Abstract
Purpose:
To assess the use of gender-identity inclusive language in breastfeeding education materials publicly available on U.S. Hospital websites.
Methods:
Hospitals were identified through the American College of Obstetricians and Gynecologists website. Breastfeeding education materials were searched online at each hospital. The first breastfeeding material on each website was used for our evaluation. Gender-identity inclusive versus traditional sexed language terms were curated a priori by referencing the National Institutes of Health and American Psychological Associations’ guidelines. Education materials were categorized into: (1) “gender-identity inclusive language,” (2) “mix of inclusive and traditional sexed language,” or (3) “traditional sexed language.” Frequencies of the type of language and specific gender-related terms were calculated.
Results:
In total, n = 112 hospitals with publicly available breastfeeding education materials were included. Most hospitals used both traditional sexed and inclusive language (69%, n = 77), followed by only traditional language (31%, n = 35). None of the hospitals used solely gender-identity inclusive language. One hospital provided material “intended for LGBTQI+” populations.
Conclusion:
Education materials provided by hospitals for breastfeeding do not utilize gender-identity inclusive language As such, there remains uncertainty and hesitancy on how to provide appropriate breastfeeding education for all persons who identify as transgender and/or non-binary, yet choose or are able to breastfeed. Further research in this area could ascertain the impacts of using gender-identity inclusive language in breastfeeding education materials for the general, transgender, or non-binary populations.
Background
Breastfeeding supports the normal health, growth, and development of infants as well as providing benefits for both members of the dyad. 1 The World Health Organization, among many other academies, recommends exclusive breastfeeding for the first 6 months of life and until 12 months of life with complementary feeding2,3 but, in the United States, at 6 months only 24.9% of infants are exclusively breastfed. 4 Given the importance of breastfeeding for the dyad, health care providers should strive to make breastfeeding equitable across all populations.
Terms like woman or mother are often used in clinical lactation and considered to be sexed language. The use of such terms may not align with those who identify as transgender or non-binary. For example, a transgender man may have a uterus and breasts, but not identify as a woman. Thus the use of “woman” or “mother” in breastfeeding education may not be appropriate. Additionally, gender-diverse individuals may already be experiencing dysphoric relationships with their anatomy further leading to uncertainty or lack of confidence to breastfeed. 5 The lack of knowledge or skills of health care providers to include gender-identity-centered care in clinical lactation may be associated with health care avoidance among this population. 6 A study in China reported that transgender and gender-diverse parents who experience discrimination (such as health providers not respecting identity or showing prejudice) during lactation care were less likely to provide their child with human milk during the first feed and were associated with shorter duration of breastfeeding. 7
Utilizing gender-identity inclusive language, when appropriate, in health care could acknowledge diverse gender identities and ensure transgender and non-binary individuals feel comfortable in clinical lactation care. One-on-one clinical settings allow clinicians within an appropriate environment to utilize patient-preferred language and terms to ensure patient-centered care and comfortability. A qualitative study by MacDonald et al. in Canada highlighted the “lactation experience” of transgender people. 8 One participant described that a nurse’s use of “dad’s chest” was a positive experience. 8 However, readily available patient education materials provided by hospital systems may not have the same level of individualization required to ensure transgender and non-binary populations feel welcome and included.
Health education materials are often free and readily available on hospital webpages, posted in waiting and patient rooms, and provided to patients after individualized care is received. To our knowledge, no literature exists on the use of gender-identity inclusive language in practice, particularly for breastfeeding education. Therefore, we aimed to assess free, readily accessible health education materials related to breastfeeding education on hospital websites to describe and characterize their use of gender-identity inclusive language.
Methods
This cross-sectional study was conducted to evaluate the use of gender-identity inclusive language in publicly available breastfeeding education materials from U.S. hospitals. As a research team, we agreed upon using the term “breastfeeding” throughout the article, rather than chestfeeding to accurately represent the studies that are referenced. Chestfeeding, in general, is compounded regarding its definition by representing a multitude of scenarios such as using it as a generic term for any kind of feeding from a person’s body no matter what gender a person identifies or using it for a transgender man who has had a chest masculinization mastectomy using a tube taped to the nipple or nipple graft. 9 Additionally, we focused primarily on the breastfeeding person/parent in our characterization of terms rather than infant or child-directed terms (such as he/she to describe the infant).
Identification of obstetrics and gynecology units
To identify hospital units that may provide support on breastfeeding through online resources, we used the American College of Obstetricians and Gynecologists (ACOG) registry of hospitals that host obstetric and gynecology residency programs in the United States and Puerto Rico. 10 ACOG-accredited residency institutes were utilized as birthing institutes as they are more likely to interact with pregnant, and thus, breastfeeding individuals. The list was curated in a Google Sheet and finalized in October 2023.
One researcher did an internet search on each hospital to locate breastfeeding education material. Breastfeeding education material was defined as any document or webpage that provided guidance for breastfeeding, including a video, a downloadable PDF or other file type, or just a webpage. If the hospital had education materials available online, the researcher linked it to the Google Sheet. If a hospital had multiple education materials related to breastfeeding, the researcher linked the first listed. If hospitals were duplicates (i.e., in the same health care system with the same materials), they were consolidated. If the researcher could not locate education materials, it was flagged and revisited by an alternate researcher to confirm that materials were not available.
Review criteria
A list of gender-identity inclusive versus traditional language sexed terms was identified by reading recently published guidelines from the National Institutes of Health and American Psychological Association. 5 The list was modified once we read through the materials and identified more terms. See Table 1 for the final terms used in the review. Following the evaluation of the first material listed, the same researcher who did the initial review, scanned each hospital site that listed the breastfeeding materials to determine if the hospital provided a separate gender-identity inclusive material targeted specifically to the transgender or non-binary populations.
Curated List of Sexed and Gender-Identity Terms Used for the Education Material Review
Sources: Adapted from the National Institute of Health (NIH). Inclusive and Gender-Neutral Language. Last updated January 2024; American Psychological Association (2022). Inclusive language guidelines. https://www.nih.gov/nih-style-guide/inclusive-gender-neutral-language.
AFAB, assigned female at birth; AMAB, assigned male at birth.
Education material evaluation
The same researcher who identified the education materials categorized each hospital into (1) “used gender-identity inclusive language,” (2) “used a mix of gender-identity inclusive and traditional sexed language,” or (3) “used traditional sexed language.” For each education material, the researcher used a mix of a deductive and inductive approach to identify the terms preidentified that were used in the material but to add to the list of terms if novel terms were published, respectively. The representative text was identified to illustrate each type of language used and the specific terms.
Data analysis
The frequency of the type of language used across each education material was calculated overall and by state. The frequency of each specific gender-related term was calculated. The distinct gender-identity inclusive education materials were tallied. Because the data we reviewed were publicly available and did not involve interacting with human subjects, this work did not require institutional review board approval.
Results
At the end of the data collection, 112 hospitals with obstetrics and gynecology residency programs had publicly accessible breastfeeding education materials that were included in the data analysis. The majority (59%, n = 66) of hospitals provided a single item with the educational information and 41% (n = 46) provided multiple educational materials of which we reviewed the first item listed.
Education material evaluation
Most hospitals used a mix of traditional sexed and gender-identity inclusive language (69%, n = 77), followed by only traditional sexed language (31%, n = 35). None of the hospitals used solely gender-identity inclusive language.
The most used terms included the following: breastfeeding, mother, nursing, and woman (Table 2). None of the hospitals used the following terms: reproductive health, birthing patient, people with uteruses, bodyfeeding, assigned female at birth, assigned male at birth.
Frequency Distribution of Terms Used Among Breastfeeding Hospital Education Materials (n = 112)
Data was collected in October 2023 in the United States.
Review for distinct gender-identity inclusive education materials
Of the 112 hospitals with accessible education materials, one hospital (0.9%) provided distinct, stand-alone materials intended for “LGBTQI+ populations.” The education material included separate sections that focused on co-lactation, inducing lactation, chestfeeding, affirming care treatment, and donor milk use.
Discussion
After evaluating a sample of breastfeeding education materials in the United States, the majority do not incorporate gender-identity inclusive terms. A small proportion of the materials had a mix of traditional sexed and gender-identity inclusive terms. The use of gender-identity inclusive terms was primarily related to the use of terms such as nursing, parent, and partner, which have long been used. While gender-identity inclusive terms that are more recent, such as “birthing person” or “pregnant person,” were less commonly used. One hospital provided information “intended for LGBTQI+” populations.
The use of gender-identity inclusive language, although it may include transgender and non-binary populations, is alienating or confusing to the general population of mothers as it removes the personal connection of pregnancy and lactation.11–13 Kinney et al. provide a detailed view of the understanding, acceptance, and face validity of gender-identity-inclusive language use in a Women, Infants & Children (WIC) program questionnaire. 14 Overall, the most inclusive language terminology was well understood. However, the face validity and acceptability of terms were mixed. Additionally, some participants reported they rejected the material if it used terms such as “chestfeeding” or “bodyfeeding.” Although these data are informative, there remain gaps in research for this population. Not only do we need to better understand the best communication tools for transgender and non-binary populations but also we must better understand their clinical needs around issues such as breastfeeding grief or complications after chest masculinization surgery. 15
The relevance of using gender-identity inclusive language for medical care and education has been highlighted,11,16,17 yet, the integration of gender-identity inclusive language is complex for lactation or breastfeeding care with various factors that need to be considered. The Academy of Breastfeeding Medicine released a statement regarding gendered language in lactation care, providing alternative gender-identity inclusive terms that could be used as well as appropriate instances for their use, such as replacing “mother” with “lactating individual” or “parent.” 12 The authors make a point that gender-identity inclusive language may be used in “document[s] with an audience of health care professionals in a country where openly transgender or non-binary persons give birth and breastfeed or chestfeed, such as a hospital policy in the United Kingdom or United States.” 12 However, emphasizing that traditional sexed terms may be more appropriate for general public documents due to concerns of literacy and clarity. They highlight scientific accuracy, masking research needs, and personal preferences as key factors that justify the use of gender-identity inclusive language. For example, they highlight that gender-identity inclusive terms often do not have equivalent meanings with words they replace, creating translation difficulties for languages or cultures without traditional translations for such languages. Additionally, within the medical field, they discuss that current lactation research has focused on presumed cisgender populations and the need for lactation research on transgender parents. 12
Due to the complexity of gender-identity inclusive language, some research has suggested the use of additive language, such as replacing “women” or “mothers” with “women and birthing people” instead of replacing it with “birthing people.” 11 This approach of additive language has been identified as a potential solution in midwifery education programs to ensure that those who identify as transgender as well as those who do not see the material as applicable to them.18,19 However, additive language may not abide by the plain language principle of health communication is vital in medical care to ensure understanding among a variety of populations 20 and to ensure patients’ needs are not masked. 12 Additionally, the acceptability, validity, and understanding of additive language in breastfeeding or reproductive health have not been evaluated to our knowledge. As such, the generation of health education materials that are tailored to transgender and non-binary populations may be beneficial, but in our assessment, we only identified one hospital out of 112 with tailored materials. Tailored health communication has been shown to be effective in promoting health behavior change.21,22 The patient-care needs may differ among transgender populations during lactation, as evidenced by recent case reports to induce lactation.23,24 Thus, the generation of breastfeeding education materials that are focused on specific transgender and non-binary populations could ensure specific needs are met, as well as ensuring plain language use for other communities.
Limitations
Our review was limited by focusing solely on ACOG-accredited hospitals and the first item listed on the website. Of the hospitals that listed more than one material, there could be variations of gender terms that were used. Also, it is unknown whether the authors of the education materials unequivocally meant to use gendered terms such as “mother” or developed the material assuming transgender women, for example, may prefer to be called “mother.” Next, the scope of our project focused on the transgender and non-binary populations, yet we acknowledge there are other sensitive populations to breastfeeding discrimination when it comes to education and care such as individuals who are blind or those who identify with a racial or ethnic minority group. Lastly, we did not include pronouns in our analysis but observed a high use of “you” in which education materials avoided nouns such as “woman.” The inclusion of how pronouns are used in future studies and additional hospitals will be important to consider.
Conclusions
The majority of hospitals used both traditional sexed and inclusive language within the publicly available breastfeeding resources with a smaller proportion using only traditional language. Additional research is needed to understand the preferred use of language in publicly available breastfeeding education materials, from various gender identities including transgender and non-binary populations.
Footnotes
Authors’ Contributions
S.B. contributed to the data analysis. A.G. and O.S.A. contributed to the article drafting. A.G. and O.S.A. contributed to the study’s conception and design. All authors reviewed and approved the final article for submission.
Disclosure Statement
The authors of this study have no conflicts of interest to report.
Funding Information
This research did not receive funding.