The Role of Gender and Power Dynamics in Injection Initiation Events within Intimate Partnerships in the US-Mexico Border Region

Abstract

Women’s initiation into injection drug use often establishes a pattern of risk following first injection. This study explored sources of gendered power dynamics in injection initiation experiences for people who inject drugs. A qualitative subsample from two prospective community-recruited cohorts of people who inject drugs in San Diego and Tijuana provided data on the contexts surrounding injection initiation processes. Intimate partnerships were identified in initiation, and sub-themes were identified drawing on three concepts within the theory of gender and power. Building on the sexual division of labour, men were often responsible for access to resources in partnerships across both contexts, although there were limited accounts of women obtaining those resources. Extending the structure of power, women in San Diego reported that initiation events involving an intimate partner occurred from a position of vulnerability but expressed greater agency when providing initiation assistance. Regarding the structure of cathexis, social norms proscribing injection initiation among women exist, particularly in Tijuana. Gendered power dynamics are a multifaceted component of injection initiation events, especially for women in intimate partnerships. These results stress the need for nuance in how the intersection of risk, gender, and harm reduction is understood within injection initiation events across socio-cultural contexts.

Background

People who inject drugs are disproportionately impacted upon by HIV, hepatitis C (HCV), and bacterial infections (World Health Organization 2017). Furthermore, people who inject drugs are at greatest risk of these injection-related harms within the first few years of beginning injecting, likely due to their reliance on more experienced persons to teach them the skills necessary for injection, and the sharing of drug preparation equipment (Garfein et al. 1998). Additionally, drug injecting is a key risk factor for overdose death, especially given the current US opioid crisis and the availability of high potency, synthetic opioids such as fentanyl (National Institute of Drug Abuse 2018). Because of this, research has focused on understanding the contexts of transitions into injection drug use as they may provide important points of intervention for harm reduction education (Harocopos et al. 2009; Garfein et al. 1998).

Past literature has noted significant gender differences in injection initiation processes (Fraser et al. 2014; Bryant et al. 2010; El-Bassel et al. 2014). Women who inject drugs may be more likely to have been initiated by a male sexual partner whereas men may be more likely to have been initiated by a casual acquaintance (Rance et al. 2017; Bryant et al. 2010; El-Bassel et al. 2014; Fraser et al. 2014). In such contexts, women may be at even greater risk of blood borne pathogens due to increased rates of equipment sharing (Bryant et al. 2010; El-Bassel et al. 2014) and being more likely to be injected after their initiator (Fraser et al. 2014; El-Bassel et al. 2014).

Intimate partnerships have been identified as a particularly salient social context for individuals’ injection drug use initiation processes (Simmons, Rajan and McMahon 2012; Wright, Tompkins and Sheard 2007; Wenger et al. 2016). For people who inject drugs, intimate partnerships can be an important source of care, social protection, and insulation against stigma (Rhodes et al. 2017; Syvertsen et al. 2013). Intimate partnerships, however, have also been found to be sites for potential injection-related risk behaviour and HCV transmission. Injection equipment sharing among sexual partners can occur as an expression of caring, trust, intimacy and security, and reflects a prioritisation of relationship security over the potential risk of infection (Fraser, Rance and Treloar 2016; Rance et al. 2018, 2017; Guise et al. 2018).

Additionally, men may experience a “burden of care” in drug using relationships, by assuming the risk of obtaining illicit substances and being responsible for the cost of maintaining both their own and their partners’ drug supply (Simmons, Rajan and McMahon 2012). In some instances, the economic burden of partners trying to maintain their drug habits has caused women to feel coerced into injection by their intimate partners (Wright, Tompkins and Sheard 2007). Reports from women have detailed that the decision to switch from non-injection to injection drug use was due to their male partner’s inability to afford or obtain enough drugs to combat the couple’s increasing tolerance and the perception that injection is a more efficient method of use (Wright, Tompkins and Sheard 2007). Alternatively, women have also reported engaging in sex work in response to the financial pressures of maintaining their substance use within intimate partnerships (Iverson et al. 2015). Women’s vulnerability within intimate partnerships, however, comes within potentially complex relationship dynamics. For example, injection initiation can also result from women’s requests for, and active participation in, initiation (Simmons, Rajan and McMahon 2012).

Past literature has also highlighted the importance of geographical context for injection drug use behaviour. The Tijuana-San Diego region is a key node along a drug trafficking corridor that has shifted towards supplying fentanyl from Mexico into the USA (Dibble 2017), making this a critical region in which to understand drug injecting practices. In Tijuana, proximity to a US setting in which social norms protective against injection are comparatively weaker (Wagner et al. 2011), along with the migration of people who inject drugs from other parts of Mexico and deportees returning from the USA, have contributed to the expansion of the population of people who inject drugs (Volkmann et al. 2012). In the case of people who inject drugs in San Diego, the city’s high-volume border crossing and status as a transit point for drug trafficking increases the availability of drugs commonly used by injection (Volkmann et al. 2012). Current evidence suggests that these factors contribute to a San Diego-Tijuana environment conducive to injection-related harms (Rhodes 2002). Furthermore, gender differences in injection initiation process across these contexts have been found, with men in Tijuana, but not in San Diego, being twice as likely to provide injection initiation assistance when compared to women (Meyers et al. 2018). Further research is needed to fully understand the gendered nature of injection initiation dynamics within this international region.

Gendered power dynamics and geographical context, then, are potential contributing factors for injection initiation and assistance to it. Limited literature exists, however, examining the gendered power dynamics within injection initiation events across differing geographic contexts. We therefore sought to (1) characterise gender dynamics within injection initiation events, including both participants’ own initiation and their provision of injection initiation assistance to others; and (2) identify commonalities and differences in gender dynamics across two cities in a US-Mexico border region: San Diego, California, USA and Tijuana, Baja California, Mexico.

Methods

Conceptual framework

To expand on previous literature on the gendered nature of injection drug use initiation processes, this study employed the theory of gender and power. This framework contains three concepts that are posited to explain the culturally specific roles that women and men occupy (Connell 1987): (1) the sexual division of labour, which refers to the allocation of specific types of work based on an individual’s sex; (2) the structure of power, which refers to the inequalities in power between the sexes; and (3) the structure of cathexis, which refers to the social norms that determine appropriate sexual behaviour for women and that involve emotional attachments in social relationships (Connell 1987).

Each of these concepts is rooted in historical and sociopolitical forces that separate power and assign social norms on the basis of gender, and are maintained through societal institutions and social mechanisms (Wingood and DiClemente 2002). The theory has been adapted and expanded to further postulate that gender-based inequities and disparities resulting from the three aforementioned concepts serve to generate differing exposures and risk factors that impact women’s vulnerability to disease (Wingood and DiClemente 2002). The theory has also previously been modelled as it relates to condom use behaviours and has been applied to assess HIV-related risks among women (DePadilla et al. 2011; Wingood and DiClemente 2000). Additionally, the framework has been used to investigate the relationship between intimate partner violence and gender-based risk for HIV (Raj, Silverman and Amaro 2004). Due to the relevance of this theory to other gendered HIV-risk behaviours, such as injection drug use, the present study sought to add to the existing literature by analysing the sources of gendered power dynamics within injection initiation processes.

Sample and data collection

The parent study from which the data reported on here come, Preventing Injecting by Modifying Existing Responses (PRIMER), is a multi-cohort mixed methods study exploring the contexts and processes of injection initiation assistance (Werb et al. 2016). The methodology is described in detail elsewhere (Werb et al. 2016). Briefly, the study links existing cohort studies of participants who inject drugs to quantitatively and qualitatively explore the contexts and processes of injection initiation assistance provision. For this article, we used qualitative methods to assess the gendered context of injection initiation events among participants of two cohort studies within the parent study: the Study of Tuberculosis, AIDS, and Hepatitis C Risk (STAHR) II in San Diego, USA and the Proyecto El Cuete IV (ECIV) in Tijuana, Mexico (Robertson et al. 2014).

Initially, a purposive sample of participants who reported having assisted others in injection initiation was recruited, along with a sample of participants who did not report assisting others to bring further insight to the social norms and stigma associated with helping others to inject (Guise et al. 2018). Semi-structured qualitative interviews were conducted to explore participants’ experiences of injection initiation assistance as well as the gender differences, social norms, and contexts for assisting others (Werb et al. 2016). Interviews commonly lasted one hour and were conducted by social scientists with qualitative research experience with communities of people who use drugs. All interviews were audio recorded and transcribed, and Spanish language interviews were translated to English. For this article, an exploratory analysis was conducted with a subset of the qualitative data that were pertinent for the research aims, and a thematic approach guided by the theory of gender and power was utilised (Connell 1987).

A total of 42 participants (21 each in site; 27 men and 15 women) were interviewed for the parent study regarding injection initiation experiences, of which 21 (San Diego: 10,Tijuana 11; 19 who had provided injection initiation assistance and 2 who had not) indicated that intimate partnerships played a role in their injection initiation events. In consequence, intimate partnerships were identified as a core theme, and these narratives were analysed for power dynamics (Table 1). To further understand these accounts, the theory of gender and power guided a thematic analysis of gendered power dynamics within intimate partnerships. Those accounts that demonstrated unequal access to resources between the genders were coded as corresponding to the sexual division of labour, those that exhibited uneven distributions in power (i.e. instances of control or coercion) between men and women were coded as referring to the structure of power, and those that contained gender-specific social norms for injection initiation were coded as examples of the structure of cathexis. Of the remaining 21 participants who did not report intimate partnerships in injection initiation events (San Diego: 11, Tijuana: 10), 13 had provided initiation assistance, 4 had not, and 4 provided accounts that were too unclear to determine whether they had provided initiation assistance.

Table 1.

A subsample of PRIMER qualitative study participants that mentioned intimate partnerships within injection initiation events from San Diego, USA and Tijuana, Mexico (n = 21).

Location of Interview	Pseudonym	Gender	Age	Race/ Ethnicity	Reported Ever Providing Injection Initiation Assistance in Survey (# of persons)	Reported Ever Providing Injection Initiation Assistance in Interview	Referenced an Intimate Partner in Own Initiation	Referenced am Intimate Partner in Provision of Injection Initiation Assistance
San Diego	Sharon	Woman	62	Black	0	Did not assist	Yes	No
San Diego	Sandra	Woman	31	Hispanic	1	1	Yes	Yes
San Diego	Kim	Woman	43	White	4	2	Yes	No
San Diego	Arron	Man	34	Hispanic	1	3	No	Yes
San Diego	Barbara	Woman	32	White	0	She supported her son’s initiation with someone else’s help	Yes	Yes
San Diego	Agnes	Woman	56	White	1	2	No	Yes
San Diego	Patricia	Woman	54	Hispanic	3	3	Yes	Yes
San Diego	Jenny	Woman	48	White	1	1	Yes	No
San Diego	Kevin	Man	52	White	2	1	Yes	No
San Diego	Robert	Man	37	White	3	2	Yes	Yes
Tijuana	Aaron	Man	30	Hispanic	10	1	Yes	No
Tijuana	Nancy	Woman	39	White	1	Assisted multiple people, but unclear on how many	Yes	Yes
Tijuana	Martha	Woman	36	White	1	1	Yes	No
Tijuana	Edgar	Man	55	Hispanic	1	3	Yes	No
Tijuana	Lucia	Woman	36	Hispanic	2	14	Yes	No
Tijuana	Leticia	Woman	41	Hispanic	3	50	Yes	No
Tijuana	Julia	Woman	27	Hispanic	3	4	Yes	No
Tijuana	Bryan	Man	35	White	2	3	No	Yes
Tijuana	Polo	Man	41	Indigenous	1	1	No	Yes
Tijuana	Martina	Woman	38	Hispanic	1	1	Yes	Yes
Tijuana	Luna	Woman	25	Indigenous	6	“Like some 5 or 7”	Yes	No

Ethical approval was obtained from the Human Research Protections Programs of the University of California, San Diego and Universidad de Xochicalco in Tijuana. All participants gave informed consent and received $25 USD compensation for their time and travel costs. Pseudonyms were used in place of participant names to preserve anonymity.

Results

Initially, a thematic analysis of the narratives identified intimate partnerships as a core theme within injection initiation processes. A total of 21 participants (7 men and 14 women) identified intimate partners as having influenced either their own initiation into injection drug use or their provision of injection initiation assistance. Of this subset of participants, 17 referenced an intimate partner in their own initiation (San Diego: 8, Tijuana: 9), 10 referenced an intimate partner in their provision of assistance (San Diego: 6, Tijuana: 4), and 6 referenced an intimate partner in both their own initiation and their assistance of others (San Diego: 4, Tijuana: 2).

Narratives from those participants that reported intimate partnerships within accounts of injection initiation were further synthesised, and subthemes were identified through the theoretical framework. The mean age of the participants within this subset was 41 years (range: 25 to 62 years) and the mean number of people the participants reported assisting was 4 people. Nine participants (42.9%) identified as White, nine identified as Hispanic (42.9%), two identified as Indigenous (9.5%) and one identified as Black (4.7%).

The sexual division of labour: Limited resources and injection initiation

The narratives collected demonstrated sexual divisions in labour, across both San Diego and Tijuana equally, in that men were primarily responsible for obtaining and controlling the substances used and the other resources needed in their relationships. Conversely, women often recounted feeling constrained in their ability to secure necessary resources, which was a crucial factor within their injection initiation events. This dynamic is manifested within Sharon’s account below:

‘I started to inject because…at the time, the guy that I was dealing with [dating] was a drug dealer and he went to jail, and, um, he [asked] his brother to…bring me stuff over, but it wasn’t as much as I was used to doing, so I had an, uh friend—this girl—who told me that I would feel it if I would inject it.’ (Sharon, 62, San Diego)

This narrative shows how Sharon’s access to drugs was limited to what her partner could provide for her. In the absence of this resource, Sharon needed to find another way in which she could manage her drug use. Consequently, her limited resources and imminent withdrawal resulted in her initiation into injecting. Although Sharon’s own initiation into injection drug use involved a female friend, we observe that her male intimate partner, and the gender dynamics between them, played an integral role in this event.

The sexual division of labour is further evidenced within the following narrative from Polo, a man in Tijuana who initiated his intimate partner to treat her pain:

‘Everything started, I remember that…that she was pregnant, and her tooth hurt her a lot, and um… and I would buy her pills and it wouldn’t go away, and she was crying every day, and she had, like, three days like that. So, I know that heroin takes the pain away, right? And it was easy for me to tell her, “look I am going to give you 10 lines [from a syringe] and it’s going to calm your pain,” and yes. I did it for the first time. And that was it, I injected her. And she calmed down a little, and when it started again and [she said], “give me,” and like that.’ (Polo, 41, Tijuana)

Here, there is evidence of Polo’s intimate partner relying on him to care for her emotional and physical needs. Consequently Polo, distressed by his partner’s pain and the limited medications available due to her pregnancy, used the resources available to him to minimise the toothache that she felt. Polo was able to obtain resources that enabled him to buy pills and heroin, provide injection initiation assistance to his intimate partner, and tend to her emotional and physical needs.

Other narratives, however, illustrate that the sexual division of labour can conform less within initiation events. Below, Martha describes the division of labour between her intimate partner and herself, and how this division influenced her own initiation into injecting:

‘Yes, well… at that time I was working and my partner wasn’t so, when….it lasted like 15 days that he wasn’t working and he said... “lend me some money.” “Lend me money” in the morning, “lend me money” in the afternoon, “lend me money” in the night, so… here you have then… I said, “I am going to give you some more money to bring me some drug.” So, he went, and he brought, and he played like a fool, like he didn’t want to [provide initiation assistance]. He started saying stuff [to persuade her not to inject], I said “Stop it,” he said, “No, you stop it and I’ll also stop”… but he had already injected himself…so that’s how I used [injected] for the first time.’ (Martha, 36, Tijuana)

In this account, Martha was, at least temporarily, the person with access to financial resources within this relationship as a result of her engagement with sex trading. Despite Martha having access to money, her partner was still responsible for buying the drugs for them both, and he was ultimately the one who provided initiation assistance. Martha’s responsibility for the finances within the relationship, however, led to her ability to bargain for her initiation into injecting. While her partner originally refused, his own desire for drugs and his lack of access to money led to his acquiescence. This example suggests that the division of labour within injection initiation events can vary within intimate partnerships and by gender. Furthermore, the narrative shows that the distribution of resources, like money and drugs, within intimate partnerships can shape the power dynamics within initiation events.

The structure of power: Intimate partnerships, vulnerability, and agency

Evidence of power dynamics was found within accounts of the injection initiation events, specifically within the context of intimate partnerships. Intimate partners played a key role with respect to participants’ perception of both their agency and their vulnerability within initiation events, specifically for women in San Diego. For example, some women in San Diego reported initiating injection drug use as either an effort to win their partner back or to prevent them from leaving. Such accounts conform to previous reports that have emphasised women’s vulnerability and how injecting initiation can figure within efforts to stabilise potentially precarious relationships (Simmons, Rajan and McMahon 2012; Wright, Tompkins and Sheard 2007). Barbara’s narrative below is exemplary of this.

‘… And it broke my heart ‘cause I was—I had given up my apartment, given up my job, gave my mom temporary custody of my kids to come out to the streets for this guy who had been on the run. And he leaves me for some other chick, so I told him I wanted to slam, and he told me, “no.” I told him it was him or somebody we didn’t know and trust like that. So, he had no choice and he did my injection… so I figured I might as well do what it takes to get him back, so I figured I’d start with that, start selling drugs and start learning about it. And I did get [her partner] back.’ (Barbara, 32, San Diego)

In Barbara’s account of her own initiation into injection, she describes a loss of power with her sacrifice of resources and family, coupled with her intimate partner’s subsequent decision to leave her. Despite this experienced vulnerability, Barbara also displayed a certain level of agency in her response. She manifested this agency by convincing her former partner to provide initiation assistance, despite his initial refusal to do so. According to Barbara, her decision to join him in injecting served to bring her intimate partner closer to her, which resulted in reuniting them as a couple. This example shows that women who inject drugs may portray a nuanced tension between vulnerability and empowerment, specifically within intimate partnerships, in the context of injection initiation events. Barbara’s determination in initiating injection was undertaken within a broader context of vulnerability and fear of losing her partner. By Barbara’s account, her initiation into injecting was in fact, based on the constrained set of choices she had to maintain her relationship rather than for pleasure or drug experimentation.

This tension between vulnerability and empowerment was further highlighted by Patricia, a woman who recounted the initiation of her boyfriend. In this atypical account, Patricia demonstrated clear agency, and even manipulation, within her provision of injection initiation assistance to her boyfriend. While no other participants reported this type of manipulation within their accounts, Patricia’s account is nevertheless representative of one form of agency that women express within injection initiation experiences:

Patricia: ‘A boyfriend of mine he wanted to do meth IV [intravenously] and he had never done it before so I purposely gave him too much so that really he would have a bad high and so he would never do it again. It wrecked him he never did it again.’

Interviewer: ‘And why did you decide to…?’

Patricia: ‘He treated me like shit, so…plus…I was selling a lot of drugs at the time and he was trying to handle my business and get in my pocket… He was like, “well, I’m her old man so I get…” and he was getting in my pocket, and all of sudden he wanted to do drugs and wanted some. “Okay well, do some, watch this,” and I drew up a big shot and gave it to him. He never did it again.’ (Patricia, 54, San Diego)

Within Patricia’s account, in which she recalls providing initiation assistance to her male partner, she reports providing this assistance with too large of a dose to deter him from injecting, to keep him from taking her drug dealing business, and because he treated her poorly. Her use of power over her boyfriend, the source of which was her own expertise with injecting, was in response to a perceived financial threat. Additionally, Patricia had a history of physical abuse from her ex-husband and she thought that her partner at the time of this initiation event had not been treating her well. Consequently, she exerted power over the resources she had available to her to defend herself.

Despite the prominence of women’s agency within injection initiation events in many of the narratives, these accounts were often situated within a broader context of vulnerability, echoing past literature on how women experience vulnerability within intimate partnerships (Simmons, Rajan and McMahon 2012; Wright, Tompkins and Sheard 2007). As such, individual agency in the accounts of injection initiation events is often described as occurring in response to experienced or anticipated vulnerabilities; indicating that gendered power dynamics are not only constraining but are also productive of agency. This was especially evident in the accounts from the women in our sample, like Patricia, that displayed both histories of trauma and reactionary or exaggerated forms of agency in injection initiation. In these narratives, the agency expressed can be conceptualised as a form of self-defence that has developed from past experiences of vulnerability.

The structure of cathexis: Unacceptability of injection among women in Tijuana

There were no explicit references to the norms that govern acceptable behaviour for men and women within injection initiation events. The existence of distinct social mores for women, however, was implied within narratives from Tijuana. Specifically, participants highlighted the existence of norms pertaining to the unacceptability of injection initiation by, and for, women. For example, Lucia from Tijuana acknowledged these existing social norms as she explained her provision of initiation assistance below:

‘You’re not, technically, I’m not supposed to do what I do [initiate others], politically… wise, you know what I mean. But I do, I don’t give a shit. I’m evil, I guess, Rosemary’s baby, whatever you call it.’ (Lucia, 36, Tijuana)

Lucia, who had been injecting drugs for the past 14 years, also depicted herself as a tough woman who, not only has assisted others in their first injection, but also warns others about the strength they need to have when engaging in injection drug use:

‘When they see me do it [inject], [they’re] like, “chh, I wanna try it.” [I say] Oh, you sure? You sure? This is gangsta shit, this is gangsta shit, it ain’t for the weak, it is not for the, the, the, los que son bien débiles [the ones that are very weak], ‘cause it will consume your life if you let it.’ (Lucia, 36, Tijuana)

Lucia’s acknowledgement of the norms surrounding providing injection initiation assistance as a woman was evidenced by her own self-devaluation, specifically through her self-identifying as “Rosemary’s baby;” a reference to a popular movie in which the main character, Rosemary, gives birth to the devil’s son. Lucia’s response to requests for initiation assistance also indicate a degree of compensatory exaggerated agency, specifically in her warning of potential assistees and her description of injecting being, ‘not for the weak.’

These accounts highlight the existence of social norms proscribing women from engaging in injecting, as well as norms against women initiating others in Tijuana. In Lucia’s account, these two prohibitive social norms appear to have resulted in her self-devaluation and compensatory exaggerated agency in reference to her injection initiation experiences. Additionally, the following narrative from Israel in Tijuana further illuminates the structure of cathexis surrounding the initiation of women into injecting:

‘Well yeah, you know, here in TJ [Tijuana]… I always said, “you know, I am never going to inject a woman [as opposed to in the US]. Never.” And here in TJ, uh, I injected my own sister you know, and she’s brought friends that, you know, want to try it. All she cares about is getting high and, I have done it. I guess just to appease my sister, I guess, you know, so that she could get her…what she wants.’ (Israel, 44, Tijuana)

From Israel’s perspective, the initiation of women into injecting by men, as well as injection among women more generally, are both stigmatised practices in Tijuana. In line with past research on gender norms surrounding substance use, reproductive health, and mental health for people in Mexico (Firestone Cruz et al. 2007; Rafful et al. 2012; Robertson et al. 2014; Cleland et al. 2007; Robertson et al. 2011; Maternowska, Withers and Brindis 2014) , Israel’s resolution to never inject women in Tijuana potentially illuminates the existence of a higher moral order for women in Tijuana that is influenced by the traditional gender roles that appear to be more prevalent in the northern Mexican border region compared with large cities in Southern California (Schmitz and Diefenthaler 1998; Fragoso and Kashubeck 2000). This potential higher moral order for women in Tijuana was further exemplified by the following narrative from Polo:

Interviewer: ‘Do you think it’s [learning to inject] the same for women too?’

Polo: ‘Well yes, but the woman is more, like the service is more degrading.’

Interviewer: ‘In what sense?’

Polo: ‘Well, in what the women, well she prostitutes herself, or does things that just don’t fly. It’s uglier because I have seen it, for women the addiction is uglier.’(Polo, 41, Tijuana)

The perspective presented in Polo’s narrative further exemplifies the existing structure of cathexis and accepted traditional gender norms within Tijuana. From the previous account, it also seems as though Israel broke the pact he made with himself in regard to avoiding providing injection initiation assistance to women. He broke this pact, however, in the context of helping his sister obtain the dose of drugs she needed. This could indicate that, related to the greater moral sanction afforded women who inject drugs in Tijuana, there are social norms in which men are viewed as the providers and protectors of women. The resistance from men regarding the initiation of women, Israel’s unfulfilled desire to protect women, and Lucia’s description of self-devaluation indicate the presence of potentially powerful gendered social norms in this setting.

Discussion

Through our exploratory analysis of qualitative interview data collected in San Diego and Tijuana, we have examined the gender power dynamics in experiences of people who inject drugs in injection initiation events across contexts. Intimate partnerships were a common thread through the accounts of injection initiation and were further synthesised through the themes of the sexual division of labour, power, and cathexis. The gendered division of labour was seen equally across San Diego and Tijuana, with men often being responsible for attaining necessary resources in injecting intimate partnerships, but with evidence indicating that these divisions are dynamic and can shape power dynamics. Within intimate partnerships and injection initiation events in San Diego, women displayed a tension between vulnerability and empowerment. While much of the previous literature has emphasised the evident vulnerability of women who inject drugs (Wright, Tompkins and Sheard 2007; Simmons, Rajan and McMahon 2012; Wenger et al. 2016), the narratives presented here demonstrate that women’s experiences of vulnerability are multifaceted, with injection initiation events engendering not only vulnerability but agency as well. The results suggest, however, that the broader contexts of vulnerability that women who inject drugs are situated in, such as histories of trauma, unequal access to resources and context-specific gender norms (i.e., proscriptive norms against women injecting in Tijuana), play an important role in injection initiation events. Furthermore, while a limited number of narratives from men also reflected the sexual division of labour, the uneven distribution of power between genders and gendered social norms surrounding injection initiation, this theoretical model did not serve to fully capture the experiences of the men who had provided injection initiation assistance to other men. Consequently, research is needed to further explore the dynamics within men-to-men initiation, potentially with a more suitable theoretical framework.

These findings have important implications for future research and the development of interventions to prevent both the harms and incidence of injection drug use initiation. Future research could build on the information presented by quantitatively comparing these gendered sources of vulnerability and empowerment in injection initiation processes across geographic contexts with a larger, more diverse sample. Additionally, intervention and prevention services could be strengthened by the results of this investigation by accounting for the potential coercion that may exist for women within injection initiation events, as well as the agency women demonstrate within the context of initiating injecting. Past literature with people who inject drugs demonstrates that intimate partnerships can be an important site of care, support, and injection-related risk reduction in addition to the complex agency and vulnerability depicted in both existing literature (Rhodes et al. 2017; El-Bassel et al. 2014, 2014a; Fraser 2013; Fraser et al. 2017, 2014; Treloar et al. 2016) and in this analysis. Additionally, research has indicated that health education is more effective when it is either gender-transformative (Dworkin, Fleming and Colvin 2015) or tailored to specific segments of the population such as women or couples who inject drugs (Dwyer, Fraser and Treloar 2011; Treloar et al. 2016; Fraser et al. 2017, 2014). As such, the results presented in this qualitative analysis could serve to inform and develop gender-specific, and couple-focused, education and outreach services for people who inject drugs.

Additionally, the results highlight the importance of geographic context in the gendered power dynamics and social norms involved in injection initiation. For example, while intimate partnerships served to influence the sexual division of labour for both contexts and the gendered power dynamics for those participants recruited from San Diego, the participants from Tijuana, displayed differing gendered social norms in which injecting and initiation were heavily stigmatised for women. This could be due to the existence of more traditional gender norms in Northern Mexico that impact the acceptability of drug use and serve to constrain women’s roles within drug using scenes (Fragoso and Kashubeck 2000). Additional research is needed to fully understand this phenomenon and harm reduction efforts should be tailored to accommodate context-specific injection initiation factors.

Limitations

A number of limitations must be considered when interpreting these findings. First, injection initiation assistance, especially of close family and intimate partners, is a highly stigmatised topic. Consequently, it is possible participants underreported injection initiation assistance of intimate partners. However, study staff presented the rationale for this study and conducted interviews in a non-judgemental manner to minimise potential discomfort. Second, findings are based on specific samples of people who inject drugs located in urban areas. We sought to address this limitation by including samples of two contiguous urban settings that have distinct social norms pertaining to injection and gender roles.

Conclusions

Study findings indicate that intimate partnerships are an integral component of injection initiation events in our study setting, particularly for women. There is evidence that intimate partnerships may amplify gendered economic disparities in San Diego and Tijuana and may contribute to nuanced power dynamics that influence individuals’ initiation of injecting and their provision of injection initiation assistance in San Diego. There may also be important social norms in which injecting and the provision of injection initiation assistance on behalf of women is unacceptable, particularly in Tijuana. This may explain why the theme of gendered divisions of power within intimate partnerships were not as salient within the narratives of participants from Tijuana. Harm reduction programmes should adopt couple- and group-focused strategies that can respond to the found gender dynamics within injection initiation events for women in San Diego. Additionally, harm reduction efforts should be responsive to the differences in gendered norms and power dynamics within injection initiation across contexts, with traditional gender roles being a potential focus within Tijuana, Mexico.