Human Trafficking of Immigrants and Refugees in North Carolina

Ifeoma

I have interviewed many foreign-born victims of trafficking; some of their stories remain indelible, while other stories meld into a compilation of sadness joined by their commonality. “Ifeoma” is a character; her story encompasses the multiple narratives of human trafficking victims that I have met while conducting research. She was brought to the United States under false pretenses by acquaintances from her African village introduced to her by a “facilitator,” an extended member of her own family. This family member knew that Ifeoma was recently widowed with five children; one child suffered from sickle cell disease and the family was unable to provide medical care or food and shelter. Ifeoma's traffickers, a couple living in the United States, promised paid work caring for their children and an opportunity for Ifeoma to attend school. After arriving in the United States, Ifeoma quickly learned that she would not be allowed to attend school and that she would be required to work without time off. She spent years away from her family, told that her pay was sent abroad to care for her children — a lie. She was coerced by the fear that her traffickers would report her to immigration and that she would be arrested; she was confined, isolated from everyone except for her traffickers and their minor children, and abused psychologically and physically. She was prevented from receiving medical care when she was sick until she became seriously ill, prompting her traffickers to bring her to the hospital. In this setting, her nurse recognized “red flag” indicators of human trafficking during the assessment and screening process. When rapport was developed, Ifeoma was able to confide her situation to her nurse. This was Ifeoma's end and her beginning.

Legal definitions of immigrants, migrants, and refugees can have subtle differences while also being very complex. As a general category, immigrants include all those who arrive legally as well as those who cross borders without documentation, often referred to as undocumented migrants. The distinction between immigrants, migrants, and refugees can be crucial; such distinctions relate to US immigration policies and may dictate one's length of stay and governmental services that can be received. By definition, refugees flee their country due to a well-founded fear of persecution. Their petition for status is vetted by a series of organizations including the United Nations High Commissioner for Refugees (UNHCR); the Refugee Support Center (RSC) through the US Department of State's Bureau of Population, Refugees, and Migration (PRM); and finally the Department of Homeland Security's US Citizenship and Immigration Services (USCIS) if they are resettled in the United States.

Refugees and immigrants (both legal immigrants and undocumented migrants) are at particular risk of becoming victims of human trafficking. Undocumented migrants have illegally entered the United States without proper documentation and may have agreed to be smuggled into the country understanding that they are subject to deportation [3]. A large number of undocumented migrants, specifically women, experience sexual and physical exploitation before, during, and after their passage (L. Cook Heffron, unpublished data, 2015). Smuggled migrants may be forced into trafficking, forced labor, or sexual exploitation upon arrival thinking they have to “pay off” their smuggling debt. Legal immigrants and refugees may also be convinced to rely on nefarious people or groups who can easily control and mislead them for the sole purpose of making money or providing a service for the trafficker. Fraud and deception are often employed to manipulate foreign-born victims, who are often unfamiliar with US laws and policies; language and cultural barriers may further limit their ability to understand their rights, trust authority figures, and seek assistance [3].

What is Human Trafficking?

Regardless of their immigration classification, victims of human trafficking are identified using a definition initially based on the United Nations' global definition (2000) and current US federal laws (Victims of Trafficking and Violence Protection Act [TVPA] and Violence Against Women Act). The TVPA defines human trafficking as “the recruitment, harboring, transporting, provision or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, slavery, or forced commercial sex acts” [4]. The terms force, fraud, and coercion are paramount to the TVPA's definition of human trafficking as they depict a victim's lack of human agency and the trafficker(s)' abuse and manipulation of their victim(s). Human trafficking falls into two categories: sex trafficking and labor trafficking. Some reports indicate a third category that combines sex and labor trafficking.

Evidence

Despite being the fastest growing crime in the United States, human trafficking is notably under-reported; consequently, statistics on human trafficking are difficult to compile [5]. Data collected from 40,000 case contacts (each possibly reflecting more than one victim) made by the National Human Trafficking Hotline and Polaris' BeFree text line during 2007-2017 are often used for reports but do not provide a full scope and scale of this crime. The national data that we do have shows 8,759 trafficking cases in 2017, an increase of 13% from the previous year [5]. Data reflects that females rank significantly higher than males as victims. Latinos and Asians are the largest number of minority victims; not surprisingly, the top risk factor for human trafficking is recent migration/relocation [6]. North Carolina's 2018 statistics report 297 calls and 126 human trafficking cases (these include both US-born victims and foreign-born victims) reported to the National Human Trafficking Hotline, ranking us 8th in the nation for number of reported human trafficking cases [6]. This ranking may reflect our state's progress in developing and disseminating materials to raise awareness of human trafficking and consequently greater success in identifying victims. Other reasons for North Carolina's high ranking may be our state's proclivity as a site for human trafficking due to our agricultural industry and need for migrant labor, multiple thoroughfares that connect northern and southern states, a rise in the number of gangs, and the location of businesses that cater to the sex industry near our military bases [6]. Additionally, 2018 North Carolina statistics report approximately equal numbers of foreign-born and US victims, perhaps reflective of North Carolina's steady in-migration of refugees and immigrants [7].

Human Trafficking as a Public Health Issue

Human trafficking is a felony in North Carolina as well as a public health concern. There is a fundamental need for health care providers to implement human trafficking awareness programs and develop specialized training to effectively and accurately identify victims [8] since many victims do not come forward on their own. As first responders, health care providers may have the initial or only contact with a victim of human trafficking, especially when the victim is currently enslaved. These caretakers may be doctors, nurses, and other health care professionals serving in hospitals, clinics, and other public and private institutions. Patients may initially present with physical injuries resembling medical neglect or harm due to sexual assault or domestic violence; therefore, medical providers must become adept at interviewing human trafficking victims, understanding their nonverbal cues, and accurately assessing their medical and mental health needs to prevent misidentification. It is also essential that health care providers receive specific education to competently serve foreign-born victims of human trafficking as these patients and their captors may easily go unnoticed and fall through the cracks.

Trafficking and North Carolina

North Carolinians have worked diligently to combat human trafficking. There are a number of significant accomplishments that can be pointed out: We have 12 rapid-response teams throughout the state, a mandatory training program for law enforcement, and numerous nonprofit agencies dedicated to providing human trafficking awareness, education, and services in our community. The first shelter in the nation to house boys who have been victims of sex trafficking opened in North Carolina. Our state wisely utilizes a number of national and local resources such as the Blue Campaign, the National Human Trafficking Resources Center (NHTRC) that serves as our state's official hotline for human trafficking, and Project NoREST, which is charged with circulating the hotline number throughout our state.

North Carolina's Human Trafficking Commission has worked collaboratively with a variety of stakeholders and coordinated efforts between government and non-government agencies have yielded positive outcomes. Shared Hope International (SHI) compiles a yearly state-by-state report card that assesses each state's handling of human trafficking cases and their legislative advancement in sex trafficking and commercial sexual exploitation of children (CSEC) cases. North Carolina's rating increased three grade levels from 2011 to 2018; in 2017 we earned a B and our 2018 score is an A [9].

North Carolina has worked diligently since 1983 to pass legislation related to human trafficking, and the General Assembly has enacted several statutes to combat it. Many of these laws specifically focus on protecting child victims, such as GS.14.430-20, known as Safe Harbor/Victims of Human Trafficking, which “provides protections for and responses to minor victims of human trafficking” and mandates that law enforcement and child welfare develop plans of action [6]; and a 2013 bill primarily sponsored by Senators Goolsby, Bingham, and Newton known as “An Act to Add the Offense of Human Trafficking to the List of Criminal Convictions That Require Registration under the Sex Offender and Public Protection Registration Program.” However, very few North Carolina accomplishments specifically relate to foreign-born victims of human trafficking.

North Carolina is fortunate to have strong leadership and governmental support to address human trafficking. We have access to a variety of tools and educational materials to support victims, community stakeholders, and first responders. In particular, health care professionals have access to a variety of resources including: screening tools, assessment cards, a health care brochure, a poster, and a pocket card. However, more work is needed.

Some Future Needs

Despite the significant work that North Carolina has done to address sex trafficking of US victims, culturally relevant information and resources to assist health care providers in serving foreign-born victims of both labor and sex trafficking is particularly lacking and sparse. The United Nations Office of Drugs and Crime website provides access to officially documented cases of human trafficking around the world [10]. A review of North Carolina cases documents labor trafficking of migrant workers who were controlled by physical violence and a case where a migrant worker was denied medical assistance for heat stroke and died on a bus where he was placed after collapsing in the field.

This same website describes two North Carolina sex trafficking cases of foreign-born teenage girls, one victim from Mexico and the other from Honduras. They were forced to have sex with dozens of men a day and traded among various traffickers.

To address victims' needs, culture-specific education and training for working with foreign-born victims should be required. This training is necessary to properly and consistently identify victims of human trafficking, as misidentification often occurs with foreign-born victims. Health care professionals may continue to provide medical care as victims' long-term needs are identified. Foreign-born victims benefit from a culturally relevant, trauma-informed, and survivor-centered approach. A continuum of care model includes interdisciplinary coordination of services (legal, medical, law enforcement, social work, etc.), skilled interpretation and translation services, and an understanding and appreciation of cultural barriers and trauma that may prevent victims from accepting, utilizing, and accessing services [3]. At the system level, there are needs for improved communication between NGOs and Department of Social Services agencies regarding processing certification letters that formally recognize the client as a victim of trafficking; this is required to receive work authorization and social service benefits through the Department of Health and Human Services Office of Refugee Resettlement.