Feature: The Gender Kidney Donation Gap – Where are All the Male Kidneys?

by Nate Hodson

Writing for New Delhi’s The Quint in February 2018, Kaushiky Kashyap reported on what she called “the gender gap in organ donation”. Although it has been known for some time that women are more likely than men to become living kidney donors, Kashyap’s critique addressed cultural factors underpinning the female propensity to donate kidneys and drew a parallel with the well-known concept of a gender pay gap.

As with the gender pay gap, the preponderance of female kidney donors is revealed again and again. Researchers in Birmingham, UK, studied 713 living-donor kidney transplants. They showed women donated 55% of kidneys but only received 40%. In a Norwegian study, 58% of kidney donors were female compared with 37% of recipients. A similar pattern has emerged in every age group and every racial group except for black people under 19 years old.

The extent of the gender kidney donation gap varies depending on the relationships investigated. One of the largest investigations of gender and kidney donation used the Scientific Registry of Transplant Recipients to study more than 30,000 American living kidney donations between 1990 and 1999. The majority of these donations were between related and unrelated non-spousal donors, where 56% of donors were woman. However 8% of the donations they studied, some 2,367, were spousal donations. Strikingly, women donated to their husbands in 68% of these cases and men to their wives in only 32%. A similar study of data from 1964 to 2000 at the University of Michigan Health System found that in 69% of spousal donations women were giving kidneys to men. The researchers concluded that “gender disparities in [living donor] transplantation are primarily due to a higher proportion of wife-to-husband donations”.

In her report for The Quint, Kashyap picked up on this point, drawing particular attention to the gender kidney donation gap in heterosexual marriage and attributing the gap to cultural expectations. Before reaching the conclusion that this is a manifestation of patriarchy it is worth ruling out more benign explanations.

There are two possible medical explanations. Husbands may be physically unfit to donate to wives due to illnesses such as heart disease. Wives may be unable to receive a kidney from their husband due to immunological sensitization to him through pregnancy. In an innovative study, Deborah Zimmerman and colleagues followed 104 couples through the donation process. She showed that among those fit to donate, only 5 out of 31 husbands went ahead with immunological testing, compared with 22 out of 53 wives. Furthermore only 1 husband was excluded at the stage of immunological testing. Ultimately, 18 of the 53 medically fit wives went on to donate (that’s 36%). However, out of 31 medically fit husbands, only 2 (7%) donated. Evidently, neither medical factors nor immunological incompatibility account for this vast discrepancy.

Kashyap argues that female preponderance in organ donation arises because women are socialized into sacrificial manifestations of care, with powerful descriptions of this in an Indian context. Carol Gilligan’s analysis in a Western context, In A Different Voice, concurred: self-giving expressions of care predominate in the moral life of women whereas justice and rules are the focal points of male ethics. Denigrating the authentic values of women is a form of sexism which perpetuates both the criticism of female morality as irrational or incoherent, and male ethical hegemony. Rather than reinforcing a patriarchal individualistic worldview, we should ask why men in heterosexual marriages are, on the whole, failing to make a kidney donation within their most significant relationship. Rather than asking “why do women give away so many kidneys?” we should start asking “Where Are All The Male Kidneys?”

The reframing of norms seems to be central. Men who have donated kidneys are more likely to report a sense that they have done something “heroic”. Women, meanwhile, seem to view it as a no-brainer. This is strange because we might expect men to be more likely to donate if they see it as a great act. In fact, evidence from behavioural economics shows that opposite is the case: people tend to do what they believe is normal, not what is exceptionally good (see Mindspace: Influencing Behaviour Through Public Policy for a more in-depth examination of the risks of social norms). A masculine morality seems to view donation as supererogatory, an act that goes beyond the call of duty. Meanwhile, from a stereotypically feminine perspective there is a normative assumption in favour of donation, so failure to donate would be to fall short. Whereas the man who donates sees himself as a hero, and the woman who considers non-donation may view it as a failure, the man who does not donate stays in neutral, his kidney stuck in an ethical no-man’s land.

This difference can be understood through the two-cultures model of gender differences in language and their impact on heterosexual relationships. In You Just Don’t Understand, linguist Deborah Tannen argues that women describe their relationships in terms that emphasise closeness and support, whereas the way that men talk about relationship tends to assert their independence. For one who views a couple as an interdependent unit, the notion of donating a kidney to a partner is natural; less of a transplant and more of a repositioning. But if the partnership comprises two individuals then the prospect of transplantation is alien and the organ graft threatens individual independence. This is borne out in the bodytalk of male donation which seems to assert that man is an island entire of itself whereupon we could find these missing male kidneys.

Some criticize Tannen’s style, saying she “perpetuates negative stereotypes of women [and] excuses men their interactive failings” thus letting men off the hook and treating male failure as an equally valid manifestation of moral diversity. When it comes to the gender kidney donation gap, the stereotypes are there in the data. The point is that donation is a morally positive act and expectations that promote donation are, all things considered, better than those that undermine it.

Whether or not one agrees that the gender kidney donation gap can be attributed to masculine and feminine views of relationships, there remains something alarming about a gender kidney donation gap where kidneys flow overwhelmingly from wives to husbands. The evidence that 68% of spousal donations are from wives to husbands and that women who are fit to donate are over five times more likely than fit men to donate to their spouses would support the hypothesis that there is a malaise in heterosexual relationships.

It is not the sacrificial impulse that needs to be toned down, but the individualism preventing heterosexual couples actualising their potential. Men need to be socialised into generous connectedness. We must move beyond the narrative that donation is extraordinary, towards an expectation of perfect interdependence. I believe in redemption and that men are not hard-wired toward selfishness. So let’s find these kidneys, plug the gap and keep track of them. Let’s see if we can’t transplant a new heart into this stuttering heterosexuality.

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