“It is easier to dissuade a man [who wants to donate his organs] than a woman,” says Dr Sunil Shroff, urologist and managing trustee of MOHAN Foundation, an NGO that promotes and facilitates organ donation. A recent report published by the Foundation states that 80% of live organ donors in India are women, while they constitute only 18.9% of organ recipients. Explaining a potential reason behind the high number of woman donors, the doctor says, “I believe this has to do with the social conditioning imposed on women, which requires them to be nurturing caregivers even if it poses a risk to their well-being. But men are not at the receiving end of any such conditioning.”
The report was based on a research paper published in the Experimental and Clinical Transplantation Journal in 2021. According to their findings, for every woman who underwent an organ transplant between 1995 and 2021, four men went through the same procedure. That is, of the 36,640 donations during this period, only 6,945 (18.9%) were women recipients. This skewed sex ratio brings to light several socio-cultural factors that keep women at a disadvantage when it comes to organ donations. Many doctors and transplant specialists also attribute this disparity in numbers to the pattern of liver and kidney diseases across genders.
The breadwinner dilemma that guilts women into organ donation
MOHAN Foundation’s report draws attention to the ‘breadwinner dilemma’ that makes men more reluctant to be organ donors. At the same time, since men are the sole breadwinners in many families, there is a sense of ‘heightened responsibility' among family members, especially the women, to donate their organs for the men. To preserve the health of the ‘breadwinner’, women find themselves pressured to donate organs, paying little heed to their own physical and emotional well-being. This phenomenon highlights the implicit bias against women’s welfare and health that continues to exist within family structures.
Dr Sunil Shroff elaborates on how the gender disparity among organ donors is connected to emotions. He says, “There is more to it than men being expected to be in good health as they are the breadwinners. This is also an emotional issue. Women are expected to be emotionally giving, especially when their loved one is suffering. It is a psychological dilemma that needs to be studied further.”
Shedding light on factors other than gender that are in play during organ donations, Dr J Amalorpavanathan, former general secretary of the Transplant Authority of Tamil Nadu (TRANSTAN) says, “The donor is almost always poorer than the recipient [when they are not from the same family]. At the same time, the donor is often younger and the recipient, older. Along with the skewed gender ratio, these factors hold true for most developing countries where men hold greater power over women. This pattern can be seen in most ‘developed’ nations like the USA as well. In the case of solid organs like kidneys and livers, women continue to be the larger number of donors.” He further adds that since women are already preferred donors, it makes them more vulnerable to being trafficked for their organs.
When asked why women constituted a low number of organ recipients, both doctors agreed that they are not prioritised as much as the men and male children in the traditional family structure. Dr Shroff says, “If the family is from a lower socioeconomic background, they might be reluctant to spend around Rs 25 lakh on a woman for an organ transplant. This might not be the case if the man needs an organ transplant. Because of this, families can sometimes be hesitant to even enrol women for organ transplants.”
“When a woman is a kidney recipient, the person who donates is usually a sister, mother or daughter. Most women are ready to offer their kidneys to their ailing husbands to save their lives, but the converse seldom happens. Scratch the veneer of democracy and modernity in India and you will find that we are still a feudal, casteist, misogynistic, and patriarchal community,” wrote Chennai-based urologist Dr Jaison Philips on X (formerly Twitter). He added that in his career, he has not seen a husband come forward to donate his kidney to his wife even once.
However, the disparity may not be related to only patriarchal factors that surround organ donation and health care. Dr Vivek Shanmugam, a liver transplant surgeon based out of Chennai, explained that the numbers in the report could also be a result of who is more likely to develop liver diseases.
According to Dr Vivek, “On average, men consume more alcohol and cigarettes than women in India. Due to excessive consumption, men are at a higher risk of fatty liver, which leads to cirrhosis. As men are more prone to such ailments, women are expected to donate their organs for their well-being. It is often the woman who donates her organ to her husband as their children might be hesitant and his parents might be too old to be a donor. I think this gender discrepancy exists because of the disease pattern.”
He also pointed out that when a woman is affected with liver disease, her children come forward to donate their organs as, oftentimes, the husband might have crossed the age threshold to be a donor.
The toll on the donor
Organ donations, especially if coerced, causes physical and emotional stress to women. Live organ donation is a complex surgery that can have lasting effects on the donor, as all the doctors who spoke to TNM acknowledged. This is compounded by the fact that a significant number of Indian women are malnourished and anaemic. According to the 2022 survey of National Family Health Survey, 182.9 million people are malnourished in the country, a majority of them being women and children. As a result of this poor nourishment status, women suffer from anaemia, which further affects their newborns.
Apart from being at a disadvantage in terms of nutrition and general physical health, women often have little bodily autonomy in most Indian families. Combined with poor literacy, lack of independent income, and vulnerability to domestic violence, women are often left with little choice when there is pressure to donate their organs to make family members.
Dr Amalorpavanathan agrees. He says, “Women have little agency when it comes to decisions like this. This is a major surgery — will anyone happily take on a major surgery to lose an organ? In most cases, there is enormous pressure on the woman to donate an organ or even sell it in the black market.”
Even while validating the anxieties of donors, the doctors say that on-table fatality, that is, the donor losing their life mid-surgery, is little to none. They agree that around a decade ago, when organ donation was still in its nascent stage, a few donor deaths were reported. However, advancements in medicine and technology have helped minimise donor deaths.
They are expected to undergo several tests to see if they are suited to undergo this complex surgery before the organ is harvested. Dr Vivek recounted instances where the donor was operated on to harvest the organ but found the liver unsuitable, after which the medical team decided to not proceed with the transplant.
How can gender bias be combatted?
To ensure that the burden of organ donations does not fall unfairly on women, transplant surgeons suggest cadaver transplants instead of live transplants. As the name suggests, cadaver transplants rely on organs harvested from dead bodies. Dr Amalorpavanathan explains that cadaver organs are distributed based on a waitlist that patients have to enrol in. He says, “Cadaver organs are donated strictly based on the waitlist, irrespective of gender. One of the main goals of promoting cadaver organ transplants is to ensure that women do not become victims of forced donations.”
The doctor added that even cadaver transplants can do little good unless patriarchal notions around organ donations are dismantled. He says, “If 100 men and women are diagnosed with renal failure, there is a high chance that all the men will enrol for a kidney transplant. But only 50 or 60 women might do the same. This is a reflection of how society treats women.”
Dr Sunil too believes that cadaver donations are the way forward. He says, “The gender disparity among organ donors will not go away until we shift focus from live donations to cadaver donations. For instance, the country witnesses a large number of road accidents. If the organs of those who lose their lives in road accidents are donated, it could pave the way for more cadaver donations.”