BROKEN LAWS BROKEN LIVES MEDICAL EVIDENCE OF TORTURE BY US PERSONAL AND ITS IMPACT : Cleveland IMC (((i)))

Broken laws, Broken Lives - Medical Evidence of Torture by US Personnel and Its Impact A Report by Physicians for Human RightsJune 2008http://brokenlives.info/BROKEN LAWS,BROKEN LIVESMedical Evidence of Torture byUS Personnel and Its Impact List of Acronyms BHS: Behavioral Health Science TeamsCIA: Central Intelligence AgencyCIDT: Cruel, Inhuman, or Degrading TreatmentDoD: Department of DefenseDTA: Detainee Treatment Act of 2005ECHR: European Court of Human RightsERB: Ethics Review BoardFBI: Federal Bureau of InvestigationIACHR: Inter-American Court of Human RightsICRC: International Committee of the Red CrossICCPR: International Covenant on Civil andPolitical RightsICTR: International Criminal Tribunal for RwandaICTY: International Criminal Tribunal for YugoslaviaIRF: Immediate Reaction ForceIRCT: International Rehabilitation Council forTorture VictimsMCA: Military Commissions Act of 2006MDD: Major Depressive DisorderNOS: Not Otherwise SpecifiedOLC: Office of Legal Counsel, Departmentof JusticePHR: Physicians for Human RightsPOW: Prisoner of WarPTSD: Post-traumatic Stress DisorderSERE: Survival, Evasion, Resistance, andEscape trainingSOP: Standard Operating ProcedureTVPA: Torture Victims Protection Act of 1991WCA: War Crimes Act This report tells the largely untold human story ofwhat happened to detainees in our custody whenthe Commander-in-Chief and those under himauthorized a systematic regime of torture. This story isnot only written in words: It is scrawled for the rest ofthese individual?s lives on their bodies and minds. Ournational honor is stained by the indignity and inhumanetreatment these men received from their captors. The profiles of these eleven former detainees, noneof whom were ever charged with a crime or told whythey were detained, are tragic and brutal rebuttals tothose who claim that torture is ever justified. Throughthe experiences of these men in Iraq, Afghanistan, andGuantanamo Bay, we can see the full-scope of the damagethis illegal and unsound policy has inflicted ?both onAmerica?s institutions and our nation?s founding values,which the military, intelligence services, and our justicesystem are duty-bound to defend. In order for these individuals to suffer the wantoncruelty to which they were subjected, a governmentpolicy was promulgated to the field whereby the GenevaConventions and the Uniform Code of Military Justicewere disregarded. The UN Convention Against Torturewas indiscriminately ignored. And the healing professions,including physicians and psychologists, becamecomplicit in the willful infliction of harm against thosethe Hippocratic Oath demands they protect. After years of disclosures by government investigations,media accounts, and reports from humanrights organizations, there is no longer any doubt as towhether the current administration has committed warcrimes. The only question that remains to be answeredis whether those who ordered the use of torture will beheld to account. The former detainees in this report, each of whomis fighting a lonely and difficult battle to rebuild his life,require reparations for what they endured, comprehensivepsycho-social and medical assistance, and even anofficial apology from our government. But most of all, these men deserve justice as requiredunder the tenets of international law and the UnitedStates Constitution. And so do the American people. Major General AntonioTaguba, USA (Ret.)Maj. General Taguba led the US Army?s officialinvestigation into the Abu Ghraib prisoner abusescandal and testified before Congress on hisfindings in May, 2004. Preface1This report provides first-hand accounts andmedical evidence of torture and cruel, inhuman,or degrading treatment or punishment (?illtreatment?)of eleven former detainees who were heldin US custody overseas. Using internationally acceptedstandards, Physicians for Human Rights (PHR) conductedmedical evaluations of the former detainees to documentthe severe, long-term physical and psychologicalconsequences that have resulted from the torture and illtreatment. The evaluations provide evidence of violationof criminal laws prohibiting torture and of the commissionof war crimes by US personnel. Four of the men evaluated were either arrested in orbrought to Afghanistan between late 2001 and early 2003and later sent to Guant?namo Bay, Cuba, where theywere held for an average of three years before releasewithout charge. The other seven were detained in Iraqin 2003 and released without charge later that year or in2004, with an average period of detention of six months.All of the former detainees evaluated by PHR reportedhaving been subjected to multiple forms of torture orill-treatment that often occurred in combination over along period of time. The medical evaluations were based in each caseon intensive two-day clinical interviews that includeddiagnostic testing and, in two cases, review of medicalrecords. With this evidentiary record, this report providesthe most detailed account available thus far of the experienceof detainees in US custody who suffered torture ? awar crime ? at the hands of US personnel. Additionally,this report provides further evidence of the role healthprofessionals played in facilitating detainee abuse bybeing present during torture and ill-treatment, denyingmedical care to detainees, providing confidential medicalinformation to interrogators, and failing to stop or documentdetainee abuse. Methods of torture experienced by the formerdetainees evaluated by PHR included interrogation anddetention practices such as isolation, sleep deprivation,forced nakedness, severe humiliation and degradation,and sensory deprivation that were officially authorizedby military and civilian officials during certain periodswhen these men were incarcerated. Additional practicesrecounted by the interviewees including beatingsand other forms of severe physical and sexual assaultthat, while not officially authorized by government documentsnow part of the public record, came to be part ofa regime of brutality at the facilities where the detaineeswere held. This report demonstrates that the permissive environmentcreated by implicit and explicit authorizations bysenior US officials to ?take the gloves off?4 encouragedforms of torture even beyond the draconian methodsapproved at various times between 2002 and 2004.5 In anenvironment of moral disengagement that countenancesauthorized techniques designed to humiliate and dehumanizedetainees, it is not surprising that other formsof human cruelty such as physical and sexual assaultwere practiced. The fact that these unauthorized torturepractices happened over extended periods of time atmultiple US detention facilities suggests that a permissivecommand environment existed across theatres andat several levels in the chain-of-command. This climateallowed both authorized and unauthorized techniques tobe practiced, apparently without consequence. Given the limited number of detainees evaluated, thefindings of this assessment cannot be generalized to thetreatment of all detainees in US custody. The patterns ofabuse documented in this report, however, are consistentwith numerous governmental and independent investigationsinto allegations of detainee ill-treatment,6 makingit reasonable to conclude that these detainees were notthe only ones abused, but are representative of a muchlarger number of detainees subjected to torture and illtreatmentwhile in US custody. MethodsPHR identified individuals through referring nongovernmentalorganizations and law firms that providelegal representation to former and current detainees inUS custody. The evaluations were conducted betweenDecember 2006 and September 2007, after consent wasobtained by the individuals. No former detainee PHRlocated who was eligible and consented to an evaluationwas excluded from the study. For each formerdetainee, a team of two experienced clinicians evaluatedthe individual and documented allegations of tortureand ill-treatment in accordance with the guidelines forassessing physical and psychological evidence of tortureset out in the Istanbul Protocol, Manual on the EffectiveInvestigation and Documentation of Torture and OtherCruel, Inhuman or Degrading Treatment or Punishment(hereafter Istanbul Protocol).7 Sources of informationfor the medico-legal reports include the clinical interview,psychological testing, physical examinations andmedical diagnostic tests. The Guant?namo Bay detentionmedical records of one individual and an independentmedical record of another former detainee were availablefor review as well. In each case, the clinicians providedopinions on possible torture and ill-treatment based oncorrelations between individual allegations of tortureand specific physical and psychological evidence. Theyfound no evidence of deliberate exaggeration in anycase. The study was approved by PHR?s Ethics ReviewBoard. In order to protect confidentiality, the names ofthe individuals evaluated were changed and informationthat could potentially identify the former detainees hasbeen omitted. Summary of FindingsSynopses of the Cases of Former DetaineesProfiled The following summaries of three evaluations of theeleven cases illustrate the torture and ill?treatmentthat the detainees experienced and the resultinglong-term physical and psychological harm. The tortureand ill-treatment described were corroborated by themedical evidence. Kamal is in his late forties. He served in the Iraqi Armyduring the 1980s and later became a businessman andImam of a local mosque. In September 2003 he wasarrested by US forces. At the time of his arrest, he wasbeaten to the point of losing consciousness. After beingbrought to Abu Ghraib prison, he was kept naked andisolated in a cold dark room for three weeks, where bothduring and in between interrogations he was frequentlybeaten, including being hit on the head and in the jaw witha rifle and stabbed in the cheek with a screwdriver. He was then placed in isolation in a urine-soakedroom for two months. When Kamal was allowed to wearclothes, they were sometimes soaked in water to keep himcold. On approximately ten occasions he was suspendedin a stress position, causing numbness that lasted for amonth. He was made to believe that his family memberswere also in prison and that they were being raped andtortured. He recounted, ?[T]hey were telling me, makingme hear voices of children and women, and told me theywere my children and [wife].? He was eventually transferredto a tent area of Abu Ghraib, where he remainedfor seven months until his release in June 2004.PHR?s clinicians found physical and psychologicalevidence consistent with the abuse Kamal reported. He continues to experience chronic pain in his jaw andnumbness from the suspensions. He also meets diagnosticcriteria for several psychiatric diagnoses, includingmajor depressive episodes, a panic disorder, and posttraumaticstress disorder (PTSD) that are attributable tohis experience in detention. Particularly striking is theseverity of Kamal?s depressive symptoms, with feelingsof hopelessness, worthlessness, and guilt, and difficultysleeping. His symptoms are indeed so severe that, in theopinion of PHR?s clinicians, they would qualify him forhospitalization in the United States. Amir is in his late twenties and grew up in a MiddleEastern country. He was a salesman before beingarrested by US forces in August 2003 in Iraq. After hisarrest, he was forced, while shackled, to stand nakedfor at least five hours. For the next three days, he andother detainees were deprived of sleep and forced to runfor long periods, during which time he injured his foot. After Amir notified a soldier of the injury, the soldierthrew him against a wall and Amir lost consciousness.Ultimately, he was taken to another location, where hewas kept in a small, dark room for almost a month whilebeing subjected to interrogations that involved shackling,blindfolding, and humiliation. Approximately one monthlater, he was transferred to Abu Ghraib. At first he wasnot mistreated, but then was subjected to religious andsexual humiliation, hooding, sleep deprivation, restraintfor hours while naked, and dousing with cold water. Inthe most horrific incident Amir recalled experiencing, hewas placed in a foul-smelling room and forced to lay facedown in urine, while he was hit and kicked on his backand side. Amir was then sodomized with a broomstickand forced to howl like a dog while a soldier urinatedon him. After a soldier stepped on his genitals, hefainted. In July 2004, he was transferred to the prisonat Camp Bucca, where he reported no abuse. He wasreturned to Abu Ghraib in November 2004 and releasedtwo days later. Amir continues to experience physical symptomsconsistent with the abuse he reported. Physical examinationrevealed features consistent with his account,including tenderness of one of his testicles and rectaltearing. Psychologically, he continues to suffer fromdebilitating symptoms of severe PTSD, disturbed sleep,moodiness, anxiety, sexual dysfunction, hostility andoutbursts of anger, and very frequent suicidal thoughts.He has changed from a stable provider for his family to anunemployed man. Although stressors related to the warin Iraq may exacerbate his symptoms, his most debilitatingsymptoms are attributable to his experience oftorture and sexual violation. ?No sorrow can be comparedto my torture experience in jail,? he said. ?That is thereason for my sadness.? Youssef is in his early thirties. Unable to find work in hiscountry of origin, he sought employment in Afghanistan.In late 2001 or early 2002, Youssef was detained as heattempted to cross the Afghanistan-Pakistan borderwithout a passport while trying to return home. He washeld in a Pakistani prison for two months, where he wasoften shackled in unsanitary conditions and given little food.During this time, he was interrogated by US personneland eventually hooded, shackled, and transferred to theUS detention facility in Kandahar, Afghanistan. In Kandahar, Youssef was immediately interrogatedand subjected to beatings with sticks and fists as well askicking, although he did not sustain serious injuries at thetime. After that, he was stripped naked. The first night hewas not allowed to sleep, as guards hit the detainees andthrew sand at them. While in Kandahar, Youssef enduredforced nakedness, intimidation by dogs, hooding, andrepeated assaults by being thrown against a wall. He wassubjected to electric shock from a generator, feeling ?asif my veins were being pulled out.? After about six weeks, he was transferred to the USdetention facility at Guant?namo Bay, Cuba. During thetransatlantic flight he was dressed in an orange suit,fitted with dark goggles and headphones and shackledto the floor of the plane. The tight cuffs caused his wriststo swell. Upon arrival, he was stripped, sprayed withwater and examined by a doctor. Like other detainees,he described the conditions at Camp X-Ray as deplorable,with detainees living in cages that were extremelyhot and denied anything but a bucket for a toilet. In CampX-Ray lengthy interrogations accompanied by sleepdeprivation began. Small infractions such as speakingwith other detainees led to beatings, and a person whomhe perceived to be a doctor checked the injuries of thedetainees after the beatings. In order to avoid beatings,Youssef was compliant. Nevertheless, the ImmediateReaction Force (IRF) team forced him into stress positions,including sitting on his knees with his handspressed together behind his back or head and tied tohis feet, forcing his legs up. After approximately three months, Youssef and otherswere transferred to Camp Delta, where general cellconditions were better, although detainees were rarelylet out of their cells. He was beaten once for hiding foodin his cell. An IRF team also sprayed him in the eyes withwhat may have been pepper spray, so that ?my wholebody would feel like it was burning ? not just my face,but my whole body?I felt like I was losing consciousnessfrom the burning.? His interrogations, which took place almost everyother day during his initial period at Guant?namo and hewould be kept in the interrogation room for as long aseighteen to twenty hours. He denied having been beatenduring the lengthy interrogations or while being held inthe interrogation room. Youssef described these episodesas some of his most painful experiences at Guant?namo.He was chained and forced to assume stressful positions;at times, ice-water was poured on him and, atother times, loud music was played. He was deprivedof access to the toilet and time for prayer. While beingheld in the interrogation room, the temperature in theroom would be made extremely cold or hot for extendedperiods of time. Demands for confessions were constant,accompanied by claims by interrogators that his namewas found on documents and that his brother, who hasleukemia, had been arrested; soldiers also threatenedto shoot him. Humiliation was part of the interrogationregime: he was forced to look at pornography, andsoldiers ripped the Koran apart and threw it in the toiletin front of him. He described being horrified by an incidentin which a naked woman entered the interrogationroom and smeared what he believed to be menstrual bloodon him. He reported being given injections of unknownsubstances against his will, and these injections oftencaused rashes several hours later. He believes that insome interrogations medical personnel were present andthat they examined him periodically. Although he was notprivy to the discussions between the medical personneland interrogators, it appeared to Youssef that that themedical personnel were being consulted as to whetherinterrogations should continue. They always did. At one point while at Camp Delta at Guant?namo,Youssef asked to speak with a psychologist because ofthe distress and sadness he felt due to the separationfrom his family. He believes that not only did his interrogatorshave access to the information he sharedwith the psychologist, but that they exploited it bythreatening that he would spend the rest of his life inGuant?namo. Following this interrogation session, hewas moved to what he believed to be the worst sectionof Camp Delta, where he was not allowed to have ablanket or mattress. After being transferred out of Camp Delta and signinga form, he was released in the fall of 2003. He was againhandcuffed and chained to the floor of the plane duringthe lengthy flight. Upon returning home, he served overa year of military service, during which he was mostlyconfined in a psychiatric hospital because he was deemed?too aggressive.? On physical examination, Youssef was noted to havesurgical scars on his wrists consistent with his report ofsurgery following his release for chronic wrist pain as aresult of shackling during his detention. Pain in his rightwrist still persists. He also has a scar on the back of hisleft wrist consistent with the handcuffing he described.While Youssef experienced symptoms of depressionbefore detention, PHR?s evaluators concluded that thesesymptoms became more pronounced, disabling andchronic as a result of his experience; he also now suffersfrom moderate PTSD. Many of his physical symptoms,including shortness of breath and ?heart problems,? areconsistent with a panic disorder. Youssef acknowledgeddifficulty functioning and has not found steady employmentsince his detention. Common Experiences of Torture and Ill-Treatment Even though the eleven detainees examined by PHR wereheld at different places, and each person?s experiencewas unique, certain detention and interrogation practicesappear over and over again in the accounts. Beatings During Arrest, Transport, and Initial Custody Many of the most severe injuries from beatings thatthe former detainees reported were sustained shortlyafter they were arrested. All seven of the men whowere detained in Iraq (hereafter referred to as ?theIraqi former detainees?) recounted experiencing violenttreatment during their arrests, some of which involvedsevere physical assault on their family members as wellas destruction or looting of their homes. The beatings inflicted on detainees at US facilities atBagram and Kandahar in Afghanistan were particularlyintense, and included beatings with sticks and fists, kicksto the stomach and genitals and blows to the head. As aresult, Haydar, who was held at Kandahar before beingtransferred to Guant?namo, lost three of his teeth andRasheed, who was held at both Bagram and Kandaharfacilities, lost consciousness and was hospitalized. Similarly, all former detainees held at Guant?namoreported that the most intense and widespread physicalbeatings they experienced at the facility took place duringtransfer and shortly after arrival there. The Iraqi former detainees also reported severe beatingsduring the first days and weeks of detention at facilitiesincluding one at Baghdad International Airport. Hafez,who was held at a US facility at Baghdad InternationalAirport and Abu Ghraib for over seven months, was forcedto the ground and beaten severely on his legs and back,causing his lips, forehead, and nose to bleed; he alsoreported being stripped and having his chest and pubichair ripped out by hand and being simultaneously beaten,hit, and choked while being doused with cold water. While physical evidence of beatings often may not bedetectable in later medical evaluations, findings frombone scans of six of the former detainees as well asscars and lesions visible during physical examinationare consistent with the history of beatings described bythe victims. Deprivation of Basic Necessities and Sanitary Conditions All of the former detainees reported frequent denialof basic necessities during periods of their detention;over half of the men evaluated reported being deniedfood on at least one occasion. Each former detaineealso reported being subjected to extreme temperaturesduring his confinement. The conditions detainees in Iraq endured were particularlyappalling. Among the conditions one or more ofthe detainees reported were placement in a urine-soakedpunishment room, being forced to wear soiled underwear,often for weeks or months at a time, denial of access tofood, water and toilets of any kind, and exposure to coldwithout blankets. Two of the detainees who were held in Guant?namoduring the first year the facility was in operation reportedharsh physical conditions and being housed in steelcages. Although as time passed, the physical conditionsimproved there, deprivation sometimes accompaniedby acts of cruelty continued. Haydar reported that inGuant?namo the soldiers would often either spit in orthrow out part of their food rations. Stress Positions: Forced Standing, Handcuffing, and Shackling All of the former detainees reported having beensubjected to painful stress positions that involved havingtheir hands and feet bound for extended periods of times,or suspension from walls or barbed wire. These positionswere often coupled with the use of blindfolding,sleep deprivation, isolation, and exposure to temperatureextremes, either as components of interrogationsor conditions of confinement. For example, three former detainees evaluated byPHR reported that in Guant?namo they were kept inextremely hot or cold interrogation rooms, chained in acrouching position to a ring on the floor for eighteen totwenty hours. Two of the Iraqi former detainees reportedlosing consciousness as a result of being subjected tostress positions. Findings on medical examination were consistent withthese accounts. All of the former detainees reported thatthey continue to suffer from a wide range of musculoskeletalpains. For example, Laith, an Iraqi former detaineewho was held in Abu Ghraib for nine months, reportedarm numbness and weakness following being suspendedby his arms, which is highly consistent with a brachialplexus (nerve group supplying the upper extremity) injurythat often results from suspension. Isolation, Sensory Deprivation, or Bombardment A) Prolonged IsolationAll of the former detainees reported being subjectedrepeatedly to lengthy periods of isolation that rangedfrom ten days to as long as two months in duration. Theinterviewees reported that, while being kept in isolation,they were subjected to shackling, blindfolding,physical abuse, humiliation, sexual humiliation, andstress positions, as well as temperature extremes andlight control. During periods of isolation, the Iraqi former detaineesconsistently reported being kept hooded and naked insmall, dark holding cells that made Rahman, who washeld at Abu Ghraib for nine months, feel ?claustrophobic.?Similarly, former Guant?namo detainees reported thatthey were repeatedly held in isolation. The psychologicalimpact of isolation and other forms of abuse wasenormous. Rasheed engaged in hunger strikes, exhibitedpsychotic behavior, and even became suicidal afterprolonged isolation. B) Hooding/BlindfoldingSensory deprivation by means of hooding or other typesof blindfolding was frequently used in combination withother techniques in the places the former detainees wereheld (Afghanistan, Iraq, and Guant?namo Bay, Cuba).According to the detainees, blindfolding and hoodinginstilled in them a sense of fear, disorientation, anddependency on their captors. According to the detainees evaluated, sensory deprivationwas employed in Afghanistan during arrest andtransportation between facilities as well as duringinterrogations. At Guant?namo, however, the fourdetainees evaluated experienced hooding only whenbeing transferred. In Iraq, hooding was routinely usedduring interrogations and general detention and wascombined with forced nakedness and isolation, amongother techniques. C) Sensory BombardmentEight former detainees reported that sensory bombardmentwith loud noise or music was utilized frequentlyin what appeared to be a strategy to disorient them ordisrupt detainees? sleep.The detainees who were held in Afghanistan reportedthat they were subjected to loud music over long periodsof time, and in one case exposed to powerful flood lightstwenty-four hours a day. At Guant?namo, Rasheedreported that during a period of isolation and frequentlengthy interrogations, his cell was bombarded with loudunpleasant noise. The former detainees reported that in Iraq this techniquewas combined with forced running, isolation, andsleep deprivation. Similar to three other Iraqi formerdetainees, Morad, who was held in various facilities fora total duration of ten months, was subjected to ?deafening,loud music? while being held in Saddam Hussein?sformer ranch (used as a US detention facility). Threats of Harm to Detainees and Their Families Almost all of the detainees reported being threatenedwith severe harm, most commonly through verbalthreats during interrogations. Eight of the eleven menreported that the US military utilized dogs to instill fearin the detainees. Two of the Iraqi former detainees werethreatened with execution, and two others were threatenedwith forced disappearance since they did not haveprisoner identification numbers, were unregistered, andtherefore considered ?ghost? detainees. Youssef recalledbeing threatened with being shot by a guard during aninterrogation in Guant?namo. Interrogators also told detainees that their familieswould be killed or severely harmed. Laith told PHR thatthe interrogators ?were threatening me?they were saying?Then you will hear your mothers and sisters when we areraping them.?? Interrogators also threatened detaineeswith harm or torture following their release. Strikingly,transfer to Guant?namo was a threat used on half ofthe former detainees held in Iraq. Yasser recalled beingtold he would be sent to Guant?namo ?where even dogswon?t live.? Use of Extreme Temperatures All of the former detainees reported being exposed toextremes of temperature in their cells. For some of theIraqi former detainees, this practice was coupled withweeks of isolation and sexual humiliation; for others,this practice was used as a form of group punishment.Four detainees, of whom three were held in Guant?namo,reported that cold water was poured on them duringinterrogation. In the cases of three individuals who wereheld in facilities in Iraq, cold water was used in combinationwith lengthy interrogations, sensory bombardment,beatings, and sexual humiliation. Electric Shocks, Sexual Assault, and Physical Assault In addition to the beatings upon arrest, initialdetention and transfer described earlier, some of thedetainees were physically assaulted again later duringtheir detention. Two former detainees were sodomizedwith a broomstick or a rifle at Abu Ghraib and three weresubjected to electric shock (two in Iraq and one while atKandahar, Afghanistan). Physical assaults during detention included beingkicked, stepped on, dragged, slapped, and forcefullythrown against a wall. Adeel, who was later transferredto Guant?namo Bay, reported receiving daily beatingswhile he was held at the Bagram facility. The Iraqi formerdetainees described being struck with a rifle, stabbedin the cheek with a screwdriver, burned on the chestwith a cigarette, and other episodes of severe physicalabuse during interrogations that in some cases resultedin loss of consciousness. Five former detainees reportedsoldiers exploiting detainees? injuries. For example,Yasser, who was held at Abu Ghraib for four months,stated that his injured hand was deliberately stepped onand squeezed by soldiers at Abu Ghraib. Of the Guant?namo detainees, only one reportedroutine physical abuse: Rasheed reported frequent beatingsand one episode of harsh beatings during an interrogation.Youssef and Haydar stated that multiple timesthe IRF teams (referred to by the former detainees asthe ?riot police?) subjected them to chemical spray andpressurized water, which left Haydar ?writhing on theground in pain.? Many of the physical assaults reported would likelyhave resulted in bruises and soft tissue injuries thatwould not leave lasting physical marks. However, thebone scan findings of six individuals, and scars andhealed lesions observed on physical examination ofall detainees corroborated their specific allegationsof physical assault. Scarring on Yasser?s thumbs washighly consistent with the scarring caused by electricshock. Further, reports of rape and sexual assault werecorroborated in two cases by medical examination. Sleep Deprivation Nine of the eleven former detainees evaluated reportedthat they were often subjected to sleep deprivation, incombination with other techniques, through loud noiseor banging, use of cold water, or stress positions. Laithexplained: ?If you ask me about being chained to thewindow [standing], it was every day. They were especiallydoing that at night, to prevent me from me sleeping.? Sexual, Religious, Cultural, and Other Forms ofDegrading Treatment According to detainee accounts, humiliation waspervasive in detention facilities in both Iraq and Afghanistan.Guards taunted, shamed, insulted, spat and urinatedupon, and embarrassed detainees, forced most to benaked, observed some on the toilet, wrote degradingphrases in indelible marker on the body of one, and forciblycut the beards and shaved the heads of others. Inone incident, Amir reported having been pulled by a leatherdog leash in Abu Ghraib and was ordered to ?howl likedogs do.? He was repeatedly kicked when he refusedto do so. Cultural and religious humiliation was reported bymore than half of the individuals evaluated, and took manyforms, including taunting men at prayer and desecratingthe Koran. Rasheed stated that in protest of suchpractices, detainees in all five blocks of Guant?namoheld a simultaneous uprising by banging their headsagainst the walls and demanding ?an end to the mockingof their religion.? One of the worst forms of humiliation detaineesreported, though, was sexual, and it was reported by virtuallyall of the individuals evaluated by PHR, at facilitiesin Afghanistan, at Guant?namo, and in Iraq. The formsof sexual humiliation were as varied as they were cruel:parading men naked in front of female soldiers, forcingthem to disrobe before female interrogators, touching orprovoking them in a humiliating way, and forcing them towatch pornography or real or feigned sexual activities.Furthermore, nakedness became the normal mode ofoperation in the Iraqi detention facilities, especially inAbu Ghraib, where the detainees were forced to be nakedfor long periods of time. Kamal stated that his genitalswere touched multiple times during interrogations in AbuGhraib. Further, he reported that when the Americansoldiers ?got me naked, they used to bring all femalesoldiers to look at me and say, ?Hello, Imam?.? Witnessing Torture and Cruel Treatment More than half of the former detainees evaluatedby PHR recounted witnessing torture and other cruel,inhuman or degrading treatment towards other detaineesby US personnel. Two detainees witnessed other detaineesbeing bitten by dogs; others witnessed detainees beingsubjected to various forms of sexual humiliation. In AbuGhraib, Rahman recounted that he was forced to watchother detainees being forced to simulate anal intercourseand recalled that the detainees ?were begging, ?This is asin against our religion, please show mercy.? The soldierswere pushing them into each other, and these guys weretrying to push away, and this was more than half an hourand this was in front of our eyes.? Health Professional Complicity and Denial ofMedical Care Health professionals in detention settings are required bydomestic and international standards not only to providemedical care to detainees but to protect their health andwell-being. A few of the former detainees reported thatthey received appropriate care from health professionalswhile in US custody.8 Adeel was diagnosed and treatedfor tuberculosis while detained in Guant?namo, andMorad received ?humane treatment? from a doctor forhis diabetic foot ulcer. At the same time, former detainees reported thatmedical personnel played a role in facilitating tortureand ill-treatment in all three theatres of operationsthrough the monitoring of abuse during interrogations,providing medical information to interrogators, denyingmedical care, and failing to take action to stop and/ordocument detainee abuse. Three of the Iraqi formerdetainees and one former Guant?namo detainee reportedthat individuals acting in a health professional capacityexamined their condition during an episode of torture orphysical abuse but made no effort to stop it. Two formerGuant?namo detainees suspected that the psychologistshared information about them with interrogators. Several men reported facing difficulties accessingcare while in detention. At Guant?namo, Youssefrecounted that he never received treatment despitehis ?many, many? requests for medical attention to hispersistent stomach pain, as well as for swelling in hiswrists. Two men detained at Abu Ghraib reported beingdenied medical treatment, including for injuries inflictedby soldiers. In response to PHR?s query whether or notany doctors treated Amir?s injuries in Abu Ghraib; heresponded: ?Did I need to ask for help? I was there nakedand bleeding? .These were not real doctors.? In addition, all the former detainees from Guant?namoreported that they were given injections or medicationwithout their consent and medical procedures wereperformed on them against their will. The medical records of one of the former detainees,Rasheed, illuminate the role of medical personnel atGuant?namo, and PHR?s evaluators were able to comparehis account with entries in his medical file. The recordsare largely consistent with his own account: shortly afterarriving at Guant?namo in 2002, Rasheed?s mental healthbegan to deteriorate; he attempted suicide and other actsof self-harm, including self-mutilation. Mental healthstaff at Guant?namo responded with heavy doses ofmedication, which made him feel unbearably hot andmade his skin and joints ache. When his acts of selfharmcontinued, medical staff placed him in restraintsand treated his access to bottled water and blankets asprivileges. In response to his repeated requested to beremoved from isolation, the medical files note that thepsychiatric personnel ?informed him that [they] had nocontrol over that and told him to ask his interrogator tohave him moved.? It is not clear exactly how long Rasheed was kept inisolation or how long Rasheed?s interrogations continuedafter his severe signs and symptoms appeared ?although it appears to have been at least one year. Whatis clear, though, is that during the critical periods in2002 and 2003 when his health severely deteriorated,his health condition did not result in halting interrogations,nor in relieving a regime of isolation and sleepdeprivation; nor do the records indicate that the medicalstaff connected his ill-treatment ? including use of isolation,sleep deprivation, physical assault, violation of hisreligious and moral codes, and the use of sexual humiliation? to the obvious decline in his mental condition.Nor is there evidence from the records that the medicalstaff intervened to end his torture, except for one notewith a recommendation that resulted in a brief move outof isolation. Instead, the thinking of the medical staffappears reflected in a medical note that mentions himbeing subject to ?routine stressors of confinement.? Further, one of the most likely diagnoses for Rasheed?spsychological symptoms, PTSD, is never mentioned inthe medical record. The medical staff thus not only failedto document that Rasheed was being tortured throughthe use of isolation and other methods (and presumablydid not report it), but also became complicit themselvesin his abuse. Indeed their mental health interventionsmay have worsened Rasheed?s suffering by patchinghim up so that further interrogation and torture couldbe inflicted. Short-Term and Lasting Harm from Tortureand Ill-Treatment All the detainees experienced severe, even excruciatingphysical pain from being kicked, punched, choked,shocked or sodomized, and many were terrorized by boththe experience of the assaults on them and threats ofmore to come. Most of the detainees lost consciousnessat least once as a result of beatings or other physicalassaults. Some experienced bruising and trauma totheir genitals. Some of the men were not only severelyinjured as a result of torture, but they then had to endureadditional pain from the exploitation of those injuries bytheir tormenters. Almost all of the men PHR interviewedcontinue to experience physical after-effects from thetorture they experienced, including chronic headaches aswell as persistent pain in their limbs, joints, back, muscles,and ligaments from being beaten or kept suspended orin other stress positions for long periods of time. The experience of torture was horrifying to the men asit was taking place. Men experienced shame, humiliation,and terror that they or their loved ones would suffer evenmore; others were terrified by the claustrophobic conditionsof isolation. These in turn brought about symptomsranging from chest pain to severe anxiety to sleeplessness.One reported: ?I was having really bad nightmares?I felt like I couldn?t breathe.? According to medical files,during an interrogation session in Guant?namo onedetainee had a seizure and ?was unresponsive and fell?[while] his feet [were] buckled.? Lasting Psychological Consequencesof Ill-Treatment With one exception, the former detainees have experiencedand continue to experience severe psychologicaleffects of torture and ill-treatment as a result of theirdetention in US custody. All but one feel utterly hopelessand isolated, and lack the ability to sleep well, work, orengage in normal social relationships with their families.Seven individuals disclosed having contemplatedsuicide either while in detention or after being released.Most of the released detainees, to this day, live withsevere anxiety, depression, and post-traumatic stressdisorder, including intrusive recollections of traumasuffered in detention, hyperarousal (persistent symptomsof increased arousal, e.g., difficulty falling orstaying asleep, anger, and hypervigilance), avoidanceand emotional numbing behavior. PHR?s clinicians determinedthat these symptoms were directly related to thetorture and ill-treatment reported having taken placewhile in US custody, even after taking into account thefact that the released Iraqi former detainees are livingin a war-torn environment. Amir explained, ?These arethe memories that I can never forget. I want to forget,but it is impossible.? For the four detainees who had experienced symptomsof depression or other mental disorders prior to detention,torture and ill-treatment by the US Personell severelyexacerbated these conditions, and in one case it ignitedsuch deep despair and dysfunction as to lead the detaineeto repeated suicide attempts while at Guant?namo. Diminution of Social and work Life After Detention Many former detainees reported encountering socialstigma and fear in their communities as a result of theirstatus as former US detainees. Some relocated, and othersattempted to do so unsuccessfully. All except one havelost their livelihood and are facing financial hardships,and many were concerned about their physical safety andsecurity. These fears are not unfounded as three Iraqiformer detainees were rearrested and detained by bothAmerican forces and the Iraqi government, though subsequentlyreleased. Since the interviews were completed,PHR has authoritatively learned that one of the formerGuant?namo interviewees has been arrested in his homecountry and is still being detained. Legal Prohibitions Against Tortureand Ill-Treatment All of the abusive interrogation techniques and patternsof ill-treatment endured by these eleven men ? includingbeatings and other forms of severe physical and sexualassault, isolation, sleep deprivation, forced nakedness,severe humiliation and degradation, and sensory deprivation,many of which were experienced over long periods of time andoften in combination with other prohibited acts ? constitutedacts of torture as well as cruel, inhuman or degradingtreatment under domestic criminal statutes and internationalhuman rights and humanitarian treaties, includingthe Convention Against Torture and the Geneva Conventions,that were in effect at the time the acts were committed. According to courts and entities responsible for interpretingthe Convention Against Torture, including the UNSpecial Rapporteur on Torture and the UN CommitteeAgainst Torture, each of the interrogation techniquesand conditions of incarceration and treatment identifiedin this report, when considered on its own, constitutesprohibited conduct in the form of torture or cruel,inhuman or degrading treatment or punishment. Infulfilling its obligation to assess and report upon thehuman rights conditions in other countries, the US StateDepartment relies upon international human rights treatiesincluding the Convention Against Torture; in innumerableinstances, it has identified the very practicesevidenced by this study, when committed in foreign countries,as torture or cruel, inhuman or degrading treatmentor punishment. In addition, based on the severityof physical and psychological pain and suffering causedby these practices, the Istanbul Protocol has determinedthat they constitute torture and/or ill-treatment.9 Likewise,the medico-legal evidence leaves little doubt that the interrogationmethods used by US personnel constitute tortureunder the US Torture Act, the Uniform Code of MilitaryJustice (UCMJ),11 and other laws. Recommendations Based on the findings of this investigation, the UnitedStates should take the following actions:The executive branch must repudiate all forms 1. oftorture and cruel, inhuman or degrading treatment.It should explicitly and in writing establish a uniformstandard of conduct for all agencies that prohibitsany of its military, intelligence or other officials,including all forms of contract personnel, fromengaging in torture and cruel, inhuman or degradingtreatment, including but not limited to any of thefollowing interrogation or conditions of confinementmethods, either alone or in combination: ? Stress positions? Beatings and other forms of physical assault? Use of extremes of temperature? Waterboarding or any other form of simulateddrowning? Threats of harm to the detainee, his family, orfriends? Sleep deprivation? Sensory bombardment through the use ofextreme noise and/or light? Violent shaking? Religious, cultural, and sexual humiliationincluding, but not limited to, forced nakedness? Prolonged isolation? Sensory deprivation, including, but not limitedto, hooding and blindfolding? Use of psychotropic, mind-altering, or otherdrugs for the purpose of decreasing resistanceor gaining information? Mock execution? Exploitation of phobias, psychopathology, orphysical vulnerability? Rape and sexual assault? Electric shocks? Deprivation of basic necessities and sanitaryconditions Congress should enact into law the prohibitions listedabove and establish criminal liability for their violation.The executive branch and Congress should establishan independent commission to fully investigate andpublicly report on the circumstances of detentionand interrogation in Bagram, Kandahar, and elsewherein Afghanistan, Iraq, Guant?namo Bay, and otherlocations since 2001. This independent commissionshould have subpoena power to compel witnessesand have full access to all classified materialsconcerning interrogation techniques and conditionsof detention, including medical records and documentationby behavioral health science consultantpersonnel, in order to establish a full public record. The investigation should extend to individuals in theposition of making policy as well as those who carriedthose policies out, including all healthcare profes-sionals who were in the position of providing care orsupporting the interrogation of detainees. All individuals who played any role in the tortureor ill-treatment of detainees, including thosewho authorized the use of methods amounting totorture or exercised command authority over them,should be held to account through criminal and civilprocesses (such as disciplinary action). Officials atevery level should be held accountable for crimesthey committed or for the acts of officials subordinateto them. Health professionals, both civilianand uniformed, who engaged in or facilitated theabuse of detainees and/or failed to report tortureand ill-treatment should be investigated, appropriatelysanctioned, and disciplined via the Departmentof Defense, other executive branch agencies, andstate licensing boards. The government should issue a formal apology todetainees who were subjected to torture and/or illtreatmentas part of US military and intelligenceoperations since fall 2001 in Afghanistan, Iraq,Guant?namo Bay, Cuba, and elsewhere. The government should establish a fair process forcompensation and victim assistance, includingaccess to rehabilitation and re-integration services, forindividuals subjected to torture or ill-treatment inUS custody. All places of detention operated by the United Statesshould be subject to monitoring by internationalbodies that investigate detainee treatment andare capable of reporting findings to the public andgovernment, including the UN Special Rapporteuron Torture, the UN Committee Against Torture, andthe International Committee of the Red Cross. Theseorganizations tasked by treaties to which the UnitedStates is a party must be granted full access todetainees, their medical records, and all other pertinentfiles documenting past and current treatmentof detainees during their incarceration. Furthermore,Congressional and executive branch oversight ofUS military and intelligence activities relevant todetainee treatment and interrogation should beimmediately strengthened and improved. The US Department of Justice should publiclyrelease all legal opinions and other memorandaconcerning standards regarding interrogation anddetention policy and practices.

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