The Role of the Forensic Nurse Examiner at the U.S.-Mexico Border
Submitted by Julie T. Bowles, MSN, RN, CCRN
Coming to the U.S.A.: Migrants and Gender-Based Violence
International migration and migrant safety are a concern worldwide. While politicians and nationalists worry about border security, ordinary people flee their homelands worldwide, seeking safety and security on paths often fraught with danger and violence. Over twenty years ago, women comprised 49% of all international migrants (un.org, 2004). More recent data from 2018 suggests that over 50% of migrants from low-income countries are female (Rubiano-Matulevich & Beegle, 2018).
The reasons for migration are complex and vary according to region and country. Violence, climate change, rising poverty, corruption, and economic instability are fueling a surge of migrants fleeing from northern Central America (known as the Northern Triangle and including the countries of El Salvador, Guatemala, and Honduras), Mexico, and other regions to walk thousands of miles in search of safety in the United States (IRC, 2022).
Historical Context of Migration
The Northern Triangle of Central America is one of the world’s most impoverished territories. It has one of the highest rates of homicide in the world outside of official war zones (Obinna, 2021). These Central American countries are sandwiched between the largest producers of illicit drugs in South America (Bolivia, Columbia, and Peru) and on a direct path to the country with the highest demand for illegal drugs in the world, which is the United States (Smith et al., 2020).
In addition to rampant cartel-related gang violence, decades of economic instability arising from civil wars and foreign interventionist regime change during the Cold War have contributed to a steady flow of migration from the Northern Triangle since the 1980s (Morales, 2021). All three Northern Triangle countries rank near the bottom for gross domestic product per capita among Latin American countries and Caribbean states and have suffered from environmental crises, including the destruction of coffee crops and back-to-back hurricanes in recent years (Cheatham, 2021).
Mexico has seen a curb in migration to the U.S. in recent years. Still, Mexicans living in border towns have higher migration rates than other municipalities due to proximity to the border and increased cartel violence in these communities (Latapi et al., 1998). The Mexican drug cartels are the leading suppliers of heroin, methamphetamine, cocaine, and other illegal drugs to the U.S. and contribute to Mexico’s high rate of homicides each year (cfr.org, 2021). These factors contribute to migrants crossing the border into the U.S. and seeking asylum.
Entrenched patriarchal cultures and toxic machismo in these countries contribute to gender-related crimes going unpunished and aggressors acting with impunity (Obinna, 2021). Femicide is the leading cause of female death in Northern Triangle Central American countries (Obinna, 2021). Mexico saw a 2.7% increase in femicide in 2021 to 1,004 deaths, despite an overall decrease in homicide in the country (Madry, 2022). Femicide has been defined as the killing of women by men because they are women and is the end of a cycle of terror and violence directed at women (Pasinato, 2022). These acts of violence, coupled with extreme poverty and cartel violence, motivate women and girls to walk sometimes over 2,000 miles to journey to what they view as safety in the United States.
A Violent Journey
Female migrants often suffer rape, assaults, and gun violence on the path northward towards the United States (Cleaveland & Kirsch, 2020). These women and children are frequently trafficked and forced to barter sex for protection along their journey from their homelands. These migrants are often forced to hire “Coyotes, or smugglers,” to protect them on their journey, often at exorbitant costs. These migrants become part of the human economy of migration (Cleaveland & Kirsch, 2020). One woman described being held in a “safe” house and forced to have sex with the smugglers or face physical violence and the threat of guard dogs (Cleaveland & Kirsch, 2020). Another related being gang-raped by a group of three men in the desert after being forced to walk naked for miles by her smugglers (Cleaveland & Kirsch, 2020). These stories are common. Women who can travel with male family members may not fare any better than those hiring so-called protection. One female migrant reported being abducted outside the city of Tuuxtla after walking with her cousin for four straight days. Municipal police picked the woman and her cousin up and drove them to a wooded area where they told the woman that if she did not have money, they would have raped her. The police then took all of her money and her cell phone and left her and her cousin for dead in the middle of the forest (Angulo-Pasel, 2018). These atrocities happen every day. From rape and physical assault to robbery and being witness to murders (Cleaveland & Kirsch, 2020) countless women are subjected to horrors for which they may never recover.
Violence Does not End at the Border.
Women living in border towns are poor and living in vulnerable conditions, often travelling dangerous routes to work for low wages in unsafe conditions (Ferreira, 2020). Female migrants endure abuse for fear of being deported or separated from their children (Ferreira, 2020). These women would rather endure abuse than be separated from their children. As a mother, this writer cannot fathom the difficult choices these women are forced to make every day to survive.
The violence does not stop at the border towns. An epidemic of sexual assault has been reported in detention facilities across the United States. Data from the Department of Homeland Security’s Office of the Inspector General indicate that in the years between 2014 and 2016, there were 1,016 reports of sexual abuse filed by people in detention nationwide. Of those reports, 2.4% were investigated (O’Leary, 2019). Migrant women and children are particularly vulnerable to sexual assault and abuse in these facilities. One migrant from Central America made it to the United States and was granted asylum due to credible threats of persecution in her home country, only to be allegedly sexually assaulted by an ICE agent on her way to the airport (ACLU.org, 2022). It is reported that the agency was to fire the individual, but the outcome is unknown.
Other allegations of sexual assault by ICE guards exist at detention facilities in El Paso, Texas. A complaint filed by a Texas advocacy group alleges that guards systematically engaged in a pattern and practice of abuse, often in areas of the detention center not seen by security cameras (Kriel, 2020). Data from 2010 to 2016 reveals approximately 14,700 complaints of sexual and physical abuse by ICE, with only a fraction being investigated by the Office of Inspector General (Kriel, 2020).
Rights of Migrants and Implications for Nurses.
Under U.S. immigration law, migrants have a legal right to seek asylum and, if granted such, may lawfully remain in the United States (UNHCR.org, 2022). Despite this law, many migrants cannot effectively argue their case in court. Many do not have access to an attorney and do not speak the language (Moore, 2022). The Istanbul Protocol was developed by the United Nations in 1999 to assist healthcare providers and advocates with the documentation of torture and its consequences. It is used domestically as a guide for documentation of human rights violations (Payne, 2018). Immigrant victims are protected under the UN Convention against Torture and may remain in the United States legally for this reason (Payne, 2018). Despite legal protections and as a result of the aforementioned barriers, many migrants are inappropriately denied asylum. After journeying sometimes thousands of miles from their home and facing countless untold threats and abuse, these women are turned away and often separated from their families. They are not granted asylum and do not receive treatment for the real trauma they have experienced on their journey northward. They face going back to their homeland and the possibility of more violence, poverty, and death.
Questions remain as to how best to access and provide help and treatment for these migrants, many of whom have been subject to physical violence and sexual assault. Many violent incidents go unreported due to fear of reprisal and lack of trust in law enforcement. It is estimated that 6 in 10 female migrants are sexually assaulted on their journey to the United States (Soria, et al., 2020), but underreporting of these assaults may make this number higher than 60%. Forensic nurse examiners and other healthcare providers face unique challenges in helping a population that will not voluntarily seek help due to these and other factors. Couple these challenges with a border region that is extensively rural and a poor, uninsured population, and one will see these challenges become natural barriers to healthcare access (Lady et al., 2017).
There have been efforts to address these challenges by introducing a SANE program in a U.S.-Mexico border town. The program received 3-year grant funding and increased access of these providers to a rural area where the nearest healthcare facility with SANE nurses was 150 miles away (Torregosa et al., 2022).
Women from the Northern Triangle of Central America and Mexico are taking the dangerous journey towards the United States, seeking safety, a refuge from poverty and danger, and a better life. These women routinely experience violence in their home countries and then experience repeated abuse and violence on their dangerous journeys northward. Sexual Assault Nurse Examiners (SANE) play a critical role in helping to identify victims of violence and trafficking in their intake process (Payne, 2018). Accurate and careful forensic documentation may not only solve crimes in these cases but also help to advocate for victims seeking asylum in court, utilizing the Istanbul protocol (Payne, 2018). Nurses are first-line responders for these victims of abuse and trafficking. Each time a nurse recognizes a victim of abuse and provides critical forensic services, she saves a life. It is this author’s opinion that healthcare is a human right. Safety is a human right and no one individual is illegal. Florence Nightingale is widely considered to be the founder of the nursing profession. She believed that everyone is equal and deserves equal rights and opportunities (Selanders and Crane, 2012). It is appropriate that nurses lead by her example and provide care for this vulnerable population. These women need nurses now more than ever. We should be honored to have the ability to serve them.
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