A Report by Physicians for Human Rights
© 2008, Physicians for Human Rights
Cover image: © Fernando Botero, courtesy, Marlborough Gallery, New York.
Detail from Abu Ghraib 44 (right panel), 2005, 191 x 107 cm
Report Design: Glenn Ruga/Visual Communications
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Part 1 of 2
PHYSICIANS FOR HUMAN RIGHTS
Physicians for Human Rights (PHR) mobilizes health professionals to advance the health and dignity of all people through actions that promote respect for, protection of, and fulfillment of human rights. PHR has a track record of more than 20 years documenting torture around the world, including in Turkey, Chile, Chechnya, Kosovo, Israel, India, and Chiapas, Mexico. PHR has extensive expertise in evaluating survivors of torture as well as experience with prisoner health issues. PHR was one of the lead initiators and authors of the Istanbul Protocol on the investigation and documentation of torture, adopted as an official document by the United Nations in 1999.
As one of the original steering committee members of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Prize for Peace.
About PHR's Campaign Against Torture
PHR has documented the systematic use of torture by the United States during its interrogations of detainees at US detention facilities, including those at Guantanamo Bay, in Iraq and Afghanistan, and elsewhere. It has previously published two groundbreaking reports on the human impact and the legality of abusive interrogation tactics authorized by the Bush Administration: Break Them Down: Systematic Use of Psychological Torture by US Forces and Leave No Marks: "Enhanced" Interrogation Techniques and the Risk of Criminality. PHR has repeatedly called for an end to the use of the "enhanced" tactics by all US personnel, an end to all health professional participation in interrogations, a full Congressional investigation of the use of psychological and physical torture by the US Government, and accountability for perpetrators.
PHR has successfully organized and mobilized thousands of health professionals and helped to secure the leadership of the major health professional associations to develop ethical guidelines related to interrogation that protect against medicine and science being employed to aid the abuse of prisoners. PHR's work contributed to the adoption of ethical standards by the American Medical Association, the World Medical Association, and the American Psychiatric Association prohibiting direct participation of physicians in interrogations. PHR has helped move the American Psychological Association (APA) to prohibit the involvement of its members in the Central Intelligence Agency's "enhanced" interrogation techniques and has supported a movement within the APA to end the direct participation of psychologists In interrogations.
Physicians for Human Rights
2 Arrow Street, Suite 301
Cambridge, MA 02138
Tel. (617) 301.4200
1156 15th Street, Suite 1001
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Tel. (202) 728.5335
The lead author for this report was Farnoosh Hashemian, MPH, Research Associate, Physicians for Human Rights (PHR), who was joined in its writing by Sondra Crosby, MD, Boston Center for Refugee Health and Human Rights; Vincent Iacopino, MD, PhD, PHR Senior Medical Advisor; Allen Keller, MD, Bellevue/NYU Program for Survivors of Torture; Leanh Nguyen, PhD, Bellevue/NYU Program for Survivors of Torture; Onder Ozkalipci, MD, International Rehabilitation Council for Torture Victims; Christian Pross, MD, Berlin Center for the Treatment of Torture Victims; and Juda Strawczynski, LLB, former PHR Research Fellow. Leonard Rubenstein, JD, PHR President, oversaw the report and provided crucial guidance throughout on report’s structure and content; Alicia Yamin, JD, MPH, former PHR Director of Research and Investigations oversaw the planning and implementation of the investigation its initial stages.
Scott Allen, MD, PHR Medicine as a Profession Fellow; Vincent Iacopino, MD, PhD, PHR Senior Medical Advisor; and Brigadier General Stephen Xenakis, MD, USA (Ret.) offered detailed comments on the medical evaluations and, along with Drs. Ozkalipci and Pross, reviewed the medical records of one of the detainees held at Guantánamo. Nathaniel Raymond, PHR Senior Communications Strategist, reviewed, edited, and provided technical expertise for the report. This report was edited and prepared for publication by Tara Gingerich, JD.
This report has benefited from review by Shereef Akeel, JD, Akeel & Valentine, PLC; Barbara Ayotte, former PHR Director of Communications; John Bradshaw, JD, PHR Director of Public Policy; Carolyn Patty Blum, JD, Consultant, Center for Constitutional Rights; Susan Burke, JD, Burke O’Neil, LLC; Colonel Daniel L. Cohen MD, USAF (Ret.); Frank Davidoff, MD, and Vice President PHR Board of Directors; Benjamin Davies, former PHR Chief of Staff; Frank Donaghue, PHR Chief Executive Officer; Sebnem Korur Fincanci, MD, Professor of Forensic Medicine, Istanbul University; Justice Richard J. Goldstone, Justice of the South African Constitutional Court, Retired, and member of PHR Board of Directors; Emi MacLean, JD, Staff Attorney, Center for Constitutional Rights; Paul Rocklin, JD, former PHR Senior Program Associate; Barry Rosenfeld, PhD, Professor and Director of Clinical Training, Fordham University; Susannah Sirkin, PHR Deputy Director; and Ronald Waldman, MD, MPH, Professor of Clinical Population and Family Health, Mailman School of Public Health, Columbia University, and member of PHR Board of Directors.
PHR is grateful for the dedication and extensive research assistance over many months by Klara Bolen. The following individuals contributed to legal and other research: Patrick Childress, Joanne Cossitt, Jesse Hamlin, Louise Place, Brent Savoie, and Daniel Scarvalone. Remy Gerstein and Majid Jumoor assisted with the logistics and played an essential role in ensuring that investigations were carried out successfully.
PHR extends special gratitude to the following organizations for their pivotal support: Akeel & Valentine, PLC, Bellevue/NYU Program for Survivors of Torture, Berlin Center for the Treatment of Torture Victims, Boston Center for Refugee Health and Human Rights, Burke O’Neil, LLC, Center for Constitutional Rights, Fordham University, and International Rehabilitation Council for Torture Victims. Two centers affiliated with IRCT facilitated the medical evaluations and made this investigation possible; they cannot be named to protect the confidentiality of the participants.
PHR thanks the JEHT Foundation, the Morton and Jane Blaustein Foundation, The Open Society Institute and the Herbert Block Foundation for financial support that made this investigation and report possible.
PHR would like to acknowledge the artist Fernando Botero for granting PHR permission to use one of the paintings from his Abu Ghraib series on the cover of this report.
We are most indebted, however, to the eleven former detainees who were willing to share their painful experiences with us, sometimes at significant risk to themselves and their families.
LIST OF ACRONYMS
BHS: Behavioral Health Science Teams
CIA: Central Intelligence Agency
ClDT: Cruel, Inhuman, or Degrading Treatment
DoD: Department of Defense
DTA: Detainee Treatment Act of 2005
ECHR: European Court of Human Rights
ERB: Ethics Review Board
FBI: Federal Bureau of Investigation
IACHR: Inter-American Court of Human Rights
ICRC: International Committee of the Red Cross
ICCPR: International Covenant on Civil and Political Rights
ICTR: International Criminal Tribunal for Rwanda
ICTY: International Criminal Tribunal for Yugoslavia
IRF: Immediate Reaction Force
IRCT: International Rehabilitation Council for Torture Victims
MCA: Military Commissions Act of 2006
MDD: Major Depressive Disorder
NOS: Not Otherwise Specified
OLC: Office of Legal Counsel, Department of Justice
PHR: Physicians for Human Rights
POW: Prisoner of War
PTSD: Post-traumatic Stress Disorder
SERE: Survival, Evasion, Resistance, and Escape training
SOP: Standard Operating Procedure
TVPA: Torture Victims Protection Act of 1991
WCA: War Crimes Act
This report tells the largely untold human story of what happened to detainees in our custody when the Commander-in-Chief and those under him authorized a systematic regime of torture. This story is not only written in words: It is scrawled for the rest of these individual’s lives on their bodies and minds. Our national honor is stained by the indignity and inhumane treatment these men received from their captors.
The profiles of these eleven former detainees, none of whom were ever charged with a crime or told why they were detained, are tragic and brutal rebuttals to those who claim that torture is ever justified. Through the experiences of these men in Iraq, Afghanistan, and Guantanamo Bay, we can see the full-scope of the damage this illegal and unsound policy has inflicted —both on America’s institutions and our nation’s founding values, which the military, intelligence services, and our justice system are duty-bound to defend.
In order for these individuals to suffer the wanton cruelty to which they were subjected, a government policy was promulgated to the field whereby the Geneva Conventions and the Uniform Code of Military Justice were disregarded. The UN Convention Against Torture was indiscriminately ignored. And the healing professions, including physicians and psychologists, became complicit in the willful infliction of harm against those the Hippocratic Oath demands they protect.
After years of disclosures by government investigations, media accounts, and reports from human rights organizations, there is no longer any doubt as to whether the current administration has committed war crimes. The only question that remains to be answered is whether those who ordered the use of torture will be held to account.
The former detainees in this report, each of whom is fighting a lonely and difficult battle to rebuild his life, require reparations for what they endured, comprehensive psycho-social and medical assistance, and even an official apology from our government.
But most of all, these men deserve justice as required under the tenets of international law and the United States Constitution.
And so do the American people.
Major General Antonio
Taguba, USA (Ret.)
Maj. General Taguba led the US Army's official investigation into the Abu Ghraib prisoner abuse scandal and testified before Congress on his findings in May, 2004
This report provides first-hand accounts and medical evidence of torture and cruel, inhuman, or degrading treatment or punishment ("ill-treatment" ) of eleven former detainees who were held in US custody overseas. Using internationally accepted standards, Physicians for Human Rights (PHR) conducted medical evaluations of the former detainees to document the severe, long-term physical and psychological consequences that have resulted from the torture and ill-treatment. The evaluations provide evidence of violation of criminal laws prohibiting torture and of the commission of war crimes by US personnel. 
Four of the men evaluated were either arrested in or brought to Afghanistan between late 2001 and early 2003 and later sent to Guantanamo Bay, Cuba, where they were held for an average of three years before release without charge. The other seven were detained in Iraq in 2003 and released without charge later that year or in 2004, with an average period of detention of six months. All of the former detainees evaluated by PHR reported having been subjected to multiple forms of torture or ill-treatment that often occurred in combination over a long period of time.
The medical evaluations were based in each case on intensive two-day clinical interviews that included diagnostic testing and, in two cases, review of medical records. With this evidentiary record, this report provides the most detailed account available thusfar of the experience of detainees in US custody who suffered torture -- a war crime -- at the hands of US personnel. Additionally, this report provides further evidence of the role health professionals played in facilitating detainee abuse by being present during torture and ill-treatment, denying medical care to detainees, providing confidential medical information to interrogators, and failing to stop or document detainee abuse.
Methods of torture experienced by the former detainees evaluated by PHR included interrogation and detention practices such as isolation, sleep deprivation, forced nakedness, severe humiliation and degradation, and sensory deprivation that were officially authorized by military and civilian officials during certain periods when these men were incarcerated.  Additional practices recounted by the interviewees including beatings and other forms of severe physical and sexual assault that, while not officially authorized by government documents now part of the public record, came to be part of a regime of brutality at the facilities where the detainees were held.
This report demonstrates that the permissive environment created by implicit and explicit authorizations by senior US officials to “take the gloves off”  encouraged forms of torture even beyond the draconian methods approved at various times between 2002 and 2004.  In an environment of moral disengagement that countenances authorized techniques designed to humiliate and dehumanize detainees, it is not surprising that other forms of human cruelty such as physical and sexual assault were practiced. The fact that these unauthorized torture practices happened over extended periods of time at multiple US detention facilities suggests that a permissive command environment existed across theatres and at several levels in the chain-of-command. This climate allowed both authorized and unauthorized techniques to be practiced, apparently without consequence.
Given the limited number of detainees evaluated, the findings of this assessment cannot be generalized to the treatment of all detainees in US custody. The patterns of abuse documented in this report, however, are consistent with numerous governmental and independent investigations into allegations of detainee ill-treatment,  making it reasonable to conclude that these detainees were not the only ones abused, but are representative of a much larger number of detainees subjected to torture and ill-treatment while in US custody.
PHR identified individuals through referring non-governmental organizations and law firms that provide legal representation to former and current detainees in US custody. The evaluations were conducted between December 2006 and September 2007, after consent was obtained by the individuals. No former detainee PHR located who was eligible and consented to an evaluation was excluded from the study. For each former detainee, a team of two experienced clinicians evaluated the individual and documented allegations of torture and ill-treatment in accordance with the guidelines for assessing physical and psychological evidence of torture set out in the Istanbul Protocol, Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (hereafter Istanbul Protocol).  Sources of information for the medico-legal reports include the clinical interview, psychological testing, physical examinations and medical diagnostic tests. The Guantánamo Bay detention medical records of one individual and an independent medical record of another former detainee were available for review as well. In each case, the clinicians provided opinions on possible torture and ill-treatment based on correlations between individual allegations of torture and specific physical and psychological evidence. They found no evidence of deliberate exaggeration in any case. The study was approved by PHR’s Ethics Review Board. In order to protect confidentiality, the names of the individuals evaluated were changed and information that could potentially identify the former detainees has been omitted.
Summary of Findings
Synopses of the Cases of Former Detainees Profiled
The following summaries of three evaluations of the eleven cases illustrate the torture and ill-treatment that the detainees experienced and the resulting long-term physical and psychological harm. The torture and ill-treatment described were corroborated by the medical evidence.
Kamal is in his late forties. He served in the Iraqi Army during the 1980s and later became a businessman and Imam of a local mosque. In September 2003 he was arrested by US forces. At the time of his arrest, he was beaten to the point of losing consciousness. After being brought to Abu Ghraib prison, he was kept naked and isolated in a cold dark room for three weeks, where both during and in between interrogations he was frequently beaten, including being hit on the head and in the jaw with a rifle and stabbed in the cheek with a screwdriver.
He was then placed in isolation in a urine-soaked room for two months. When Kamal was allowed to wear clothes, they were sometimes soaked in water to keep him cold. On approximately ten occasions he was suspended in a stress position, causing numbness that lasted for a month. He was made to believe that his family members were also in prison and that they were being raped and tortured. He recounted, “[T]hey were telling me, making me hear voices of children and women, and told me they were my children and [wife].” He was eventually transferred to a tent area of Abu Ghraib, where he remained for seven months until his release in June 2004.
PHR’s clinicians found physical and psychological evidence consistent with the abuse Kamal reported. He continues to experience chronic pain in his jaw and numbness from the suspensions. He also meets diagnostic criteria for several psychiatric diagnoses, including major depressive episodes, a panic disorder, and post-traumatic stress disorder (PTSD) that are attributable to his experience in detention. Particularly striking is the severity of Kamal’s depressive symptoms, with feelings of hopelessness, worthlessness, and guilt, and difficulty sleeping. His symptoms are indeed so severe that, in the opinion of PHR’s clinicians, they would qualify him for hospitalization in the United States.
Amir is in his late twenties and grew up in a Middle Eastern country. He was a salesman before being arrested by US forces in August 2003 in Iraq. After his arrest, he was forced, while shackled, to stand naked for at least five hours. For the next three days, he and other detainees were deprived of sleep and forced to run for long periods, during which time he injured his foot. After Amir notified a soldier of the injury, the soldier threw him against a wall and Amir lost consciousness. Ultimately, he was taken to another location, where he was kept in a small, dark room for almost a month while being subjected to interrogations that involved shackling, blindfolding, and humiliation. Approximately one month later, he was transferred to Abu Ghraib. At first he was not mistreated, but then was subjected to religious and sexual humiliation, hooding, sleep deprivation, restraint for hours while naked, and dousing with cold water. In the most horrific incident Amir recalled experiencing, he was placed in a foul-smelling room and forced to lay face down in urine, while he was hit and kicked on his back and side. Amir was then sodomized with a broomstick and forced to howl like a dog while a soldier urinated on him. After a soldier stepped on his genitals, he fainted. In July 2004, he was transferred to the prison at Camp Bucca, where he reported no abuse. He was returned to Abu Ghraib in November 2004 and released two days later.
Amir continues to experience physical symptoms consistent with the abuse he reported. Physical examination revealed features consistent with his account, including tenderness of one of his testicles and rectal tearing. Psychologically, he continues to suffer from debilitating symptoms of severe PTSD, disturbed sleep, moodiness, anxiety, sexual dysfunction, hostility and outbursts of anger, and very frequent suicidal thoughts. He has changed from a stable provider for his family to an unemployed man. Although stressors related to the war in Iraq may exacerbate his symptoms, his most debilitating symptoms are attributable to his experience of torture and sexual violation. “No sorrow can be compared to my torture experience in jail,” he said. “That is the reason for my sadness.”
Youssef is in his early thirties. Unable to find work in his country of origin, he sought employment in Afghanistan. In late 2001 or early 2002, Youssef was detained as he attempted to cross the Afghanistan-Pakistan border without a passport while trying to return home. He was held in a Pakistani prison for two months, where he was often shackled in unsanitary conditions and given little food. During this time, he was interrogated by US personnel and eventually hooded, shackled, and transferred to the US detention facility in Kandahar, Afghanistan.
In Kandahar, Youssef was immediately interrogated and subjected to beatings with sticks and fists as well as kicking, although he did not sustain serious injuries at the time. After that, he was stripped naked. The first night he was not allowed to sleep, as guards hit the detainees and threw sand at them. While in Kandahar, Youssef endured forced nakedness, intimidation by dogs, hooding, and repeated assaults by being thrown against a wall. He was subjected to electric shock from a generator, feeling “as if my veins were being pulled out.”
After about six weeks, he was transferred to the US detention facility at Guantánamo Bay, Cuba. During the transatlantic flight he was dressed in an orange suit, fitted with dark goggles and headphones and shackled to the floor of the plane. The tight cuffs caused his wrists to swell. Upon arrival, he was stripped, sprayed with water 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 extremely hot and denied anything but a bucket for a toilet. In Camp X-Ray lengthy interrogations accompanied by sleep deprivation began. Small infractions such as speaking with other detainees led to beatings, and a person whom he perceived to be a doctor checked the injuries of the detainees after the beatings. In order to avoid beatings, Youssef was compliant. Nevertheless, the Immediate Reaction Force (IRF) team forced him into stress positions, including sitting on his knees with his hands pressed together behind his back or head and tied to his feet, forcing his legs up.
After approximately three months, Youssef and others were transferred to Camp Delta, where general cell conditions were better, although detainees were rarely let out of their cells. He was beaten once for hiding food in his cell. An IRF team also sprayed him in the eyes with what may have been pepper spray, so that “my whole body would feel like it was burning — not just my face, but my whole body … I felt like I was losing consciousness from the burning.”
His interrogations, which took place almost every other day during his initial period at Guantánamo and he would be kept in the interrogation room for as long as eighteen to twenty hours. He denied having been beaten during the lengthy interrogations or while being held in the interrogation room. Youssef described these episodes as some of his most painful experiences at Guantánamo. He was chained and forced to assume stressful positions; at times, ice-water was poured on him and, at other times, loud music was played. He was deprived of access to the toilet and time for prayer. While being held in the interrogation room, the temperature in the room would be made extremely cold or hot for extended periods of time. Demands for confessions were constant, accompanied by claims by interrogators that his name was found on documents and that his brother, who has leukemia, had been arrested; soldiers also threatened to shoot him. Humiliation was part of the interrogation regime: he was forced to look at pornography, and soldiers ripped the Koran apart and threw it in the toilet in front of him. He described being horrified by an incident in which a naked woman entered the interrogation room and smeared what he believed to be menstrual blood on him. He reported being given injections of unknown substances against his will, and these injections often caused rashes several hours later. He believes that in some interrogations medical personnel were present and that they examined him periodically. Although he was not privy to the discussions between the medical personnel and interrogators, it appeared to Youssef that that the medical personnel were being consulted as to whether interrogations should continue. They always did.
At one point while at Camp Delta at Guantánamo, Youssef asked to speak with a psychologist because of the distress and sadness he felt due to the separation from his family. He believes that not only did his interrogators have access to the information he shared with the psychologist, but that they exploited it by threatening that he would spend the rest of his life in Guantánamo. Following this interrogation session, he was moved to what he believed to be the worst section of Camp Delta, where he was not allowed to have a blanket or mattress.
After being transferred out of Camp Delta and signing a form, he was released in the fall of 2003. He was again handcuffed and chained to the floor of the plane during the lengthy flight. Upon returning home, he served over a year of military service, during which he was mostly confined in a psychiatric hospital because he was deemed “too aggressive.”
On physical examination, Youssef was noted to have surgical scars on his wrists consistent with his report of surgery following his release for chronic wrist pain as a result of shackling during his detention. Pain in his right wrist still persists. He also has a scar on the back of his left wrist consistent with the handcuffing he described. While Youssef experienced symptoms of depression before detention, PHR’s evaluators concluded that these symptoms became more pronounced, disabling and chronic as a result of his experience; he also now suffers from moderate PTSD. Many of his physical symptoms, including shortness of breath and “heart problems,” are consistent with a panic disorder. Youssef acknowledged difficulty functioning and has not found steady employment since his detention.
Common Experiences of Torture and Ill-Treatment
Even though the eleven detainees examined by PHR were held at different places, and each person’s experience was unique, certain detention and interrogation practices appear over and over again in the accounts.
Beatings During Arrest, Transport, and Initial Custody
Many of the most severe injuries from beatings that the former detainees reported were sustained shortly after they were arrested. All seven of the men who were detained in Iraq (hereafter referred to as “the Iraqi former detainees”) recounted experiencing violent treatment during their arrests, some of which involved severe physical assault on their family members as well as destruction or looting of their homes.
The beatings inflicted on detainees at US facilities at Bagram and Kandahar in Afghanistan were particularly intense, and included beatings with sticks and fists, kicks to the stomach and genitals and blows to the head. As a result, Haydar, who was held at Kandahar before being transferred to Guantánamo, lost three of his teeth and
Rasheed, who was held at both Bagram and Kandahar facilities, lost consciousness and was hospitalized. Similarly, all former detainees held at Guantánamo reported that the most intense and widespread physical beatings they experienced at the facility took place during transfer and shortly after arrival there.
The Iraqi former detainees also reported severe beatings during the first days and weeks of detention at facilities including one at Baghdad International Airport. Hafez, who was held at a US facility at Baghdad International Airport and Abu Ghraib for over seven months, was forced to the ground and beaten severely on his legs and back, causing his lips, forehead, and nose to bleed; he also reported being stripped and having his chest and pubic hair 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 be detectable in later medical evaluations, findings from bone scans of six of the former detainees as well as scars and lesions visible during physical examination are consistent with the history of beatings described by the victims.
Deprivation of Basic Necessities and Sanitary Conditions
All of the former detainees reported frequent denial of basic necessities during periods of their detention; over half of the men evaluated reported being denied food on at least one occasion. Each former detainee also reported being subjected to extreme temperatures during his confinement.
The conditions detainees in Iraq endured were particularly appalling. Among the conditions one or more of the detainees reported were placement in a urine-soaked punishment room, being forced to wear soiled underwear, often for weeks or months at a time, denial of access to food, water and toilets of any kind, and exposure to cold without blankets.
Two of the detainees who were held in Guantánamo during the first year the facility was in operation reported harsh physical conditions and being housed in steel cages. Although as time passed, the physical conditions improved there, deprivation sometimes accompanied by acts of cruelty continued. Haydar reported that in Guantánamo the soldiers would often either spit in or throw out part of their food rations.
Stress Positions: Forced Standing, Handcuffing, and Shackling
All of the former detainees reported having been subjected to painful stress positions that involved having their hands and feet bound for extended periods of times, or suspension from walls or barbed wire. These positions were often coupled with the use of blindfolding, sleep deprivation, isolation, and exposure to temperature extremes, either as components of interrogations or conditions of confinement.
For example, three former detainees evaluated by PHR reported that in Guantánamo they were kept in extremely hot or cold interrogation rooms, chained in a crouching position to a ring on the floor for eighteen to twenty hours. Two of the Iraqi former detainees reported losing consciousness as a result of being subjected to stress positions.
Findings on medical examination were consistent with these accounts. All of the former detainees reported that they continue to suffer from a wide range of musculoskeletal pains. For example, Laith, an Iraqi former detainee who was held in Abu Ghraib for nine months, reported arm numbness and weakness following being suspended by his arms, which is highly consistent with a brachial plexus (nerve group supplying the upper extremity) injury that often results from suspension.