgender, queer, plus). In: Lawrence RA, Lawrence RM, editors. Breastfeeding. 9ª ed. Philadelphia: Elsevier; 2022. p. 646-650..

The use of names that do not match patients’ gender identity is called misgendering and is a micro-aggression described in the literature. Even when occurring unintentionally, it can have various adverse mental effects, including gender dysphoria or anguish related to differences between gender identity and bodily characteristics or others’ perception of one’s gender¹²12 Matsuno E, Bricker NL, Savarese E, Mohr Jr R, Balsam KF. "The default is just going to be getting misgendered": Minority stress experiences among nonbinary adults. Psychol Sex Orientat Gend Divers [periódico na internet]. 2022 [acessado 2023 maio 6]. Disponível em: https://doi.org/10.1037/sgd0000607.
https://doi.org/10.1037/sgd0000607... .

Despite gaps in undergraduate education and doubts during care, health education measures for HMB staffs were scarce. This finding corroborates a study in emergency environments, where most health professionals were not instructed on how to care for trans people, even though they had provided care for them²⁰20 Chisolm-Straker M, Willging C, Daul AD, McNamara S, Sante SC, Shattuck 2nd DG, Crandall CS. Transgender and gender-nonconforming patients in the emergency department: what physicians know, think, and do. Ann Emerg Med 2018; 71(2):183-188.. There is evidence that this minority’s needs are not seen clearly and continued professional development to address these limitations is lacking, exacerbating inequalities in access to health.

Difficulties were encountered in studying the topic of chestfeeding in the trans population due to the scarcity of Brazilian articles addressing the topic. One integrative review on lactation induction in trans women published in Brazil this year included nine articles, none of them Brazilian²¹21 Costa RA, Lopes IMD, Tavares CPL, Rosa CFS, Leite RSD, Nunes AVM, Martins BLM, Alves MP, Silva KS, Leite MO. Induction of lactation in transgender women: An integrative literature review. Res Soc Dev 2023; 12(2):e13412240079..

Another integrative review about the experiences of pregnant trans men considers chestfeeding, but only in international articles²²22 Pereira DMR, Araújo EC, Silva ATCSG, Abreu PD, Calazans JCC, Silva LLSB. Scientific evidence on experiences of pregnant transsexual men. Texto Contexto Enferm 2022; 31:e20210347.. One article reflected, from the perspective of intersectionality, on the use of neutral language in the field of lactation. It also cited obstacles, including failure to apply knowledge in lactation induction and ignorance of the fact that trans people can become pregnant and chestfeed²³23 Bolissian AM, Ferreira BEC, Stofel NS, Borges FA, Camargo BT, Salim NR, Teixeira IMC. Aleitamento humano e a perspectiva da interseccionalidade queer: contribuições para a prática inclusiva. Interface (Botucatu) 2023; 27:e220440.. There are no guidelines covering the necessary specifics to equip HMB professionals to accommodate this population, which leads to doubts and inequity in care.

Personal and social issues also figure prominently in this list of difficulties. These professionals culture and life history can be reflected in the treatment provided to minorities, while institutions, such as family and religion, rest on cisheteronormative norms that extend to social relationships, thus worsening discrimination³3 Lacerda JAG, Bigliardi AM. A política nacional de saúde integral LGBT aplicada no NASF-AB. Rev Contraponto 2021; 8(1):141-161.. The importance of this fact is exemplified in a study citing transphobia as a preponderant factor in health professionals’ acquisition of knowledge, despite increasing hours spent on their education²⁴24 Stroumsa D, Shires DA, Richardson CR, Jaffee KD, Woodford MR. Transphobia rather than education predicts provider knowledge of transgender health care. Med Educ 2019; 53(4):398-407..

Religiosity, another personal and social issue, tends to be tied to the cisheteronormative standard, with transphobia internalised and discrimination extended to social relationships outside the religious environment. Religious groups attempt to reconcile Christianity with non-heterosexual sexualities and/or transgenderism²⁵25 Cortes HM, Morais AVC, Lacerda LCS, Santos RO, Pinho PH. Sexuality and Religiosity: an integrative literature review. Res Soc Dev 2021; 10(2):e37910212540., thus providing opportunities for inclusiveness. At this juncture, professionals who serve the trans population should think about their role in perpetuating inequalities and how their intersecting opinions and social positions affect their relationships with minorities²⁶26 Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality research for transgender health justice: a theory-driven conceptual framework for structural analysis of transgender health inequities. Transgender Health 2019; 4(1):287-296..

The interconnections among personal, social and institutional factors highlight the core of complexity in intersectional analysis of various different structures in the production and maintenance of inequalities, all added to the complexity of the act of chestfeeding itself. Also important is to understand the context where power relations occur, as well as the culture and society that shape individuals and influence their postures⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021..

A Chinese study found that discriminatory attitudes in health services, dysphoria and prior hormone therapy may relate to lower rate and duration of chestfeeding in the trans population, as compared with the cisgender population. One third of the 647 participants decided to chestfeed exclusively, while 58.7% chestfed for less than 6 months²⁷27 Yang H, Na X, Zhang Y, Xi M, Yang Y, Chen R, Zhao A. Rates of breastfeeding or chestfeeding and influencing factors among transgender and gender-diverse parents: a cross sectional study. EClinicalMedicine 2023; 57:101847., a percentage below the World Health Organisation target for the 2030 Agenda²⁸28 World Health Organization (WHO). United Nations Children's Fund (UNICEF). Global breastfeeding scorecard, 2019: increasing commitment to breastfeeding through funding and improved policies and programmes. Geneva: WHO; 2019.. The desire to resume testosterone use may be implicated in cessation of breastfeeding. Despite reports of this hormone’s being used during lactation²³23 Bolissian AM, Ferreira BEC, Stofel NS, Borges FA, Camargo BT, Salim NR, Teixeira IMC. Aleitamento humano e a perspectiva da interseccionalidade queer: contribuições para a prática inclusiva. Interface (Botucatu) 2023; 27:e220440.^,2929 Oberhelman-Eaton S, Chang A, Gonzalez C, Braith A, Singh RJ, Lteif A. Initiation of gender-affirming testosterone therapy in a lactating transgender man. J Hum Lact 2021; 38(2):339-343., there is no evidence it is safe for the baby’s health¹³13 Rodriguez-Wallberg K, Obedin-Maliver J, Taylor B, Van Mello N, Tilleman K, Nahata L. Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines. Int J Transgend Health 2022; 24(1):7-25..

Although not related explicitly to intersectionality, there does seem to be an overlap between the tools of cisheteronormative power and the biomedical model of care in favour of early weaning, when mention is made of the violence suffered by trans bodies and this population’s worsening mental health in healthcare environments.

Discourses and practices that generate and perpetuate disparities in health institutions, including HMB settings, can be analysed using intersectionality to examine accounts of individuals’ experiences²⁶26 Wesp LM, Malcoe LH, Elliott A, Poteat T. Intersectionality research for transgender health justice: a theory-driven conceptual framework for structural analysis of transgender health inequities. Transgender Health 2019; 4(1):287-296.. Broader awareness of these obstacles will permit public policymaking and implementation in favour of social justice, a pillar of intersectionality⁴4 Collins PH, Bilge S. Interseccionalidade. São Paulo: Boitempo; 2021., in order to eradicate barriers to trans people’s access to chestfeeding support services.

Final remarks

Cisheteronormativity and professional supremacy operate in the personal, social and institutional spheres to segregate the transgender population in chestfeeding. Health professionals’ worldviews, imbued by family and religious institutions and society itself, operate jointly with muting of the topic in the educational contexts of health professionals’ undergraduate and other training. There are also no protocols covering the possible manners of feeding a baby in non-normative families to guide professionals supporting chestfeeding.

Health professionals occupy a position of power, which is reflected in their relations with trans people in relation to chestfeeding, highlighting the importance of this practice for the child’s health, on the public health paradigm, to the detriment of the subjectivity of those who chestfeed. The trans population occupies a place from which to denounce discrimination and voice demands for transcompetent care.

Intersectionality offers a broader view of these inequities for them to be considered as a whole when implementing public policies for equitable care for the trans population in HMB environments.

This study had limitations. The first was the small sample of health professionals working in HMBs and of trans health service users, which may relate to taboos on the subject of gender identity. The second was that participants were exclusively bisexual, trans men in the context of chestfeeding, while trans women wishing to lactate were not included. The lack of articles on chestfeeding among Brazil’s trans population precluded comparisons with the international trans population or with cisgender women in Brazil.

References

Publication Dates

History