Speaking Out on “Breastfeeding” Terminology: Recommendations for Gender-Inclusive Language in Research and Reporting

Introduction

In 2017, Rasmussen et al. ¹ proposed language that more clearly and comprehensively describes the various behaviors related to human milk production, feeding, and consumption. As one example, these authors note that the term “breastfeeding” is often used to describe both (1) feeding an infant at the breast and (2) feeding an infant expressed breast milk. In addition, the term does not distinguish between whether the breast milk was produced by the infant's parent or another person, as in the situation of wet nursing or shared/donated expressed milk. Given the multiple interpretations of “breastfeeding” and other associated terms, Rasmussen et al.'s ¹ recommended nomenclature promotes linguistic inclusivity of lactation-related behaviors, an important step in reducing ambiguity among practitioners and patients in clinical settings. The purpose of this Speaking Out is to propose additional terminology aimed at increasing linguistic inclusivity of all individuals engaging in lactation-related behaviors for use in research and reporting. Given both the different linguistic foci (behaviors versus individuals) and practice settings (clinical versus research), these recommendations are meant to complement rather than supersede those by Rasmussen et al. ¹

The Meaning of Sex and Gender

Before describing the rationale for additional inclusive terminology, it is necessary to differentiate between the terms “sex” and “gender,” which may be used interchangeably in both research and practice yet have distinct meanings and influences on health. According to the World Health Organization, ² National Institutes of Health, ³ American Medical Association (AMA), ⁴ American Psychological Association (APA), ⁵ and many others, “sex” refers to the different biological (e.g., chromosomes) and physiological (e.g., gonads, sex hormones, external genitalia, and internal reproductive organs) characteristics of females and males. Sex is assigned at birth and reported on the birth certificate. Differences in sexual characteristics can lead to unique health issues among females and males, such as ovarian and prostate cancers, respectively. “Gender,” however, denotes the socioculturally constructed roles, behaviors, identities, norms, and relations of women and men and girls and boys.^2–5 Gender-based discrimination and violence resulting from gender inequity are likely to harm physical, emotional, and mental health.

In recognition of the distinctions between sex and gender, the AMA has adopted several policies to “inform and educate the medical community and the public on the medical spectrum of gender identity,” ⁶ to include “sex- and gender-based differences within the curricular content for medical school accreditation,” ⁷ and to support “voluntary inclusion of a patient's biological sex, current gender identity, sexual orientation, and preferred gender pronoun(s) in medical documentation and related forms, including electronic health records.” ⁸ Similarly, the APA has published a series of policy statements on lesbian, gay, bisexual, and transgender concerns that include APA's resolution to call “upon psychologists in their professional roles to provide appropriate, nondiscriminatory treatment to transgender and gender variant individuals,” encourage “psychologists to take a leadership role in working against discrimination towards transgender and gender variant individuals,” and support “the creation of educational resources for all psychologists in working with individuals who are gender variant and transgender.” ⁹ To supplement these provider-focused policies, the AMA Manual of Style ⁴ and Publication Manual of the APA ⁵ require that authors avoid language that imparts bias on the basis of sex or gender, choose sex-neutral terms (e.g., “homemaker” instead of “housewife”), and utilize the terms “sex” and “gender” as described above.

Breastfeeding: For Mothers and Women Only?

Feeding an infant at the breast, producing and expressing breast milk, and sharing breast milk are frequently discussed from a mother's perspective and within a woman's domain. For example, the 2011 Surgeon General's Call to Action to Support Breastfeeding covers the benefits of breastfeeding on maternal health, barriers to breastfeeding faced by mothers, and recommended actions to support mothers to breastfeed their infants, along with other topics. ¹⁰ Likewise, among the Healthy People 2020 objectives is MICH-24, “Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies.” ¹¹ Even in Rasmussen et al.'s ¹ article of proposed breastfeeding language, the term “mother” was mentioned 55 times and “women” or “woman” 21 times.

Anatomically speaking, this default to a gendered perspective is expected. Humans assigned female sex at birth are physiologically designed to bear children and undergo hormonal shifts during and after pregnancy that prepare for and stimulate human milk production. In addition, individuals assigned female sex at birth are often assumed to gender identify as women, and vice versa. Yet, not all people who give birth or feed their infants human milk identify as a woman or mother.^12,13 Notably, transgender men and gender nonbinary individuals can and do become pregnant and give birth and are therefore candidates for breastfeeding their infants.^12–14 A 2016 meta-regression estimates that 1 in every 250 adults—nearly 1 million Americans—identify as transgender, meaning that one's gender identity differs from their sex assigned at birth. ¹⁵ These figures have nearly doubled over the last decade, with the highest rates among adults aged 18–24 years ¹⁶ who happen to be approaching the mean parental age of 26.8 years at first birth. ¹⁷ In addition, about 25–35% or more of transgender populations are estimated to identify as gender nonbinary (gender expression falling outside the categories of man and woman), although there is limited research in this area.^18,19 Even less is known about the number of births to transgender men ²⁰ or rates of human milk feeding among transgender and gender nonbinary individuals. ²¹

What we do know is that transgender individuals experience high rates of mistreatment, violence, discrimination, and psychological distress and that these challenges are present throughout many facets of life, including at home, school, work, and in public places. ¹⁹ From a health care perspective, the 2015 U.S. Transgender Survey ¹⁹ —the largest survey of its kind in the nation—found that one-third of respondents reported at least one negative experience related to being transgender when seeking medical care during the prior year and about one-fourth responded that they did not seek necessary health care over the past year due to fear of mistreatment. By using gendered terms like woman and mother when conducting and reporting lactation research, making infant feeding recommendations, or implementing breastfeeding policies, we risk alienating an already marginalized population. To be sure, several studies have reported how using heterosexual and woman-focused lactation language in obstetric and pediatric practice settings can misgender, isolate, and harm transmasculine parents and nonheteronormative families.^{12,13,21–23}

From a research and reporting perspective, the use of gender-inclusive language is necessary for increasing both equity and data quality. ²⁴ Threats to validity can occur if research participants are less likely to provide factual or complete information when surveys use language that does not represent them. Given the evidence-based nature of medical practice, research regarding human lactation should respect and reflect the diversity of individuals who chose to provide human milk to their infants.

Current Practice in Research Collection and Dissemination

In considering the current state of the research, we must look at the language used in both data collection tools (e.g., surveys) and research dissemination (e.g., articles published in peer-reviewed journals). To determine how U.S.-based survey questions are currently worded, 15 national surveys^25–37 that have measured breastfeeding rates, practices, and public opinions since 2000 were identified through the National Collaborative on Childhood Obesity Research Catalogue of Surveillance Systems, ³⁸ the Centers for Disease Control and Prevention's Breastfeeding Data & Statistics webpage, ³⁹ and a published review of U.S. national breastfeeding monitoring and surveillance datasets. ⁴⁰ Each survey was reviewed for its sampling methods and language used when asking questions regarding human milk feeding (Table 1).

Of the 15 surveys reviewed, 5 (33%) only sampled mothers and asked questions reflecting the respondent's role as a mother with regards to breastfeeding and human milk expression.^26,32,35,37 The remaining 10 surveys sampled either health care facilities that provide maternity care or children, parents, adults, or households without specifying that the respondent identifies as a particular gender.^{25,27–31,33,34,36} While half of these 10 surveys asked questions from the child's perspective (e.g., Was the infant ever breastfed or fed breast milk?),^{28,29,31,33,34} the other half made assumptions regarding the gender identity of the person giving birth or breastfeeding.^{25,27,30,34,36} For example, the National Survey of Children's Health (NSCH) ³⁰ asked parents, “What was the age of the mother when this child was born?” making the assumption that the gestational parent identified as a mother. Similarly, the Early Childhood Longitudinal Survey-Birth Cohort (ECLS-B) study ²⁵ and Panel Study of Income Dynamics (PSID) ³⁴ inquired whether the child's mother ever breastfed the child. Even the Maternity Practices in Infant Nutrition and Care (mPINC) survey ²⁷ —which queries U.S. maternity care facilities—asks questions that assume all individuals who give birth and breastfeed identify as a woman or mother, such as “How often is the mother's infant feeding decision recorded on a facility record?” Finally, in assessing attitudes around breastfeeding, the SummerStyles Survey ³⁶ instructed respondents to indicate their level of agreement with statements such as, “I am comfortable when mothers breastfeed their babies near me in a public place” and “Women should be encouraged to breastfeed.”

Identifying the human lactation language used during research dissemination is a much more onerous task and one that deserves a systematic review beyond the scope of this commentary. As an entry into this endeavor, it is worthwhile to assess the journals themselves, since it is unlikely that large shifts in language will take hold until journal editors recommend, require, or restrict the use of particular terminology. To determine what language guidance scholarly journals are currently provided to authors, 55 databases in EBSCOHost (including Academic Search Complete, CINAHL, MEDLINE, and others) were simultaneously searched on February 4, 2019 for the term “breastfe*,” and results were restricted to scholarly (peer-reviewed) journals published between January 2000 and January 2019. Result counts were reviewed by publication, and the top 20 journals were identified and ordered by their hit count. Each journal's website was then searched to obtain their instructions for authors,^41–60 and these were reviewed to determine any language guidelines or requirements for reporting gender, sex, lactation, breastfeeding, or related concepts. Table 2 provides these results, along with the 2017 impact factor for each journal. During this review, it was noted that half of the journals referred authors to one or more of six external style guides or recommendations, such as those of the AMA, ⁴ APA, ⁵ Council of Science Editors, ⁶¹ and others.^62–64 Table 3 provides an overview of these six style guides, along with any specific language guidelines surrounding gender, sex, and lactation.

As shown in Table 2, 8 of the 20 journals (40%) make a statement regarding gender-based language in their instructions for authors, although these statements vary in scope and specificity.^{42,46,50,52,53,57,59,60} For example, while some journals broadly state that authors are required to use “nondiscriminatory” or “inclusive” language,^57,59 others define when “sex” and “gender” are to be used, or even require that “gender” be used instead of “sex.”^42,53,60 Four of these journals,^42,46,50,57 along with six other journals that provide no language guidance,^{41,43,44,51,55,58} refer to one or more external style guides (Table 3). Like the journals, these six guides vary in their recommendations regarding inclusive language, from stating nothing ⁶⁴ to identifying preferred terms with reference to sex, gender, and/or parental role.^4,5,61–63 In total, 6 of the 20 journals (30%) that publish breastfeeding research provide no guidance on gender or breastfeeding-related language, whether directly in the instructions for authors or indirectly through referral to an external style guide.^{45,47–49,54,56}

At the time of this review, only the style guidelines recommended by the International Lactation Consultant Association (ILCA) ⁶³ mentioned gender inclusive and nongendered language options for breastfeeding-related terms. Likewise, the Journal of Human Lactation is the only journal to require specific language for breastfeeding in their instructions for authors ⁴² and the only journal that refers authors to ILCA's style guidelines containing breastfeeding-related terminology recommendations. Although the second-highest journal in terms of search hits, Journal of Human Lactation represents only a fraction (<10%) of the breastfeeding-related articles during this 19-year look back period.

A Proposal Toward Inclusive Terminology

Given the varying language currently used by national surveys and scholarly journals, it is likely that at least some populations who provide human milk to their infants are misrepresented or excluded in current research. To ensure future studies are inclusive of all who choose to feed infants human milk, I propose several nongendered terms (Table 4) drawn from the ILCA guidelines ⁶³ , published research,^{12–14,21,23,65} and/or guidance from individuals or groups working with lesbian, gay, bisexual, trans, queer/questioning, intersex, asexual, and other (LGBTQIA+) communities. These terms center around parental identity and characteristics, such as the use of “parent” instead of “mother” and “spouse” or “partner” rather than “father.”

In addition, to illustrate how these terms can be used in research and reporting, Table 4 provides examples of their application to the lactation-related behavior terms recommended by Rasmussen et al. ¹ For instance, applying the proposed gender-inclusive language to terms like “feeding at the breast” and “at-the-breast feeding” would modify them to “feeding at the breast/chest” and “at-the-breast/chest feeding.” This recommendation is supported by research of transmasculine individuals, many of whom refer to their “chest” rather than “breast” and prefer the term “chestfeeding” over “breastfeeding.”^{12–14,21,23,65} Likewise, the use of “breast milk” and “own mother's milk” assumes that the person providing the milk identifies as someone with breasts or as a mother, respectively. Instead, survey questions and research dissemination can use terms like “human milk” or “parent's milk” without gendering the term. In the event that two parents co-nurse (i.e., are both providing their own human milk to their infant) and a distinction must be made between parents, terms like “gestational parent” or “birthing parent” can be used to signify the parent who was pregnant and birthed the infant, while “nongestational parent” or “nonbirthing parent” can indicate the partner. These latter terms are not only inclusive for transgender and gender nonbinary individuals but also for lesbian couples.

Of course, to report research using these suggested terms, it is likely that at least some studies will rely on the use of this inclusive language in clinical practice. It should be noted, however, that clinicians are bound by standard medical terminology when documenting in the medical record, and language that is unfamiliar to patients or others on the health care team is at best frustrating and at worst harmful. It is therefore necessary to explore how patients and clinicians would interpret and understand the terminology proposed here. For example, compared to “breast milk,” the term “human milk” may seem too impersonal or uncomfortable for providers when used in the clinical setting, and/or it may be a welcomed change for patients who are already feeling stigmatized for their gender identity. Additional research with diverse populations of patients and clinicians is needed to understand the best alternatives to “breast milk” and other terms for use within a clinical setting that promote patient–provider trust.

Furthermore, medical education programs would need to be developed and conducted so that current and future clinicians understand the meaning of the new nomenclature and how it should be used. Such efforts are aligned with the AMA's sex- and gender-based policies and can be supported by health informatics systems, which allow for new standardized medical terms and phrases to be incorporated into electronic medical records so that they can be recorded consistently and in accordance with clinical guidelines and protocols. Still, updating or adding new standardized terms does not ensure that they will be implemented, and further research is needed to understand the institutional and contextual barriers and facilitators to adopting gender-inclusive language, both within clinical settings and for surveillance and reporting efforts.

Conclusions

The terminology proposed here build upon recent calls to reconsider the language used in breastfeeding surveillance.^1,66 While it is necessary for researchers and health care providers to increase specificity regarding “breastfeeding” behaviors, we must also acknowledge that the individuals who choose to breastfeed—in any sense of the word—are not heterogeneous in their gender identity or parental categorization. The use of more inclusive terms, such as those recommended here, will further enhance the quality of surveillance data through the representation of all individuals choosing to provide human milk to their infants. These terms are supported by international recommendations and a growing body of research and should be considered for use in future data collection and research reporting regarding lactation and human milk feeding.