Doctors who administered forced rectal feeding accused of ‘medicalised rape’

Its use in US black site prisons was first reported almost a decade ago.

The rendition, detention and interrogation program created by the US Government in the wake of the 9/11 attacks still haunts the memory.

Yes, the world likes to move on from times past but the architects and perpetrators who, to critics, carried out state-sponsored torture at Guantanamo Bay in Cuba and the CIA’s secret black site prisons have never been held to account.

And no doubt it is because that phrase “state-sponsored” offers special protections.

The US Government’s use of waterboarding, where a prisoner under interrogation was strapped to a board and a stream of water poured over a rag covering his face to induce “controlled drowning”, has been widely documented.

But while the interrogation program officially ended in 2009 under the Obama administration, the fallout has continued to rumble on in the margins.

Last month, Professor Sondra Crosby and her co-author Dr Leonard Glantz described in JAMA the use of rectal feeding by CIA doctors, a practice they described as “a form of medicalised rape”.

Its use in black site prisons was first reported almost a decade ago after a Senate Select Committee found that at least five detainees held in US custody were subjected to either rectal rehydration or rectal feeding with a liquid nutritional supplement or pureed food.

This “treatment” disappeared from modern medical practice more than eighty years ago but was still used on two detainees who were attempting hunger strikes, a detainee who partly refused liquid and a detainee who had not been medically assessed beforehand.

Further details of what happened emerged last year during pre-trial hearings involving Abd al-Rahim al-Nashiri, the man still accused (not convicted) of orchestrating the suicide bombing of USS Cole in Yemen which killed 17 US sailors in 2000.

Professor Sondra Crosby.

Professor Crosby, a physician and professor of medicine at Boston University, spoke at the hearings about her conversations with Mr al-Nashiri back in 2013 when he was being held at Guantanamo Bay.

“He described sitting in his cell when some men came in, roughed him up, took his clothes, took him somewhere else, bent him over a chair, shackled him, inserted a tube into his anus, and administered liquid food,” she said.

“There was another incident where he was shackled naked, arms extended above his head, feet shackled and sodomised with a broomstick.

“These incidents were clearly very, very distressing to him; shame, stigma, very, very painful. He experienced them as painful sexual assaults or rape.”

She was asked whether he should have been classed as a hunger striker.

Professor Crosby said he had refused to take a number of meals but, no, he was not on a hunger strike.

“I should also say the reason he was refusing meals is reportedly that he thought there were medications put into the food. He was paranoid about that.”

It is worth pointing out that whether he was a hunger striker or not is an ethical irrelevance.

As Professor Crosby’s JAMA article states somewhat euphemistically, nutrition delivered via rectal administration is “unfamiliar to modern medicine” and was never going to work because of basic biology. 

“For more than 90 years, it has been known that 95% of nutritional absorption occurs in the small intestine and that it is not possible for nutrients to travel from the rectum retrograde into the small intestine,” she writes.

“Nutritional supplements (such as Ensure) or pureed food administered into the rectum are simply expelled.

She continues: “Nutritive enemata is of historic interest only, having been used in US medicine for patients with bowel disorders dating back to the 1870s and up through the early 20th century.

“[But] scientific advances in nutrition physiology concluded that nutrients — specifically fats and proteins — are not absorbed to any significant extent through the rectal mucosa, and the practice largely vanished by 1915.

“Although fluids (water, saline) can be absorbed through the rectal mucosa, IV administration of fluids replaced hydration via the rectal route by the mid-20th century. 

“Once a physician determines that artificial administration of nutrition is medically necessary, the standard method to deliver nutrition is through a nasogastric or orogastric tube, percutaneous endoscopic gastrostomy, jejunostomy, or intravenously through a deep vein.”

Beyond the potential rectal administration of fluids for fluid resuscitation in emergency situations in remote settings when it is the only treatment available, she said rectal feeding is no longer deemed legitimate medical practice. 

“Even those who advocate for forcibly feeding individuals participating in hunger strikes never suggest the use of rectal feeding.”

Waterboarding, at least in the form of the so-called “enhanced interrogation technique” employed by CIA officers, was devised under a multi-million dollar contract with the intelligence agency by two psychologists, James Mitchell and Bruce Jessen.

Their identities were revealed in 2007 in a celebrated article by Katherine Eban published in Vanity Fair called Rorschach and Awe. They have since become pariahs. The torture technique they came up with for for eliciting intelligence then and now has widely seen to be useless, especially within the intelligence community itself.

In terms of an explanation for why they did it, it’s been suggested that psychology, when regarded as a scientific rather than therapeutic discipline, one focused on identifying the specific inputs to generate specific outputs, perhaps renders some of its practitioners blind to the ethical dimension of what they do. 

There have been questions about whether the doctors involved in monitoring prisoners undergoing “enhanced interrogation” were complicit in torture.

One possible response is to say they were present to mitigate harm even if they failed to prevent it.

There is less ethical ambiguity surrounding doctors involved in rectal feeding.

But those who took part remain unknown, at least in the public domain.  

“Publicly available information does not specify the professional identities of the medical officers who authorised and performed the rectal feeding and hydration,” Professor Crosby says.

“However, according to the chief of medical services … the CIA Office of Medical Services included physicians, psychologists, physician assistants, and nurses who were directly involved.”

She then goes through what you assume no modern doctor post-1945 needs to be told but what still, tragically, has to be repeated.

“Both ethical and legal standards require reasonable medical judgement and prohibit providing treatment that cannot benefit a patient. 

“Furthermore, international human rights laws, and basic human decency, prohibit participation in cruel, inhuman, and degrading treatment that can constitute torture.”

At this point, she makes explicit the acts these doctors perpetrated.

“Given the lack of medical benefit, those medical officers authorising, ordering, or participating in the non-consensual penetration of the anus under the guise of feeding have committed acts that meet the definition of rape under federal law 10 USC §920 (a) and (g)(c). 

“The non-consensual penetration of the anus embodies the violence, abuse, humiliation, and degradation rape victims experience.”

No doctors are absolved of ethical and legal responsibility for their actions when they commit “heinous acts” on behalf of and with permission of the state, she adds.

“We believe that any CIA medical officers who authorised or participated in the rectal feeding of these prisoners cannot be entrusted to protect the welfare of patients once they return to civilian positions.”

Read more: What happens when governments ask doctors to assist in torture?

More information: JAMA 2023; 21 Dec.