By Sondra S. Crosby, MD, and Leonard H. Glantz, JD

From JAMA Network | Original Article

Although the rendition, detention, and interrogation program officially ended in 2009, the abusive interrogation practices that occurred almost 20 years ago at Central Intelligence Agency (CIA) secret prisons are relevant in 2023. Testimony given to the military commissions pretrial hearings at Guantanamo Bay highlighted serious legal and ethical problems with “rectal feeding,” which is a form of medicalized rape.^1,2 This publicly available testimony provides previously unknown details about the brutality of rectal feeding justified as a medical procedure at CIA secret prisons, and provided previously unreported medical information on the long-lasting psychological and physical harms it inflicted on a detainee.

In an August 2023 ruling, a military judge found that the statements made by the defendant in the testimony at Guantanamo Bay in 2007 to federal agents in the absence of torture were so tainted by the detainee’s previous torture, which included rectal feeding, were inadmissible. The judge found that rectal feeding could not be justified as a legitimate medical practice.³

Rectal feeding at CIA secret prisons was first reported almost a decade ago. The Senate Select Committee on Intelligence found that at least 5 detainees held in US custody were subjected to either rectal rehydration or rectal feeding with a liquid nutritional supplement or pureed food.⁴ The Senate report recounts the experience of 1 detainee whose “lunch tray consisting of hummus, pasta with sauce, nuts, and raisins, was ‘pureed’ and rectally infused.” The report documents that CIA medical officers were directly involved in this practice, and the former director of the CIA publicly confirmed that rectal feeding was a medical procedure performed for the health of detainees.⁵ Publicly available information does not specify the professional identities of the medical officers who authorized and performed the rectal feeding and hydration; however, according to the Chief of Medical Services, during the 5 years from 2002 to 2007, the CIA Office of Medical Services included physicians, psychologists, physician assistants, and nurses who were directly involved in the program and were responsible for the health of detainees.⁶

Nutrition delivered via rectal administration is unfamiliar to modern medicine. 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. Nutritional supplements (such as Ensure) or pureed food administered into the rectum are simply expelled.

“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. This method of feeding was attempted on Presidents Garfield and McKinley prior to their deaths from gunshot injuries inflicted by assassins.⁷ In the early 20th century, 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 1915.⁷

Although fluids (water, saline) can be absorbed through the rectal mucosa, intravenous administration of fluids replaced hydration via the rectal route by the mid-20th century. Rectal administration of fluids can be attempted for fluid resuscitation in emergency situations in remote settings when it is the only treatment available.⁸ None of these considerations justify the practice of rectal feeding in detainees held as terrorist suspects at CIA secret prisons.

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. Rectal feeding is no longer recognized as a legitimate medical practice. Even those who advocate for forcibly feeding individuals participating in hunger strikes never suggest the use of rectal feeding.

In the US, nutrition via any route other than oral requires a physician’s order and would be performed by a physician or other allied health professional, both of whom are legally and ethically responsible for such activities. However, the identities of the medical officers who authorized and administered the rectal feeding for detainees have been kept secret, and the detainees’ complete medical records are not available to them or their attorneys.

Both ethical and legal standards require reasonable medical judgment and prohibit providing treatment that cannot benefit a patient.⁹ Furthermore, international human rights laws, and basic human decency, prohibit participation in cruel, inhuman, and degrading treatment that can constitute torture. These obligations apply to all physicians, including civilians, the military, and those working for federal agencies. Any medical officers who participated in the rectal feeding of these prisoners knew or should have known that rectal feeding is not a medically legitimate practice. If any of the involved medical officers were physicians, they would have violated their fundamental ethical obligations by using their medical skills to intentionally inflict harm on individuals.

Given the lack of medical benefit, those medical officers authorizing, ordering, or participating in the nonconsensual 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).¹ The sequelae of rape can persist for decades and even a lifetime. The nonconsensual penetration of the anus embodies the violence, abuse, humiliation, and degradation rape victims experience. The physical and psychological harms to the survivors of anal rape include posttraumatic stress disorder, depression, difficulty with trust and relationships, sexual dysfunction, infections, anogenital trauma, rectal perforation, pain on defecation, abdominal symptoms, and other chronic pain syndromes.

Medical officers are not absolved of ethical and legal responsibility for their actions when they commit heinous acts on behalf of and with permission of the state.¹⁰ We believe that any CIA medical officers who authorized or participated in the rectal feeding of these prisoners cannot be entrusted to protect the welfare of patients once they return to civilian positions.

At the very least, professional medical organizations must insist that federal officials, including Congress, identify the medical officers (including any who may have been physicians, physician assistants, and nurses) who participated in anal rape of federal detainees so that licensing agencies, or courts, could determine whether action is warranted against them. The medical professions should not stand silent when their members commit atrocities under the guise of medicine.

Corresponding Author: Sondra S. Crosby, MD, PharmD, Center for Health Law, Ethics, and Human Rights, School of Public Health, Boston University, 715 Albany St, Boston, MA 02118 ( This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Conflict of Interest Disclosures: Dr Crosby reported being employed by the US Department of Defense Office of Military Commissions as a medical expert on torture and has provided testimony in the pretrial hearings on this topic. No other disclosures were reported.

Disclaimer: This article reflects the views of the authors and not that of the Department of Defense or the US government.