Background
Globalization, political instability and increasing economic and social disparities between low, middle and high-income countries have led to growing waves of transnational migration [
1]. Throughout the migration experience, women asylum seekers endure multiple hardships including sexual violence, the absence of social support, and the inability to avail themselves of the protection of their countries of origin or any other institutional or legal recourse [
2‐
4]. Increased transnational migration also has challenged nation-states and societies to reassess their definitions of citizenship and their willingness to integrate refugees politically, economically and socially [
1,
5]. This tension is reflected in the degree of access to state-provided services, like health care to migrants - including those with claims for asylum [
1,
5].
These issues have become particularly salient for Eritreans in Israel where there has been substantial anti-African asylum-seeker sentiment reflected in the media and in the law [
6,
7]. Since 1951, less than one-percent of asylum seekers in Israel have been granted official political asylum (refugee recognition) [
8]. While over ninety-percent of Eritrean asylum seekers are granted refugee status in host countries around the world [
9], until 2015, Israel only recognized two asylum seekers as refugees [
10,
11]. This is because the Israeli government offered Eritrean asylum seekers ‘group protection’ while encouraging self-deportation though detention and financial support for leaving the country [
12]. In 2013, the government allowed processing of individual claims for refugee status [
12]. However, for the vast majority, the government has either rejected or failed to act upon their request. This has left Eritreans in a legal limbo in which they are neither granted official refugee status and the accompanying rights to the social welfare system and the formal work sector, nor are they being deported [
6,
13].
According to the United Nations [
14], approximately 4000 Eritreans flee their country each month [
15‐
17]. Some leave for the refugee camps in northeastern Ethiopia and eastern Sudan, while others try to reach North Africa, the Middle East, Europe, Canada and the United States [
15]. The majority of the hundreds of thousands of Eritreans leaving have fled to countries in the region including Ethiopia, Sudan, Israel, Egypt, and Kenya [
15,
16]. While the initial exodus of Eritreans was predominantly male, in recent years large numbers of Eritrean women began leaving the country, often following their husbands and other family members [
13]. Informal estimates indicate that 7000 of the approximately 35,000 Eritreans asylum seekers are women, the overwhelming majority of whom arrived in Israel after 2009 [
18].
1
Israel has been a preferred destination, and until 2012, Eritrean refugees often sought to move there from Libya, Sudan, Ethiopia and Egypt [
19]. This was because, until recently, the forced repatriations at the border and “voluntary” repatriations of Eritreans from Israel were far lower than those reported from Libya, Sudan, and Egypt [
16]. In addition, Israel was perceived to offer a more hospitable social and economic environment than neighboring countries [
16,
20]. While the vast majority of Eritreans who have entered the country since 2007 do not have permission to work officially, the money earned working informally is enough to sustain themselves, help pay their debts, pay the diaspora tax (2%) [
21] if they fear for their families’ safety or assets, and send remittances to their families in Eritrea [
13,
20].
The challenges faced by asylum seekers in Israel as a result of their temporary status have been well documented by humanitarian organizations, activists, scholars and the affected community itself [
6,
7,
11,
12,
22]. Temporary protected status, and its stipulations banning asylum seekers from working in the formal sector [
13], may result in political and economic marginalization that affects the lives of asylum seekers and shapes the risks they incur, particularly for women. Most research on sexual violence and exploitation of migrant women, including studies conducted in Israel, focus on sex trafficking in the host country, experiences during war in the home country, and experiences of violence in refugee camps [
23‐
38]. Little research has been conducted on the sexual violence and exploitation experienced by asylum-seeking women in Israel, despite the evidence that this is a particularly vulnerable group [
33,
39]. This study seeks to extend previous research by addressing how ‘temporary protected status’ and its impact on work opportunities and living conditions influences vulnerability to sexual violence and exploitation.
The organizing framework for this paper is Zimmerman’s model for migration and health [
40]. The model conceptualizes contemporary migration as a “multistage cycle that can be entered into multiple times, in various ways, and may occur within or across national borders”. According to this theory, migration includes the following stages: 1) pre-departure; 2) travel; 3) destination; 4) interception; and 5) return. Zimmerman’s theory states that understanding of the events at each stage is critical to comprehending the cumulative impact of migration on health and for strategizing appropriate interventions [
40].
We focus on the destination stage of the framework for two reasons. First, there is a dearth of research on asylum seekers and their vulnerability to violence and exploitation in their host countries in the industrialized world. Second, sexual violence and corresponding negative health outcomes that occurred during the travel stage may be compounded by additional negative experiences at the destination stage.
In order to provide a more comprehensive understanding of the “built in” barriers that shape the experiences of the study population, we applied the theoretical lens of structural violence [
41,
42]. This lens provides a framework for understanding the “structural vulnerability” [
43] of marginalized populations and that individual agency is constrained by the wider risk environment [
44]. Finally, exploring these women’s vulnerabilities to abuse, and their potential connection to national immigration and asylum policy, may lay the groundwork for future research and evidence-based policy changes at local and state levels [
33].
Methods
We conducted both in-depth individual interviews (“IDIs” with key informants and Eritrean community members) and focus group discussions (“FGDs” with Eritrean community members) (see Questionnaires for IDIs and FGDs Additional file
1). The IDIs enabled us to understand the breadth of individual experiences; while the FGDs served to gather information about social norms. Conducting both IDIs and FGDs allowed us to compare and contrast perspectives [
45‐
47] of key informants and members of the Eritrean asylum-seeking community in Israel [
45‐
47].
With the input of collaborators at Johns Hopkins and Ben Gurion University investigators, we developed guides for IDIs and FGDs. Then, with the help of a team of experts from the NGO and Eritrean community in Israel, we pre-tested and refined the guides among Eritrean community members and NGO workers. All study participants were at least 18 years old. In Phase II all participants were of reproductive age (between 18 and 49 years old). We obtained informed written consent from key informants and written or oral consent from asylum seekers (those who feared providing a signature provided oral consent) prior to each interviews. We took detailed notes and audio-recordings of all Phase I and Phase II IDIs and FGDs. Finally, we developed a referral list of existing services in the event that participants requested support (social, psychological or otherwise).
Phase I
The study was conducted in two phases. Phase I (December, 2012 to April, 2013) focused on barriers to contraceptive care-seeking from a health systems perspective. During Phase I, IDIs with 25 key informants (20 Israelis, one American and four Eritreans) were conducted by the lead author. The lead author is fluent in Tigrinya and English and conducted four interviews with Eritrean key informants independently. The lead author, with the help of an Israeli research assistant fluent in Hebrew and English, conducted the remaining 21 interviews with Israeli participants in English (and Hebrew when necessary) (see Table
1).
Table 1
Participants by Phase
Phase I | Semi-structured IDIs | Key informants (governmental and non-governmental health care and other service providers) | N = 25 individual interviews |
Phase II | Semi-structured IDIs | Eritrean men and women | N = 12 Individual interviews (n = 6 male; n = 6 female) |
| Semi-structured Focus Group Discussions | | N = 8 focus groups (4 with males and 4 with females; 4–8 people per group) N = 44 participants |
Phase I participants worked with the Eritrean asylum-seeking community in Israel (one of the eligibility criteria). Phase I participants were recruited from a list provided by various domestic and international NGOs, the Ministry of Health, private clinics and from researchers at an Israeli university [
48]. Interviews lasted approximately one to two hours.
Our Phase I interviews investigated three core topics: reasons for unwanted pregnancies; accessibility of contraception services for Eritrean women in Israel; perspectives on vulnerability of Eritrean women to sexual violence and exploitation en-route to and in Israel; and the general experiences of Eritrean asylum seekers navigating the Israeli health system. Recruitment ended after reaching data saturation (i.e. no new themes emerged during data analysis) [
49].
Phase II
Phase II (April 2013 to September 2013) focused on Eritrean community members’ perspectives on both family planning and their access to contraceptive services in Israel. Phase II consisted of 12 IDIs (six with women and six with men) and eight FGDs (four with male and four with female members of the Eritrean asylum-seeking community, total
n = 44). All Phase II IDIs were conducted in a private room in Tigrinya. Phase II participants were eligible if they were Eritreans of reproductive age (between 18 and 49 years old), who arrived in Israel after 2007 and lived there at the time. In-depth interview participants were not eligible to participate in FGDs (see Table
1).
In-depth interview participants were recruited from the PHR-Israel “Open Clinic” an Israeli NGO health facility that provides health services to the uninsured. The research team identified the “Open Clinic” as a recruitment site through the ethnographic mapping of health facilities where asylum seekers frequently obtain healthcare services (one of two humanitarian clinics serving this population in Israel). All interviews lasted between one and three hours. The interview guide investigated three core topics: knowledge of contraception methods, barriers to contraceptive careseeking, and vulnerability to unwanted pregnancies.
FGD participants were both purposively sampled (through contacts with community activists, researchers and staff at the Open Clinic) and snowball sampled [
48]. Due to concerns about detainment and deportation as well as internal political tensions within the Eritrean asylum-seeking community, the initial set of purposively sampled FGD participants were asked to recruit up to seven other people they felt comfortable sharing with to participate in a group session, for a total of four to eight members per group [
50,
51]. FGDs (held separately for women and men to observe any social norms that differed by gender) lasted between one to three hours. Refreshments were provided for participants.
The lead author conducted FGDs in locations that participants considered discrete and safe (e.g. back rooms in participants’ stores, homes and NGO meeting rooms). The FGDs explored social norms regarding fertility, unwanted pregnancy, and family planning.
Translation and data analysis
Professional transcription companies (one based in the United Kingdom and the other in Ethiopia) not affiliated with the study team fully transcribed all interviews. Interviews conducted in English were transcribed directly; interviews conducted in Tigrinya were translated and then transcribed into English by professionals fluent in both languages and then a select number were back-translated by the lead author. The lead author conducted all qualitative analyses from the onset of data collection until June 2014.
The lead author employed open, focused and axial coding using ATLAS.ti software for all data collected during Phases I and II (Atlas.ti, Berlin, Germany) and discussed themes with the group. Axial coding of focused codes was used to identify the themes described. Throughout the coding process written memos informed the conceptual development of codes and themes [
52]. Member-checking with a sub-sample of key informants and Eritrean participants provided an opportunity to share findings and to assess the trustworthiness of results [
46].
Ethical approval for this study was obtained from both the Ben Gurion University of the Negev, the Physicians for Human Rights Israel, and the Johns Hopkins University Bloomberg School of Public Health Institutional Review Boards.
This paper explores experiences of sexual violence and exploitation of Eritrean women in Israel. Analyses on barriers to contraceptive careseeking and violence en-route to Israel are reported elsewhere [
53,
54].
Discussion
The core finding of this paper is that there may be a connection between state-level policy and women asylum seekers’ vulnerability to sexual violence upon arrival in their host country - the “destination” stage of Zimmerman’s model [
40]. Our results suggest that women’s provisional status and relegation to the informal work sector heightens their vulnerability to sexual violence (e.g. from employers and fellow-countryman) and further hinders their ability to take legal action. These factors also perpetuate the economic challenges these women face, exacerbating their impoverishment, driving involvement to prostitution and crowded living conditions and consequently putting them at further risk.
Zimmerman’s model provides a framework for understanding that the experiences of sexual violence and exploitation are cumulative over multiple stages of movement [
40,
55‐
59]. Zimmerman’s model does not however delve into the political and economic environments in the destination country and their role in increasing risk of sexual violence [
40]. Using the theory of structural violence
2 [
41,
42] we were able to explore how restrictive immigration policy in Israel may have had repercussions in terms of the exigency that women have to seek necessary employment in unregulated sectors where they may be more vulnerable to sexual violence and exploitation, with little recourse to institutional support or protection. The unpacking of Zimmerman’s “destination stage” through the lens of structural violence [
42] enabled us to explore the ways in which politically-driven social inequalities contributed towards increasing women’s risk of violence and exploitation.
Political and economic marginalization in Israel affected all Eritrean participants in the study (including men). The majority of the 81 participants (37 individual interviews and 44 focus group participants) whose views are reported here claimed that Israeli policy granting them only provisional status (and the resulting barriers to employment in the formal sector) contributed to their marginalization within Israeli society. Israel’s policies leading to structural vulnerability (e.g. not being able to have work permits) were perceived to render Eritrean women (in particular) vulnerable because they lack trusted, stable and secure social support, affordable shelter, or the ability to earn a legal income enabling them to live independently. The informal policy of directly sending asylum seekers to Tel Aviv without providing additional support (in effect prior to 2012), was described as an example of a practice that resulted in many women arriving in Tel Aviv without money, connections or shelter. The lack of refugee assistance was reported to leave new arrivals dependent upon strangers for food, lodging, and employment. Participants stated that one of the repercussions of built-in exclusion from the social welfare system was an increase in sexual violence perpetrated against Eritrean women asylum seekers.
Policies giving rise to political and economic exclusion also were perceived to have repercussions for women’s structural vulnerability, referring to the vulnerability that results from economic exploitation and gender and racial discrimination within society [
43]. The decision of the Israeli government to grant provisional status with a stipulation banning Eritreans from the formal work sector may, according to participants, create conditions that foster sexual abuse. Most Eritrean asylum-seeking women in our study worked as domestic workers in the informal work sector and did not have official refugee status, which limited their recourse for legal protection.
Our findings support previous research suggesting that migrants are at high risk of sexual victimization at every stage of their migration experiences including the time after their arrival at the country of destination [
3,
4,
43,
60‐
64]. For asylum seekers who are not afforded protection under international refugee law in their host countries, risk of abuse is considerably higher than for those who are granted official refugee status [
33,
39,
65,
66]. This was relevant to the experiences of all of the Eritrean asylum seekers in our study as none of them were afforded the full protections of refugee status. All participants in the study had conditional release visas (temporary protection) that banned them from working in the formal work sector.
Studies in the Middle East, Europe, Asia and Africa, have found that migrant women without the legal status necessary for formal protection in the work sector are often sexually and psychologically abused by their employers [
33,
65,
67‐
69]. Our results reinforce these findings as women working in the informal sector indicated an increase in their risk of sexual violence by their employers. Similar to our finding that some Eritrean women asylum seekers in Israel resort to prostitution, research conducted in Europe found that marginalized African migrant women often rely on prostitution as a source of income [
34]. While we do not know of other research connecting crowded living conditions, migration and risk of sexual violence, results of this study suggested that this combination may influence risk of sexual violence and exploitation of asylum-seeking women. It may be argued that these risks are a form of structural violence that is embedded in the policies governing asylum seekers’ legal rights to settle as refugees.
We also explored the impact of political and economic marginalization on intimate partner violence. Research conducted in the United States and Europe found that the high prevalence of intimate partner violence in migrant communities is partly rooted in political and economic pressures affecting them [
70‐
72]. In addition to placing stress on a marriage, women who do not have legal status in a country or have other forms of non-permanent status do not receive necessary institutional support when experiencing domestic violence as they may fear for their own or their partner’s detention or deportation [
71,
73]. Our findings illustrate a similar situation for Eritrean women with provisional status, in which political and economic marginalization was suggested to serve as key stressors that fueled spousal abuse.
A major strength of this study is that it is the first of its kind to investigate Eritrean asylum-seeking women’s vulnerability to sexual violence and exploitation in Israel. Qualitative data about the experiences of Eritrean women in Israel allows for an in-depth exploration of the various circumstances of vulnerability in which Eritrean asylum-seeking women find themselves and their understandings of the factors creating their vulnerability. The use of information gleaned from interviews and focus group discussions with Eritreans allowed for a comprehensive understanding of the effects of political and economic exclusion and its implications for the sexual vulnerability of Eritrean women living there.
The inclusion of male Eritrean participants’ perspectives added an additional perspective, uncommon in most studies of violence against women. Male participants provided supportive detailed information about the experiences of sexual violence and exploitation faced by Eritrean women living in Israel. The willingness of men to discuss these traumatic events may be related to them not having been personally abused (men may have less fear of being re-traumatization by sharing their narratives). While the information is indirect, it complemented the information shared by the women themselves. The use of male testimonies also highlights the psychological stressors that men experience when they observe this abuse. The women themselves shifted between first- and second-person narration. This might have been a mechanism for them to distance themselves from information that could be traumatic and stigmatizing.
The study also has limitations. The focus on the testimonies of eighty-one participants (based on 25 key informant interviews as well as 12 interviews and 8 focus groups with community members) may not reflect the variety of experiences of Eritrean asylum-seeking women living in Israel and it is possible that some women may not experience sexual violence or exploitation. The overwhelming majority of employed Eritrean women in Israel and in our study work as cleaners in the informal sector, therefore experiences may be different for those in other sectors. For those who have experienced it, this study may not comprehensively describe all of the possible circumstances of risk connected to their marginalization.
An important solution to the challenges facing this population would be to provide a more sustainable legal status to asylum seekers and to authorize them to work formally without interruption. This would likely lead to economic stability and to the reduction of violence as well as access to health insurance. Another potential solution to the risk of sexual violence and exploitation these women endure would be to provide asylum seekers with social support in the form of government-sponsored safe lodging. Information about the importance of reporting sexual abuse to the police irrespective of the perpetrators background should be shared with the asylum-seeking community.