Gender and power dynamics in three types of injection partnerships among young women in rural Appalachia

BACKGROUND: Young women who inject drugs (YWID) face heightened risks for HIV, hepatitis C, and overdose that are shaped by the relational contexts in which they inject. Injection partnerships, defined as dyadic relationships between people who inject together, remain understudied beyond male-female intimate pairs. METHODS: We conducted 26 semi-structured interviews with YWID (ages 18-35) in rural Appalachian Ohio to explore dynamics within three partnerships types: dual partnerships with male intimate partners, family partnerships, and friend partnerships, with attention to female peer partnerships as a distinct subset. Guided by the Theory of Gender and Power and Bourdieu's concept of cultural capital, we analysed how access to resources, technical skills, and emotional bonds shaped power and risk across these relationships. RESULTS: Dual partnerships concentrated men's control over money, equipment, and injecting skills, limiting women's ability to negotiate safer practices and at times exposed them to violence. Family partnerships were pragmatic and offered little emotional or harm reduction support. Friend partnerships, particularly between female peers, redistributed injecting skills as care rather than control, fostering mutual protection but also normalizing distributive syringe sharing. CONCLUSIONS: Findings highlight female peer partnerships as a promising but underutilized context for harm reduction interventions tailored to YWID in rural settings.