Human Trafficking in Ethiopia: A Scoping Review to Identify Gaps in Service Delivery,Research,and Policy

Abstract

The purpose of this review is to integrate evidence on human trafficking in Ethiopia and identify gaps and recommendations for service delivery, research and training, and policy. A scoping literature review approach was used to systematically search nursing, medical, psychological, law, and international databases and synthesize information on a complex, understudied topic. The search yielded 826 articles, and 39 met the predetermined criteria for inclusion in the review. Trafficking in Ethiopia has occurred internally and externally in the form of adult and child labor and sex trafficking. There were also some reports of organ trafficking and other closely related human rights violations, such as child marriage, child soldiering, and exploitative intercountry adoption. Risk factors for trafficking included push factors (poverty, political instability, economic problems, and gender discrimination) and pull factors (demand for cheap labor). Trafficking was associated with poor health and economic outcomes for victims. Key recommendations for service delivery, research and training, and policy are identified, including establishing comprehensive services for survivor rehabilitation and reintegration, conducting quantitative health outcomes research, and reforming policy around migration and trafficking. Implementing the recommendations identified by this review will allow policy makers, researchers, and practitioners to take meaningful steps toward confronting human trafficking in Ethiopia.

Keywords

cultural contexts mental health and violence violence exposure sexual assault

Introduction

Human trafficking is a human rights violation that is occurring around the world in startling numbers (United Nations Office on Drugs and Crime [UNODC], 2004). Human trafficking involves three key elements: (1) an act such as transferring, transporting, or recruiting a person; (2) a means such as threat, coercion, force, fraud, or abduction to control the person; and (3) a purpose such as forced labor, sexual exploitation, or slavery (UNODC, 2004). Ethiopia has recently been identified as a country with a burgeoning human trafficking problem, although accurate rates of the number of trafficking victims are difficult to find (U.S. Department of State, 2014). The exact size and extent of the problem is not known, but media, government, and advocacy groups have increasingly raised concerns over human trafficking in Ethiopia in recent years, as reports of egregious human rights violations have emerged (U.S. Department of State, 2014).

Negative physical, mental, and sexual health problems have been noted among trafficking victims internationally, especially those trafficked for sexual exploitation (Oram, Stockl, Busza, Howard, & Zimmerman, 2012). The extent of these health problems and their prevalence among victims is unclear; however, it is clear that trafficking victims experience cumulative harm from the time they are recruited, throughout the time period of exploitation, with long-term consequences that persist during reintegration (Zimmerman, Mazeda, & Watts, 2011). Furthermore, as a vulnerable population, trafficking victims experience a multitude of social stressors during the exploitation and reintegration stages of trafficking that make it extremely difficult for them to reassimilate into their home countries. These stressors may include economic insecurity, occupational hazards, and legal uncertainties (Zimmerman et al., 2011).

Ethiopians are especially at risk for trafficking due to years of war, civil strife, famine, poverty, and gender inequity (Anbesse, Hanlon, Alem, Packer, & Whitley, 2009; Endeshaw et al., 2010; Minaye & Zeleke, 2015). Economic insecurity and poverty often push families to look for alternative modalities to support the family, and demands for workers in weaving and farming have pulled children and women into human trafficking to meet these demands (Endeshaw et al., 2010; Jibriel, 2014; Ynitso et al., 2009). Childhood marriage has also been identified as a risk factor for trafficking, as past studies have found a direct relationship between early marriage and migration (Endeshaw et al., 2010; Warner, 2004). Labor trafficking is the most common form of exploitation in Ethiopia, although sex trafficking has also been reported, and some researchers suggest that transnational adoption and organ harvesting should be investigated as forms of trafficking in persons as well (Bhabha, 2004; Lal Panjabi, 2010; Root, 2007).

Recent research on human trafficking in Ethiopia has focused on small qualitative studies to describe the problem. Although these studies have been critical to understanding the nature of the problem and the experiences of individual victims, very few quantitative studies or literature reviews have been conducted, making it difficult to take meaningful steps toward addressing the problem of human trafficking in policy and practice. To gain a thorough understanding of the magnitude of human trafficking in Ethiopia and begin to develop interventions and services for prevention, service delivery, and policy change, it is imperative the current literature be evaluated in a systematic manner. The purpose of this scoping literature review was to examine the phenomenon of human trafficking in Ethiopia and identify gaps in service delivery, research and training, and policy.

Method

Design

We chose to conduct a scoping literature review. Scoping reviews are often undertaken to synthesize and map topics that have not yet been thoroughly reviewed or when the topic is of a complex nature (Arksey & O’Malley, 2005; Levac, Colquhoun, & O’Brien, 2010; Pham et al., 2014). A scoping review involves (1) identifying research questions, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) summarizing and reporting the results (Arksey & O’Mally, 2005). Like other types of reviews, a scoping review is an iterative process but uses systematic methods to derive a synthesis of results (Arksey & O’Mally, 2005). Human trafficking in Ethiopia is an emerging area of research, and too few quantitative studies have been conducted on this topic to allow a systematic synthesis or meta-analysis. One systematic review has been conducted on mental health outcomes among labor-exploited children in Ethiopia (Fekadu, Hägglöf, & Alem, 2010). Our review builds on the foundation of this work by conducting a broader scoping review with an emphasis on recommendation for research, practice, and policy to address a wider range of human exploitation and adverse outcomes. As such, we included a broad range of study methodologies and types of reports. Ethical approval was not required.

Inclusion Criteria

Articles were eligible for inclusion in the review if they had a direct focus on Ethiopia (e.g., used a sample of the Ethiopian population, review of studies conducted in Ethiopia), were research or other professional reports, and were published in English. The population of interest was people trafficked into, within, or out of Ethiopia. The phenomenon of interest was human trafficking, as defined by the UNODC (2004) as

The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs. (Article 3, Para (a), p. 42)

Because of the paucity of research reports on this population and phenomenon, no time frame was specified and a broad range of publication types were allowed in the review including qualitative studies, quantitative studies, literature reviews, dissertations, theses, and government reports. (Peer review was not a requirement for inclusion.)

Search Strategy

Five electronic databases were used as information sources: CINAHL (nursing literature), Medline (biomedical literature), PsychInfo (psychology literature), Scopus (international literature), and LexisNexis (legal literature). The search took place from April 14, 2015, to July 23, 2015, using the search terms Ethiopia, human trafficking, sexual exploitation, trafficking, trafficking in persons, exploitation, labor coercion, migration, and slavery.

The abstracts of the resulting articles (n = 826) were first screened for the population and phenomenon of interest. Duplicate articles were removed at this stage. Articles were excluded if they did not relate to human trafficking, did not focus on Ethiopia, related to legal sex trading and migration, or focused on nontrafficked refugees. The resulting 57 articles were then evaluated in greater depth using the prespecified inclusion criteria. The reference lists of key articles were hand searched to identify additional relevant articles. The final number of articles that met the inclusion criteria for this review was 39. The four-phase flow diagram depicted in Figure 1 shows the literature search process.

Figure 1.

Literature search flow diagram with numbers of article exclusions made at each stage to arrive at the final number.

Data Extraction

Two reviewers critically appraised the studies and extracted data, and a third reviewer was available in case of disagreement. Data were extracted from the articles regarding risk factors, population and phenomenon characteristics, outcomes, interventions, gaps, recommendations, and study designs (if applicable). Because we used a scoping review approach, studies were not weighted according to study design (Arksey & O’Malley, 2005). However, we identified study designs and levels of evidence to review gaps in research and appropriate next steps using the Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence and evidence grading system (CEBM, 2009). These data were organized using a literature table, and a constant comparative approach was used to identify key themes (Glaser, 1992). Figures were generated using R, Version 3.2.1 (R Core Team, 2015, Vienna, Austria).

Results

Search Results

There were 39 articles that met our inclusion criteria. The time frame for research on human trafficking in Ethiopia was self-limiting, beginning in 2000 and continuing to the present. Figure 2 shows the frequencies of publications on this topic during this time frame.

Figure 2.

Publication time line showing the number of articles published each year for all articles included in the review.

Studies have been conducted in several different regions of Ethiopia and the Middle East, with the most studies taking place in urban areas. The characteristics of the studies included in this review are presented in Table 1 (location, sample, level of evidence, evidence grade, and design).

Table 1.

Study Characteristics.

Reference	Location	Sample	Level of Evidence^a	Evidence Grade (A–D)^b	Study Type
Abebe (2007)	Gedeo	None^c	Level 5	D	Qualitative
Abebe and Kjorholt (2009)	Gedeo	40 Children (10–18)	Level 4	C	Qualitative
Anbesse, Hanlon, Alem, Packer, and Whitley (2009)	Lebanon, Saudi Arabia, Abu Dhabi, Yemen	19 Women	Level 4	C	Qualitative
Azage, Abeje, and Mekonnen (2014)	Bahir Dar	417 Women (15–24)	Level 4	C	Cross sectional
Belay (2014)	Lebanon	None	Level 5	D	Narrative review
Beydoun (2006)	None	None	Level 5	D	Law review
Beyene (2011)	None	None	Level 5	D	Narrative review
Bhabha (2004)	None	None	Level 5	D	Law review
Blair (2005)	None	None	Level 5	D	Law review
Boyden and Howard (2013)	Amhara, Oromia, Southern Nations, Nationalities and People’s Region, Tigray, Addis Ababa	3,000 Children	Level 2b	B	Mixed methods
Endeshaw et al. (2010)	Addis Ababa, Bahir Dar, Awassa, Arba Minch, Dire Dawa.	67 Women and children and 38 professionals	Level 4	C	Qualitative
Fekadu, Hägglöf, and Alem (2010)	Ethiopia	37 Articles	Level 3a	B	Systematic review
Fernandez (2011)	Addis Ababa, Kuwait	35 Women and 19 professionals	Level 4	C	Qualitative
Fernandez (2013)	Addis Ababa, Lebanon, Kuwait	75 Women	Level 4	C	Qualitative
Fransen and Kuschminder (2009)	Ethiopia	None	Level 5	D	Narrative review
Gebre (2012)	Addis Ababa	400 Children	Level 4	C	Mixed methods
G/Hiwot (2013)	Metema	Eight women and four professionals	Level 4	C	Qualitative
International Organization for Migration (2014)	Ethiopia	None	Level 5	D	NGO report
Jibriel (2014)	Ethiopia	None	Level 5	D	Narrative review
Jones et al. (2014)	Hara, Tis Abay	48 Children	Level 4	C	Qualitative
Kassa and Abebe (2014)	Simalta Village	12 Children	Level 4	C	Qualitative
Kebede (2002)	Ethiopia	None	Level 5	D	Narrative review
Lal Panjabi (2010)	None	None	Level 5	D	Law review
Lawrance and Andrew (2011)	None	None	Level 5	D	Law review
Long (2012)	None	None	Level 5	D	Law review
Minaye (2012)	Ethiopia	Eight women	Level 4	C	Qualitative
Minaye and Zeleke (2015)	Addis Ababa, Wollo, Jimma, Tigray, Hadiya, Wulqite, Arsi	1,078 Men, women, and children	Level 4	C	Mixed methods
Murray (2000)	None	None	Level 5	D	Law review
Nagle (2008)	None	None	Level 5	D	Law review
Reda (2012)	Addis Ababa	Five women	Level 4	C	Qualitative
Refugee Review Tribunal (2006)	Ethiopia	None	Level 5	D	NGO report
Root (2007)	None	None	Level 5	D	Law review
Smolin (2007)	None	None	Level 5	D	Law review
Tiefenbrun (2008)	None	None	Level 5	D	Law review
Van Blerk (2008)	Addis Ababa, Nazareth	60 Adolescents	Level 4	C	Qualitative
Warner (2004)	None	None	Level 5	D	Law review
Woldemichael (2013)	Addis Ababa	Eight women	Level 4	C	Qualitative
Yntiso, Gebre, Shiferaw, and Workineh (2009)	Addis Ababa	68 Children and 30 adults	Level 4	C	Qualitative; NGO report
Yonas and Abera (2013)	Djibouti, Somalia, Yemen, Saudi Arabia	390 Men and women	Level 4	C	Cross sectional

Note. NGO = nongovernmental organization.

^aLevel 1 = systematic reviews of randomized controlled trials or randomized controlled trials; Level 2 = systematic review of cohort studies or individual cohort studies; Level 3 = systematic review of case-control studies or individual case-control studies; Level 4 = case series; Level 5 = expert opinion without explicit critical appraisal (Centre for Evidence-Based Medicine [CEBM], 2009). ^bA = consistent Level-1 studies; B = consistent Level-2 or Level-3 studies or extrapolations from Level-1 studies; C = Level-4 studies or extrapolations from Level-2 or Level-3 studies; D = Level-5 studies or troublingly inconsistent or inconclusive studies of any level (CEBM, 2009). ^cSample size not identified.

In alignment with our study purpose, we aimed to understand the characteristics of human trafficking in Ethiopia as well as identify current gaps in (1) defining and recognizing trafficking, (2) service delivery, (3) research and training, and (4) policy related to human trafficking in Ethiopia. Each of the following areas will now be considered in turn.

Characteristics of Human Trafficking in Ethiopia

Types of trafficking: Internal and external

Labor trafficking was the most widely studied type of trafficking in this literature search, encompassing both internal trafficking within Ethiopia and external trafficking to outside countries. In-country trafficking included women, girls, and boys aged 10–24 who were involved in labor or sexual exploitation in the weaving industry, farm labor, begging, domestic labor, commercial sex work, child marriage, and child soldiering (Abebe, 2007; Abebe & Kjorholt, 2009; Boyden & Howard, 2013; Endeshaw et al., 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Gebre, 2012; Kassa & Abebe, 2014; Tiefenbrun, 2008; Van Blerk, 2008; Warner, 2004; Yntiso, Gebre, Shiferaw, & Workineh, 2009). External trafficking included extensive concerns over the trafficking of women for domestic labor to countries east of the Horn of Africa. Destination countries for external trafficking were Saudi Arabia, Lebanon, Kuwait, the United Arab Emirates, and Yemen in the Middle East but also included routes to Sudan, Kenya, Djibouti, Somalia, and Europe (Anbesse et al., 2009; Belay, 2014; Beydoun, 2006; Beyene, 2011; Endeshaw et al., 2010; Fernandez, 2011, 2013; Fransen & Kuschminder, 2009; G/Hiwot, 2013; Jibriel, 2014; Kebede, 2002; Minaye, 2012; Minaye & Zeleke, 2015; Reda, 2012; Woldemichael, 2013; Yonas & Abera, 2013). Men were trafficked externally to countries in the Middle East for labor as drivers, factory workers, mechanics, laborers, farmers, guards, waiters, drafters, accountants, and engineers (Kebede, 2002). External trafficking of women and girls occurred among those aged 13–35 for labor exploitation as domestic servants; caretakers to children, the disabled, or elderly; commercial sex work; and waitressing (Anbesse et al., 2009; Belay, 2014; Beyene, 2011; Endeshaw et al., 2010; Fernandez, 2011, 2013; Fransen & Kuschminder, 2009; G/Hiwot, 2013; Jibriel, 2014; Kebede, 2002; Minaye, 2012; Minaye & Zeleke, 2015; Reda, 2012; Woldemichael, 2013; Yntiso et al., 2009; Yonas & Abera, 2013).

Risk factors: Push and pull

Push risk factors for human trafficking in and out of Ethiopia were cited as poverty, gender discriminatory practices, environmental factors, poor governance, demographic factors, famine, war, political instability, and economics (Abebe, 2007; Anbesse et al., 2009; Belay, 2014; Beydoun, 2006; Beyene, 2011; Endeshaw, et al. 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Gebre, 2012; Kassa & Abebe, 2014; Nagle, 2008; Van Blerk, 2008; Yntiso et al., 2009). Those with a lack of limited education or illiteracy were cited as the most vulnerable to trafficking (Abebe & Kjorholt, 2009; Fekadu et al., 2010; Gebre, 2012; Kassa & Abebe, 2014; Van Blerk, 2008; Yntiso et al., 2009). Sociocultural factors such as early child marriage, lack of access to social services in rural areas, limited access to education (especially for girls), limited parental education, family discord, dissatisfaction with traditional ways of life, the attraction of paid work to support natal families, pregnancy outside of marriage and associated stigma, leaving school at an early age, and large family size were identified as factors leaving women and children vulnerable to trafficking (Abebe, 2007; Abebe & Kjorholt, 2009; Boyden & Howard, 2013; Endeshaw et al., 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Gebre, 2012; Kassa & Abebe, 2014; Van Blerk, 2008; Yntiso et al., 2009). Additional risk factors identified were corruption, weakly enforced laws, inconsistent prosecution, inconsistent application of public policy, fortified organized crime networks, lack of coordination between Ethiopian authorities as well as between Ethiopian authorities and those abroad, and the government’s failure to implement international instruments to combat human trafficking (Belay, 2014; Beyene, 2011; Endeshaw et al., 2010; Fernandez, 2013; Fransen & Kuschminder, 2009; Jones et al., 2014; G/Hiwot, 2013; Jibriel, 2014; Kebede, 2002; Minaye & Zeleke, 2015; Nagle, 2008; Woldemichael, 2013).

Demand for domestic workers and cheap uncompensated labor were cited as major pull risk factors that drove the trafficking industry (Endeshaw et al., 2010; Fernandez, 2011; Minaye & Zeleke, 2015; Nagle, 2008; Reda, 2012). Multiple studies mentioned the influence of deceptive information about the description and conditions of work abroad from brokers and family members as factors that drove the decision to migrate (Anbesse et al., 2009; Belay, 2014; Beydoun, 2006; Beyene, 2011; Endeshaw et al., 2010; Fransen & Kuschminder, 2009; Minaye & Zeleke, 2015; Reda, 2012; Woldemichael, 2013). Women and girls who were trafficked reported sending some or all of their earnings as remittances to their families (Fernandez, 2011; Jones et al., 2014; Minaye & Zeleke, 2015; Van Blerk, 2008).

Resilience factors

None of the studies returned by our search identified factors that were protective against trafficking; however, two studies identified protective factors for survivor reintegration and recovery. Social support from family and peers appeared to facilitate rehabilitation and reintegration (Minaye, 2012; Yntiso et al., 2009). Spirituality was another resilience factor (Minaye, 2012). Locating and utilizing resources also promoted rehabilitation and reintegration (Yntiso et al., 2009). One study examined factors associated with awareness of sex trafficking and found access to media, more education, social support, and exposure to training on gender issues to be predictive of awareness, although associations between awareness, risk, and resilience have not yet been studied (Azage, Abeje, & Mekonnen, 2014).

Outcomes of trafficking

Poor physical and mental health outcomes were identified in victims of trafficking in several studies and reviews. Women who were trafficked experienced physical injuries, malaria, diarrheal disease, physical disabilities, and even death as a result of inhumane working conditions (Anbesse et al., 2009; Endeshaw et al., 2010; Jibriel, 2014; Minaye, 2012; Murray, 2000; Van Blerk, 2008; Yonas & Abera, 2013). One review found a high prevalence of emotional, physical, and sexual abuse (Fekadu et al., 2010). Other studies corroborated this finding, as sexual and physical violence, including assault, harassment, and rape, were also common among trafficked women (Anbesse et al., 2009; Endeshaw et al., 2010; Fransen & Kuschminder, 2009; Jibriel, 2014; Jones et al., 2014; Minaye, 2012; Reda, 2012; Van Blerk, 2008; Woldemichael, 2013). Some women experienced increased risk of HIV exposure (Minaye, 2012). Although no conclusions can be drawn about health outcomes at this time given the primacy of qualitative methodology, these reports provided preliminary evidence that trafficking was associated with poor health outcomes.

Many studies also identified mental health disorders and psychological trauma as a result of labor trafficking. Few studies measured or identified specific mental health disorders but recognized clear patterns of stress, emotional problems, and psychological distress among survivors (Anbesse et al., 2009; Endeshaw et al., 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Minaye, 2012; Reda, 2012; Woldemichael, 2013; Yonas & Abera, 2013). Suicide has also been observed among survivors (Fransen & Kuschminder, 2009; Murray, 2000). One systematic review found high prevalence of mental health disorders among child laborers (Fekadu et al., 2010). In addition, psychological distress occurred in the form of role frustration, shame, stigma, disrupted social identity, entrapment, religious discrimination, and cultural isolation among survivors (Anbesse et al., 2009; Endeshaw et al., 2010; Gebre, 2012; Jones et al., 2014; Reda, 2012). Families and communities were disappointed when survivors returned to Ethiopia without having achieved economic success and viewed them as worthless members of society who could not be rehabilitated (Anbesse et al., 2009; Gebre, 2012; Minaye, 2012).

Although health outcomes were the focus of most studies included in this review, other adverse outcomes were identified in some studies. Trafficking was related to low educational attainment (Fekadu et al., 2010). Low help-seeking behavior was also identified (Reda, 2012). Several studies noted economic problems among survivors, such as debt, unpaid wages, joblessness, and loss of identification documents (Fransen & Kuschminder, 2009; Van Blerk, 2008; Woldemichael, 2013). Given the absence of studies using longitudinal methods, evidence for distal outcomes was lacking.

Gaps in Defining and Recognizing Trafficking

Awareness of human trafficking and its associated risk factors is low in Ethiopia, as evident by the results of this scoping review. Initiatives to raise public awareness of general information about and risk factors for human trafficking are needed (Azage et al., 2014; Beyene, 2011; Endeshaw et al., 2010; G/Hiwot, 2013; Jibriel, 2014; Jones et al., 2014; Kebede, 2002; Minaye, 2012; Tiefenbrun, 2008; Woldemichael, 2013; Yonas & Abera, 2013). In particular, it is important for people to understand the risks associated with migration and the close associations between migration and trafficking. Both legal and illegal migration opportunities can be a front for trafficking operations or can turn into exploitative labor that is akin to trafficking. Because current public perception of migration is that it is simply an opportunity to earn money, initiatives are needed to educate people regarding the risks of economic, physical, and sexual exploitation and the nature of domestic migrant work. It is unlikely any policy or initiative will be effective in halting migration from Ethiopia entirely, but information can be provided on how to migrate safely and legally and what one’s rights are as a migrant worker in destination countries (Jones et al., 2014; Minaye, 2012).

Gaps in Posttrafficking Service Delivery

Health, economic, legal, and social services are needed for survivors of human trafficking in Ethiopia and in trafficking destination countries. Survivors of human trafficking need access to short- and long-term physical and mental health services to treat injuries, diseases, and psychological trauma incurred during trafficking (Anbesse et al., 2009; Beyene, 2011; Gebre, 2012; International Organization for Migration [IOM], 2014; Reda, 2012; Yonas & Abera, 2013). Family planning and reproductive health services should be readily available and combined with other mental and physical health services to ensure comprehensive care of survivors (Gebre, 2012; Murray, 2000). Immediate emergency services for survivors may be needed in some cases, such as food, water, shelter, emergency medical treatment, and transportation (Beydoun, 2006; IOM, 2014; Jibriel, 2014; Woldemichael, 2013).

Legal advocacy is needed to assist survivors with filing formal complaints against traffickers and exploitative employers in destination countries and understanding their rights (Belay, 2014; Beydoun, 2006). Some possible legal complaints are physical and sexual violence, denial of freedom, restriction of movement, confiscation of legal documents, inhumane working or living conditions, and withholding wages (Belay, 2014; Fernandez, 2011). Gender-sensitive, trauma-informed investigative procedures should be available from law enforcement and legal advocates (Beyene, 2011; Jibriel, 2014).

Vocational and life skills training opportunities are important economic service needs for both survivor rehabilitation and for prevention of trafficking (Boyden & Howard, 2013; Fekadu et al., 2010; Gebre, 2012; Jones et al., 2014; Jibriel, 2014; Minaye & Zeleke, 2015; Smolin, 2007). Because economic needs are a driving factor for migration and trafficking, services must be provided that will allow for development of income-generating skills. Financial management skills, job training, self-employment, microfinancing, and education may help facilitate this process (Beydoun, 2006; Van Blerk, 2008; Warner, 2004; Woldemichael, 2013; Yntiso et al., 2009; Yonas & Abera, 2013).

Social service needs were a neglected area of study in the articles reviewed, but there was an identified need for peer-support networks, assertiveness training, housing assistance, and focus on individual trafficking narratives (Minaye, 2012; Reda, 2012; Van Blerk, 2008). Child survivors of trafficking may especially benefit from social service assistance to reintegrate into their communities and families (Tiefenbrun, 2008). In the case of exploitative intercountry adoption, thorough assessments of the best interests of the child and the rights of the birth parents are needed by trained social work professionals (Bhabha, 2004; Root, 2007; Smolin, 2007). For all survivor services to be effective and sustainable, they should be geographically accessible, community based, comprehensive, affordable, and provisional of material needs (Gebre, 2012; Jones et al., 2014).

Gaps in Human Trafficking Research and Training

Further research on human trafficking in Ethiopia is greatly needed (Endeshaw et al., 2010; Kebede, 2002; Lal Panjabi, 2010). Much of the research conducted to date has been qualitative or has focused on precursors to trafficking. Although these studies have been critical in illuminating the nature of the problem, well-designed outcomes research is now needed to identify where interventions for survivors are needed (Fekadu et al., 2010; Jibriel, 2014; Reda, 2012). Many reports expressed concerns over adverse physical and mental health outcomes among survivors, but most relied on self-report to identify these outcomes and did not use empirical assessments or measures (Anbesse et al., 2009; Endeshaw et al., 2010; Jibriel, 2014; Minaye, 2012; Murray, 2000; Van Blerk, 2008; Yonas & Abera, 2013). Mental health outcomes, in particular, have been poorly measured (Anbesse et al., 2009; Endeshaw et al., 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Minaye, 2012; Reda, 2012; Woldemichael, 2013; Yonas & Abera, 2013). Researchers reported emotional distress and psychological trauma and called for improved attention to mental health, but specific needs have not yet been identified. It will be important for future research studies to use methods able to extract higher levels of evidence and target research on areas of human trafficking not yet known.

In addition, research is needed to identify public awareness levels of different types of trafficking and risk perception (Azage et al., 2014). Awareness of human trafficking appears to be low, but few studies on this topic have been conducted. Much research to date has focused on labor trafficking of adult women to the Middle East for domestic labor exploitation (Anbesse et al., 2009; Belay, 2014; Beydoun, 2006; Beyene, 2011; Endeshaw et al., 2010; Fernandez, 2011, 2013; Fransen & Kuschminder, 2009; G/Hiwot, 2013; Jibriel, 2014; Kebede, 2002; Minaye, 2012; Minaye & Zeleke, 2015; Reda, 2012; Woldemichael, 2013; Yonas & Abera, 2013). Other types of trafficking (e.g., commercial sexual exploitation, child trafficking, trafficking of non-Ethiopian individuals into Ethiopia, organ trafficking) have not been explored in as much depth (Lal Panjabi, 2010).

Gaps in Human Trafficking Policy

Policies against forced labor and established guidelines outlining the comprehensive rights of migrant workers would be useful in destination countries (e.g., ratify international labor and domestic work policies; Endeshaw et al., 2010; Fernandez, 2013; Kebede, 2002; Minaye, 2012). Many destination countries in the Middle East have tolerated forced labor practices and failed to protect victims (Belay, 2014). Active steps must be taken to prevent abuses, prosecute perpetrators, and assist victims, and steps should be taken cooperatively between origin and destination countries (Beyene, 2011; Fransen & Kuschminder, 2009; Woldemichael, 2013). Comprehensive policies that address trafficking in persons with stiff penalties for traffickers may benefit those at risk within Ethiopia (Lawrance & Andrew, 2011; Minaye & Zeleke, 2015; Yntiso et al., 2009). Current laws against organized crime and trafficking are not adequate. Very few trafficking cases are prosecuted by criminal law, and there are not enough resources allocated for investigation of trafficking-related offenses (Beyene, 2011; Fernandez, 2013). Resources could be made available to migrant workers, legal or illegal, explaining their rights and how to file a formal complaint in the event of sexual, physical, or labor exploitation. Capacity building is also needed for law enforcement and government agencies concerned with human services (Endeshaw et al., 2010; G/Hiwot, 2013; Jibriel, 2014).

To address the broader sociopolitical determinants of trafficking, it will be important for Ethiopia to implement policies that affirmatively increase the participation of women in economic, political, and social domains (Beyene, 2011; Endeshaw et al., 2010; Fransen &Kuschminder, 2009; Fernandez, 2012; Jibriel, 2014; Lal Panjabi, 2010). Policy changes are needed to expand access to quality education, particularly in rural areas (Boyden & Howard, 2013; Jones et al., 2014). Vocational training for nonagricultural types of work for both adults and children will help ensure there are sufficient economic opportunities within Ethiopia (Fekadu et al., 2010; Gebre, 2012). Despite its illegality, child marriage remains a problem in Ethiopia and is an important push factor in migration and risk for trafficking (Gebre, 2012). Laws against child marriage must be more strictly enforced to decrease risk for trafficking as a result of illegal child marriage (Warner, 2004). There is also a need for policies to facilitate safe, legal migration and eliminate the need for illegal brokers (Jones et al., 2014; Woldemichael, 2013).

Some scholars have suggested that the human rights issues of child marriage, child soldiering, and intercountry adoption are inherently exploitative and constitute human trafficking (Bhabha, 2004; Tiefenbrun, 2008). Assuming this point of view, several policy changes are needed to address these problems. Child marriage is currently illegal but still occurs with high frequency. Policies that nullify child marriages, make it possible for the child to leave the marriage, allow girls to leave illegal child marriages while retaining rights to children and property, and strictly penalize those who participate in or facilitate child marriages would address this issue (Warner, 2004). Implementing a system of birth and marriage registration to verify the ages of individuals who seek to marry may also help to curb child marriage (Warner, 2004). To address child soldiering, legal protections for children who are forced to commit acts of violence must be established to legally safeguard them from accountability for their actions (Tiefenbrun, 2008). Limits must also be placed on small arms trade with stronger prosecution of perpetrators (Tiefenfrun, 2008). For addressing exploitative intercountry adoption, policies should require that all efforts be made to place a child in his or her country of origin and that international adoption be considered only as a last resort (Blair, 2005; Long, 2012; Root, 2007; Smolin, 2007). In particular, resources are needed to support parents living in extreme poverty who give their children up for international adoption because they feel that they have no other choice. The financial aspects of intercountry adoption must be transparent to prevent commercial exploitation of the process, and the intercountry adoption process closely regulated and systematized to prevent abuses (Bhabha, 2004; Blair, 2005; Long, 2012; Root, 2007; Smolin, 2007). Further research and analysis is needed to determine whether or not these phenomena are in fact trafficking in persons.

Finally, policies are needed to support survivor rehabilitation and reintegration services. Easily accessible physical and mental health services to survivors and the opportunity to access education and vocational training are needed for trafficking victims (Jones et al., 2014; Jibriel, 2014; Minaye & Zeleke, 2015; Reda, 2012; Van Blerk, 2008; Yonas & Abera, 2013; Yntiso et al., 2009). Although some such services are available in Ethiopia, overall, survivor services are severely limited, and there is no central system or process for rehabilitation and reintegration. Comprehensive services that address the health, legal, economic, and social needs of survivors are urgently needed.

Discussion

This scoping literature review integrated current knowledge about human trafficking in Ethiopia, including characteristics of victims, risk factors, and outcomes. It also integrated evidence on gaps in current knowledge and recommendations for service delivery, research and training, and policy. Although prevalence estimates and evidence-based research are lacking in this area, what remains clear are the human rights violations, poor health outcomes, and difficulties with reintegration and rehabilitation that survivors of human trafficking face. The feminization of poverty worldwide has not spared Ethiopia, and the enterprise of human trafficking has flourished opportunistically in a region where drought, forced resettlement, forced repatriation, political repression, and changes in the global economy compound issues of gender-based violence and the oppression of the vulnerable, especially women and girls.

The risk factors for human trafficking in Ethiopia are well characterized, and although efforts are underway to address these factors by government and nongovernmental organizations (NGOs), a much more robust response is needed to develop trafficking-specific interventions for survivors and address their health and economic needs. Further research on outcomes for survivors is a priority prior to intervention development to ensure that interventions target the correct mechanisms for improved outcomes. Mental health screening and diagnostic tools are beginning to be adapted for Ethiopian populations (Gelaye, Arnold, Williams, Goshu, & Berhane, 2009; Hadley et al., 2008; Hanlon et al., 2008; Youngmann et al., 2002), and continued work in this area will be important for accurate identification of outcomes. Advocacy for policy changes to address risk factors for trafficking and promote human rights in Ethiopia is also critical for sustainable change.

Labor and sexual exploitation are widely recognized as forms of trafficking in persons. However, some scholars have suggested that other similar human right violations (child marriage, child soldiering, child labor, exploitative intercountry adoption, and illegal organ harvesting) are also forms of human trafficking. Child marriage and child soldiering have received very limited attention in research, and although they are certainly human rights violations, it is not entirely clear whether or not these issues meet the definition of human trafficking. Likewise, there is a similar debate around child labor as a form of human trafficking. Several articles suggest that child labor is complicated by and must be evaluated through the sociocultural, economic, and gendered realities in Ethiopia (Abebe, 2007; Abebe & Kjorholt, 2009; Boyden & Howard, 2013; Fekadu et al., 2010; Gebre, 2012; Kassa & Abebe, 2014; Van Blerk, 2008; Yntiso et al., 2009). However, child labor results in poor health and economic outcomes similar to those from other types of trafficking, suggesting further examination of the nature and consequences of child labor is needed (Abebe, 2007; Abebe & Kjorholt, 2009; Boyden & Howard, 2013; Endeshaw et al., 2010; Fekadu et al., 2010; Fransen & Kuschminder, 2009; Gebre, 2012; Kassa & Abebe, 2014; Van Blerk, 2008; Yntiso et al., 2009).

Exploitative intercountry adoption and global organ harvesting are two additional forms of exploitation reported in the literature that may fall under the definition of human trafficking. However, there is considerable debate over whether or not intercountry adoption meets the definition of trafficking in persons. Current policies and systems surrounding intercountry adoption have limitations that leave them vulnerable to exploitation for commercial gain, but it is not clear if this phenomenon should be considered human trafficking. Likewise, too few studies have been published on exploitative organ transplant to draw conclusions. Little or no information on this phenomenon is available, and published reports rely only on anecdotal evidence (Beydoun, 2006; Bhaba, 2004; Blair, 2005; Lal Panjabi, 2010; Long, 2012; Nagle, 2008; Root, 2007; Smolin, 2007).

Given this lack of agreement about what constitutes trafficking and how trafficking should be defined, further theoretical and conceptual analyses of human trafficking and specific types of trafficking are needed. For children in particular, cultural norms around child labor further complicate conceptualizations of trafficking. While some reports suggest that child migration and child labor are exploitative and constitute human trafficking, others argue that this view inappropriately applies Western norms and assumptions about the role of children in culture and society (Boyden & Howard, 2013; Kassa & Abebe, 2014). Conceptual analyses are needed to clarify the myriad terms used to describe trafficking, such as slavery, trafficking, and exploitation, with appropriate consideration of the role of sociocultural factors that may complicate established international norms for defining trafficking in persons. Theory development is also needed to describe precursors, characteristics, and trajectories of trafficking to identify optimal points of intervention by service professionals. Incorporating attention to the complex sociocultural determinants of trafficking in Ethiopia in practice, research, and policy will be important to developing trafficking solutions. Crosscultural collaborations would be beneficial in developing comprehensive, sustainable interventions but will be most effective if they are developed within the Ethiopian context.

To address the myriad of complex problems trafficking survivors face upon their reintegration into Ethiopia life, a holistic approach is required (Zimmerman et al., 2011). Comprehensive, interdisciplinary service delivery programs are needed to address the legal, economic, social, and health-related needs of survivors of human trafficking. Establishing services that are community based and easily accessible to returning survivors will support rehabilitation as well as reintegration (Gebre, 2012; Jones et al., 2014). To address the increased vulnerability of women and girls, a gender-sensitive and trauma-informed approach across the spectrum of services with appropriate referral will ease the transition for victims of human trafficking (Beyene, 2011; Jibriel, 2014). Incorporating appropriate screening and referral for a wide range of issues by all professionals (e.g., health care, legal, and social services) as they come into contact with survivors of human trafficking can begin immediately. The complexity of the issues faced by trafficking survivors to rehabilitate and reintegrate into their communities and lead a healthy productive life will require an interdisciplinary approach to develop innovative, bold solutions. No one discipline can meet all the needs of trafficking victims. Without an interdisciplinary approach, survivors will continue to be disenfranchised upon their return home.

Research to date has focused primary on trafficking of Ethiopian women to the Middle East for domestic labor exploitation, and the majority of work in this area has been qualitative. Outcome studies and interventions are now needed to advance this area of research and take meaningful steps toward reducing human trafficking in Ethiopia. In addition, further research is needed on other types of trafficking. Sex trafficking, trafficking of children, organ trafficking, and other closely related human rights issues of child marriage, child soldiering, and exploitative intercountry adoption have not received adequate attention in research or policy. There is also an immediate need for interventions at the individual, family, community, system, and policy levels. This review did not identify any intervention studies. Research on human trafficking in Ethiopia is still emerging, but the available evidence indicates that intervention research is needed in regard to prevention and known risk factors (Endeshaw et al., 2010; Kebede, 2002). Early evidence regarding resilience factors and facilitators of recovery identified by this review should be considered in designing future research studies and interventions (Azage et al., 2014; Minaye, 2012; Yntiso et al., 2009). Social support, spirituality, and accessibility of resources were factors that were associated with survivor reintegration and recovery, and future interventions can incorporate attention to these factors. It is important for future research studies to systematically and comprehensively assess resilience and protective factors related to trafficking. These factors can then be used in community-based participatory models of research and intervention to address risk together with resilience to promote survivor recovery.

There is not adequate awareness of or response to human trafficking from the professional community in Ethiopia (Jibriel, 2014). Even those professionals who interface directly with survivors, like health-care providers, law enforcement, immigration personnel, and government workers, do not have access to comprehensive information and training resources to know how to recognize and respond to human trafficking. Trainings should be developed using the best available knowledge about human trafficking and related issues (e.g., trauma-informed care, gender-sensitivity training) and should be culturally relevant. All trainings should be manualized, evaluated, and continuously improved to promote sustainability.

Policy development will require the inclusion of all key stakeholders including health-care providers, academics, NGOs, policy makers, and survivors if they are to be sustainable. Ethiopia has the potential to take the lead in this area and set the standard for other countries. This can begin with education on human trafficking for law enforcement, health-care providers, and government agencies providing social services (Endeshaw et al., 2010; G/Hiwot, 2013; Jibriel, 2014). Increasing awareness among the general population through radio announcements and public service posters will alert the citizens of Ethiopia to the widespread problem of human trafficking.

Limitations

There are some limitations to this review. Given the relatively recent recognition of human trafficking in Ethiopia as a health and human rights problem, there were few published empirical studies on this topic. Longitudinal and intervention studies were lacking, and some of the study methodologies may have introduced sources of bias (e.g., omission bias, reporter bias), limiting the conclusions that can be drawn from the data. Some review articles did not use systematic methods. Articles used different definitions of and terminology for human trafficking and exploitation, and only articles published in English were included. There are strengths to this review as well. We used systematic methods to search a broad body of literature with an interdisciplinary approach, integrating evidence from medicine, nursing, psychology, law, and international sources. Many types of study methodologies were included in the review, and qualitative reports corroborated quantitative findings.

Conclusion

Human trafficking is an egregious violation of human rights. Evidence has emerged indicating that attention to human trafficking in Ethiopia is warranted in service delivery, research and training, and policy. Given the complexity of the problem, there is a need for interdisciplinary engagement in combating human trafficking at each of these levels. Policy makers, researchers, and practitioners should respond to the gaps and recommendations identified by this review with attention to the unique cultural factors that affect trafficking of persons in Ethiopia.

Footnotes

Acknowledgments

The authors gratefully acknowledge Dr. Bridgette Carr (University of Michigan Law School Human Trafficking Clinic), Ms. Eva Foti (University of Michigan Law School Human Trafficking Clinic), and Dr. Harvey Leo (University of Michigan School of Public Health). We are also grateful to the University of Michigan EM-PACE (Ethiopia-Michigan Platform for Advancing Collaborative Engagement) Seed Grant for supporting our interdisciplinary research team.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Abebe

(2007). Changing livelihoods, changing childhoods: Patterns of children’s work in rural Southern Ethiopia. Children’s Geographies, 5, 77–93.

Abebe

Kjørholt

A. T.

(2009). Social actors and victims of exploitation: Working children in the cash economy of Ethiopia’s south. Childhood: A Global Journal of Child Research, 16, 175–194.

Anbesse

Hanlon

Alem

Packer

Whitley

(2009). Migration and mental health: A study of low-income Ethiopian women working in Middle Eastern countries. International Journal of Social Psychiatry, 55, 557–568.

Arksey

O’Malley

(2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32.

Azage

Abeje

Mekonnen

(2014). Sex trafficking awareness and associated factors among youth females in Bahir Dar town, North-West Ethiopia: A community based study. BMC Women’s Health, 14, 1.

Belay

Y. D.

(2014). Migration and State responsibility: Ethiopian domestic workers in Lebanon. International Journal of Scientific and Research Publications, 4, 1–8.

Beydoun

K. A.

(2006). The trafficking of Ethiopian domestic workers into Lebanon: Navigating through a novel passage of the international maid trade. Berkeley Journal of International Law, 24, 1009–1045.

Beyene

S. G.

(2011). Investigation and prosecution of transnational women trafficking: The case of Ethiopia. Cape Town, South Africa: Faculty of Law, University of Western Cape.

Bhabha

(2004). Moving babies: Globalization, markets, and transnational adoption. The Fletcher Forum of World Affairs, 28, 181–197.

10.

Blair

(2005). Safeguarding the interest of children in intercountry adoption: Assessing the gatekeepers. Capital University Law Review, 34, 349–351.

11.

Boyden

Howard

(2013). Why does child trafficking policy need to be reformed? The moral economy of children’s movement in Benin and Ethiopia. Children’s Geographies, 11, 354–368.

12.

Centre for Evidence-Based Medicine. (2009). Oxford centre for evidence-based medicine—Levels of evidence. University of Oxford. Retrieved from http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/

13.

Endeshaw

Gebeyehu

Reta

(2010). Assessment of trafficking in women and children in and from Ethiopia. Addis Ababa, Ethiopia: International Organization for Migration. Retrieved from http://www.africanchildinfo.net/index.php?option=com_sobi2andsobi2Task=sobi2Detailsandcatid=6andsobi2Id=819andItemid=73andlang=en

14.

Fekadu

Hägglöf

Alem

(2010). Review of child labor with emphasis on mental health. Current Psychiatry Reviews, 6, 176–183.

15.

Fernandez

(2011). Household help? Ethiopian women domestic workers’ labor migration to the Gulf countries. Asian and Pacific Migration Journal, 20, 433–457.

16.

Fernandez

(2013). Traffickers, brokers, employment agents, and social networks: The regulation of intermediaries in the migration of Ethiopian domestic workers to the Middle East. International Migration Review, 47, 814–843.

17.

Fransen

Kuschminder

(2009). Migration in Ethiopia: History, current trends and future prospects. Maastricht, the Netherlands: Maastricht Graduate School of Governance.

18.

Gebre

(2012). Migration patterns of children exposed to sexual exploitation in selected zones of Ethiopia. Journal of Children’s Services, 7, 262–274.

19.

Gelaye

Arnold

Williams

M. A.

Goshu

Berhane

(2009). Depressive symptoms among female college students experiencing gender-based violence in Awassa, Ethiopia. Journal of Interpersonal Violence, 24, 464–481.

20.

G/Hiwot

(2013). The situations of trafficking women from Ethiopia to Sudan: The case of Metema Route. Master’s thesis, Addis Ababa University, Ethiopia.

21.

Glaser

B. G.

(1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press.

22.

Hadley

Tegegn

Tessema

Cowan

J. A.

Asefa

Galea

(2008). Food insecurity, stressful life events and symptoms of anxiety and depression in east Africa: Evidence from the Gilgel Gibe growth and development study. Journal of Epidemiology and Community Health, 62, 980–986.

23.

Hanlon

Medhin

Alem

Araya

Abdulahi

Hughes

… Prince

(2008). Detecting perinatal common mental disorders in Ethiopia: Validation of the self-reporting questionnaire and Edinburgh Postnatal Depression Scale. Journal of Affective Disorders, 108, 251–262.

24.

International Organization for Migration. (2014). Emergency post-arrival assistance to vulnerable Ethiopian migrants returning from Saudi Arabia. External Situation Report. Retrieved from https://ethiopia.iom.int/emergency-post%E2%80%90arrival-assistance-vulnerable-ethiopian-migrants-returning-saudi-arabia

25.

Jibriel

(2014). A human rights-based approach to counteract trafficking in women: The case of Ethiopia. Oromia Law Journal, 3, 212–259.

26.

Jones

Presler-Marshall

Tefera

Emirie

Gebre

& Gezahegne

. (2014). Rethinking girls on the move. London, England: Overseas Development Institute.

27.

Kassa

S. C.

Abebe

(2014). Qenja: Child fostering and relocation practices in the Amhara region, Ethiopia. Children’s Geographies, 14, 1–17.

28.

Kebede

(2002). Ethiopia: An assessment of the international labour migration situation: The case of female labour migrants. Geneva, Switzerland: International Labour Office, Gender Promotion Programme (Series on Women and Migration, Working Paper No. 3).

29.

Lal Panjabi

R. K.

(2010). The sum of a human’s parts: Global organ trafficking in the twenty-first century. Pace Environmental Law Review, 28, 1–144.

30.

Lawrance

B. N.

Andrew

R. P.

(2011). A “Neo-Abolitionist Trend” in Sub-Saharan Africa? Regional anti-trafficking patterns and a preliminary legislative taxonomy. Seattle Journal for Social Justice, 9, 599–678.

31.

Levac

Colquhoun

O’Brien

K. K.

(2010). Scoping studies: Advancing the methodology. Implementation Science, 5, 69.

32.

Long

(2012). Where are they coming from, where are they going: Demanding accountability in international adoption. Cardozo Journal of Law and Gender, 18, 827–865.

33.

Minaye

(2012). Trafficked to the Gulf states: The experiences of Ethiopian returnee women. Journal of Community Practice, 20, 112–133.

34.

Minaye

Zeleke

(2015). Re-conceptualizing human trafficking: The experiences of Ethiopian returnee migrants. Journal of Trafficking, Organized Crime and Security, 1, 9–23.

35.

Murray

R. B.

(2000). Sex for food in a refugee economy: Human rights implications and accountability. Georgetown Immigration Law Journal, 14, 985–1025.

36.

Nagle

L. E.

(2008). Selling souls: The effect of globalization on human trafficking and forced servitude. Wisconsin International Law Journal, 26, 131–140.

37.

Oram

Stockl

Busza

Howard

L. M.

Zimmerman

(2012). Prevalence and risk of violence and the physical, mental, and sexual health problems associated with human trafficking: Systematic review. PLoS Medicine, 9, e1001224.

38.

Pham

Rajić

Greig

Sargeant

Papadapoulous

McEwen

S. A.

(2014). A scoping review of scoping reviews: Enhancing the consistency. Research Synthesis Methods, 5, 371–385.

39.

R Core Team. (2015). R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. Retrieved from https://www.R-project.org/

40.

Reda

A. H.

(2012). An investigation into the experiences of female victims of trafficking in Ethiopia. (Master’s thesis). University of South Africa, Pretoria.

41.

Refugee Review Tribunal. (2006). RRT research response—Ethiopia. Retrieved from http://www.justice.gov/sites/default/files/eoir/legacy/2013/06/11/eth31133.pdf

42.

Root

V. S.

(2007). Angelina and Madonna: Why all the fuss? An exploration of the rights of the child and intercountry adoption within African nations. Chicago Journal of International Law, 8, 323–355.

43.

Smolin

(2007). Intercountry adoption and poverty: A human rights analysis. Capital University Law Review, 36, 413–453.

44.

Tiefenbrun

(2008). Child soldiers, slavery, and the trafficking of children. Fordham International Law Journal, 31, 415–485.

45.

U.S. Department of State. (2014). Ethiopia: 2014 Trafficking in persons report. Office to monitor and combat trafficking in persons. Retrieved from http://www.state.gov/j/tip/rls/tiprpt/countries/2014/226721.htm

46.

United Nations Office on Drugs and Crime. (2004). United Nations convention against transnational organized crime and the protocols thereto. Protocol to prevent, suppress and punish trafficking in persons, especially women and children, supplementing the United Nations convention against transnational organized crime . New York, NY: United Nations Publication. Retrieved from https://www.unodc.org/documents/treaties/UNTOC/Publications/TOC%20Convention/TOCebook-e.pdf

47.

Van Blerk

(2008). Poverty, migration and sex work: Youth transitions in Ethiopia. Area, 40, 245–253.

48.

Warner

(2004). Behind the wedding veil: Child marriage as a form of trafficking girls. American University Journal of Gender, Social Policy & the Law, 12, 233–271.

49.

Woldemichael

S. B.

(2013). The vulnerability of Ethiopian rural women and girls: The case of domestic workers in Saudi Arabia and Kuwait. (Master’s thesis). Uppsala University, Sweden.

50.

Yntiso

Gebre

Shiferaw

Workineh

(2009). Resilience in children exposed to sexual abuse and sexual exploitation in Merkato. Geneva, Switzerland: Oak Foundation.

51.

Yonas

Abera

(2013). Assessment of health hazards and associated factors among the returned migrants living at Bati Woreda, Oromia Zone, Amhara National Regional State. Ethiopian Journal of Health Development, 27, 55–63.

52.

Youngmann

Zilber

Kaveh

Zere

Workneh

Bekele

Giel

(2002). Development of a culturally sensitive psychiatric screening instrument for detecting emotional problems among Ethiopian immigrants in Israel. Harefuah, 141, 10–16.

53.

Zimmerman

Mazeda

Watts

(2011). Human trafficking and health: A conceptual model to inform policy, intervention, and research. Social Science and Medicine, 73, 327–335.