# Force-feeding

Force-feeding is the practice of feeding an animal or human, against their will.

## Quotes

* The American Medical Association and the Red Cross both condemn force-feeding as a form of torture. And yet, the U.S. government and the United Nations have both force-fed hunger-striking prisoners. The real problem? Most people probably don’t realize how complicated force-feeding is, and how much can go wrong.
** Esther Inglis-Arkell, "Here's What Really Happens When You Force-Feed Someone", IO9, (4/21/15).
* 1914 New York World magazine article. Barnes wrote, "If I, play acting, felt my being burning with revolt at this brutal usurpation of my own functions, how they who actually suffered the ordeal in its acutest horror must have flamed at the violation of the sanctuaries of their spirits. I had shared the greatest experience of the bravest of my sex."
** Djuna Barnes; as qtd. in Mills, Eleanor; with Kira Cochrane (eds.) Journalistas: 100 Years of the Best Writing and Reporting by Women Journalists. New York: Carroll & Graf. (2005). p 163–166.
* In 2013, a mass hunger strike took place in Guantanamo Bay as a response to the indefinite detention and unjust treatment of prisoners captured during the ‘war on terror’. In response, the US used force-feeding against the hunger strikers, arguing it was needed to save their lives and uphold US security. Although the US argued its force-feeding policy was legal and humane, human rights and medical organisations criticised US force-feeding practices as constituting torture or cruel, inhuman or degrading treatment or punishment. This article argues that the US undermined international human rights norms, laws and medical ethics in its management of hunger striking prisoners by using force-feeding to suppress hunger strikers and achieve national security interests. In doing so, the Obama administration reignited accusations of US torture and harmed its ethical standing in international society. The article argues that the US needs to incorporate international human rights standards into its hunger striker policy to uphold the dignity of prisoners in detention and overcome its legacy of torture in the ‘war on terror’.
** Jamal Barnes, “Force-feeding and the legacy of torture in the ‘war on terror’”, The International Journal of Human Rights, Volume 23, 2019 - Issue 7, (Published online: 25 Mar 2019), pp.1074-1097
* Dec. 30, 2005 – At least 46 people held at the Guantánamo Bay, Cuba detention camp joined a disputed number of fellow detainees already refusing food in protest of their indefinite detention last week, the Department of Defense said in a statement yesterday. The announcement puts the official number of prisoners still fasting at 84. The Center for Constitutional Rights (CCR) and other humanitarian groups maintain that the real number of detainees refusing food could be much higher, a contention that is impossible to verify because the prison facility is closed to nearly all visitors. Two months after the hunger strike began, CCR and other detainee lawyers put the number who have been involved in the fast at over 200. But the military told The NewStandard that the number topped off at 131 and had dropped to about 26 in October. In a recent statement released by the Southern Command, the military said the number of participants fluctuated with the anniversary of the September 11 attacks and with the arrival of detainee lawyers, possibly accounting for the discrepancies between the two sides. "This technique [hunger striking] is consistent with Al-Qaeda training and reflects detainee attempts to elicit media attention and bring pressure on the United States government to release them," the statement added. The new hunger strikers refused food on Christmas day, according to the military, and joined a five-month fast kept up by detainees to draw attention to what they, human rights groups and their lawyers say are inhumane conditions outlawed by international accords and domestic law. The renewed strike comes amid accusations from the United Nations that long-term hunger striking detainees have been treated cruelly. According to UN torture investigator Manfred Nowak, prison guards and doctors involved in force-feeding some of the prisoners did so with particular zealousness, causing an unspecified number to bleed and vomit. Nowak was among the investigators who had previously turned down an invitation to visit the camp, citing access restrictions imposed by the US. Thirty-two hunger strikers have been hospitalized and force-fed through nasal tubes, a prison camp spokesperson told the Boston Globe. In late October, US District Judge Gladys Kessler ordered the Defense Department to notify the lawyers of prisoners it intends to force-feed before doing so.
** Brendan Coyne, "Gitmo Hunger Strikers' Numbers Grow". The New Standard. 2005-12-30. Archived from the original on 2010-03-14. Retrieved 2007-09-17.
* A man jailed in the US for trying to blow up an airliner with explosives hidden in his shoes has gone on hunger strike, court papers have revealed. Briton Richard Reid is said to have been refusing food for several weeks and is being force-fed and hydrated.
** "'Shoe bomber' is on hunger strike". BBC News. (June 11, 2009; page last updated at 21:31 GMT, Thursday, 11 June 2009 22:31 UK).
* A government lawyer said that Reid had refused 58 meals by 9 April and that prison officials decided "that medical intervention was necessary". The lawyer added that prison officials were monitoring his condition.
** "'Shoe bomber' is on hunger strike". BBC News. (June 11, 2009; page last updated at 21:31 GMT, Thursday, 11 June 2009 22:31 UK).
* Six weeks into his hunger strike, Israel's parliament passed a law permitting the force-feeding of prisoners in order to keep them alive. Allan might have become a test case for the law, but doctors made it clear they would not participate, calling it unethical medical treatment. "It's like rape," says Yoel Donshin, a retired anesthesiologist and a member of Physicians for Human Rights. "You will ask a physician to rape a patient for treatment? This is unacceptable." Donshin doesn't believe Israeli politicians who supported the law want to save the lives of prisoners. "They do not care for the welfare of the prisoners," he says. "They just want him not to become a symbol or martyr."
** Yoel Donshin in "Hunger Strike Raises Debate About Force-Feeding In Israeli Prisons", NPR, (22 August 2015).
* Romanos has not been charged with terrorism. But two cases concerning terrorism acts are still pending — a fact that has kept Romanos from attending school. The only way he could think to claim his rights was to use his “body as a roadblock, for a breath of freedom,” as he stated at the start of his hunger strike. At N.Gennimatas general hospital, where Romanos was transferred after his health began to deteriorate, the atmosphere is tense. Hundreds of protesters are gathered outside. Inside, police officers are everywhere, trying to control the flow of information. The minister of justice is working on a proposal that would allow Romanos to take distance learning courses. But Romanos has rejected that idea, insisting he should be able to attend classes. With the help of the doctors in the hospital, Romanos is successfully resisting an order issued by a district attorney to force feed him. His lawyer confirmed last week that the order had been issued, adding that “This is obviously torture. It’s something never seen before in Greece.”
** GlobalPost, "As protests mount, Athens braces for the worst". The World from PRX. (December 6, 2014)
* When federal prison officials at British Columbia’s Matsqui Psychiatric Centre routinely examined a Doukhobor woman on a hunger strike last week, they quickly realized that the frail 69-year-old was deteriorating. Doctors who saw Mary Astaforoff, a member of the radical Sons of Freedom sect, sent her by ambulance to Vancouver General Hospital about 90 km away. There, hospital staff force-fed Astaroroff for the second time since she again began refusing food in late September to protest against a three-year prison sentence for arson.
** O'Hara, Jane (November 7, 1983). "Force feeding to end a fast". Maclean's. Canada: St. Joseph Communications. Archived from the original on 9 January 2023.
* Previously secret sworn statements by detainees at the Abu Ghraib prison in Iraq describe in raw detail abuse that goes well beyond what has been made public, adding allegations of prisoners being ridden like animals, sexually fondled by female soldiers and forced to retrieve their food from toilets. The fresh allegations of prison abuse are contained in statements taken from 13 detainees shortly after a soldier reported the incidents to military investigators in mid-January. The detainees said they were savagely beaten and repeatedly humiliated sexually by American soldiers working on the night shift at Tier 1A in Abu Ghraib during the holy month of Ramadan, according to copies of the statements obtained by The Washington Post. The statements provide the most detailed picture yet of what took place on the cellblock. Some of the detainees described being abused as punishment or discipline after they were caught fighting or with a prohibited item. Some said they were pressed to denounce Islam or were force-fed pork and liquor. Many provided graphic details of how they were sexually humiliated and assaulted, threatened with rape, and forced to masturbate in front of female soldiers.
** Scott Higham and Joe Stephens "New Details of Prison Abuse Emerge". The Washington Post. P.1, 2004-05-21.
* Mohanded Juma Juma, detainee No. 152307, said he was stripped and kept naked for six days when he arrived at Abu Ghraib. One day, he said, American soldiers brought a father and his son into the cellblock. He said the soldiers put hoods over their heads and removed their clothes. Then, they removed the hoods. "When the son saw his father naked he was crying," Juma told the investigators. "He was crying because of seeing his father." He also said Graner repeatedly threw the detainees' meals into the toilets and said, "Eat it."
** Scott Higham and Joe Stephens "New Details of Prison Abuse Emerge". The Washington Post. P.2 2004-05-21.
* Doctors force-feeding prisoners at |Guantanamo are acting as an arm of the military and have abrogated their medical-ethical duties.
** William Hopkins; as qtd. in "Doctors attack U.S. over Guantanamo", BBC News, 2006-03-10.
* Through the biotechnology of the force-feeding chair and the hunger strike in Guantanamo, this paper examines the camp as a site of necropolitics where bodies inhabit the space of the Muselmann – a figure Agamben invokes in Auschwitz to capture the predicament of the living dead. Sites of incarceration produce an aesthetic of torture and the force-feeding chair embodies the disciplining of the body and the extraction of pain while imposing the biopolitics of the American empire on “terrorist bodies”. Not worthy of human rights or death, the force-fed body inhabits a realm of indistinction between animal and human. The camp as an interstitial space which is beyond closure as well as full disclosure produces an aesthetic of torture on the racialised Other through the force-feeding chair positioned between visibility and non-visibility. Through the discourse of medical ethics and the legal struggle for rights, the force-feeding chair emerges as a symbol of necropolitics where the hunger strike becomes a mechanism to impede death while possessing and violating the corporeal body.
** Yasmin Ibrahim, Anita Howarth; “Hunger strike and the force-feeding chair: Guantanamo Bay and corporeal surrender”, (December 5, 2018)
* In February 1914 Ethel Moorhead became the first suffragette to be force fed in Scotland. Force feeding, whilst it could never be described as fun, was particularly brutal in Perth Prison where rectal feeding was forced on some suffragettes. Fortunately for Ethel, she was confined in Calton Jail in Edinburgh and was released with nothing more severe than double pneumonia – the result of food getting into her lungs whilst being forcibly fed.
** "Force Feeding Purvis Moorhead". www.johndclare.net. (This account of Ethel Moorhead was published on the www.firstfoot.com 'Great Scotswomen' web pages, but the website was not active in May 2009.)
* She was on the run for several months during which time police attributed at least four arson attacks to her. Presumably they would have ascribed a fifth if she hadn't been spotted and arrested at Traquair House. This time though there was no Cat and Mouse Act release and she was force fed, causing the double pneumonia. She was released again with instructions to return to prison to complete her sentence. Guess what .... she went on the run again.
** "Force Feeding Purvis Moorhead". www.johndclare.net. (This account of Ethel Moorhead was published on the www.firstfoot.com 'Great Scotswomen' web pages, but the website was not active in May 2009.)
* A Greek prosecutor on Tuesday called for convicted terrorist Dimitris Koufontinas to be forced-fed as he entered the 47th day of a hunger strike, demanding to be moved to an Athens prison. Koufodinas, 62, has been in intensive care at Lamia Hospital since last week. On Monday he announced that he will also stop receiving liquids, including water. A Lamia court of first instance prosecutor ordered that all necessary medical measures be taken to ensure that he continues to receive liquid pharmaceutical treatment. The prosecutor’s order was issued at the suggestion of doctors “for the purpose of ensuring the life and health of the hunger striker.” Doctors say that the convicted killer’s life is in danger.
** Tasos Kokkinidis, "Greek Prosecutor Calls for Force-Feeding of Convicted Terrorist Koufontinas". “Greek Reporter”, (24 February 2021).
* 3rd. By means of “gavage”.-This way of feeding infants is in use in France only, so far as I know. It is easily learnt, but cannot be performed by an uninstructed person. It is of great service in the case of prematurely born or weakly infants, whose power of suction is feeble. The illustration is from a photograph taken at the “Maternite de Paris”. Belluzzi appears to have been the first to try “gavage”.
** Sadler, S H (1896).“ Infant feeding by artificial means: a scientific and practical treatise on the dietetics of infancy”], (2nd ed.). London. p. 18.
* Margaret Sanger opened the first birth control clinic in the U.S. on October 16, 1916 in the Brownsville section of Brooklyn, New York. Sanger, her sister Ethel Byrne, who was a registered nurse, and Fania Mindell, an interpreter from Chicago, rented a small store-front space in Brownsville and canvassed the area with flyers written in English, Yiddish and Italian advertising the services of a birth control clinic. Sanger modeled the Brownsville Clinic after the birth control clinics she had observed in Holland in 1915. For ten cents each woman received Sanger's pamphlet What Every Girl Should Know, a short lecture on the female reproductive system, and instructions on the use of various contraceptives. The Clinic served more than 100 women on the first day and some 400 until October 26 when an undercover police woman and vice-squad officers placed Sanger, Byrne and Mindell under arrest. After being arraigned, Sanger spent the night in jail and was released the next morning. She re-opened the Clinic on November 14, only to be arrested a second time and charged with maintaining a public nuisance. Sanger opened the Clinic once again on November 16, but police forced the landlord to evict Sanger and her staff, and the Clinic closed its doors a final time. Sanger, Byrne and Mindell went to trial in January of 1917. Byrne, tried first, was convicted and sentenced to 30 days in Blackwell's Island prison and immediately went on a hunger strike. After 185 hours without food or water, she was forcibly fed. Before Byrne's condition proved fatal, Sanger and supporters prompted New York's Governor Whitman to issue a pardon. Sanger's own trial began on January 29, and she too was convicted. However, the court offered her a suspended sentence if she promised not to repeat the offense. She refused and was offered a choice of a fine or jail sentence. She chose the latter and spent thirty days in the Queens County Penitentiary without incident.
** "About Sanger". Margaret Sanger Papers Project. MSPP. Retrieved 1 September 2015.
* I'll fuckin', I'll fuckin', sew your asshole closed, and keep feedin' you And feedin' you, and feedin' you, and feedin' you.
** Method Man, “Wu Tang Clan”, Method Man, B-side to the single "Protect Ya Neck", (May 3, 1993); featured on the album Enter the Wu-Tang (36 Chambers).
* Leaflet issued by the Men's Political Union for Women's Enfranchisement referring to 'The Case of William Ball.' In 1912 William Ball was sentenced to two months in Pentonville prison for breaking a window in the Home Office in protest against the sentence passed on a fellow suffragist. Subtitled 'Official Brutality on the Increase' the leaflet written by Henry W. Nevinson refers to the hunger-strike and force-feeding of William Ball whilst in prison and his subsequent detention in a 'lunatic' asylum for the mentally disturbed. The militant Men's Political Union for Women's Enfranchisement was founded in 1910 by Victor Duval as a male counterpart to the Women's Social and Political Union. This leaflet, printed in purple and green reflects the close links between the two organisations that shared the same colour scheme.
** "Museum of London | Free museum in London". collections.museumoflondon.org.uk. (Last Updated 2020-12-13)
* Mr Nowak has not been to Guantanamo, and turned down an invitation to the camp because the US refused to give him unrestricted access to the detainees. He told the BBC that he had received reports that some hunger strikers had had thick pipes inserted through the nose and forced down into the stomach. This was allegedly done roughly, sometimes by prison guards rather than doctors. As a result, some prisoners had reported bleeding and vomiting he said. "If these allegations are true then this definitely amounts to an additional cruel treatment," Mr Nowak said.
** Manfred Nowak in “UN concern at Guantanamo feeding”, BBC, (30 December 2005)
* Faced with the nightmarish conditions of the voyage and the unknown future that lay beyond, many Africans preferred to die. But even the choice of suicide was taken away from these persons. From the captain's point of view, his human cargo was extremely valuable and had to be kept alive and, if possible, uninjured. A slave who tried to starve him or herself was tortured. If torture didn't work, the slave was force fed with the help of a contraption called a speculum orum, which held the mouth open.
** Africans in America Part 1: "The Middle Passage", PBS, (22 October 2017).
* Holloway became a place of horror and torment. Sickening scenes of violence took place almost every hour of the day, as the doctors went from cell to cell performing their hideous office. …I shall never while I live forget the suffering I experienced during the days when those cries were ringing in my ears.
** June Purvis; Emmeline Pankhurst, London: Routledge, p 134, ISBN 0-415-23978-8
* Thursday morning, 16th July ... the three wardresses appeared again. One of them said that if I did not resist, she would send the others away and do what she had come to do as gently and as decently as possible. I consented. This was another attempt to feed me by the rectum, and was done in a cruel way, causing me great pain. She returned some time later and said she had ‘something else’ to do. I took it to be another attempt to feed me in the same way, but it proved to be a grosser and more indecent outrage, which could have been done for no other purpose than torture. It was followed by soreness, which lasted for several days.
** June Purvis, "Force-feeding extracts from Purvis", www.johndclare.net, retrieved 2016-02-26.
* WASHINGTON -- The US military said yesterday that a long-running hunger strike among detainees at the Guantanamo Bay prison underwent a very significant increase" starting on Christmas Day, more than doubling the number of prisoners who are protesting their indefinite detention without trial by refusing to eat. A bloc of 46 prisoners began refusing meals on Dec. 25, the military said, bringing the total number of participants in the hunger strike to 84. A spokesman at the base said yesterday that 32 of the longer-term strikers have been hospitalized and are being force-fed through nasal tubes and the rest are under close medical observation. The numbers had more or less stayed at the same levels -- in the mid to high 30s -- for several weeks," said Army Lieutenant Colonel Jeremy Martin, a spokesman for the prison. Then we had this very significant increase in the number of hunger strikers all of a sudden."
** Savage, Charlie (2005-12-30). "46 Guantanamo detainees join hunger strike". Boston Globe. Archived from the original on 2010-03-14. Retrieved 2007-09-17.
* In October, lawyers for detainees told a judge that medics tried to persuade those on a hunger strike to start eating on their own by force-feeding them with unusually large feeding tubes inserted through their noses -- without painkillers.
** Savage, Charlie (2005-12-30). "46 Guantanamo detainees join hunger strike". Boston Globe. Archived from the original on 2010-03-14. Retrieved 2007-09-17.
* Since President Obama mentioned Supermax in a speech about Guantanamo, we wanted to take you there again. It's a sort of a 21st century Alcatraz, where convicted al Qaeda terrorists are force-fed and some guards worry about their own safety.
** Produced By Henry Schuster, "Supermax: A Clean Version Of Hell". CBS News. (October 14, 2007, updated on June 19, 2009.)
* 60 Minutes has been told that there have been frequent hunger strikes among the Islamic terrorist inmates inside Supermax and to keep the inmates alive there are often force feedings. That's when an inmate is restrained and liquid nourishment is poured down a tube in his nose. We're told there have been about a dozen hunger strikers and one of them used to be Osama bin Laden's secretary. Former Warden Robert Hood told us that he supervised many of these feedings. "I probably conducted, authorized, conducted 350, maybe 400 of involuntary feedings. Again, not…individuals, because you could have one person, three meals a day for, you know, two months. That adds up," he tells Pelley. Bureau of Prisons' records that 60 Minutes has seen show there have been as many as 900 of what the bureau called "involuntary feedings" of terrorists in H-unit since 2001. Why did the prisoners stop eating? What was the complaint? Says Hood, "It was conditions of confinement." Some of the conditions they object to are outlined in a document: inmates get letters only from people approved by the prison and they get one, monitored, phone call a month, for 15 minutes.
** Produced By Henry Schuster, "Supermax: A Clean Version Of Hell". CBS News. (October 14, 2007, updated on June 19, 2009.)
* We must face the fact that artificial feeding is attended with risk and we must teach [suffragette prisoners] that, while we appreciate the risks, we are quite prepared to go on and will not be deterred from detaining people like [Moorhead] because there is a risk to their health, if we take the necessary steps to make sure their detention is effective... They have the idea that they can frighten us by pointing out the risk to health.
** William Stewart as quoted in Atkinson, Diane (2018). “Rise up, women! : the remarkable lives of the suffragettes”. London: Bloomsbury. pp. 471, 505. ISBN 978-1-4088-4404-5. OCLC 1016848621.
* The nation of Mauritania faces a myriad of social, political and economic problems, which has greatly impacted it’s ability to develop. While most Mauritanians live and work in urban centers, a sizable number still depend on agriculture and animal husbandry, specifically in rural areas where the government has had little influence in affecting policy. One area where this is most apparent has been with gavage, or the practicing of force feeding. In his book Mauritania, Alfred G. Gerteiny wrote this of gavage: Women are subjected to gavage-that is, forced feeding, in order to gain weight. Fathers send daughters 10 or 11 years of age to live with herdtending dependent aznagui who see to it that the girls gain weight … often by being tied to the ground, and, to expand their stomachs, given nothing by water for three days. Then they are crammed with milk, usually camel’s milk. Though decades have passed since Gerteiny wrote of the practice, gavage still occurs. In Mauritania, women who are overweight, or in some cases, obese, are considered beautiful and alternatively, women who weigh what we here would consider a healthy weight are shunned. In recent years, the government and NGO’s have forcefully led a campaign to discourage the practice. The forceful feeding of adolescent girls creates a plethora of health complications as the young girls mature into women. In the larger cities, the practice has visibly been cut, both by a changing of the times and by the discouragement of the practice. However, things are different in the desert, where people continue traditional practices.
** themuslimwoman.org, "Gavage in Mauritania" [Subalternate Reality] , (August 17, 2008)
* They have to restrain the prisoners when they feed them because they attack the nurses. They spit in their faces. They're simply restrained for 20 minutes so they can be fed Ensure. They get their choice of four flavors of Ensure. It's put in a very unobtrusive feeding tube smaller than a normal straw and it's put in there for 20 minutes, so they get breakfast, lunch, and dinner.
** Paul E. Vallely, "A View from Inside Gitmo", FrontPage Magazine, May 5, 2006.
* 6. Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner.
** [https://web.archive.org/web/20151207065303/http:/www.wma.net/en/30publications/10policies/c18/ " WMA Declaration of Tokyo -
Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment"]. wma.net. World Medical Association. Archived from the original on 7 December 2015. Retrieved 12 December 2015.
* The unfortunate patients had their mouth clamped shut, had a rubber tube inserted into their mouth or nostril. They keep on pressing it down until it reaches your esophagus. A china funnel is attached to the other end of the tube and a cabbage-like mixture poured down the tube and through to the stomach. This was an unhealthy practice, as the food might have gone into their lungs and caused pneumonia.
** World Medical Association, "Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment", wma.net, (12 December 2015).
* While stating that any force-feeding deemed necessary for lifesaving purposes should not contradict "compelling internationally accepted standards of medical ethics or binding rules of international law", the judges at the tribunal also noted that the body of law laid down by the European court of human rights did not view force-feeding as "torture, inhuman or degrading treatment if there is a medical necessity to do so ... and if the manner in which the detainee is force-fed is not inhuman or degrading".
** United Nations Warcrimes Tribunal, Hague, (December 6, 2006); as qtd. in Ian Traynor, “War crimes tribunal orders force-feeding of Serbian warlord", The Guardian, (December 7, 2006).

### “Beyond Guantanamo: Torture Thrives in Connecticut” (Mar 18, 2010)

Appel, Jacob M. “Beyond Guantanamo: Torture Thrives in Connecticut”, “Huffington Post”, (Mar 18, 2010, Updated May 25, 2011)
* Opponents of torture have spent the past seven years advocating for a halt to the brutal excesses of the "War on Terror" from the Bush administration's rejection of the Geneva Conventions for detainees in Afghanistan to the waterboarding of prisoners at Guantanamo Bay. Ironically, as progress is finally being made in the international struggle against torture, the state of Connecticut has chosen this moment to launch a radical, pro-torture initiative of its own. In the case of Coleman v. Lantz, now awaiting a ruling by Superior Court Judge James T. Graham, the state's Department of Corrections has argued for the right to force feed a hunger-striking inmate in an excruciatingly painful manner -- although doing so has been condemned by the American Medical Association, the World Medical Association and the nation's leading medical ethicists.
* Coleman's stated purpose in starving himself was to draw attention to perceived injustices within Connecticut's legal system. He was neither suicidal nor mentally ill -- and, even today, retains his full mental capabilities. On September 16, 2008, he raised the stakes of his protest by refusing liquids. Shortly afterward, the prison's medical director, Dr. Edward Blanchette, had Coleman strapped down and -- without sedation -- tried to force a feeding tube through his nose into his stomach. This first attempt failed. "Success" only came after the inmate was screaming in agony and sneezing up blood. Eventually, Coleman succumbed to this torture and agreed to ingest liquids once again. He is now fighting in court for the right to resume his hunger campaign.
* One of the nation's preeminent bioethics scholars, Arthur Caplan of the University of Pennsylvania, testified on Coleman's behalf that the feeding of competent prisoners against their will -- even to save their lives -- violates the most basic tenets of the medical profession. Rational, competent adults have a fundamental right to reject medical care. Force-feeding prisoners is no different than forcibly transfusing Jehovah's Witnesses or providing unwanted chemotherapy to terminally-ill cancer patients. The World Medical Association's 1975 Declaration of Tokyo strictly prohibits physicians from engaging in such practices, which it describes as "contrary to the laws of humanity." The AMA has fully embraced this document. When the United States began force-feeding prisoners at Guantanamo Bay, two hundred fifty prominent physicians signed an open letter to a leading British journal, The Lancet, called for sanctions against the medical professionals involved in these nonconsensual interventions. Among the reasons for this outcry is that forcible feeding through a naso-gastric tube ranks alongside the most unpleasant and downright horrific experiences that one human being can inflict upon another. The British journalist Djuna Barnes volunteered to be "forcibly" fed for a muckraking exposé in The World Magazine (1914) and later wrote that "it is utterly impossible to describe the anguish of it." Others have compared it to being orally sodomized while paralyzed. Having placed such tubes into the noses of willing patients myself, in order to save their lives, I can assure you that driving one down the throat of an unwilling subject must be unspeakably ghastly.
* Another reason that physicians and bioethicists so strongly oppose forcible feeding is that this procedure is intimately tied to the ugliest passages in the history of modern medicine and associated with the worst political and social abuses of the calling. Great Britain inadvertently turned public opinion in favor of women's suffrage by force-feeding hunger-striking suffragists before World War I. Britain used the same tactic, with no more success, against Irish Republicans -- a practice that led to the gruesome death of Tom Ashe at Dublin's Mountjoy Jail in 1917. Finland adopted such tactics to suppress Communists in the 1930s; Turkey allegedly force-fed leftist prisoners as recently as 2001. Most notoriously, the Soviet Union pumped food into the stomachs of prominent dissidents, including Vladimir Bukovsky and Andrei Sakharov, to prevent the negative publicity that might have stemmed from their starvation. In Bukovysky's description of his torment, among the most haunting of all descriptions of human torture, he wrote, "I would have screamed if I could, but I could not with the pipe in my throat. I could breathe neither in nor out....I wheezed like a drowning man -- my lungs felt ready to burst." That is the species of "medical care" that Connecticut now seeks to defend.

### “Rise up, women! : the remarkable lives of the suffragettes” (2018)

Atkinson, Diane (2018). “Rise up, women! : the remarkable lives of the suffragettes”. London: Bloomsbury. pp. 471, 505. ISBN 978-1-4088-4404-5. OCLC 1016848621.
* Lloyd George arrived at the Music Hall in Aberdeen unscathed. En route Ethel Moorhead, alias ‘Miss Humphreys’, had thrown a stone at a car she thought he was traveling in, but broke a window in the wrong vehicle. Hiding in the music hall were three more of Emily’s comrades: Fanny Parker, alias ‘Janet Arthur’, Olive Wharry, alias ‘Joyce Locke’, and May Pollok Grant, alias ‘Marion Pollock’, the latter a Dundee clergyman’s daughter. They smuggled themselves into the building to interrupt the chancellor of the exchequer’s meeting, but were found and their protest was thwarted. They were sentenced to five days in prison for behaving in a disorderly manner and committing a breach of the peace: Fanny Parker went on hunger strike but was not force-fed and was released at the end of her sentence. Ethel Moorhead caused chaos when she refused to leave the court, and Olive Wharry added to the excitement when she threw her shoes at the magistrate and the Procurator-Fiscal. Ethel Moorhead served four days of her ten-day sentence and was released early when her fine was paid. When Olive Wharry was released she told the Aberdeen Evening Gazette, using her alias ‘Joyce Locke’ that she was a ‘physical wreck’. Her eyes were ‘sunken’, her face was pale, her tongue was ‘blistered and coated’ and she spoke with ‘much difficulty and pain’. She had eaten no food and only takena few drops of water, and felt ‘rather nervous, and not in a fit condition to tell you everything’. Emily Davison spent Christmas with her mother in Longshorsley, Northumberland. On Boxing Day she wrote to an unnamed suffragette, “My DeadC omrade’, thanking for her ‘amusing but wicked booklet’. Referring to her recent spell in Holloway, ‘As to my little “do”, I was very kindly treated by the members when I got “out” and son puled round’, but since then she ahd experienced ‘a good deal of rheumatism in my head and back’. Emily was disappointed that she had not managed to attack Lloyd George himself: ‘Never mind it will no doubt have given him a fright, and he can’t always expect to hav a double handy.” She was unrepentant at having hit the clergyman, the Reverend Forbes Jackson: ‘he was a fool not to accept the apology and did not show up favourably.’ She was delighted with her protest: ‘We made things hum in Aberdeen!” The year drew to a close with bangs and bells: letters and packages were damaged or destroyed, and fire alarms were set off in London, Birmingham, Cardiff, Nottingham, Preston, Bradford, Newscastle and Bath. Christabel Pankhurst explained the militant’s rationale in “The Suffragette”, whose tone was far more strident than Votes for Women, as follows: ‘The suffragists who have been burning and otherwise destroying letters have been doing this for a very plain and simple reason. They want to make the electors and the Government so uncomfortable that, in order to put an end to the nuisance, they will give women the vote … Women will never get the vote except by creating an intolerable situation for all the selfish and apathetic people who stand in their way.’ She dismissed the argument that many hundreds of women were being inconvenienced by this form of militancy, saying that such women were at least ‘suffering in their own interests and not only in the interest of other people as is so often the case where sacrifices made by women are concerned. In December the newspapers carried outraged editorials and letters from readers frustrated that so few culprits were being caught. Most attacks were carried out in the early hours of the morning. Only a handful of women, such as Elsie Howey, were caught red-handed. Elsie, who had not long been out of Aylesbury Gaol, was released in a weak condition from her four-month sentence, during which she was force-fed. Bravely she put herself in trouble again on 10 December when she set off a fire arm and caused threepence worth of damage to the fire-alarm bell. She was sent again to Holloway, this time for two months, and suffered more than usual from a new bout of force-feeding. In 1928 Elsie’s mother wrote to Elsa Gye saying that her daughter has almost lost her voice: ‘She almost became dumb for life from the injuries inflicted on her throat … it took four month’s treatment to save her and her beautiful voice was quite ruined.’ While Elsie was recovering she had to carry a pencil and paper and write down anything she wanted to say. Invalid-tricycle-bound May Billinghurst had to hobble and hop into the dock of Greenwich Magistrates’ Court on her crutches when she was accused of a ‘pillar box ourtage’, damaging letters in a pillar box in Blackheath on 17 December. Her case was tried at the OldBailey on 8 January 1913 and she was convicted of placing a black fluid into pillar boxes. In a written statement May said she wanted to ‘wake up the minds of the public to the subject of votes for women’. She made a defiant speech,and was sentenced to eight months in Holloway in the first division; she went on hunger strikeand was fed by force ‘at a terrible cost to herself’, and released ten days into her sentence. During one of the attempts to feed May her teeth were damaged and her face was cut. This was May Billinghurst’s second spell in Holloway in 1912: in March she had been sent to prison for a month served with hard labour for breaking windows. Kitty Marion also spent Christmas in gaol after breaking the glass of a fire-alarm post with a hammer in Wellington Street, Covent Garden, on 17 December, near to Bow Street Court. Five fire engines rushed to the scene. A few hours later at Bow Street Court Kitty proudly reminded the magistrate, Mr Marsham, that three years earlier she had broken windows at the Moss Empire office, to draw attention to the unsavoury conditions under which many actresses worked. Kitty toldthe court that since 1909 she had been almost boycotted by the profession. The court heard that the strength of her blow to the glass was such that it broke the hammer, and that she had waited patiently for a police constable to arrest her. As she was taken to the police station she shouted, ‘I want to turn the Government out’ Kitty was given the option of paying a L25 fine or going to prison for a month in the second division. She chose the latter. When asked if she had the money to pay the fine she said: ‘No; and if I had twenty million pounds I would not pay.’ She was taken to Holloway and, after taking breakfast on Christmas Day, Kitty went on hunger strike. The next day two doctors examined her and at tea time she was fed by force: ‘I was lying on my bed and turned my face to the wall, but they wheeled the bed into the middle of the cell, and after a violent struggle held me down by sitting on my legs. I was fed through a nasal tube and was so sick and exhausted that a wardress remained with me for some time.Kitty was fed every day for the rest of her sentence until she was released on 17 January 1913. She put her ability to bear the pain down to her ‘robust constitution and excellent health’. She was met at Holloway’s gates by her friends who nursed her back to health and when she was fully recovered she stayed with Lilla Durham in her cottage in Sussex.

### "Serb prisoners 'forced to eat soap' during months of beatings in solitary confinement" (30 March 1996)

Banks, Lynne Reid (30 March 1996). "Serb prisoners 'forced to eat soap' during months of beatings in solitary confinement". The Independent. London.
* Doboj, Bosnia - Outside the door of the Red Cross office here in the Serbian sector of northern Bosnia, a dozen anxious women gather on the off-chance of news. Their husbands are not among the 109 prisoners released by the Bosnian Muslims in Tuzla, 60 miles away, but perhaps one of the former captives has seen or heard of their men, most of them missing since the Serbs were pushed back in the September 1995 offensive. No news is not good news. One woman, pale and jumpy, poured out her fears that her husband had been "ritually murdered" by the mujahedin, whom many Serbs believe were sent in their thousands from Arab countries to fight for the Muslims. The Red Cross managed to register lists of Tuzla prisoners last month, but many men are unaccounted for. Former prisoners said they were not visited by any humanitarian agency for the first three or four months of their captivity. All the newly released prisoners I talked to were reluctant conscripts, and none seemed to know what the war was about. One, a grizzled, unshaven sergeant wearing a bright new jacket, described his 45 days of solitary confinement and of interrogation - on how many women he had raped and how many Muslims he had killed - accompanied by blindfolding and beatings. Later, he said, he was put in a shared cell in a regular prison. "Work" consisted of being handcuffed to a fence and made to pull grass. Sometimes he was taken into the prison yard to pick up cigarette butts dropped by more-kindly treated Muslim prisoners - deserters - who were kept separate from the Serbs, but who could watch him at his task. His guards got some fun out of making him shout: "I'm a dirty Chetnik!" Another prisoner, Goran Pandurevic, told of being captured when Muslim forces overran Serb positions. He was shut in a disused ambulance shed for two days, where he claimed he and his companions were beaten and humiliated, forced to "eat paper and soap", and given one-and-a-half litres of water a day for 30 men. Later, the prisoners were taken to Tuzla and put into a civilian prison, he said. Forty men were held in a cell measuring four metres by five and were kept there for three months without exercise or medical attention, apart from aspirins, for the wounded and sick. The men were often forbidden to sit down during the day. Drinking-water had to be collected in bottles from the toilets, which they visited three times a day. They were given no changes of clothes, no heating, and nothing to do. After three months they were taken out on work details, digging canals and rebuilding ruined buildings. After the months of darkness and confinement, Mr Pandurevic said, they "could hardly see or walk". He claimed that as the prisoners worked, guards subjected them to random beatings. Mr Pandurevic described his release as "a new birth". I asked him what he had done the night before, after being reunited with his family. "No going out drinking", he said. "I was drunk on the alcohol of life."

### "Scottish suffragettes braved hunger strikers, prison and violence to win vote" (2020-02-11)

Bird, Jackie (2009-10-09). "Scottish suffragettes braved hunger strikers, prison and violence to win vote". dailyrecord. Retrieved 2020-02-11.
* "The tube filled up all my breathing space, I couldn't breathe. The young man began pouring in the liquid food. "I heard the noises I was making of choking and suffocation - uncouth noises human beings are not intended to make and which might be made by a vivisected dog. Still he kept on pouring." These horrific words aren't from the dark ages or a testimony of torture. They are the memories of a Scottish suffragette named Ethel Moorhead, and they describe events in a Scottish jail less than 100 years ago.
* [W]hat's not widely known is that Scotland was a key battleground of the suffragette movement. Our cities were the scenes of demonstrations and violent protest. Politicians were attacked, buildings were set on fire. Women who'd been brought up to be second class citizens found themselves battling with the authorities, going on hunger strike and facing the dehumanisation of being force fed. They did it for the right to vote and Ethel Moorhead was just one of the many Scots women at the front of the campaign. But how did a beautiful and talented artist form a well-to-do family end up being held down and force fed in Edinburgh's Calton jail?
* One perpetrator of militancy was Ethel Moorhead, the daughter of an army surgeon. In 1911 she threw an egg at Winston Churchill, who was an MP for Dundee and a bitter opponent of votes for women. Later, Ethel was jailed for breaking a glass case at the Wallace monument, an act symbolising women's fight for freedom. She was jailed several times, but even behind bars Ethel ran the authorities ragged. But in 1914 she became the first woman to be force-fed in Scotland. Force-feeding had been carried out in England and doctors wrote petitions condemning the practice as barbaric. In Scotland, the judiciary was reluctant to follow, but in 1914 they capitulated. A newspaper spoke of "Scotland disgraced and dishonoured." "...Instead of passing through into the throat, the tube went into the top of my nose and injured the nerves of my right eye. They began feeding me through the mouth. One doctor used to put his finger through the extreme end of the left side of my jaw and cut me while the wardress put her finger through the right side of my jaw. Between the two my lips were nearly torn." That account from a recipient of force-feeding shows why it polarised public opinion. Perth prison became notorious for its brutal treatment of the women it held.

### "UN concern at Guantanamo feeding" (30 December 2005)

BBC News: "UN concern at Guantanamo feeding.", (Last Updated: Friday, 30 December 2005)
* There are credible allegations that Guantanamo hunger strikers are being force-fed in a cruel manner, the UN special rapporteur on torture has said. Manfred Nowak's comments came after it emerged that the number of detainees refusing food at the prison camp had more than doubled since 25 December. Some 84 inmates are now refusing food, according to the US military.
* Mr Nowak has not been to Guantanamo, and turned down an invitation to the camp because the US refused to give him unrestricted access to the detainees. He told the BBC that he had received reports that some hunger strikers had had thick pipes inserted through the nose and forced down into the stomach. This was allegedly done roughly, sometimes by prison guards rather than doctors. As a result, some prisoners had reported bleeding and vomiting he said. "If these allegations are true then this definitely amounts to an additional cruel treatment," Mr Nowak said. The allegations were rejected by Pentagon spokesman Lieutenant Colonel Brian Maker. "To suppose that these people are being left bleeding - I know of no instance of that, there's been no reports of that, there's been no credible evidence produced by any investigation of that fact," he told the BBC. All those receiving what he called "internal nutrition" were being monitored by trained medical personnel, Lt Col Maker said.
* The US military defines a hunger strike as missing nine consecutive meals. Lawyers for some of the detainees have said the hunger strikers are protesting against their continued detention without trial and against the conditions in which they are being held, he adds. About 500 prisoners remain at Guantanamo, many of them captured in Afghanistan. Some have been held for nearly four years without charge. Human rights campaigners have expressed growing concern about the treatment of inmates at Guantanamo. The Bush administration has denied allegations of abuse at Guantanamo, insisting it does not torture prisoners.

### "Doctors attack U.S. over Guantanamo" (2006-03-10)

"Doctors attack U.S. over Guantanamo". BBC News. 2006-03-10. Archived from the original on 2010-01-21. Retrieved 2006-03-15.
* More than 250 medical experts have signed a letter condemning the US for force-feeding prisoners on hunger strike at Guantanamo Bay, Cuba. The experts, from seven nations, said physicians at the prison had to respect inmates' right to refuse treatment. The letter, in the medical journal The Lancet, said doctors who used restraints and force-feeding should be punished by their professional bodies.
* The open letter in the Lancet was signed by more than 250 top doctors from seven countries - the UK, the US, Ireland, Germany, Australia, Italy and the Netherlands. "We urge the US government to ensure that detainees are assessed by independent physicians and that techniques such as force-feeding and restraint chairs are abandoned," the letter said. The doctors said the World Medical Association - a world body representing physicians, including those in the US - specifically prohibited force-feeding. They said the American Medical Association, a member of the world group, should instigate disciplinary proceedings against any members known to have violated the code. Detainees at the camp have said hunger-strikers were strapped into chairs and force-fed through tubes inserted in their noses.
* Dr David Nicholl, a UK neurologist who initiated the Lancet letter, told the BBC's World Today programme that US doctors going to Guantanamo Bay were being screened to ensure they agreed with the policy of force-feeding. "In effect they are screened to make sure they don't have doctors with a conscience." Dr Nicholl said it was the patient's decision to go on hunger strike and the doctor's responsibility was to explain the consequences and confirm the patient was sane. In February, Lt Col Martin, chief military spokesman at the US detention facility, said force-feeding was administered "in a humane and compassionate manner" and only when necessary to keep the prisoners alive. But Dr Nicholl said that "horrible as it may sound" the doctor had to conform to the wishes of hunger strikers, even if it led to their deaths. Dr Nicholl said the letter's signatories felt there was not enough publicity about the matter in the US media and that Americans needed to be challenged.
* July 2005: 52 detainees begin hunger strike, second of the year, in protest at detention and treatment 14 Sept: Lawyers say more than 200 are refusing food. The US military says 128 21 Sept: US says number falls to 45. No explanation given but some tube-feeding admitted 7 Oct: US says number down to 28, 20 of whom are force-fed 27 Oct: US judge "deeply troubled" by force-feeding 25 Dec: Hunger strikers leap to 84, the US says 9 Feb, 2006: US says number down from 84 to four but gives no reason

### "UN: US force-feeding immigrants may breach torture agreement" (2019-02-08)

GARANCE BURKE, "UN: US force-feeding immigrants may breach torture agreement". Associated Press. 2019-02-08.
* The United States could be violating the U.N. Convention Against Torture by force-feeding immigrant detainees on a hunger strike inside an El Paso detention facility, the United Nations human rights office said Thursday. The Geneva-based Office of the High Commissioner for Human Rights is concerned that force-feeding could constitute “ill treatment” that goes against the convention, which the United States ratified in 1994, spokeswoman Ravina Shamdasani told The Associated Press. The U.N.'s statement echoes concerns raised by 14 Democratic lawmakers who sent a letter to U.S. Immigration and Customs Enforcement on Thursday requesting more information about nine Indian men who are being force-fed through nasal tubes after refusing to eat to protest what they described as unfair treatment. One of the hunger strikers, a 22-year-old asylum seeker who has not eaten in more than a month, said he was dragged from his cell three times a day and strapped down on a bed as a group of people poured liquid into tubes inserted into his nose. “It is critical that ICE commit to ending this practice,” said the letter spearheaded by Texas Democratic Rep. Veronica Escobar, who toured the El Paso Processing Center and met with the men after AP reported on the force-feeding last week.
* Hunger strikes are relatively uncommon inside ICE detention. Last month, ICE began non-consensual feeding and hydration of numerous El Paso detainees after a federal judge issued a court order allowing them to be force-fed against their will. “ICE is committed to preserving the lives of those in its custody and maintaining orderly detention facility operations,” the agency said Thursday in response to the U.N.'s statement. “For their health and safety, ICE closely monitors the food and water intake of those detainees identified as being on a hunger strike. Medical staff constantly monitor detainees to evaluate whether the hunger strike poses a risk to the detainee’s life or permanent health.” While ICE doesn’t keep statistics on force-feeding throughout the immigration detention system, attorneys, advocates and agency staffers AP spoke with did not recall a situation where it had come to force-feeding. Federal courts have not conclusively decided whether judges must issue orders before ICE force-feeds detainees, so rules vary by district and orders are sometimes filed secretly. The controversy comes as President Donald Trump prepares to visit El Paso on Monday for his first campaign rally of the year to be held at a coliseum in the bustling border city. The detainees, who are refusing food to protest what they describe as verbal abuse and threats of deportation from guards, are being held in a highly guarded facility surrounded by a chain-link fence on a busy street near the airport.
* Force-feeding raises ethics issues for medical professionals who work inside ICE facilities. The American Medical Association has expressed its concerns about physicians participating in the force-feeding of hunger strikers on multiple occasions, and its own principles of medical ethics state “a patient who has decision-making capacity may accept or refuse any recommended medical intervention.” The association also endorses the World Medical Association Declaration of Tokyo, which states that when prisoners refuse food and physicians believe they are capable of “rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially.”

### "Hunger Strike Raises Debate About Force-Feeding In Israeli Prisons" (August 2015)

Emily Harris, "Hunger Strike Raises Debate About Force-Feeding In Israeli Prisons". Weekend Edition Saturday, NPR, 22 August 2015.
* When a Palestinian man in Israeli custody came close to death this week, doctors challenged an Israeli law. Palestinian prisoner Mohammad Allan was in critical condition after he had refused food for two months, protesting his detention since last November in Israeli custody. Suspected of ties to a militant group, he was held with no charges, no lawyer and no accusations to face in court. Six weeks into his hunger strike, Israel's parliament passed a law permitting the force-feeding of prisoners in order to keep them alive. Allan might have become a test case for the law, but doctors made it clear they would not participate, calling it unethical medical treatment. "It's like rape," says Yoel Donshin, a retired anesthesiologist and a member of Physicians for Human Rights. "You will ask a physician to rape a patient for treatment? This is unacceptable." Donshin doesn't believe Israeli politicians who supported the law want to save the lives of prisoners. "They do not care for the welfare of the prisoners," he says. "They just want him not to become a symbol or martyr."
* Mohammad Allan's situation was different. Solo, and much closer to death, Palestinian protests over his continued detention grew as his health got worse. Israeli authorities feared his death could trigger street violence. But amid the turbulent public debate, one lawmaker who had voted against allowing force-feeding said he changed his mind. Yaakov Peri also used to head Israel's internal security. "The only solution is that he be fed," said Peri on an Israeli radio program last Wednesday. "I was against the force-feeding bill, but the alternative is an end to his life. There are times when the state of Israel has to make a decision, and if we need to force-feed him, we will have to force-feed him." He spoke before an Israeli high court ruling that ended the question of force-feeding Allan. The court suspended his detention until doctors could determine any long-term health consequences and Allan agreed to take nutrients.
* Israel's public security minister opposed the ruling. He warned that more Palestinian prisoners will now go on extreme hunger strikes and, on his Facebook page, criticized the doctor who heads the Israel Medical Association for telling physicians to ignore the new Israeli law. (Updated 1:30 p.m., Aug. 24: On Sunday, four days after the court ruling, Israeli media reported that more than a dozen well-known Israeli academics and physicians signed a paper supporting the state's position, saying a doctor's responsibility is to save lives). That doctor, Leonid Eidelman, says he did nothing wrong. "It's not breaking [the] law because there is no law in Israel to force doctors to use a treatment they don't believe should be used," he said. Under Israel's force-feeding law, a judge can allow, but not order, a doctor to participate. Israel is not the only place force-feeding is an issue. The U.S. military has repeatedly force-fed hunger strikers held at Guantanamo Bay, and American courts have upheld the practice.
* In Israel, Eidelman and other physicians say they would honor a patient's wish to refuse food, but would step in to save that same patient's life if he or she were unconscious. Eidelman says that worked for Mohammad Allan, who wanted a trial or freedom — not death. "And in this case actually, it was proven. Because after he was resuscitated he regained his consciousness and didn't regret that he was resuscitated." Mohammad Allan ended his hunger strike after the Israeli court ruling. The force-feeding law remains on the books, awaiting a future case and a future debate with Israel's doctors.

### "Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa" (2020)

Kodua, Michael; Mackenzie, Jay-Marie; Smyth, Nina (2020). "Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa". International Journal of Mental Health Nursing. 29 (6): 1181–1191. doi:10.1111/inm.12758. ISSN 1447-0349. PMID 32578949. S2CID 220046454.
* Manual restraint, a type of physical restraint, is a common practice in inpatient mental health settings linked to adverse physical and psychological staff and patient outcomes. However, little is known about the use of manual restraint for compulsory nasogastric feeding of patients with anorexia nervosa within inpatient eating disorder settings. The present phenomenological study aimed to explore nursing assistants’ experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. The study followed COREQ guidelines. Eight semi-structured interviews were conducted with eight nursing assistants from one UK inpatient child and adolescent eating disorder service. Interviews were transcribed verbatim and analysed using Thematic Analysis. Three themes were extracted: An unpleasant practice, Importance of coping, and Becoming desensitised and sensitised. Nursing assistants commonly experienced emotional distress, physical exhaustion, physical injury and physical aggression as a result of their manual restraint use. Nursing assistants appeared to cope with their distress by talking with colleagues and young persons who were further in their recovery, and by detaching themselves during manual restraint incidents. The findings highlight that the use of manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa in the UK, is a highly distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings.
* p.2
* Manual restraint is a form of physical restraint practice, used particularly within inpatient mental health settings, whereby one or more persons restrict the movement of another by manually holding them (Stewart et al., 2009; Stubbs & Paterson, 2011). This differs from mechanical physical restraint which refers to the use of devices (e.g., belts or cuffs) to restrict movement (Care Quality Commission, 2018). Manual restraint is commonly used in conjunction with seclusion and chemical restraint to prevent harm to patients and staff, or to administer medications and other treatments (Chapman et al., 2016; Hawkins et al., 2005; Ryan & Bowers, 2006). For instance, the literature has highlighted the use of manual restraint in response to patient self-harming, aggressive and attempted absconding behaviours (Bowers et al., 2015), and patient medication refusal (Owiti & Bowers, 2011). Concerns have been raised about manual restraint use (Mind, 2013), and internationalguidelines and programmes advocating for its reduction have emerged (e.g., Department of Health, 2014; Mental Health Commission, 2014; O’Hagan et al., 2008; Royal Australian and New Zealand College of Psychiatrists, 2016). Within England alone, over 50,000 incidents of manual restraint were recorded between the years of 2016 and 2017 in National Health Service funded secondary mental health, learning disability (LD) and autism services (Collinson, 2017), demonstrating the commonality of manual restraint practice. This study explores nursing assistants’ experiences of administering manual restraint for compulsory nasogastric feeding (CNF) of young persons with anorexia nervosa (AN).
** p.3
* The literature has highlighted the numerous adverse physical and psychological staff outcomes as a result of manual restraint use. Staff have reported experiencing physical exhaustion, physical pain and injury, and numerous unpleasant emotions (e.g., anxiety, fear, anger) as a result of administering manual restraint (Bigwood & Crowe, 2008; Bonner et al., 2002; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Manual restraint has also been linked to staff feelings of internal conflict, as staff may perceive the act of manually restraining patients as incongruent with their therapeutic role (Bigwood & Crowe, 2008; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Although manual restraint is commonly administered within inpatient mental health settings (Stewart et al., 2009; Wilson et al., 2017), the literature has also illustrated its use within the emergency department, LD services, and paediatric general hospital and residential childcare settings (Chapman et al., 2016; Fish & Culshaw, 2005; Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). The manual restraint of young persons raises ethical and moral issues for staff, and this has been evidenced by the distress and internal conflict staff may experience when manually restraining young persons (Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). For instance, staff have reported feeling guilty when restraining children for medical procedures, with some describing how “difficult and demanding” the process can be (Lombart et al., 2019; Svendsen et al., 2017). Presently, little research has been conducted on the use of manual restraint within child and adolescent settings. However, even less research has been conducted on the use of manual restraint for CNF of patients with AN within inpatient eating disorder settings.
** pp.3-4
* AN is an eating disorder characterised by an extremely low body weight, a severe restriction of food, a strong desire to be thin, and an intense fear of gaining weight (National Institute of Mental Health, 2018). Under relevant mental health legislation, patients with AN can be administered CNF in extreme cases when they are presenting with very low body weight, and refusing to eat and/or drink (Fuller et al., 2019; Royal College of Psychiatrists, 2014). In the rare case when a patient is resistant to nasogastric feeding, staff members may administer manual restraint to ensure the safety of themselves and the patient during feeding (Fuller et al., 2019, 2020; Neiderman et al., 2001). Within the UK, manual restraint in this context may be used in the absence of other restrictive practices (e.g., seclusion), and may involve holding the patient’s arms, legs and head in a safe position, in order to allow for the safe passing of a nasogastric tube and subsequent feeding (Fuller et al., 2019; Neiderman et al., 2001). Feeding in the context of active resistance is a rare event and raises ethical, legal and clinical issues for all those involved (National Collaborating Centre for Mental Health, 2004). Despite the wealth of research that exists on the treatment of AN, we could only locate one published qualitative study that explored the experience of CNF in the context of AN, including the experience of CNF under manual restraint (Neiderman et al., 2001). In this qualitative survey study exploring children and adolescent patients’, and their parents’ experiences of nasogastric feeding, the authors summarised patients’ nasogastric feeding experiences into two main categories: “I regretted it at the time but think that it was necessary” and “I hated it then and hate it now”. This study however did not focus specifically on the practice of CNF under manual restraint, and did not use in-depth qualitative data collection methods such as individual interviews (the authors used qualitative questionnaires). Studies specifically exploring the experience of CNF under manual restraint from either the patient or staff member’s perspective using in-depth data collection methods, could provide valuable insight into this under-researched practice.
** p.4
* Within the UK, it is common for graduates of non-nursing degrees (e.g., psychology) who are wishing to pursue a career in mental health (e.g., clinical psychology) to first start out working as healthcare and nursing assistants in mental health settings to gain relevant clinical experience.
** p.5-6
* Participants were recruited from a private 25-bed locked inpatient specialist child and adolescent eating disorder service in the UK which provides inpatient treatment to young persons aged 9-18 years with eating disorders. In addition to providing multidisciplinary input from a number of professionals including psychiatrists, paediatricians, psychologists, family therapists and dieticians, the eating disorder service, under the powers of the Mental Health Act 1983 (Department of Health, 2015), and occasionally parental consent, also provides CNF under manual restraint as an intervention to young persons with AN presenting with ongoing food and/or fluid refusal and subsequent non-compliance with nasogastric feeding. A standard CNF intervention under manual restraint within the eating disorder service could typically last between 10 and 30 minutes, and involve up to five nursing assistants restraining the young person in the seated position, and up to two registered mental health nurses inserting the nasogastric tube, checking the tube’s placement, and delivering subsequent dietary nutrition through the tube via syringe. As reported by participants, up to 12 CNF interventions under manual restraint could occur per shift within the eating disorder service. This was owing to the fact that some young persons had care plans in place for pre-planned CNF interventions under manual restraint to be implemented multiple times per day (e.g., at specific times during the mornings, afternoons and evenings) due to their global and ongoing refusal of all foods and fluids, and their non-compliance with nasogastric feeding. Chemical restraint was not routinely used within the eating disorder service, and there was a service policy in place for CNF interventions under manual restraint to be aborted and reattempted at a later time in circumstances where it was not possible to safely administer nasogastric feeding within 30 minutes of manual restraint holds being applied.
** p.6
* Three themes were extracted from the analysis: An unpleasant practice, Importance of coping, and Becoming desensitised and sensitised. It is important to consider these themes in relation to the 5-36 month difference within the experience level of nursing assistants.
** p.8
* An Unpleasant Practice Administering manual restraint for CNF of young persons with AN was an unpleasant practice for all nursing assistants, and this was evidenced by the numerous reported adverse physical, psychological and interpersonal outcomes. Some felt that they did not receive enough support from the eating disorder organisation in managing these outcomes. Six subthemes are reported. Emotional distress. Despite recognising the necessity of CNF under manual restraint for young persons with AN who were refusing all foods and/or fluids, seven of the eight nursing assistants described the emotional distress they experienced as a result of administering manual restraint. Some described the practice as “traumatising” both for themselves and the young person; this was predominately attributed to the coercive nature of the practice and the young person’s distressing response to it, which typically included active resistance, aggression, screaming, coughing, complaints of discomfort, and occasional nasal bleeding from nasogastric tube insertion: It’s scary, it’s emotionally draining for both the patient and staff . . . there’s blood coming out [from the young person’s nose], the child is screaming down the place, so as much as you’re supporting the child, it becomes very difficult because it seems like you’re either attacking or physically punishing somebody. (Participant 2) Seven nursing assistants reported experiencing a range of unpleasant emotions as a result of applying manual restraint for CNF. Anxiety, guilt and anger were commonly cited emotions. Participants felt anger, often, in response to being hurt by the young person during restraint, and the young person’s lack of cooperation. Anxiety and guilt were commonly attributed to the unpredictability and coerciveness of manual restraint respectively: Before I go into a restraint, my heart starts pumping a bit more . . . I feel very anxious because we don’t know what could happen. (Participant 4)
** pp.8-9
* Physical exhaustion. All nursing assistants described the physical exhaustion they felt in relation to applying manual restraint for CNF, especially in circumstance where the young person was highly resistive. There were multiple manual restraints to perform per shift, and reports of sweating during restraints were not uncommon. At times, the manual restraint continued even after nasogastric feeding had been completed because the young person was either trying to self-harm or purge the liquid supplement they had just been given. This made the whole restraint even more tiring for participants: Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5) Despite the physical exhaustiveness of using manual restraint, all nursing assistants also reported that the restraint of some young persons involved minimal physical exertion because of their increased compliance and preference to be fed under restraint: I was restraining her arm and one of her legs, and it wasn’t very intense. The patient was going through this process for a very long time, so she was at that stage where she wanted this holding let’s say, but she wasn’t aggressive or very resistive. (Participant 1) Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5)
** p.9
* Patient aggression. All nursing assistants frequently reported being subjected to physical and/or verbal aggression by some young persons during manual restraint use. It appeared from their accounts that these young persons were using whatever means they could, to prevent or stop the restraint, in order to stop or avoid nasogastric feeding. Commonly cited verbal aggression included swearing and shouting. Commonly cited physical aggression included spitting, kicking, scratching, biting, punching and head-butting. Some participants reported being subjected to such physical aggression even when nasogastric feeding had been completed: We were starting to leave the restraint . . . I was doing the lower part of the legs and I was kind of tilted over and she actually head-butted me on the head . . . the feed’s finished but she still lashes out at staff. (Participant 4) Being on the receiving end of physical aggression elicited reciprocal urges of aggression for two nursing assistants. These urges were cited in the context of self-defence and the participants in question were clear that they did not reciprocate aggression in any form: One of the patients was trying to dig her nails in my skin and rip whatever I was wearing to protect my arms. . . I hate these moments particularly because I feel I want to hurt the child . . . at that moment you want to hurt them in order to protect yourself. (Participant 1)
** pp.9-10
* Physical injury. All nursing assistants reported sustaining frequent physical injuries as a result of applying manual restraint for CNF. Injuries typically ranged from back pains to bruises and were reportedly sustained by the physical aggression of young persons or through the execution of the manual restraint itself: When the patient was moving, as we were restraining her, I got thrown at a door handle and that caused quite big bruising on my back. (Participant 8) Some nursing assistants reported only becoming aware of a sustained injury after they had returned home from their shift: Sometimes it happens with bruises, like you go home, you haven’t realised how you might have sustained this bruise and then you realise . . . or you might feel back pains which you don’t really realise when you’re in the restraint. (Participant 6) In addition to back pains and bruises, two participants reported that they had either obtained, or had witnessed their colleagues obtain more severe physical injuries during manual restraints such as dislocated shoulders, head injuries and being kicked in the groin. In all reported instances this was due to the physical aggression of a young person: For some reason, one of the legs had not been held tightly, and she kicked the nurse who fell over and landed down. That was very scary because the staff banged her head and she got unconscious . . . they had to call an ambulance. (Participant 2)
** p.10
* Pressure and responsibility. Six of the eight nursing assistants voiced feeling pressured and responsible for their colleagues and themselves while applying manual restraint for CNF. These participants appeared to attribute these feelings to their manual restraint performance, which could have a direct impact on their colleagues’ ability to effectively restrain, and the overall success of the nasogastric feeding procedure: You know in every restraint that if you lose your grip and they get a hand through or a leg through, the whole thing’s going to go wrong, so you feel responsible . . . If you lose their hand, they’ll grab the tube out and then the whole process has to start again . . . you feel the responsibility from all the other staff as well. (Participant 7) Failure to execute or maintain restraint positions could result in feelings of frustration and failure, and this was explicitly expressed in four nursing assistants’ interviews. It appeared that these participants placed a great deal of pressure and responsibility on themselves to execute their designated manual restraint positions.
** pp.10-11
* Importance of Coping Seven of the eight nursing assistants valued coping, and this was evidenced by the strategies they consciously employed which helped them cope with applying manual restraint for CNF. Coping strategies were typically utilised during and after manual restraint use. Two subthemes are reported.
** p.11
* Detaching the self. Five of the eight nursing assistants reported actively detaching themselves from the process when they were administering manual restraint for CNF. This was predominately described by female nursing assistants and was evidenced through the use of terms such as “zoning out”, “shutting off” and “taking my mind off”. Detaching the self appeared to be a conscious response used by participants to cope with the adverse psychological outcomes of manual restraint use: I sort of try to stay focused on what I’m doing during the whole process but sort of try to take my mind out of this as well so that I can cope with it because it’s a very stressful procedure so I’m trying to think of something more calming. (Participant 1) I get to a point when I just shut off and then I’m just staring into nowhere and just trying to remain in the restraint position because it’s just too much to take in. (Participant 8) For one nursing assistant, detaching the self was a “necessary” coping strategy that guarded against the adverse psychological outcomes that could result from paying attention to the young person’s distress during restraint. Failing to “zone out”, in this participants view, was self-destructive: It becomes quite emotionally damaging to pay attention too much to what the patients are screaming and shouting about in the feed so I prefer to kind of zone out, it’s my coping mechanism . . . it’s necessary to zone out and I kick myself if I don’t do it because it’s just self-destructive not to. (Participant 5)
** pp.11-12
* Talking with others. Six of the eight nursing assistants reported seeking out conversations with their colleagues and young persons who were further in their recovery, after they had been involved in a manual restraint for CNF. For some participants, this appeared to be a method of cheering up through humour: Sometimes you just need to get away and be lifted up by someone else. If you can bounce off of a staff member it’s pretty good...or go to some of the hyper kids, the kids that at the moment are really doing well, and if they’re all having banter with each other, you can sort of get brought into it and sometimes you just forget what’s just happened in the restraint. (Participant 5) For other participants conversing with their colleagues was a method of “venting out” after a particularly challenging restraint which had elicited feelings of frustration: You can vent out amongst each other as the people that have done the restraint. (Participant 3) Four nursing assistants reported seeking out trusted staff members to confide in. For the majority of these participants this was a method of expressing their feelings, especially in circumstances where they had partaken in a restraint that had upset them: . . . and then I spoke to a member of staff that I trusted in that situation and it turned out that the same thing had happened to her so it was nice to have that understanding, it made me feel much less alone. (Participant 7)
** p.12
* Becoming desensitised and sensitized Despite the physical and emotional challenges that encapsulated participants’ experiences of administering manual restraint for CNF of young persons with AN, and unlike the “Importance of coping” theme which described participants’ conscious attempts to cope with the procedure, five of the eight nursing assistants reported becoming emotionally desensitised to the practice over time. This was an adaptation predominately reported by male nursing assistants through descriptions such as “getting used to it”, becoming “desensitised” and becoming “immune”: We’re kind of immune to the screams, the noises, the fighting, the everything so it’s much easier nowadays, if it’s done properly and you’re not being hurt, it’s easy to go through a restraint without feeling very guilty that you’re doing anything wrong. (Participant 2) For some nursing assistants, this familiarity to the practice of applying manual restraint for CNF appeared to be facilitated by a change in their attitudes towards the practice over time. This attitude change appeared to involve the acceptance of CNF under restraint as something that was necessary, either as part of their job role or for the young person’s own safety: Now it’s just what needs to be done, it’s what needs to be done because the patient is not taking the responsibility of feeding themselves so we have to take on that responsibility. (Participant 4) In contrast to becoming desensitised, two nursing assistants reported that they had become emotionally sensitised to the manual restraint procedure. Participating in the restraint had become more emotionally challenging for these participants over time due to the therapeutic relationship they had built with the young person over time: The first restraints were a lot easier because I didn’t have a connection with the patients, whereas the later on it’s got, the more connection I have with the patients, the more worried I am, and the more emotionally demanding it is. (Participant 5)
** pp.12-13
* The purpose of this phenomenological study was to explore nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. The findings paint a physically and emotionally distressing picture of the participants’ experiences and provide valuable insight into the experience of applying manual restraint for CNF of patients with AN. It is clear from the analysis that administering manual restraint for CNF of young persons with AN was a distressing practice for nursing assistants. The practice elicited numerous unpleasant emotions including anxiety, guilt and anger, and a small number of participants described becoming emotionally sensitised to the practice over time. Although the majority of participants expressed becoming emotionally desensitised to the manual restraint procedure, their accounts were often contradictory, suggesting that they had not necessarily become desensitised to the practice. These findings are in line with that of previous studies of staff’s manual restraint experiences in both child and adolescent, and adult consumer settings, which have also highlighted the experience of distress and numerous unpleasant emotions as a result of administering manual restraint (e.g., Bigwood & Crowe, 2008; Bonner et al., 2002; Chapman et al., 2016; Lombart et al., 2019; Sequeira & Halstead, 2004; Steckley & Kendrick, 2008; Svendsen et al., 2017; Wilson et al., 2017). It is not surprising that the theme “Importance of coping” was extracted from the analysis, given the illustrated adverse physical and psychological staff consequences that could result from applying manual restraint for CNF of young persons. The majority of nursing assistants described consciously detaching themselves from manual restraint incidents as a means of coping with the distress it elicited. Detaching oneself appeared to serve a protective function for participants, somewhat safeguarding them against the experience of distressing emotions; this is in line with the findings of previous studies in both child and adolescent, and adult consumer settings which have highlighted how some staff “switch off” their feelings or “temporarily suspend” their ability to empathise with patients during manual restraint incidents (Lombart et al., 2019; Sequeira & Halstead, 2004). Talking with colleagues and young persons who were further in their recovery were also cited by nursing assistants as coping strategies. These strategies appeared to help nursing assistants regulate their emotions through humour (e.g., “banter”), and through cathartic processes (e.g., “venting out”). Staff participants from previous studies of manual restraint within adult mental health settings have similarly highlighted the importance of colleague support in coping with restraint use (Bigwood & Crowe, 2008; Bonner et al., 2002; Sequeira & Halstead, 2004). However, this finding has not been explicitly reflected in studies within child and adolescent settings (e.g., Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017).
** pp.13-14
* By far the most prevalent finding in this study concerned the adverse physical outcomes that pervaded nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. Nursing assistants were subjected to frequent physical aggression by some young persons, they sustained physical injuries from being physically abused and from executing manual restraints, and they were often physically exhausted from applying manual restraint, typically multiple times during each shift. These findings are in line with previous studies of manual restraint within adult consumer settings which have highlighted the commonality of staff injuries during manual restraint use (Chapman et al., 2016; Lancaster et al., 2008; Southcott & Howard, 2007; Wilson et al., 2017), the physical exhaustion associated with administering manual restraint (Hawkins et al., 2005), and the patient physical aggression staff may be subjected to during manual restraint incidents (Wilson et al., 2017). However, with the exception of one study which reported staff physical exhaustion (Lombart et al., 2019), these findings have not been reflected in previous studies of manual restraint within child and adolescent settings. An important finding in this study concerned the interpersonal challenges that the majority of nursing assistants reported experiencing including staff conflict, and feelings of pressure and responsibility. In almost all cases, the former and latter experiences were associated with manual restraint performance, that is, the nursing assistants’ effectiveness at executing their designated manual restraint positions. Although these findings have not been explicitly reflected in previous studies of staff manual restraint experience, two of the participant extracts in one study within an adult mental health setting, were illustrative of the feelings of pressure and responsibility described by participants in this study (e.g., “they were all there watching, and I am thinking Oh God, have I done this right”; Bigwood & Crowe, 2008, p. 219).
** pp.14-15
* In light of the findings of this study, it is crucial that eating disorder services providing CNF under manual restraint sufficiently support their frontline nursing staff. Support can include the implementation of policies ensuring that manual restraints are spread out fairly between nursing staff, so that the same staff members are not repeatedly involved in manual restraint incidents. Support can also include, access to adequate manual restraint training and refresher training, access to adequately sized and ventilated ward areas/rooms for administering manual restraint for CNF, and access to sufficient supervision, post-restraint debriefing, reflective sessions, and talking therapy. Under the close working between psychiatrists, physicians and anaesthetists, it would also be reasonable for relevant eating disorder services to consider the supplementary risk-assessed use of chemical restraint (e.g., oral and parenteral benzodiazepines and oral olanzapine) and mechanical restraint (e.g., restraining belts and soft cuffs) in extreme cases where patients present with ongoing extreme levels of physical aggression and resistance to staff during manual restraints for CNF (Ridley & Leitch, 2019; Royal College of Psychiatrists, 2012, 2014). The aforementioned points are particularly important given the risk of burnout, compassion fatigue and physical injury which may lead to high staff turnover and sickness, and poor standards of care if left unresolved.
** p.15
* It is critical that relevant eating disorder services prioritise the use of psychological interventions, and alternatives to CNF interventions under manual restraint where practically possible, given the highly distressing impact this practice may have on both nursing staff and patients. This can include offering a range of psychological interventions (e.g., art, family, individual and group therapy, etc) and dietary choices to patients (e.g., diverse food types, liquid supplements, etc), with such options frequently being re-communicated to patients who refuse them. The provision of staff training in communication and trauma-informed approaches may help nursing staff develop improved therapeutic relationships with patients (Maguire & Taylor, 2019), which in turn may have an impact on patients’ receptiveness towards staff support, their willingness to accept dietary intake, and in turn, their recovery from AN (Sly et al., 2013). CNF interventions under manual restraint should only be used as a last resort after exhaustive unsuccessful attempts have been made to offer oral dietary intake to patients, and there is a clinical need for feeding. This is particularly important for patients who present with ongoing refusal of significant dietary intake, where there may be a risk of the habitual use of manual restraint for CNF as a first resort intervention rather than a last resort. The findings of this study can be used as a useful source of information for relevant eating disorder services, to illustrate the potential adverse physical, psychological and interpersonal challenges that administering manual restraint for CNF of patients with AN, could pose to their nursing staff. The findings from this study could also be used as a reference for manual restraint for CNF training programmes to highlight the challenges this practice may pose to trainees.
** p.16
* The participants in this study were recruited from a single inpatient eating disorder service in the UK, meaning that their experiences are likely to have been specific to this service. Caution is thus needed when transferring the findings of this study to other inpatient eating disorder settings. Further research exploring the phenomenon of CNF under manual restraint within different inpatient eating disorder services would be valuable in clarifying the extent to which the experience described in this study is common. The first author [MK] had lived experience of administering manual restraint for CNF of patients with AN, and conducted all interviews and performed data analysis. Although he maintained a descriptive phenomenological stance throughout, kept a reflexive diary, and made revisions to the analysis following discussions with [JM] and [NS] who both had no lived experience of manual restraint, his lived experience is likely to have had some influence on the analysis. However, we employed member checking to improve credibility, and all our participants expressed that the analysis had accurately captured their experiences. Notwithstanding, it may be beneficial for future research exploring staff’s experiences of CNF under manual restraint to be conducted by researchers who do not have lived experience of this practice, in order to reduce potential bias. The participants in this study were nursing assistants and thus were not registered nurses. Consideration thus needs to be taken into account of how this participant group may differ to registered nurses, for example, in their training, experience, duties and levels of responsibility. Although the majority of our participants were educated to degree or masters level in related subjects such as Psychology and Biology, and were supervised by registered mental health nurses (so it is likely that they possessed adequate clinical knowledge and skills), the aforementioned points still need to be taken into consideration when transferring the findings of this study to other inpatient eating disorder settings. Participants all volunteered to participate in this study. Therefore, they were self-selected. Consequently, the participants may have potentially represented those who were more vocal or those with more negative or positive experiences. This needs to be taken into consideration when interpreting the findings of this study.
** pp.16-17
* To our knowledge, this study is the first to explore nursing assistants’ experiences of administering manual restraint for CNF of patients with AN, and makes a substantial contribution to the limited literature on this practice. The findings highlight that the use of manual restraint for CNF of young persons with AN is a highly physically and emotionally distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings.
** p.17
* Eating disorder services that provide CNF under manual restraint as an intervention need to ensure that their frontline nursing staff have access to sufficient support, supervision and training at a minimum, given the adverse physical and psychological staff outcomes that may result from this practice. Such eating disorder services also need to have policies in place that ensure that manual restraints for CNF procedures are spread out fairly amongst staff, especially in services in which this intervention is frequently used.
** p.17

### "Lantz v. Coleman", 978 A. 2d 164 (Conn. Super. Ct. 2009)

* This case presents the question of whether the state may force-feed an inmate engaged in a hunger strike. There appears to be no recorded Connecticut decision on point.[1] The plaintiff, Theresa C. Lantz, is the current commissioner (commissioner) of the department of correction (department). The defendant, William B. Coleman, is a sentenced prisoner, under the care of the department. He was convicted, after a jury trial, of sexual assault in a spousal relationship and unlawful restraint in the first degree. In May, 2005, he was sentenced to fifteen years imprisonment, execution suspended after eight years. His maximum discharge date is December 30, 2012.
** p.165
* On January 9, 2008, the plaintiff filed a verified complaint, seeking both a temporary and permanent injunction to allow the department to force-feed the defendant. On January 14 and 23, 2008, the court held an evidentiary hearing on the application for a temporary injunction. At the conclusion of the evidence, the court heard oral argument from counsel for each party and, because of the exigent circumstances, issued an order orally. The court issued a temporary injunction authorizing the department to provide the defendant with intravenous fluids or nasogastric feeding and other necessary health care measures, even by means of reasonable force, and enjoining the defendant from interfering with same. The court's findings and reasoning were deferred to this subsequent written decision.
** p.165
* Ducate has experience with hunger strikes, and ending them, on six occasions in Texas. She indicated that the preferred means of feeding an inmate on a hunger strike is to sedate the prisoner, insert a nasogastric tube into his stomach, via the nose and throat, and then pipe nourishing liquid directly into the stomach. It is not a medically difficult procedure, and, in her experience, inmates who are so fed begin to eat normally soon thereafter. On the basis of her experience with hunger strikes in Texas, she believes that such incidents have a serious and detrimental effect on the other inmates. In her experience, inmates look to the department for their care and would be shocked if an inmate was allowed to kill himself without intervention. She adds that a hunger strike has a detrimental impact on prison safety and security. In this case, where the defendant is in the infirmary full-time, it leads directly to mentally ill prisoners being transferred to other facilities, away from treatment teams familiar with them, because this inmate is taking an otherwise available bed for his self-induced hunger strike.
** p.166
* Edward Blanchette, an internist, is the clinical director for the department. He has examined the defendant from a physical aspect and has been monitoring his condition since the end of last September. He reviews the defendant's medical records thrice weekly and has met with him twice. The defendant has been taking only liquids, those being water, some juice and some milk. Although the defendant is adequately hydrated, he is taking insufficient calories to sustain himself. The defendant has already suffered muscle wasting and anemia but, by taking some milk, has slowed the speed of his deterioration. Blanchette testified that as of January 14, the defendant could cause himself serious physical damage within one month, and be in dire straits. Risks include the possibility of heart arrhythmia due to electrolyte imbalance, a life threatening situation. A sustained hunger strike will lead to kidney and liver failure, and eventually to death. Blanchette opined that the timing of such deterioration is not subject to precise calculation by a physician or fine-tuning by an inmate. He stated that it is unusual for an inmate to engage in a protracted hunger strike, such as the defendant's. Brian K. Murphy, deputy commissioner of operations for the department, who is responsible for supervision of all inmates and is a career department employee, testified as to the impact of a hunger strike on the inmate population. Murphy has risen, in twenty-six and one-half years, from a correctional officer to his present position, always with direct supervision of inmates. He became aware of the defendant's hunger strike last September and has been following it since, including meeting with the defendant. The department has taken no disciplinary action of any kind against the defendant for his hunger strike. On more than twenty past occasions, Murphy has had to deal with hunger strikes. He is adamant that there are no secrete in prisons, that inmates rely on the department to intervene to protect inmates from self-harm and that the defendant's death from a hunger strike could cause unrest, including demonstrations and physical violence. There is also the risk of copycat hunger strikes to manipulate the prison system, should the defendant's hunger strike continue.
** pp.166-167
* In State ex rel. Schuetzle v. Vogel, 537 N.W.2d 358, 360-61 (N.D.1995), the Supreme Court of North Dakota determined that the state could force-feed and administer insulin to a diabetic prisoner who refused to eat or take medicine. Finding that the prisoner attempted this to "manipulate the system and ... blackmail ... prison officials"; (internal quotation marks omitted) id., at 360; the court ruled that "the state's interest in orderly prison administration is the controlling factor here...." Id., at 361. This issue has arisen in federal cases in the specific context of civil contemnors trying to circumvent the judicial process. A civil contemnor being held for refusing to testify before a grand jury went on a hunger strike for political and religious reasons. In re Grand Jury Subpoena John Doe v. United States, 150 F.3d 170, 171 (2d Cir.1998) (per curiam). In a very brief opinion, the court held that "the district court's force-feeding order ... does not violate a hunger-striking prisoner's constitutional rights.... Although Doe, as a civil contemnor, has been convicted of no crime, the institution where he is housed is still responsible for his care while incarcerated. Other compelling governmental interests, such as the preservation of life, prevention of suicide, and enforcement of prison security, order, and discipline, outweigh the constitutional rights asserted by Doe in the circumstances of this case." Id., at 172. The United States District Court for the Southern District of New York has also addressed this issue in the context of a civil contemnor, focusing on preventing the contemnor from undermining the judicial process. In re Sanchez, 577 F.Supp. 7 (S.D.N.Y.1983). The court held that "Sanchez is, by his own admission, attempting to bring maximum pressure to bear upon the Judge who will ultimately rule upon his motion to vacate the contempt order. Moreover, the prolongation of this hunger strike will soon render Mr. Sanchez physically or mentally incapable of testifying before the grand jury, thereby rendering further coercive sanctions futile. In one sense, therefore, Mr. Sanchez is attempting to escape from prison and to frustrate the lawful authority of the courts. This is a purpose that we cannot condone." Id., at 9.
** p.170
* In contrast, three courts have decided that the state has no right to force-feed an inmate. The Supreme Court of Georgia affirmed a trial court's decision to deny the state's petition to force-feed a hunger striking inmate. Zant v. Prevatte, 248 Ga. 832, 286 S.E.2d 715 (1982). In so doing, the court considered that "[the inmate] is not mentally incompetent, nor does he have dependents who rely on him for a means of livelihood. The issue of religious freedom is not present. Under these circumstances, we hold that [the inmate], by virtue of his right of privacy, can refuse to allow intrusions on his person, even though calculated to preserve his life. The State has not shown such a compelling interest in preserving [the inmate's] life, as would override his right to refuse medical treatment." Id., at 834, 286 S.E.2d 715. The state did not claim any of the traditional factors except a duty to preserve the inmate's health and life. In 1993, the Supreme Court of California determined that the state had no authority to interfere with an inmate's hunger strike. Thor v. Superior Court, supra, 5 Cal.4th 725, 21 Cal.Rptr.2d 357, 855 P.2d 375. The court's holding specified that "under California law a competent, informed adult has a fundamental right of self-determination to refuse or demand the withdrawal of medical treatment of any form irrespective of the personal consequences." Id., at 732, 21 Cal.Rptr.2d 357, 855 P.2d 375. The court further stated that "[u]nder the facts of this case, we further conclude that in the absence of evidence demonstrating a threat to institutional security or public safety, prison officials, including medical personnel, have no affirmative duty to administer such treatment and may not deny a person incarcerated in state prison this freedom of choice." Id.
** p.171-172
* Thor involved a prison physician petitioning the court to allow him to force-feed a quadriplegic patient who had decided to die. Id. The court considered four state interests: preserving life; preventing suicide; maintaining the integrity of the medical profession; and protecting innocent third parties. Id., at 737, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the court considered how this would affect orderly administration of the prison system. Id., at 744, 21 Cal.Rptr.2d 357, 855 P.2d 375. In considering the first four factors, the court, noted that this patient was quadriplegic and serving a life sentence; the patient's decision to refuse medical treatment was an informed decision, and there were no other persons involved in this decision. Id., at 743-44, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the state had presented no evidence on the effect this would have on administration of the prison system. Id., at 745, 21 Cal.Rptr.2d 357, 855 P.2d 375. The third case prohibiting state interference with a prisoner's hunger strike is from Florida. The inmate went on a hunger strike to protest his transfer to a different prison and to protest the lodging of complaints against a prison chaplain. Singletary v. Costello, 665 So.2d 1099, 1101 (Fla.App.1996). The court first recognized a strong interest in the inmate's rights to privacy and to refuse medical treatment. Id., at 1104. The court then weighed the state's interests in preserving life, preventing suicide, protecting third parties, maintaining the ethics of the medical profession, and maintaining order in the prison. Id., at 1105. On the facts of the case, the court stated that "although the state interest in the preservation of life is powerful, in and of itself, it will not foreclose a competent person from declining life-sustaining medical treatment.... This is because the life that the state is seeking to protect is the life of the same person who has competently decided to [forgo] the medical intervention." (Citation omitted.) Id., at 1109. The court found it important, also, that the prisoner had expressly stated that he did not want to die, meaning that the state's interest in preventing suicide was not implicated. Id. Finally, no evidence was offered on the other factors; therefore, the court denied the state's petition.
** p.172

### "Enteral Feeding of the Neonate" (4/9/2019)

Newborn Services Clinical Practice Committee, "Enteral Feeding of the Neonate". www.starship.org.nz. (Date last published: 04 September 2019)
* Nasogastric/Orogastric Tube Placement Indications: * Pre-term: immature suck swallow reflex * Neurological disease: impaired sucking reflex * Respiratory support: increased tachypnea with risk of aspiration * Gastric decompression * NEC * Abdominal surgery
* Nasogastric tubes should be used preferentially except under conditions below where orogastric tubes may need to be placed: *Nasal prong CPAP *Choanal atresia *Respiratory distress respirations >60bpm grunting recession *Babies with an oxygen requirement *Nasal trauma *Cranio-facial anomalies
* Follow the steps to measure the correct length of tube required and ensure the baby's comfort. 1.Measure the distance from either the nostril or the mouth (depending on insertion site) to the earlobe then to the half way point between the xiphisternum and the umbilicus. 2.Swaddle infant to provide comfort, offer dummy if infant normally has one. 3. Gently check nostrils for patency if inserting nasogastrically. 4. Select the appropriate size gastric tube; size 6 French for the majority of infants, alternatively size 8 French for large infants or those requiring gut drainage. 5. Gently insert the tube in a smooth swift motion, advancing slightly down and towards the ear on that side, to the desired length. Do not force the tube -if resistance is felt or the tube comes back via the mouth or other nostril then the procedure should be stopped to allow the child to recover prior to any further attempts. If a tube is unable to be inserted in after two attempts, a senior nurse colleague may have one further attempt. If still unsuccessful, discontinue procedure, notify medical staff and document same in clinical record.
* Follow the steps below to ensure correct tube placement, and the ongoing safety of the baby is maintained whilst receiving tube feeds. 1.On inserting a new tube verify placement by aspirating gastric contents and test with the pH indicator strips. Correct position is confirmed when the pH reading is less than or equal to 5. Presence of aspirate alone does not guarantee correct placement Note: Some medications, frequent feeds and continuous feeding may alter the pH and/or the colour of the aspirate e.g. acid inhibiting medications. If pH is >5 or there is difficulty in obtaining aspirate, follow the NPSA Decision tree for nasogastric tube placement checks in Children and Infants. The ‘whoosh’ test (injecting air down the tube and listening) is no longer considered safe practice and should not be used to confirm correct tube placement. 2. Record citing of tube, including internal length and pH in the child’s care map and observation chart. 3. Ensure tube remains in correct position by visually checking the tube position, and checking the aspirate with pH strips prior to each bolus feed or administration of any oral medications. This should be recorded in the feeding section of the observation charts. Note: The tube does not need to be fully aspirated prior to each feed, only enough to pH test, or if there is significant abdominal distention from air which needs aspirating. Infants on continuous feeds should have the position of the tube visualised every hour with routine observations, and pH tested every 4 hours with bottle/syringe changes. 4. Secure the tube using duoderm and hypafix tape placed either on the cheek or chin, and ensure this is firmly attached to the tube. 5. Continually assess feeding tolerance. Observe for vomiting, painful and firm abdominal distension, abdominal discolouration, abnormal bowel sounds, blood in stools, haemorrhagic or heavily bile stained (spinach or avocado) gastric aspirate during pH check. Seek medical review if there is any suspicion of feed intolerance. 6. If findings are not reassuring on medical review then feeds should be withheld. Start gastric decompression, consider further investigation and management for suspected NEC, discuss a feeding plan at the next ward round. 7. Ensure infants who are NBM have their gastric tubes on free drainage with the free end of the tube draining into a specimen pot. Do not attach the syringe connected to the gastric tube to the lid of the incubator. For infants on respiratory support, consider aspirating air from the stomach before each feed. 8. Tubes should be routinely replaced every 2 weeks. Note: if the gastric tube is not to be removed this should be recorded clearly on the observation chart and in the clinical notes (e.g. post TOF repair – see surgical guideline)
* Trans-pyloric feeding All infants with a trans-pyloric feeding tube require a gastric tube in place for aspiration, potentially drainage and possible medication administration (consult the Pharmacist or Neonatologist involved). Trans-pyloric tubes may be on free drainage but are not used for regular aspiration. Indications *Infants who are not tolerating gastric feeds. *Duodenal atresia - post-operatively *Infants who are at great risk for aspiration, e.g. gastro-oesophageal reflux receiving CPAP. Risk is minimised because the end of the tube is beyond the pyloric sphincter. Complications *Aspiration *Difficulty with tube placement *Perforation of the gut *Malabsorption Considerations *Trans-pyloric feeding may induce symptoms of malabsorption because the stomach is not able to aid in digestion e.g. frequent bowel motion, slow weight gain, necrotising enterocolitis. *Consider where medication is absorbed prior to administration (i.e. stomach or small intestines)
* Trans-pyloric tube placement Follow the steps below for placement of trans-pyloric tube. 1. A weighted tube is required for trans-pyloric placement (white Vygon paediatric duodenal tube with weighted tip, 6 Fr or Corpak Jejunal weighted tube). These do not harden over time and may be left in situ for several weeks. 2. Length for tube insertion is measured from as per gastric placement with a further length from the xiphoid to the left or right costal margin. 3. The tube is allowed to cool in the refrigerator for an hour; this reduces the chance of it coiling during insertion. 4. Swaddle infant to provide comfort 5. With the infant lying supine at a 15o-40o angle, insert the tube to the stomach as normal. 6. Check stomach positioning by aspirating and testing on a pH strip (reading of 5 or less) 7. Place the infant into a right lateral position 8. Advance the tube 1 cm at a time while instilling up to 2-3 ml of air and auscultate the abdomen 9. Transpyloric placement is characterised by high pitch crackles and the inability to withdraw air ('snap test') 10. Insert further length (as measured) to ensure distal duodenal or proximal jejunal placement. 11. Give a 3 ml feed and remove stylet (if present with brand). 12. The infant should then be placed right side down for 1-1.5 hours 13. Confirmation of placement will then be made by a radiograph. 14. Secure tubing to infant's cheek in same manner as gastric tubes 15. Insertion should be documented in the infant's caremap (equipment section) and in the clinical notes
* Commencing continuous Gastric or Trans-pyloric feeding Continuous feeding should only be instituted once the infant has reached volumes of at least 7 ml/hr, or on discussion with Neonatologist. This restriction is to avoid the need to purge the tubing every 4 hr with the change of bottle that would be required for lower rates (due to safe hang times). Follow the steps below for commencing continuous Gastric or Jejunal feeding: 1. Draw up prescribed volume of milk. 2. Label with type of milk, date and time. 3. Ensure the correct procedure for setting up the continuous feed pump is observed. 4. Check that the tube is in the correct position and the tape is secure (observe hourly). 5. Commence continuous feed 6. Aspirate gastric tube at least once per shift to confirm placement and determine residual volume
* Follow the steps below to ensure the nutritional needs of the baby are met. 1. Check that the correct ml/kg are calculated daily 2. Infant's weight is updated as ordered and documented. 3. Observe for spills and abdominal distension. 4. Accurate intake is recorded hourly. 5. Ensure correct type of milk is given and documented. 6. Ensure the amount of EBM/milk mixture in the bottle is recorded
* Follow the steps below to ensure the safety of the infant is maintained. *That the correct hourly rate on the continuous feed pump is maintained *The total volume infused is accurate. *Two nurses check and sign on the balance sheet each time rate is changed and at the change of shift. *The tubing is changed every 24 hours and labelled clearly with date, time and EBM/NIF. *Ensures that the trans-pyloric tube is not aspirated unless on Doctor's/NS-ANP's orders. *Gastric tube is aspirated 6 hourly and documented. *Administer medication as prescribed by disconnecting at the junction of the trans-pyloric tube and the pump tubing or as per medical staff/NS-ANP instruction (be aware of where of where medication is absorbed) *Only use four hours worth of milk at a time (unless otherwise specified on the bottle label)
* If an infant is expected to require long term gastric feeding the parents need to be taught care and insertion techniques prior to discharge. See Parent information. 1. Prior to tube insertion the tube must be lubricated with water. 2. Measure length of tube as for short term gastric tubes. 3. Ensure that the cap is on the medication port of the Corpak long term feeding tube. 4. Insert long term feeding tube as for short term tubes. 5. Remove stylet once inserted. 6. Establish gastric placement by aspirating stomach contents and testing on pH strips. A reading of 5 or less should be apparent when touched with stomach fluid. 7. If unable to aspirate fluid then push 1-2 ml of air with a 50 ml syringe. Listen with a stethoscope on the baby's stomach. You should hear a 'whoosh' of air. 8. Secure tube to face with duoderm base and hypafix on top. 9. Flush tube with 3 ml of water using 50 ml syringe. 10. Rinse stylet with warm soapy water and save for future use.
* Follow the steps below for commencing feeds via a long term tube. 1. Warm milk in a bottle and bowl of warm water as usual. 2. If the infant is in a cot pick them up for feeds and utilise a pacifier for non-nutritive sucking if appropriate 3. Connect a 50 ml syringe to the long term feeding tube and pour feed into syringe. 4. Adjust the flow of the feed by raising or lowering the height of the syringe. 5. When finished flush the tube with 3 ml of sterile water via 50 ml syringe. 6. Close tube. Note: USE ONLY A 50 ML SYRINGE TO ADMINISTER ANY MILK OR MEDICATION. The higher pressure of the smaller syringes has potential to perforate the tube.
* Short term enteral feeding in NICU *The optimal care is for all babies to receive breast milk only. This addresses those infants who do not need IV fluids and whose mothers have not established a breast milk supply. *In general, IV infusions should not be started if there are no medical indications for IV fluids (such as respiratory distress, hypoglycaemia etc.) *Babies who need feeding should be given what mother's breast milk is available and always receive mother's breast milk in preference to formula. Be sure to check that no breast milk is available before considering infant formula. *If they require additional feeds, infants should then be started on term infant formula, after discussion with their mother/father. In such discussions, parents should be informed that there are few - if any - adverse effects of formula used short term in this way in a neonatal unit. *For a baby who is already on an IV infusion, it is reasonable to continue the infusion for a short time if mother's milk supply is being established and there is a reasonable expectation that she will be producing enough breast milk with in a day or so. This time period needs to be judged against the ease of IV access and the condition of the baby. Babies should not have IVs re-inserted solely because no breast milk is available. *Smaller preterm infants will often have a medical indication for ongoing IV fluids and in them it is desirable to increase the oral fluids slowly. The pace of increase of oral fluids can usually be matched to the increase in the availability of expressed breast milk. *Mothers should be advised and helped with expressing. NICU staff should discuss expressing as soon as possible. It is accepted that the role of initially helping with expressing lies with postnatal ward staff. NICU staff should support mothers' expression of breast milk. *Nasogastric feeding rather than bottle or cup feeding is advantageous for ex-premature babies. Term babies who do not have problems with hypoglycaemia can usually transition directly from IV fluids to breast feeds. Alternatively, bottle or tube feeds may be used for larger infants. *NICU does not provide hydrolysed formula unless there is a clinical indication (other than a history of allergy). If there is a very strong family history of allergy, hydrolysed formula may be supplied on an individual basis. Parents may supply their own formula (hydrolysed or non-cow's milk preparations) if they wish.

### "The Guantánamo Prisoner Hunger Strikes & Protests: February 2002 – August 2005" (2005-09-08)

Barbara Olshansky, Gitanjali Gutierrez (2005-09-08) "The Guantánamo Prisoner Hunger Strikes & Protests: February 2002 – August 2005" (PDF). Center for Constitutional Rights. Archived from the original (PDF) on 2010-02-02.
* In recent years, two hunger strikes by prisoners received extensive international attention, in part because a number of prisoners died during the protests: the 1981 hunger strike by Irish prisoners in Maze prison during which ten prisoners died, and the hunger strike by Turkish political prisoners in the summer of 1996 during which at least twelve prisoners died and numerous others suffered neurological and psychiatric problems. When the ICRC visited Maze prison in Ulster, the ICRC team members became very concerned despite the fact that, unlike at Guantánamo, medical personnel were authorized to see the hunger strikers and permitted to maintain close communication with the prisoners’ families: “‘[O]utside intervention’ was totally unacceptable in the (northern) Irish hunger strikes of 1980 and 1981. Although the ICRC sent a team with a medical doctor to see the fasting prisoners (as was widely reported in the press at the time), the hunger strikers in this case refused to accept any outside medical mediation. As soon became clear, the hunger strikes in Ulster were deadly serious, with a total of ten prisoners dying over several months. The prison doctors respected the expressed will of the hunger strikers, and force-feeding was not envisaged at any time. (This position based on respect for a patient’s integrity and his right to refuse treatment, was the exact opposite of the attitude held earlier in the century, when political hunger strikers were force-fed by court order in 1909). In the Irish strike, the prisoners’ families were very much involved and communicated with the prison doctors. In a few cases, it was the families of prisoners who asked doctors to intervene at an advanced stage to save their sons’ lives, a request that was complied with. The bottom line in the doctors’ position was that a prisoner’s express will (not to be nourished) would be respected as long as he was fit to decide, but that families could obtain medical assistance for their fasting relatives if [the prisoners] were no longer in a position to express refusal. (This sometimes led to bitter arguments, with some hunger strikers telling their families they would never forgive them if they broke the strike by asking for medical assistance on their behalf. Most families, in fact, supported their sons or husbands on the strike.)
** pp.4-5
* The ICRC’s observation of the Irish prisoners’ protest also emphasizes the ethical issues for medical providers raised by hunger strikes in prison facilities, particularly concerning the issue of force-feeding such prisoners. As is widely known, the World Medical Association (WMA) Declaration of Tokyo of 1975 prohibits a medical doctor’s participation in torture, whether actively, passively, or through the use of medical knowledge. Article 5 of the Tokyo Declaration also stipulates that prisoners on hunger strikes shall not be force-fed. According to Dr. André Wynen, former and Honorary Secretary-General and founding member of the WMA, Article 5 of the Tokyo Declaration relates to the declaration’s prohibition on medical providers’ involvement intorture. “If a prisoner undergoing torture decided to protest against his plight by going on a hunger strike, a doctor should not be obliged to administer nourishment against the prisoner’s will and thereby effectively revive him for more torture.” The WMA supplemented Article 5 of the Tokyo Declaration with the 1991 Declaration of Malta. The Malta Declaration also prohibits force-feeding, but stipulates that doctors should ultimately act for the benefit of their patients when the prisoner’s detention does not raise concerns about physician involvement in torture and the hunger striker is no longer capable of sound judgment because of the effects of long-term fasting.
** p.5
* As described below, the U.S. military has admitted to force-feeding prisoners at Guantánamo who are participating in hunger strikes. Although the ICRC stated that the indefinite detention and current conditions at Guantánamo are “tantamount to torture,” it is difficult to assess the ethical obligations of military medical personnel at Guantánamo without further information about the treatment of detainees and the psychological impact of their indefinite detention. The prisoners’ families, moreover, have little or no knowledge of whether their sons or husbands are participating in a strike. And if their relatives are participating in a protest, military medical personnel have not informed the families of their relatives’ health status or their wishes concerning nourishment. This failure contradicts the policy of the WMA that a “doctor has a responsibility to inform the family of the patient that the patient has embarked on a hunger strike, unless this is specifically prohibited by the patient.”
** pp.5-6
* The first coordinated large-scale mass protest at Guantánamo began on February 27, 2002 when prisoners initiated a rolling hunger strike. This hunger strike appears to have started when an MP removed a homemade turban from a prisoner during his prayer. As the hunger strike expanded to a peak of 194 participants over a two-month period, it became a protest of the prisoners’ indefinite detention without any legal process and their harsh living conditions. A spokesman for the Guantánamo Joint Task Force, Marine Captain Alan Crouch, acknowledged in a February 28, 2002 official statement that 159 prisoners refused lunch and 109 refused dinner on February 27, 2002. On February 28th, 107 refused breakfast and 194 did not eat dinner. At the beginning of the hunger strike, the military attempted to minimize the seriousness of the protest. In a prepared statement, a Joint Task Force public affairs officer, Marine Major Steve Cox, stated that “[b]y no means is this an organized, concerted effort by the camp’s detainee population, but merely a demonstration of some of the detainees’ displeasure over the uncertainty of their future.” Several days into the hunger strike, Brig. Gen. John W. Rosa, Jr., Deputy Director for Operations, Joint Chiefs of Staff, stated that the detention center commander and the chaplain “have been out and around with and speaking to the detainees. The tensions have eased in their opinion.” But by mid-March, three detainees who had refused food and water for approximately fourteen days were forcibly given intravenous fluids. By this time, military officials were acknowledging that the prisoners were protesting “the fact that they don’t know what is happening to them” and that the hunger strike participants’ primary concern was “their murky future.” In early May, only two prisoners continued to participate in this hunger strike. Both men had been striking since March 1, 2002 to protest their indefinite detention. The military returned one man to Camp Delta on May 2, 2002 after force-feeding him, ending his 63-day hunger strike. The other final participant was forcibly fed through a tube inserted in his nose on May 10, 2002 after 71 days of fasting.
** p.7

### “ICE detainees on hunger strike are being force-fed, just like Guantánamo detainees before them” (February 7, 2019)

A. Naomi Paik, “ICE detainees on hunger strike are being force-fed, just like Guantánamo detainees before them”, The Conversation, (February 7, 2019)
* U.S. Immigration and Customs Enforcement, or ICE, is force-feeding nine detainees who are on a hunger strike at a detention center in El Paso, Texas. The protesters are mostly from India and are being held in ICE custody while their asylum or immigration cases are processed. Since the beginning of the year, they have been protesting their detainment and mistreatment by guards who they allege have threatened them with deportation and withheld information about their cases, according to the detainees’ lawyers. In mid-January, a federal court ordered ICE to force-feed the strikers. An ICE official stated: “For their health and safety, ICE closely monitors the food and water intake of those detainees identified as being on a hunger strike.” ICE policy states that the agency authorizes “involuntary medical treatment” if a detainee’s health is threatened by hunger striking. Force-feeding involves tying a detainee to a bed, inserting a feeding tube down the nose and esophagus and pumping liquid nutrition into the stomach. ICE detainees have reported rectal bleeding and vomiting as a consequence of being force-fed.
* Hunger strikes have plagued Guantánamo since it opened in 2002. In one of the largest hunger strikes to occur in a U.S. detention facility, about 500 detainees stopped eating under the slogan “starvation until death” in late June 2005. They began this strike to protest the conditions of their confinement, including alleged beatings, abuse of their religious freedom by mishandling the Koran and indefinite detention without trial. In response, military doctors authorized “involuntary intravenous hydration and/or enteral tube feeding” – in other words, IV treatment and force-feeding. Prisoners found ways to get around the feedings, like making themselves vomit or siphoning out their stomachs by sucking on the external end of the feeding tube. The strike overwhelmed camp commanders. In December 2005, they called in help from the Federal Bureau of Prisons, which had previously authorized force-feeding. The consultants observed as strikers were force-fed twice a day and recommended using the emergency restraint chair, a “padded cell on wheels.” That requires strapping detainees down onto the chair, making it easier for guards to insert and remove a feeding tube. Detainees referred to it as the “execution chair.” This had the desired effect on the prisoners: Only a handful continued the hunger strike and it was over by February 2006. The camp ordered 20 more chairs.
* In 2013, a widespread hunger strike again swept through Guantánamo – 106 of 166 prisoners participated. Forty-one detainees met the requirements for being force-fed: skipping nine consecutive meals or their BMI dropping below 85 percent of their intake weight. One participant, Samir Naji al Hasan Moqbel, a Yemini citizen detained for 11 years, told The New York Times, “I had never experienced such pain” as from the feedings.
* Guantánamo hunger strikers filed lawsuits against the U.S. government for force-feeding prisoners and using the restraint chair. Several judges ruled that force-feedings are legal. In one case, a judge wrote that it did not constitute a violation of the Eighth Amendment against cruel and unusual punishment. Rather, she wrote that administrators “are acting out of a need to preserve the life of the Petitioners rather than letting them die.” This contradicts what many experts the medical and human rights professionals have said about force-feeding. The World Medical Association, an international medical ethics organization, asserted that force-feeding is “unjustifiable.” Organizations ranging from the ACLU to Human Rights Watch condemn the practice as “inherently cruel, inhuman, and degrading.”
* While the courts can authorize interventions requested by the government such as force-feeding, immigrant detainees have limited power to appeal to courts about the conditions of their detention. As with the Guantánamo detainees, migrants are risking starvation, but not because they want to die. As Amrit Singh, the uncle of two men being force-fed, stated, “They want to know why they are still in the jail and want to get their rights and wake up the government immigration system.” Hunger striking offers one of few ways they can protest their prolonged confinement in pursuit of this goal.

### Pankhurst, Sylvia (1911). The Suffragette. New York: Sturgis & Walton Company.

* Eventually eight of the women received sentences of imprisonment varying from one month to fourteen days, whilst Charlotte Marsh was sent to prison for three months' hard labour, and Mrs. Leigh for four. We knew that Mrs. Leigh and her comrades in the Birmingham Prison would carry out the hunger strike, and, on the following Friday, September 24th, reports appeared in the Press that the Government had resorted to the horrible expedient of feeding them by force by means of a tube passed into the stomach. Filled with concern the committee of the Women's Social and Political Union at once applied both to the prison and to the Home Office to know if this were true but all information was refused. The W. S. P. U. now made inquiries as to the probable results of this treatment, and were informed that it was liable to cause laceration of the throat and grave and permanent injury to the digestive functions, and that, especially if the patient should resist, as the tube was being inserted or withdrawn there was serious danger of its going astray and penetrating the lungs or some other vital part. The whole operation, together with all the attendant circumstances, could not fail to put a most excessive strain upon the heart and the entire nervous system, and, if there were any heart weakness, death might ensue at any moment. In the Lancet for September 28th, 1872, a case was reported of a man under sentence of death, who had been forcibly fed by means of the stomach pump, that is to say by means of an india-rubber tube passed through the mouth into the stomach, the method used in the case of the Suffragettes. The man had died. In the same issue of the Lancet, appeared the opinion upon this question of several prominent medical men. Dr. Anderson Moxey, M.D,, M.R.C.P., had said: " If anyone were to ask me to name the worst possible treatment for suicidal starvation I should say unhesitatingly, forcible feeding by means of the stomach pump." Dr. Tennant stated that this method of feeding produced " an incentive to resistance," and that the exhaustion thereby introduced was sometimes so great as to cause death by syncope. Dr. Russell had met with a case in which death had occurred immediately after the placing of the tube " before it could be withdrawn, much less used " ; and Dr. Conolly was " appalled by the dangers resulting from the forcible administration of food by the mouth." Amongst the various important medical experts consulted by The Women's Social and Political Union was Dr. Forbes Winslow, whose wide experience in cases of insanity could not be questioned. When asked professionally to give his views on the subject he said: So far as the stomach pump is concerned it is an instrument I have long ago discontinued using, even in the most serious cases of melancholia, where the victim, perhaps from some religious delusion, refuses all nourishment. It possibly may be regarde by some as the most simple means of administering food, but this I challenge by saying at once that it is the most complicated and the most dangerous. . . . I have known some of the most serious injuries inflicted by the persistent use of the stomach pump. I have known a case in which the tongue has been partly bitten off where it had been twisted behind the feeding tube. He added that forcible feeding was especially dangerous in cases of heart and lung weakness or of rupture or hernia, and that the result of persistent use would be to seriously injure the constitution, to lacerate the parts surrounding the mouth, to break and ruin the teeth.
** pp. 430-433
* When the House of Commons met on Monday we learnt that our fears were only too well founded for Mr. Keir Hardie drew from Mr. Masterman who spoke on the Home Secretary’s behalf, the admission that the Suffragettes in Wison Green Gaol were being forcibly fed by means of a tube which pas passed through the mouth and into the stomach and through which the food was pumped. The unprecedented and outrageous nature of the assault was glossed over by the use of the term, “Hospital treatment,” in connection with it. Mr. Masterman admitted, however, that there were no regulations which authorized the proceeding, but he stated that it was resorted to in the case of men and women prisoners who were “weak minded” or “contumacious”. Mr. Hardie’s indignant protest and reminder that the last man prisoner to whom such treatment had been meted out had died under it, were met with shouts of laughter by the supporters of the Government. Horrified by their heartless and unseemly levity in the face of so serious a question, he at once addressed a statement to the Press in which he declared that he " could not have believed that a body of gentlemen could have found reason for mirth and applause " in a scene which had " no parallel in the recent history of our country." As far as he could learn, no power to feed by force had been given to prison authorities, save in the case of persons certified to be insane. He concluded by warning the public of the danger that one of the prisoners would succumb to the so-called "hospital treatment," and by appealing to the people of these islands to speak out ere our annals had been stained by such a tragedy. Others hastened to second this protest. Mr. C. Mansell-MouUin, M.D., F.R.C.S., wrote to The Times, as a hospital surgeon of thirty years' standing, to indignantly repudiate Mr. Masterman's use of the term " hospital treatment," declaring that it was a " foul libel " for that " violence and brutality have no place in hospitals as Mr. Masterman ought to know." Dr. Forbes Ross of Harley Street wrote to the Press saying: As a medical man, without any particular feeling for the cause of the Suffragettes, I consider that forcible feeding by the methods employed is an act of brutality beyond common endurance, and I am astounded that it is possible for Members of Parliament, with mothers, wives and sisters of their own, to allow it. A memorial signed by ii6 doctors, headed by Sir Victor Horsley, F.R.C.S., W. Hugh Fenton, M.D. M.A., C. Mansell-MouUin, M.D., F.R.C.S., Forbes Winslow, M.D., and Alexander Haig, M.D., F.R.C.P., was organised by Dr. Flora Murray and addressed to Mr. Asquith, protesting against the artificial feeding of the Suffragette prisoners, on the ground that it was attended by the gravest risks and was both unwise and inhuman. To this memorial many of the doctors added descriptive notes of their own. Mr. W. A. Davidson, M.D., F.R.C.S., wrote: " A most cruel and brutal procedure. Were the tubes clean? Were they new? If not they have probably been used for people suffering from some disease. The inside of the tube cannot well be cleaned; very often the trouble is not taken to clean them." In spite of every form of discouragement and ridicule, Mr. Keir Hardie continued constantly to raise the question of forcible feeding in the House of Commons only to be met by evasive, and sometimes grossly, inaccurate replies from the Home Office. Mr. Gladstone tried to shelter himself behind the officials who were his subordinates, and to place the responsibility on the medical officers. For this he was strongly condemned by the British Medical Journal which characterised his conduct as contemptible.*
** pp.433-435
* In reply to the protests of medical men and the memorial from doctors, which had been addressed to him, Mr. Gladstone succeeded in drawing a statement from Sir Richard Douglas Powell, the President of the Royal College of Physicians, who said that he thought the memorial exaggerated, though he admitted that forcible feeding was not " wholly free from possibilities of accident with those who resist." He added that, in dissenting from the view expressed by the memorialists, he was assuming that the feeding of the prison patients was " entirely carried out by skilled nursing attendants under careful medical observation and control." We, of course, know that this was not the case. A large number of doctors, including Dr. R. G. Layton, physician to the Walsall hospital, replied to Sir Douglas Powell by again recapitulating the dangers of forcible feeding. But indeed the opinions of medical men were unnecessary to those who afterwards came in contact with the women who had been forcibly fed. Their exhausted condition was a form of evidence that no argument could upset. It is important to note also that during the year 1910 two ordinary criminals, a man. and a woman, were subjected to forcible feeding. The man died during the first operation; the woman committed suicide after the second.
** pp.435-436

### "Force-feeding extracts from Purvis" (1995)

Jane Purvis, "Force-feeding extracts from Purvis". www.johndclare.net. (From Jane Purvis, 'The Prison Experiences of the Suffragettes', in Women's History Review (1995)
* From 1905 until the outbreak of the First World War in August 1914 about 1000 women were sent to prison because of their suffrage activities, most of these being members of the WSPU... While these prison ‘experiences’ have not been ignored by historians, they have been discussed as a part of a broader account of the suffrage movement rather than focused upon in depth as a subject worthy of investigation. Furthermore, a dominant narrative of these experiences has emerged which [asserts] that the women themselves were to blame for their often harsh prison experiences, including the pain of hungerstriking and forcible feeding....
* Early histories of the suffrage movement present a more sympathetic picture of prison life than many subsequent accounts. Metcalfe, for example, writing in 1917, speaks of the “scenes of horror which had taken place in Holloway and other prisons ... in the unavailing effort to govern women against their consent”. However, it is the history written by the constitutional suffragist, Ray Strachey, a member of the NUWSS and hostile to the WSPU, that became the influential text. Strachey blames the WSPU women themselves for the treatment they received... Unwilling to acknowledge the hunger strike as a political tool, Strachey comments how the suffragettes, once in prison, ceased to be militant and created a number of protests including the refusal to eat food. “Forcible feeding was tried in vain”, she continues; “the prisoners struggled so violently against it that the process became actually dangerous, and the prison officials were obliged to let them starve till they came to the edge of physical collapse, and then to let them go”. In spite of the severe pain and damage to health which the process involved, “scores of suffragettes adopted it ... The officials tried everything they could think of in vain ...”. This picture of irrational women, deliberately seeking their own torture was eagerly seized upon by male historians who sought to ridicule the WSPU and its politics. George Dangerfield’s The Strange Death of Liberal England, first published in 1935, discusses the suffragette movement as... a form of “pre-war lesbianism” of “daring ladies”... Dangerfield too presents the suffragettes as fanatical women who chose the hardships of prison life in a sado-masochistic way ... “How can one avoid the thought”, he questions, “that they sought these sufferings with an enraptured, a positively unhealthy pleasure?” If the victim does not resist, “forcible feeding is no more than extremely unpleasant. But the suffragettes were determined to resist”. In view of the fact that Dangerfield’s account contained no footnotes whatsoever to primary sources to support his claims, it is incredulous that his analysis was received so enthusiastically and became so influential. The Times and Tribune, for example, hailed it as “brilliant”... Thus the scene of the drama is set and the props are changed only with slight variations. Roger Fulford in 1957... mocked their prison experiences, claiming that solitary confinement in prison was “not always unwelcome to adults”. Furthermore, although “forcible feeding is a disgusting topic ... it was not dangerous ... [It] is of course a familiar form of treatment in lunatic asylums”. While Andrew Rosen is much more sympathetic to the women prisoners, he too, in a matter of fact way speaks of how forcible feeding involved mouths being prised open, lacerations, phlegm, vomiting, pain in various organs, loss of weight “and so on”...
* Hunger striking and force feeding were acts committed by, and on, individuals in their own cells. Whether force fed by a cup, tube through the nostril (the most common method) or tube down the throat into the stomach (the most painful), the individual suffragette struggled on her own and often feared damage to the mind or body. Kitty Marion’s screaming in prison greatly upset the other women, but she found it was the only way she could fight against the torture of forcible feeding and remain sane. Rachel Peace, an embroideress, who had already experienced several nervous breakdowns, was not so fortunate. During a period of prolonged hunger striking and forcible feeding three times a day she feared, “I should go mad ... Old distressing symptoms have re-appeared. I have frightful dreams and am struggling with mad people half the night”. Her fears became true when she “lost her reason in prison” and spent the rest of her life in and out of asylums, with Lady Constance Lytton, an upper-middle-class WSPU worker, maintaining her. The forcible feeding of the disabled May Billinghurst in Holloway in January 1913 brought a particular wave of revulsion since she was “small, frail, and ha[d] been a cripple all her life”. Paralysed as a child and confined to a tricycle for mobility, she told how the three doctors and five wardresses who held her down: “forced a tube up my nostril; it was frightful agony, as my nostril is small. I coughed it up so that it didn’t go down my throat. They then were going to try the other nostril, which, I believe is a little deformed. They forced my mouth open with an iron instrument, and poured some food into my mouth. They pinched my nose and throat to make me swallow”. After 10 days of “almost incredible suffering”, when she was fed three times every 24 hours, she was released “a physical wreck”. Margaret Thompson, in prison in 1912, had a facial disability, resulting from a car accident; after examining her face to see if it was “fit” for forcible feeding, the doctor decided she should be fed by the cup rather than the tube. Miss McCrae, in prison at the same time, thought she too should take food through the cup, on account of her deafness, although she feared the other women would scorn her for doing so. For women with disabilities such as those mentioned here, imprisonment and forcible feeding were particular acts of courage.
* For many of these women, the worst feature of prison life was the ‘public’ violation of their bodies when being forcibly fed. Helen Gordon Liddle hated the lack of privacy when enduring the pain of forced feeding. Nell Hall spoke of the “frightful indignity” of it all. For Sylvia Pankhurst, the sense of degradation endured was worse than the pain of sore and bleeding gums, with bits of loose jagged flesh, the agony of coughing up the tube three or four times before it was successfully inserted, the bruising of her shoulders and the aching of her back. Sometimes, when the struggle was over, or even in the heat of it, she felt as though she was broken up into many different selves, of which one, aloof and calm, surveyed all the misery, and one, ruthless and unswerving, forced the weak, shrinking body to its ordeal. Although the word ‘rape’ is not used in the personal accounts of force fed victims, the instrumental invasion of the body, accompanied by overpowering physical force, great suffering and humiliation was akin to it, especially so for women fed through the rectum or vagina. 'Janet Arthur’, later identified as Fanny Parker, in Perth prison in 1914, was one such victim: Thursday morning, 16th July ... the three wardresses appeared again. One of them said that if I did not resist, she would send the others away and do what she had come to do as gently and as decently as possible. I consented. This was another attempt to feed me by the rectum, and was done in a cruel way, causing me great pain. She returned some time later and said she had ‘something else’ to do. I took it to be another attempt to feed me in the same way, but it proved to be a grosser and more indecent outrage, which could have been done for no other purpose than torture. It was followed by soreness, which lasted for several days. When released, a medical examination revealed swelling and rawness in the genital region. The knowledge that new tubes were not always available and that used tubes may have been previously inflicted on diseased persons and the mentally ill or be dirty inside the tube, issues that had been openly discussed in Votes for Women, undoubtedly added to the feelings of abuse, dirtiness and indecency that the women felt.

### "Women rethink a big size that is beautiful but brutal" (11 July 2006)

"Women rethink a big size that is beautiful but brutal" Clare Soares 11 July 2006. Christian Science Monitor
* Big has long been considered beautiful in Mauritania. But now, a generation of women are abandoning an ancient practice to fatten up – and some are even redefining beauty to put their health first. It's not a lifetime spent scoffing junk food and slurping fizzy drinks that's to blame for obesity here; rather, a tradition as old as the desert: gavage. On the tree-lined boulevards of Paris, the French word describes the process of fattening up geese to produce foie gras. On the sand-blanketed streets of Mauritania's capital, Nouakchott, it describes the process of forcibly funneling sweetened milk and millet porridge down the throats of young girls. In this vast nomadic nation, thin women are an admission of poverty. Voluptuous wives and daughters, by contrast, are displays of a man's wealth, and that's where force-feeding comes in. After campaigns at the national and community level, the brutal practice is on the way out. The latest government survey, in 2001, estimated that about 10 percent of women ages 15-19 were force-fed as young girls, down from 35 percent among 45 to 54-year-olds. But that older generation of women is now battling a variety of illnesses as well as child-bearing complications, doctors and midwives say. "Even getting out of bed is difficult for some of them, never mind working," says Mariame Baba Sy, the head of a government commission on women's issues.
* While it's clear that the practice of force-feeding women is on the decline, the government doesn't keep statistics on obesity, or track if the decline in gavage is translating into a slimmer, healthier population. Indeed, some young girls may just be turning to a less painful way to meet the Mauritanian beauty ideal. "The real gavage is on the point of becoming extinct. But there's a new method," says Ms. Baba Sy. "They take pills, some of them ones you usually give to an animal."
* After being force-fed as a child, M'haimid now won't touch milk or millet, staples that were pumped into her every two hours, even when she kept vomiting. While she talks proudly about the 22 lbs. she has lost in the past month, she knows that at 264 lbs., she cannot rest. "My husband tells me not to tire myself out with this weight loss. These Mauritanian men, they still love fat women. But my health is more important," she says. Mariam Aicha, a former mayor of Nouakchott, recalls a doctor addressing delegates at a recent conference on health. "He said that, from his professional point of view, it was the thinner the better, but then admitted that as a man, he liked something to hold on to," she says.

### "War crimes tribunal orders force-feeding of Serbian warlord" (December 7, 2006)

Traynor, Ian (December 7, 2006). "War crimes tribunal orders force-feeding of Serbian warlord". The Guardian. London.
* The UN war crimes tribunal in The Hague last night ordered the force-feeding of a Serbian warlord and senior politician who has been on hunger strike in custody for almost a month. The decision, the first such order since the court was set up more than a decade ago to deal with war crimes in the former Yugoslavia, came after a medical examination of Vojislav Seselj concluded that he might be a fortnight away from dying.
* The tribunal last night told Dutch authorities to force-feed Mr Seselj if there was a risk of him dying. "There is a prevailing interest in continuing with the trial of the accused in order to serve the ends of justice," it said in a statement. "The trial ... should not be undermined by the accused's manipulative behaviour." Mr Seselj, who surrendered to The Hague tribunal more than three years ago, has consistently sought to use the court as a stage to belittle and mock the institution. He went on hunger strike last month to demand unlimited conjugal visits and the opening of frozen bank accounts in the US, he insisted on defending himself at the trial and has hurled abuse at anyone who contradicts him.
* Last night's statement from the tribunal was the first time it had resorted to such orders. It appears anxious to avoid creating another Serbian "martyr" after Milosevic died in its custody this year. Another Serbian warlord, Milan Babic, the former Croatian Serb leader, committed suicide while in custody. The tribunal said it had issued an "urgent order to the Dutch authorities" to ensure Mr Seselj did not die as a result of his hunger strike, now in its 27th day. While stating that any force-feeding deemed necessary for lifesaving purposes should not contradict "compelling internationally accepted standards of medical ethics or binding rules of international law", the judges at the tribunal also noted that the body of law laid down by the European court of human rights did not view force-feeding as "torture, inhuman or degrading treatment if there is a medical necessity to do so ... and if the manner in which the detainee is force-fed is not inhuman or degrading".

## See also

* Anorexia nervosa
* Eating
* Mental health
* Prison
* Slavery
* Starvation
* Torture