Introduction

Power is in the air we breathe, and no matter where we are there are always individuals with more power over others. In “An anthropology of structural violence” Paul Farmer (2004) famously described the ways systems of power operate to produce structural inequalities and forms of violence inherent within. Farmer defines structural violence as “the experience of people who live in poverty or are marginalized by racism, gender inequality, or a noxious mix of all of the above” (308). Drawing on experiences as a doctor and medical anthropologist researching in Haiti, Farmer found that many people receive inadequate medical care because they are unable to pay. In his findings, Farmer observed a correlation between limited access to care and the inability to pay for care contributing to feelings of powerlessness. Building on Farmer’s concept of structural violence, this paper considers from a feminist perspective how some women are more affected than others by systemic violence. In particular, I explore how social inequalities shape the impacts of surrogacy for women in India. In doing so, this essay exposes the physical and structural impediments that women are willing to endure during the surrogacy process.

Surrogacy is defined as a practice where a woman gives consent to carry someone else’s child and receives payment in return (Pande 2010b:971). The research on Indian surrogacy is fairly recent, and has largely been conducted over the last several years by feminist scholars of color (Pande 2010a; Pande 2010b, Pande 2011; Bharadwaj 2012; Deomampo 2013; Saravanan 2010; Singh 2014; Vora 2009). The vast majority of these individuals use a feminist lens to assess power and agency among surrogates in India. Overall, the consensus is that surrogates are exploited based on their socioeconomic class. Many surrogates have hopes and dreams but are unable to fulfill them because they do not have the economic means. Scholars found that surrogates faced stigmatization, expressed having almost no autonomy, and described feeling like their voices were not being heard.

In the review of contemporary research that follows, I focus on issues of stigmatization and diminished autonomy to argue that structural violence negatively shapes the lives of surrogates in India. Structural dispositions force surrogates into subordinate roles that require them to comply to the orders of the physicians and biological parents. I also evaluate how the physical and biological repercussions of surrogacy impinge upon the bodily autonomy and health of surrogates. In the context of Indian surrogacy, physical and biological dispositions are external factors that negatively affect a surrogate’s mind and body. Using Farmer’s concept of structural violence, I argue that surrogates in India are willing to face structural and physical dispositions that render them powerless in hopes of a better future.

Indian Surrogacy

Advancements in globalized medical care have led to a growth in medical tourism, whereby Westerners can attain high quality healthcare in a developing nation at an affordable cost (Boyle 2011). India is one of the leading countries in Asia for medical tourists to seek care because of their highly trained clinicians, low costs, and interpersonal services (Wong et al. 2014). For example, there is a 41% price difference in overall surgery costs in India compared to similar procedures in the UK (Lunt and Carrera 2010:29). As a result, the availability of high quality affordable care has led to an increased demand for surrogacy. At the same time, however, this practice in India has had a relatively negative effect on Indian women who act as surrogates.

First of all, surrogates are forced to become “docile” and are rendered powerless once in the confines of the surrogacy hostal, where they reside until the child is born (Pande 2010:970). Surrogates are essentially renting out their womb for around nine months in exchange for payment. Bharadwaj (2012) asserts that surrogates are often stigmatized as being a “prostitute,” creating a “Madonna” and “Whore” complex (153). Surrogates profit from selling their bodies and are treated as being angelic or othered by society. Moreover, surrogates are putting their lives on the line. Unfortunately, not everyone in India views surrogates as being a worthy line of work. In India, there is a fine line between sex work and surrogacy, resulting in surrogates feeling unable to tell their family about their work outside of the home (Pande 2010b). Surrogates may profit from their services, but face the burden of selling their bodies for money. Both surrogacy and sex work consist of women selling their bodies to make a living. However, surrogacy implies purity for women, without the means of sexual intercourse. Nonetheless, both are subjected to the same judgments, even though the situations are vastly different.

Second of all, women who decide to become surrogates often lose access to networks of social and family support. In part, this is because surrogacy is not a socially acceptable practice in India. Surrogates face being stigmatized by their peers and kin because they are seen as social outcasts. As a result, surrogates will often distance themselves from their biological families;thus, surrogacy is a life away from home that takes women from their families for nine months. Once surrogates have given birth, they must relinquish all attachment to the child (Pande 2010b). The sole purpose of a surrogate is to nurture and deliver someone else’s child without gaining a lasting emotional attachment. To produce a quintessential “mother-worker body,” surrogates find themselves confined under lock and key in surrogacy hostels (Pande 2010b). As surrogates, women agree to inhabit a subordinate role, where they are willing to objectify their bodies and minds. For example, Saravanan (2010) found that surrogates felt disposable and unable to assert their thoughts to the biological parents or the staff at the surrogacy hostal (27). Further, if surrogates fail to comply, they will be dismissed from their duties (e.g. failure to go to a doctor’s appointment) (Saravanan 2010:27). In an attempt to resist feeling powerless, surrogates will sometimes seek to build rapport with the biological mother (Pande 2010b:986). Indeed, surrogates may attempt to blur the lines between friend and worker to de-stigmatize their work. Nevertheless, surrogates are still wage-earners, working and being indirectly paid by the biological parents. Thus, surrogacy both entails a particular form of wage-labor and remakes kinship, wherein surrogates may feel intimately tied to the child they are carrying, despite having no biological connection, while at the same time, their experience of pregnancy is monetized

Third of all, the process of surrogacy forces women to navigate a capitalist system that promotes systemic oppression. However, working within the capitalist system allows for women the potential to gain more autonomy in the future. The commodification of Indian surrogacy can be described as a form of “biological labor” (Vora 2009:268). Deomampo (2013) points out how surrogacy on a global scale reinforces inequalities, which yields both empowerment and disempowerment (169). Surrogates feel empowered by earning a substantial sum while giving the gift of life (Vora 2009:273). In rare instances, surrogates can rise from poverty and provide their children with the opportunity to go to college. For example, Antara (post-surrogate) was able to advance in a career as an agent, earn money, and provide her family with amenities for the household (Deomampo 2013:179). At the same time, surrogates become disempowered as they are stripped of almost all of their rights while being separated from their biological families. When women become surrogates, their personhood becomes stripped bare to a mere body. Essentially, surrogates are forced to navigate different channels of power in order to gain upward mobility and financial stability. Through participant observation, Pande finds the vast majority of surrogates express wanting the best for their biological children, with the hope of “a better future” (2010a:55-80). In post-surrogacy, former surrogates can send their biological children to college and be able to afford amenities for the home. Moreover, surrogacy allows for women to potentially free themselves from the constraints and dispositions of being lower class, even while still creating conditions for exploitation and stigmatization.

Structural Dispositions

Despite the potential for achieving upward mobility and other freedoms afforded by surrogacy, this kind of work is not desirable and is deemed an economic necessity only (Vora 2009:274). Class and socioeconomic status oftentimes promote a power divide among the services provided by the surrogate and the biological parents (Bharadwaj 2012; Saravanan 2010). On the one hand, Western tourists (who are often White) have the means to travel outside of their country to seek medical care. On the other hand, Indian surrogates (who are women of color) will most likely never have the opportunity to travel abroad. Deomampo (2013) recounts a story from one of her surrogate informants, Nishi, who reveals her dream of becoming a doctor (174). However, Nishi is unable to go to school because of “financial constraints” (Deomampo 2013:174). Nishi’s predicament illustrates how surrogates are generally are not given the opportunity to improve their financial situation through education. Unfortunately, being uneducated and of low economic status creates more challenges for surrogates in understanding their rights. India is a caste-based society, where individuals are confined to their ascribed statuses. Surrogacy generates the potential for Indian women to earn money and move up in their class bracket. Nevertheless, surrogates still find themselves with less say than their clients, which creates an ongoing imbalance of power.

Being a surrogate yields vulnerability, making those who participate feel voiceless and confined to the rules of their arcane contract. Surrogates oftentimes have trouble understanding the contract they are instructed to sign because the document is written mostly in English, which almost none of the surrogate can read or speak (Pande 2010b; Deomampo 2013). Being uneducated can restrict one’s future opportunities and also can hinder a surrogate’s ability to “negotiate” with the biological parents (Singh 2014:826). Essentially, surrogates are understanding their rights on a need to know basis, and not being told the full extent of what they are getting themselves into (Pande 2010b:976). When hostal workers relay information from surrogates to the biological parents, they are potentially distorting the communication between parties. Saravanan (2010) finds that doctors do not see themselves participating in exploiting their surrogate patients, simply operating as bystanders without questioning their ethical dilemma. Nevertheless, the vast majority of surrogates are unable to break free from their ascribed statuses and face physical dispositions that have the potential to harm one’s body and mind.

Physical Dispositions

Despite the promise of gaining financial stability, the process of surrogacy comes at a cost for a woman’s body. Adverse effects from surrogacy include psychological distress, vomiting, fainting, and the potential of contracting hepatitis (Venkatashivareddy et al. 2016). Undergoing surrogacy forces women to be willing to suffer and experience pain to their physical form. The potential hazards of surrogacy seem to trump the benefits of upward mobility. By agreeing to the terms of the surrogacy contract, surrogates are forced into the position of separating one’s body from self (Vora 2009). Distancing one’s mind from the soul seems dehumanizing and objectifying, which may stem from the desperation to feed oneself and family.

The ultimate goal of surrogacy is for surrogates to enhance their socioeconomic status and to be able to provide for their families. The trade-off for surrogates is receiving roughly the equivalent of five years worth “of total family income” for one birth (Pande 2010b:974). Surrogates who already had children before becoming surrogates were not able to adequately nourish themselves when they were pregnant with their children; this demonstrates how power is unequally distributed amongst the rich and the poor (Sarojini et al. 2011). However, when women in India become surrogates, they find themselves able to feed themselves substantially. The only reason their situations have changed is that the wellbeing of the surrogate child is linked to the surrogate’s health. The physical and psychological pain surrogates are willing to endure demonstrates how far women are willing to go to gain more power and autonomy over their lives.

Closing Remarks

Through globalization and the rise in technology, women can now seek alternative ways of having children (Sarojini et al. 2011:2). Western tourists who travel to India can attain cheaper surrogacy services while contributing to the economy in India. Whereas, surrogates can make a living and provide for their families; their bodies become an “economic capital” (Sarojini et al. 2011:2). Medical tourists who are coming from Western countries, do not face the same hardships as surrogates in India. Essentially, tourists are not fully realizing that their solicited services come at a cost for the surrogate. When tourists do not take into account the implications of surrogacy, they are continuing the cycle of physical and structural vulnerability towards women. A medical tourist’s intent in seeking surrogacy in India is to bring home the child that they could not bear themselves. Nevertheless, individuals who are providing surrogacy services face structural and physical dispositions, placing them in a power predicament that obstructs their ability to negotiate their rights. Despite the possibility to earn a substantial sum, surrogates still face physical and psychological harm. “Structural violence is structured and stricturing… It tightens a physical noose around their necks, and this garroting determines the way in which resources—food, medicine, even affection—are allocated and experienced” (Farmer 2004:315). The vast majority of surrogates in India are poor and cannot seek out education because of their socioeconomic status. The hope for surrogates is that their children will become educated and be free from poverty. Unfortunately, chances for post-surrogates to go back to school is quite slim, but at least their children may have the opportunity to enhance their status.

Works Cited

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Lunt, Neil, and Percivil Carrera. “Medical tourism: assessing the evidence on treatment abroad.” Maturitas 66, no. 1 (2010): 27-32.

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Pande, Amrita. “Commercial surrogacy in India: Manufacturing a perfect mother-worker.” Signs: Journal of Women in Culture and Society 35, no. 4 (2010b): 969-992.

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Saravanan, Sheela. 2010. “Transnational Surrogacy and Objectification of Gestational Mothers.” Economic and Political Weekly 45(16):26-29.

Sarojini, Nadimpally, Vrinda Marwah, and Anjali Shenoi. 2011. “Globalisation of Birth Markets: A Case Study of Assisted Reproductive Technologies in India.” Globalization and Health 7(1):27.

Singh, Holly D. 2014. ““The World’s Back Womb?”: Commercial Surrogacy and Infertility Inequalities in India.” American Anthropologist.116(4):824-28.

Venkatashivareddy, B., Arti Gupta, and Viviktha Ramesh. 2016. “Surrogacy: blessing or curse to poor society in India.” Healthcare in Low-resource Settings 3(2).

Vora, Kalindi. 2009. “Indian Transnational Surrogacy and the Commodification of Vital Energy.” Subjectivity 28(1):266-78.

Wong, Kee Mun, Peramarajan Velasamy, and Tengku Nuraina Tengku Arshad. “Medical tourism destination SWOT analysis: A case study of Malaysia, Thailand, Singapore and India.” In SHS Web of Conferences, vol. 12, p. 01037. EDP Sciences, 2014.

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Emma Abell-Selby is an undergraduate anthropology major at San Francisco State University. She is interested in social determinants of health, institutional and self-care practices, as well as historical and contemporary archaeology. Previously, she has worked on an archaeological collection from the San Francisco Presidio, where she studied the effects of compliance v. deviance on self-care and institutional care practices of U.S. military men from 1890 to 1950.