Profile 10: Youssef

This is the summary of a medical examination of former Guantánamo prisoner Youssef (not his real name).⁵⁴ This examination was carried out under the auspices of Physicians for Human Rights by a team consisting of a physician and a psychologist/psychiatrist. The summary is taken from pages 56-61 of the Physicians for Human Rights' report Broken Laws, Broken Lives: Medical Evidence of Torture by US Personnel and its Impact, published in June 2008.

Youssef was originally detained at the border of Pakistan in late 2001 or early 2002. He was held by US personnel at Kandahar and Guantánamo Bay detention centers. He was subjected to beatings, electric shocks, sleep deprivation, and sexual and cultural humiliation. He was released in November 2003. The medical findings indicated that Youssef is suffering from a major depressive episode, moderate PTSD, and panic disorder without agoraphobia.

“[In Kandahar] as soon as we landed they started hitting us — some of them were hitting us with sticks, and some of them were punching us, and some of them were kicking us, and when we were on the ground some of them were kicking us between the legs.”

Background

Youssef, a male in his early forties, grew up in a large family. His father was a factory worker. His family often suffered from financial difficulties and illness. One of his brothers developed leukemia, and another had a physical disability. He described being raised as an observant Muslim.

Youssef attended school until the age of eighteen but dropped out because of his family’s financial difficulties. He had problems finding work in his home town and eventually moved to another city where he found occasional employment as a construction worker. Later, he delivered water and medical supplies to refugees for a local charity. Still unable to meet his financial needs after several months, Youssef decided to travel with a friend to Afghanistan in early 2001. He recalled that he was “told by a friend that my life would be better there — and I guess I believed him.” After he arrived, he quickly learned there was little hope for employment in Afghanistan, but said he could not leave because his friend had taken his passport to get him a work visa. After the US war in Afghanistan began, he decided to leave Afghanistan via Pakistan and return to his home country.

Allegations of Arrest and Abuse

Youssef recalled being detained at the Pakistani border in late 2001 or early 2002, while trying to cross the Afghan-Pakistan border without his passport. He requested access to his home country’s authorities but was placed in a Pakistani prison for nearly two months where he experienced harsh treatment (legs shackled constantly, no ability to bathe, and little food). While in Pakistani custody he was interrogated by “the Americans” and, eventually, was transferred to a US prison in Kandahar, Afghanistan. During his transfer, he was hooded, making it difficult to breathe, and was shackled to the floor of the plane with his hands tied behind his back. He was never informed of where he was being taken or why and realized he was in US custody only when the bag was removed from his head in Kandahar.

Youssef reported, “As soon as we landed [at Kandahar] they started hitting us — some of them were hitting us with sticks, and some of them were punching us, and some of them were kicking us, and when we were on the ground some of them were kicking us between the legs.” He related that the initial assault lasted for three to four hours and was extremely painful, although he suffered no serious injuries at the time. He also stated that he had difficulty urinating for the first “one or two weeks” after this assault, presumably from groin injuries. Youssef noted that he was interrogated during this initial encounter but stated that he did not understand the questions because he did not speak Arabic and only recognized the word “Taliban.”

Youssef recalled that after his interrogation, soldiers stripped him naked. He noted that many of the soldiers were female and he believed that “they were just trying to humiliate us.” He was allowed no sleep during his first night in Kandahar because the guards “kept kicking us [and] throwing sand at us.” Throughout his roughly six weeks in Kandahar, he endured other abuse, including being stripped naked, being intimidated by dogs, being hooded, and being thrown against the wall on repeated occasions. He did not lose consciousness during these assaults. He also recalled having been subjected to electric shocks once by purposefully being pushed into a generator and described feeling “as if my veins were being pulled out.” He was threatened with electric shock on other occasions, but was shocked only that one time. With the exception of persistent wrist pain, he denied any lasting physical injuries from the beatings or the electric shock.

Youssef was subsequently transferred to Guantánamo in early 2002. He recalled that he was forced to disrobe in front of female soldiers, was clothed in an orange suit and dark goggles, and his ears were covered with headphones. He stated, “They didn’t tell us anything — I remember the plane and the doors opening and there was warm air.” He stated that he was unsure how long the flight lasted “but it felt like 24 hours.” Youssef added that he was handcuffed and shackled to the floor of the airplane throughout the trip and noted, “We had those cuffs on for a very long time … and they tightened up the cuffs on the plane and my hands started swelling up.”

Youssef injured his leg when he slipped and cut his leg on a piece of metal while being transported to Guantánamo, but reported that it was not the result of ill-treatment. He stated before being taken to “Camp X-Ray,” he was again stripped, sprayed with water and superficially examined by a doctor looking for wounds or broken bones (“They just asked if I had any pain … I told them about my foot — and they took a blood sample and a hair sample, and they took saliva.”).

Youssef described the conditions at Camp X-Ray as deplorable: “It was just a big plot of concrete and they had these steel cages [and] it was really, really hot…even in the night.” The prisoners were let out of the two-squaremeter “cages” only for questioning, were not allowed to speak to each other, and had to use a bucket as a toilet. Even small infractions could result in beatings. “If they would find one piece of string on the floor they would send in the ‘robocops’ [the IRF soldiers dressed in riot helmets and padded uniforms] to beat us.” The detainees were kicked all over, including in the back, legs, and head. According to Youssef, during the two to three times that he was beaten this way in Camp X-Ray someone who he presumed to be a doctor was always present; he suspected this was to make sure there were no injuries. Youssef suffered bruising as a result of these beatings and did his best to follow prison rules in order to avoid such abuses. However, he witnessed other detainees being beaten this way on a daily basis.

In other incidents, he recalled, “the robocops” would enter his cell, forcing him to sit on his knees with his hands pressed together behind his back or head; or forcing him to lie on the floor with his hands behind his back and tied to his feet, forcing his legs to lift up. He stated that he was forced to maintain these stress positions for up to an hour.

He noted that he was provided adequate food and water in Camp X-Ray (“Compared to normal daily intake it wasn’t enough, but we survived on it — it was bearable”). He reported frequent sleep deprivation and fatigue due to lengthy interrogations and the guards disrupting his sleep whenever his hands or feet were under the blanket.

After the first few weeks at Camp X-Ray, conditions improved slightly. Youssef and the other detainees were no longer beaten for speaking to each other, and he was allowed out of his cell at noon “to go to the bathroom” and for weekly showers, in addition to for occasional interrogations.

Youssef was transferred to Camp Delta with other detainees after approximately three months. He described the overall conditions at Camp Delta as better than those at Camp X-Ray. The camp had been built recently and included toilets and running water in the cells. The detainees were allowed to speak with each other; they were still confined to their two-squaremeter cells, however, and let outside to exercise only for about fifteen minutes once a week, although this later increased to two and even three times per week.

Youssef reported that he was sometimes beaten by the IRF guards after interrogations and for infractions like hiding food in his cell. Once, following an interrogation, the chains on his wrist were pulled, causing him severe pain. He also recalled that the guards “would come with a spray and spray us in the eyes” causing severe pain. (“My whole body would feel like it was burning — not just my face, but my whole body, and it felt like they had filled my eyes with sand. And sometimes I felt like I was losing consciousness from the burning.”) He noted that he “felt very dizzy and…I felt it very hard to breathe.”

Apart from following interrogations or beatings, and despite his frequent requests for medical attention (“many, many” requests) for persistent stomach pain and swelling in his wrists, Youssef noted that he rarely saw physicians at Guantánamo. He was of the opinion that no one was concerned with the detainees’ health and recalled having been told by one of the physicians, “We’re making sure you don’t die in here — besides that whatever happens doesn’t interest us.” Youssef reported that he was forced to take medications as part of what he considered “experiments” and recalled receiving an estimated ten to fifteen unknown injections, often developing rashes several hours after these injections (“red dots on my body and shoulders that would start to itch”). A fellow detainee informed him that the injections could cause impotence or heart attacks, although nothing was ever said by the doctors. He also indicated that some individuals administering the injections were “civilians … coming to take lessons — it was like internships” but acknowledged that this may only have been his perception.

Youssef stated that he was interrogated almost every other day while at Camp Delta. Although he was not subject to any physical assaults while being interrogated, some of his most painful experiences at Guantánamo occurred while being held in the interrogation rooms. He recalled being held in extremely hot or cold interrogation rooms for extended periods of time (“forcing us to sit chained for eighteen or twenty hours”); sometimes ice cold water was poured over him. He added that “sometimes they were playing very loud music” that was painful, although he denied sustaining any hearing damage. During the lengthy interrogations, he was not allowed to use the toilet or pray and described experiencing significant back pain from the extended forced sitting. He recalled “physicians” participating in these interrogations and occasionally checking on him; he thought their job was to determine whether the abuse could continue. He acknowledged, however, that he was unsure of precisely what was said between those he perceived to be the doctors and the soldiers, only that the abuse always continued (“The doctor was working with [the soldiers]”).

While in Camp Delta, Youssef asked to speak with a psychologist because he was distressed, and the two spoke about him missing his family and his feelings of sadness. Although Youssef believed the meeting was confidential, he stated that shortly after the psychologist left, he was brought to an interrogator who immediately brought up information connected to his disclosures, such as telling him that he was going to stay at Guantánamo for the rest of his life and discussing his family (“Don’t you want to leave this place and get back together with your family?”...If you do as we tell you, you can get back to your family.”). He stated, “I figured out the reason they had called me for the interrogation was because the psychologist had told them about the meeting.” He stated, “They were stressing these fears very much.” Following this interrogation, Youssef reported that he was moved to the “worst” section in Camp Delta, where he was not allowed to have a blanket or a mattress.

Youssef also described a number of experiences that were extremely upsetting and humiliating. He reported being forced to look at pornography and to witness naked men and women appearing to have intercourse. He also described an incident in which a woman entered the interrogation room naked and smeared what he perceived to be menstrual blood on him, which he described as horrifying. He also witnessed soldiers desecrating the Koran, ripping it apart or writing offensive words on the pages, and occasionally throwing the Koran in the toilet or deliberately stepping on it. He also stated that the soldiers in Camp Delta loudly hit the cell bars with sticks when the detainees were praying. Youssef also said he was threatened by guards during interrogations, including threats that he would be shot. Interrogators claimed that his fingerprints had been found on weapons and that his name was in documents found in Afghanistan. They also claimed that his brother with leukemia had been arrested. He stated that he was asked to confess to both fighting against the United States and being part of al Qaeda or the Taliban. He was told that he would be released if he confessed to these accusations.

Youssef was transferred out of Camp Delta to another location that he referred to as “Camp Four.” He explained, “It was better — generally they were saying that people who were sent there would eventually leave.” He received medical attention for his stomach pain, headaches, and other problems (e.g., feet and eye problems), but added that, “They never treated anything.” However, he acknowledged that “When I first got [to Camp Four I thought] I was about to die, because of the change in temperature [in the interrogation room] — that’s when they gave me saline.” He stated that he was eventually returned to Camp Delta for another few days and told that if he signed a statement he would be released. He stated that he agreed to sign this form because “I was already under so much pressure.” He was released in November 2003 without any charges being brought against him. He was then handcuffed, chained to the floor of an airplane, and returned to his home country.

Upon arrival at his home country, Youssef was detained by the local police but “was taken to court and I was set free.” He noted that, in contrast to his detention at Guantánamo, the local authorities “were very civilized.”

Youssef reported that he has had difficulty functioning since his release and has not been able to find steady employment, in large part due to his psychological problems. As soon as he returned to his home country, he served fourteen months of mandatory military service, where he spent most of the time in a psychiatric hospital ward because he was labeled “too aggressive” and “was not treating people above me the way I should have been.” At the time of the evaluation, Youssef was unemployed and volunteering part-time for a refugee aid organization.

Medical Evaluation

Assessment of Physical Evidence

Youssef denied having any significant medical problems prior to his imprisonment. He reported, however, that since his release from Guantánamo, he has felt chronically tired and weak. He did not mention any persistent back or muscle aches at the time of his evaluation, although he reported severe pain while in custody. He underwent surgery on both wrists to alleviate chronic pain caused, he believed, by the extended time he spent in handcuffs. Nonetheless, he noted that he has experienced renewed pain in his right wrist. Youssef added that he has continued to experience stomach pain that began while incarcerated. He also described frequently experiencing bitemporal headaches radiating to his eyes that last two hours or more and are relieved with pain medication. Youssef reported some difficulty breathing out of the right side of his nose, but was unsure of the cause or when it started. He also reported “trouble with my heart — it feels trapped, but when I went to the hospital and had various checks done, nothing was diagnosed — but I know it contracts.”

Several significant findings were noted during Youssef’s physical examination. His nose is slightly deviated to the left, but this deviation is of unknown origin. He also has tenderness in the muscles of his right wrist with extension. There is an area on the lateral posterior aspect of Youssef’s left wrist with atrophic (i.e., thinning of the skin) changes and decreased hair, which he attributes to handcuffs rubbing against his skin. Well-healed vertical surgical scars are evident on the back of both wrists. A scar on his left ankle with slight atrophic changes is attributable to the injury he sustained while getting into a truck during his transfer to Guantánamo. Youssef has several other dermatologic findings, which he reports are unrelated to his imprisonment and is unsure of their etiology.

Medical Tests: A bone scan showed increase focal activity of both shoulders consistent with degenerative arthritis. Nasal bone X-rays showed deformation of the former detainee’s nasal bone with deviation to the left, which is highly consistent with a history of trauma.

Assessment of Psychological Evidence

Youssef was quiet and reserved, with little emotional expression in his voice or demeanor. He recounted having many friends before his incarceration but has become more isolated since his release from Guantánamo. He acknowledges that prior to his imprisonment, his family problems distressed him, resulting in some sleep difficulties, diminished appetite, lack of energy, and periods of tearfulness. He attributes this state mostly to feelings about his brother’s leukemia and not being able to help his family financially. While these symptoms were present when he was arrested, they worsened over the two years of incarceration. He described that after his release he has been “constantly sad” and noted that he cries periodically but less often than in the months following his return. He stated that he is usually lonely and is no longer able to feel happy; instead he feels irritable and short-tempered much of the time (“Nothing makes you happy — sometimes the most natural events will make you angry.”). He denied sleep difficulties at present, but reported frequent past nightmares and dreams of being re-arrested. He also described feelings of guilt and hopelessness, feeling as if he has no future. He described himself as fatigued (“I feel like I never get enough sleep”) and reported having difficulty getting out of bed. He also described feeling very uncomfortable whenever he sees military personnel or people wearing orange clothing (the color of his Guantánamo uniform).

He described being easily startled by loud noises and avoids places and interactions that remind him of his detention experiences. He cited this avoidance as one of the reasons why he left his home and is currently living in another city, i.e., to avoid discussing his experiences with his friends and family. He noted that he experiences periodic “heart problems” in which “my heart feels trapped.” He explained that he has shortness of breath and frequent stomach pains, but does not experience numbness in his extremities or amnesia. When asked about his smoking, he acknowledged his intake increased dramatically, from only a few cigarettes per day before his detention to roughly half a pack per day at present. He acknowledged having a short temper, but denied suicidal or homicidal ideation and denied auditory or visual hallucinations. However, he revealed considerable paranoid ideation, both related to his detention experiences (e.g., believing that doctors were “experimenting” on him) and at present (e.g., feeling as if the government is monitoring his activities, feeling that he is being followed in the streets).⁵⁵ He was alert and oriented to person, place and time, and his memory and concentration were grossly intact but his abstract reasoning abilities were limited. His overall intellectual functioning appeared approximately average, and his insight was fair and his judgment was intact.

Psychological Tests:⁵⁶ On the self-report measures administered, Youssef reported a number of test items indicative of depression, anxiety, and PTSD, all of which were consistent with his self-report. He demonstrated symptoms of severe PTSD, far exceeding the established cut-off for identifying individuals with clinically significant distress. However, his responses to measures of depression suggested the presence of numerous depressive symptoms but likely not of the magnitude of a major depressive disorder. Youssef also endorsed a number of physical symptoms that are typically attributable to psychological causes (e.g., dizziness, nausea, numbness, stomach pain). Although the latter symptoms cannot be conclusively attributed to psychological, rather than organic causes, the possibility that these symptoms reflect a somatization disorder certainly exists.

Analysis and Conclusions

Youssef’s clinical presentation, reported symptoms, and the results of psychological testing indicate the presence of several psychological disorders including a major depressive episode,⁵⁷ moderate PTSD, and panic disorder without agoraphobia. Specifically, Youssef described a number of symptoms of depression that, while present to a lesser extent before his arrest and extended incarceration at Guantánamo, appear to have become pronounced, disabling, and chronic since his detention. His PTSD appears to have persisted throughout the three years since his release from custody. Youssef’s description of “heart problems” and shortness of breath, with no identifiable medical etiology, is strongly suggestive of a panic disorder. It should be noted that although Youssef reported depressive symptoms prior to his incarceration, the timing of Youssef’s reported symptoms and nature of his intrusive memories and avoidance behaviors indicate that the incarceration directly caused and/or exacerbated his psychological difficulties.

The physical symptoms Youssef described and the findings on physical examination support Youssef’s reports of ill-treatment while imprisoned. Many of his scars are consistent with his described ill-treatment (e.g., being dragged while being handcuffed, beatings). Many of the beatings Youssef reported likely resulted in soft tissue injuries and bruises, which would not leave lasting physical marks. His report of headaches is certainly consistent with the history of head trauma he reported, although the possibility of a more psychogenic etiology of these headaches also exists. Likewise, his report of frequent stomach pain may be the result of a peptic ulcer disease or gastritis, but could also reflect a somatic manifestation of his psychological distress. Other findings appear clearer, such as the increased activity in both shoulders observed on the bone scan, which is consistent with degenerative arthritis. Given his young age, these findings are likely to have resulted from being forced to maintain uncomfortable arm positions as he described. The findings on a nasal bone X-ray film of a deformation of the nasal bone with deviation to the left are consistent with a prior history of trauma.

The available evidence strongly supports the credibility of Youssef’s reported symptoms and experiences. Youssef was forthcoming in describing which symptoms have continued as well as those that have resolved. He was also forthcoming in describing what he experienced, including stating that he did not personally experience certain abuses reported by others. Furthermore he readily acknowledged that many of the scars noted on physical examination were unrelated to his imprisonment and ill-treatment and acknowledged considerable psychological distress prior to his arrest. Moreover, psychological testing suggests that Youssef responded honestly to the psychological tests, with no evidence of any deliberate exaggeration.

Youssef’s apparent credibility does not, however, necessarily mean that all of his perceptions and interpretations were accurate. For example, his description of medical experimentation and involvement in forced experiments may reflect a paranoid interpretation of events. Such a paranoid interpretation of ambiguous events is consistent with the presence of PTSD, as individuals typically become hypervigilant with a heightened expectation of additional ill-treatment. His perception that the treating psychologist had conveyed information to the individuals who subsequently interrogated him seems plausible and convincing because of credible, independent reports that the Guantánamo Behavioral Sciences Consultant Teams had access to detainees’ personal health information.⁵⁸ On the other hand, Youssef’s perception may reflect a heightened sensitivity to ill-treatment that often results from exposure to traumatic abuse (i.e., torture). Youssef may also have made mistaken assumptions about the identity of various personnel he encountered; for example, it may be that medics or nurses were present at interrogations or beatings, not physicians.

In sum, the available evidence provides strong support for the validity of Youssef’s reports of abusive treatment while in US custody. In turn, this abusive treatment appears to have resulted in lasting physical and psychological symptoms that far exceed the mild level of distress Youssef reported experiencing prior to his arrest and detention by the United States.

54. Youssef’s medical evaluation was conducted by Allen Keller, MD and Barry Rosenfeld, PhD.

55. It must be noted that there may be some legitimacy to Youssef’s suspicions. His perception that psychologists were complicit in interrogations and conveying his confidential information to interrogators is consistent with the well-documented role of psychologists in the interrogations at US-run detention facilities. See M. Gregg Bloche & Jonathan H. Marks, Doctors and Interrogators at Guantánamo Bay, 353 New Eng. J. Med. 6 (2005). Further there have been numerous other allegations of experimental forced injections including for the purpose of interrogations. See Joby Warrick, Detainees Allege Being Drugged, Questioned: U.S. Denies Using Injections for Coercion, Wash. Post, Apr. 22, 2008, at A1, available at
http://www.washingtonpost.com/wp-dyn/content/article/2008/04/21/AR2008042103399_pf.html.
Psychological testing included both self-report measures of symptom distress (the Beck Depression Inventory, the Harvard Trauma Questionnaire, and the Brief Symptom Inventory) and the Dot Counting Test (a clinician-administered test of symptom exaggeration). Of note, several of the measures administered had been previously translated and validated in his original langue, with the exception of the Harvard Trauma Questionnaire (HTQ), which was translated by the interpreter.

56. Psychological testing included both self-report measures of symptom distress (the Beck Depression Inventory, the Harvard Trauma Questionnaire, and the Brief Symptom Inventory) and the Dot Counting Test (a clinician-administered test of symptom exaggeration). Of note, several of the measures administered had been previously translated and validated in his first language, with the exception of the Harvard Trauma Questionnaire (HTQ), which was translated by the interpreter.

57. A major depressive episode is not a disorder in itself, but rather is a description of part of a disorder, most often major depressive disorder.

58. Bloche & Marks, supra note 55, at 6-8.

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