The State of Israel’s Submission to the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment Report on hostage-taking as torture:

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Legal frameworks, supporting victims and families, and strengthening global response (12/24/24)

Geneva, 23 December 2024

State of Israel Ministry of Health Medical Directorate

To: Ms. Alice J. Edwards., Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment

Subject: The State of Israel’s Submission to the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment Report on hostage-taking as torture: legal frameworks, supporting victims and families, and strengthening global response

We hereby submit additional health-related data provided by the Israeli Ministry of Health in relation to the above-mentioned call for input.

Aspects of neglect, ill-treatment, torture and humiliation of the returned hostages and their consequences on their physical and mental health

Physical and sexual violence against man, women and children

Women, men, and children who returned from captivity reported that they endured severe physical and sexual abuse, such as beatings, isolation, deprivation of food and water, branding, hair-pulling, and sexual assault. Additionally, some of them reported that the captors sexually assaulted them or forced them to undress. For examples of cases of physical and sexual abuse see Annex I below.

  1. Torture by withholding medical treatment or causing intentional pain during treatment: The hostages were denied medical treatment for acute injuries caused during October 7 and subsequently, in addition to for untreated chronic conditions. Fractures, shrapnel wounds, and burns were treated inadequately, leading to complications which required additional surgeries, that could have been prevented with proper care. Upon arrival in Israel, intensive treatment was given to the returned hostages.
  2. The captors also tortured those injured by performing painful procedures without anesthesia.
  3. Many hostages also suffered from untreated chronic conditions (e.g., heart failure, diabetes, hypothyroidism), leading to severe short-term medical deterioration, such as low blood pressure, bradycardia, and hypothermia. In one case a hostage died from untreated medical complications. Also, several older women required urgent life-saving treatment due to untreated hypertension and hypothyroidism.
  4. Starvation, poor nutrition and holding of hostages in harsh sanitary conditions: About half of the returned hostages described being deliberately starved during their captivity. They were given a poor diet, which often led to hunger that worsened over time. In addition to inadequate nutrition, they were kept in dark spaces, increasing the risk of vitamin D deficiency. This malnutrition resulted in an average weight loss of 815 kg (10-17% of body weight), with children losing an average of 10%, and in one extreme case, a girl lost 18% of her body weight.
  5. Poor nutrition may lead to Sarcopenia, delayed wound and fracture recovery, and a weakened immune system. Malnutrition also negatively impacted cognitive function and mental health, and as for children, it may hinder development and growth.
  6. The captors attempted to improve some of the hostages’ appearance and weight before their release. Those who received excess food before returning to Israel were at risk of Refeeding Syndrome and electrolyte imbalances such as hypokalemia, hypomagnesemia, and hypophosphatemia, particularly among elderly hostages. In cases with complex medical backgrounds, these electrolyte disorders can be life-threatening. Additionally, the hostages were denied essential medications and treatment for their injuries, leading to the risk of widespread metabolic disorders.
  7. The poor quality of food and water, combined with unsanitary conditions, led to increased morbidity among the hostages. Many suffered from diarrhea, abdominal pain, and sometimes constipation. They had limited access to showers and returned with skin infections, including Dermatitis.
  8. Infections were detected in hospital cultures (Clostridium, Salmonella, Vibrio, Shigella, Giardia, E. coli). Some were diagnosed with Q fever, while two returned hostages suffered from acute case of Q fever. Several of the elderly women developed Deep Venous Thrombosis due to age, pre-existing medical conditions without medication, and lack of mobility during captivity.
  9. Psychological abuse of the hostages: The abduction of children, women, men, and the elderly from their homes is a traumatic event, often occurring after the murder of family members or close friends. In some cases, children were taken without their parents or after their parents’ murder. The terrorists caused widespread destruction, with hostages witnessing their homes burning, acts of rape and looting which took place in their communities. The captives were transported to Gaza in open vehicles, often alongside the bodies of those murdered. They endured beatings, humiliation, and verbal, physical, and sexual violence during the journey.
  10. The captivity was designed to torture the hostages psychologically, break their morale, and make them easier to control. Their time in captivity was marked by intense trauma: family separation, immobilization, arbitrary and frequent transfers, and exposure to further violence. Some captives witnessed the killing of other captives, further deepening their sense of helplessness and hopelessness.
  11. In captivity, the hostages were often subjected to solitary confinement, poor sanitation, severe medical neglect, lack of sleep, starvation, sexual abuse, violence, threats, and brainwashing through media designed to break their spirit and make them submissive.
  12. Medical and psychosocial teams who treated the returned hostages report severe consequences for their health and well-being. Many exhibited sharp mood swings, with some showing signs of hypomania upon return, followed by extreme depression only a few hours afterwards. Even those who appeared strong initially showed difficulties adjusting to reality, sometimes experiencing dissociative episodes.
  13. Some returned hostages had paranoid anxieties, fearing retaliation against their loved ones still in captivity if they spoke about their experiences. The inability to share their trauma with therapeutic factors, which made it harder to process their trauma.
  14. The returned hostages have been experiencing “survivor’s guilt,” feeling responsible for being rescued while their loved ones remain in Gaza. This guilt delays their return to routine and rehabilitation. Some wish to return to captivity to help those left behind, feeling they are “not rehabilitated” as long as their loved ones are still there. The concern for those remaining is unbearable for them and their families.
  15. Many returned hostages experience fear, restlessness, emotional detachment, and confusion. Some were afraid to leave their rooms, even in the hospital’s protected areas. They struggled to let go of behaviors from captivity, like barely eating and neglecting hygiene. Others hoarded food, fearing they would not have enough for the next day, despite knowing this was irrational.
  16. The returned hostages also reported severe nightmares and sleep deprivation, trying to avoid repeating nightmares. Some experienced derealization, struggling to accept their presence in the Israeli hospital as real, rather than a dream from captivity. They avoided anything that reminded them of their traumatic experiences, including certain foods.
  17. Most returned hostages had no home to return to and learned upon their arrival in Israel of the deaths of family and friends, the destruction of their homes, and the collapse of their communities. Many found themselves without the support they once had, which has significantly hindered their recovery and rehabilitation. This is compounded by the ongoing sense of threat, as the ceasefire has collapsed, and they continued to experience rocket fire from Gaza and the war on the northern front.
  18. Medical and psychosocial teams believe that the returned hostages will require substantial resources and tailored treatment to succeed in their rehabilitation and reintegration. It is clear that as long as those still in captivity are not released, the rehabilitation and integration of the returned hostages will not proceed optimally, if at all.
  19. Beneficial Therapeutic Models for Returned hostages – Insights from the Field: The medical and psychosocial treatment of the returned hostages was characterized by two stages: the initial intensive phase in the designated departments for receiving return hostages in hospitals, followed by ongoing care in the community. In the hospitals, returned hostages and their families received personalized medical and psychological support, addressing immediate needs.
  20. Longitudinal studies of Israeli prisoners of war in Egypt and Syria over 35 years have shown that the most common disorder is Delayed-Onset Stress Disorder (PTSD).1 This highlights the need for prolonged follow-up, even many years after release. Research and clinical experience indicate that humans possess an innate ability to recover and resilience to cope with trauma. Treatment is provided by both medical and mental health teams, understanding that each captive undergoes a unique process influenced by various factors: abduction circumstances, captivity conditions, family presence or loss, marital status, personality traits, and physical aspects.
  21. Leading Israeli medical centers, systematically monitor various variables, including PTSD symptoms. The recovery process is non-linear, with fluctuations between exacerbation and improvement. Factors such as the security situation, ongoing captivity of others, media exposure, and family dynamics all affect the returned hostage’s recovery. Certain events related to these factors can trigger memories of captivity.
  22. Some returned hostages show significant resilience, surpassing the diagnostic criteria for PTSD. However, it is crucial to address other mental health issues such as depression, grief, and feelings of loss.
  23. The effects of captivity cannot be measured solely by PTSD criteria, as it is a more complex disorder that may involve loss of trust, relationships damage, self-harm, and more.
  24. For examples of cases of returned hostages whose treatment process within the framework of community health services has led to a significant improvement on their health and well-being, see Annex I below.

 

1Delayed-Onset PTSD is a variation of PTSD in which symptoms appear six months or more after the traumatic event. Although the symptoms are identical to those of PTSD, they emerge significantly later and can appear even many years after the trauma, sometimes triggered by a specific event or a significant life occurrence. This phenomenon is particularly common among military personnel and war veterans. The delay in the onset of symptoms can be due to several factors, including strong psychological defense mechanisms that weaken over time, changes in life circumstances that reduce the ability to cope, delayed exposure to trauma-related triggers, or a reduction in commitments and roles that previously helped distract from the trauma. It is important to note that the diagnosis and treatment of Delayed-Onset PTSD are similar to those of PTSD, but it is especially important to understand the relationship between the original traumatic event and the delayed onset of symptoms

 

Annex I

**The age and gender of the children are not disclosed to protect their identity**

  1. Two of the children that were held together during captivity reported that they were held bound and were beaten throughout their captivity. Signs of binding, scars, and marks consistent with trauma were found.
  2. Additionally, two young children had burn marks on their lower limbs. One child stated that the burns were the result of a deliberate branding with a heated object. Both the child and adults who were with him in captivity described the incident as a purposeful branding event, not an accident. It was described as an extremely traumatic experience.
  3. Cases of Physical and Sexual Violence Against Women and Men One of the returned hostages described being sexually assaulted at gunpoint by a Hamas terrorist. On several occasions, captors forced women of all ages to undress while others, including the captors, watched. Some women reported that the captors sexually assaulted them. In addition, some women reported that they were tied to beds while their captors stared at them.
  4. Another woman, injured during the attack, was held in a dark isolation for 30 days, bound and unable to move. She had no contact with the outside world, received an inadequate amount of food and water, and did not receive treatment for her injury. Other women also reported starvation and abuse by their captors
  5. The men endured severe physical abuse, including continuous starvation, beatings, burns with galvanized iron (branding), hair-pulling, confinement in closed rooms with a limited amount of food and water, being held in isolation with hands and feet tied, and being denied access to the bathroom, which forced them to defecate on themselves.