Invisible Sacrifices: Gendered Dynamics and Social Pressures in Living Kidney Donation in India

Living organ donation in India is influenced by complex social, economic, and cultural factors. Gender disparity has been widely documented in living organ donation. The disproportionate proportion of female donors and male recipients raises fundamental questions about the underlying societal, familial, and psychological factors at play. The article by Jamwal et al.¹ in this issue of the Journal sheds light on a persistent and significant gender gap among living donors in India. Drawing on a large number of participants at a tertiary care center, using a mixed-methods design, this study not only shows that women disproportionately constitute the living donor population but also identifies social, cultural, and economic explanations for this disparity.¹

Out of a total of 1,171 living donor kidney transplants over 10 years, roughly 4/5 donors were female, and a similar number of kidney recipients were male. This imbalance is far greater than its Western counterparts. For example, in the United States, 60% of living kidney donors² and 43% of recipients are women. In Germany and the UK, women donor constitute around 55-64%.³

Among female donors, mothers (50.1%) and wives (35.6%) predominated, reflecting the stereotypical roles assigned to family members in the Indian context. The qualitative portion of the research, which involved interviewing 92 randomly selected female donors, further supports these conclusions: sociocultural conditioning (51.8%), economic dependence (33.2%), and altruism (15%) were the influences behind the women’s donation decisions.

These findings conform to numerous other reports on the gender disparities in living donor transplantation in India [Table 1].^1,4-8

Additionally, this study presents insights into the issue using a mixed-methods approach. The data reflect current trends and come from a large public hospital in India; hence, the inferences stand on stronger grounds. Analysis of motivators is categorized into sociocultural, economic, and emotional factors to present a clear view, which is often not measured in fine detail in Indian studies. Based on the identified case motivators, real, actionable steps can be taken, including implementing programs aimed at empowering women through economic and educational avenues.

The study has limitations, being single-center, hence not able to shed light on regional disparities.^4,5,8 Although 10% of female donors were randomly selected for interviews, those who chose to participate might have different views than those who did not, leading to possible selection and reporting bias.

India relies heavily on living donors, which amplifies the impact of family structure and gender norms. The National Organ and Tissue Transplant Organization documents the same gender discrepancies in living donor reports across the country,⁹ indicating that Jamwal et al.’s finding reflects broader societal trends.¹ Worldwide, sex imbalances in living organ donation have been observed, but India’s figures, with nearly 80% of the donors being women, are extreme relative to other lower-income nations, and they differ sharply from higher-income countries, where deceased organ donation policies minimize the demand for family-based “voluntary” donations.^2,3

Despite a 75% rate of awareness among women regarding organ donation, a mere 15% self-identified pure altruism as their motivation to donate. This suggests that many donors may perceive their decision in a broader context that includes sociocultural and economic obligations rather than as a purely selfless act. Educational programs should emphasize voluntary informed consent, autonomy, and provide a clear understanding of altruism. The greater issue is the high percentage of female donors who give to male breadwinners, even though policies that address barriers for male donors, who might worry about losing their income because of their role as breadwinners, are crucial. Despite their potential financial vulnerability, women donors often bear this burden due to social and familial pressure to protect the primary male earners’ health and earning potential.⁸ Recognizing that most women, particularly mothers and wives, may experience pressure from external expectations, programs should emphasize family counseling and ethical processes that encourage cooperative decision-making while avoiding coercion.

Several critical areas require more investigation to fill the gender gap in living kidney donation. Additional multicenter and national registry studies are required to confirm and build upon existing evidence across a range of backgrounds, including urban and rural settings and public and private centers. There is serious ignorance of the long-term psychological and medical consequences for women who give under perceived coercion versus those who volunteer to give.¹⁰ There is a need for targeted research involving male living kidney donors to better understand the economic challenges and barriers they face [Figure 1].

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Figure 1:

Action points to address gender disparity in living kidney donation. Adapted from Jamwal et al.^[1]

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Jamwal et al.¹ add an important voice to the knowledge about systemic and ongoing gender inequities in Indian living kidney donation. They strongly demonstrate how entrenched social and economic problems frequently dominate awareness and altruism toward donating. Making a more just transplant system a reality requires not only awareness but also actual societal and structural transformation.