Preface:

I am a civilian paramedic with no military, CIA, or other training regarding interrogation or similar topics. The following is based on my research utilizing publicly available documents and my experience/education in emergency medicine including emergency airway management, drowning victim treatment, and critical stress management.

TL;DR:

Per the CIA Protocol, known risks of waterboarding are:

Inhalation of water in to the lungs leading to pneumonia

Inhalation of vomit in to the lungs leading to pneumonia

Spasms of the larynx

The following are the means by which the CIA addresses the risks.

1. Inhalation of water in to the lungs:

A potable saline solution is used

2. Inhalation of vomit in to the lungs leading to pneumonia

Detainees are placed on a liquid diet. How long before waterboarding that diet should be in place is not noted.

3. Spasms of the larynx

A qualified physician will perform a tracheotomy (cutting a hole in the windpipe)

Overview:

Waterboarding became a household term through press surrounding its recent use as an “Enhanced Interrogation Tactic” by the US Government against detainees in US custody. The process, in one form or another, dates back to 1478 when the first documented cases occurred during the Spanish Inquisition. In modern history, waterboarding has been used by the French Military in Algiers, the Khmer Rouge in Cambodia, the Chadian Military in Chad, and by multiple groups in Peru during the Peruvian internal conflict.

Loosely defined, “waterboarding” refers to the process by which an individual is restrained to an inclined surface, a cloth is placed over the nose and mouth, and water is then poured onto the cloth. There are variations through history, but the overall objective is to simulate drowning in a, hopefully, non-lethal manner.

I cannot comment on the relative safety or danger of one method as compared to another. However, they all share some of the same risks. The greatest amount of publicly available documentation seems to be related to US methods employed by the CIA, derived from the US Military. Those are the ones that I have researched the most and therefore will be primarily speaking to.

Shared Risks Regardless of Method:

Inhalation of water in to the lungs leading to pneumonia (Per the CIA)

Ingestion of large amounts of water in to the stomach (Per the CIA)

Inhalation of vomit in to the lungs leading to pneumonia (Per the CIA)

Dry Drowning (Per the CIA)

Chronic stress disorder [ie Panic Disorder, PTSD]

Shared Risks Explained:

Water in the Lungs

Inhalation of water in to the lungs poses three risks. First, if the water contains even normally harmless bacteria, when introduced into the lungs, the bacteria cause a significant respiratory infection in the form of pneumonia. Researchers in one study were surprised to find that the fatality rate for near-drowning associated pneumonia was 60%. The researches noted, “The relatively high case fatality rate associated with near-drowning is somewhat unexpected because the victims have been young and otherwise healthy.” An additional risk is low blood oxygen levels due to the lungs being unable to exchange gases as they normally would. In even small quantities (as low as 1-3mL/kg, which works out to 6.1oz, using 2mL/kg, for a 200lb individual), 75% of blood circulating through the lungs may not be able to oxygenate. Those low blood oxygen levels will cause harm to the brain. Finally, fresh water entering the lungs can lead to a chemical imbalance called hyponatraemia or low blood levels of sodium. Dr. G Patricia Cantwell, MD notes, “Fluid aspiration of at least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is required before significant electrolyte changes develop.” Using a 200lb individual to calculate liquid volume, noticeable changes occur after 1 liter and significant changes occur after 2 liters. I’ve been the medical provider for several waterboardings in a kink setting and in one instance numerous people were waterboarded with what I believe was 1 or more liters of water but the total volume was not tracked by the top. It is very unlikely that someone would inhale enough water in to the lungs to cause altered electrolyte levels but it is a possible risk, more so if the waterboarding was occurring multiple times over a period of hours with small amounts inhaled each time. Of these three risks pneumonia is the most likely, followed by impaired gas exchange leading to low oxygen levels, and finally altered blood sodium levels.

Excessive Water in the Stomach

When water is consumed excessively, leading to hyponatreamia, it is often referred to as water intoxication, something people may have heard of more so than aspiration based hyponatreamia. This is less of an issue with waterboarding because an otherwise healthy person can excrete at least 10 liters of water per day. Hyponatreamia associated with over-consumption isn’t a concern until one reaches the 10-15 liters/per day threshold. This does not hold true for someone with compromised kidneys. Those individuals need to carefully evaluate their own risks.

A case study and general review of hyponatreamia notes, “the rate at which the sodium concentration falls is also an important factor, and the acute intake of large volumes of water over a short period of time, as occurred in this case, would have produced a rapid drop in serum sodium, which was fatal.” Early symptoms of water intoxication may include “confusion, disorientation” which could make it difficult or impossible for a bottom to use a safe word or communicate the problem. Depending on pre-existing medical history (ie kidney failure), some will be much less tolerant of drops in blood sodium levels than others but generally we won’t be introducing enough water in to the stomach to cause an issue. The scenario which the CIA cites as a way to cause hyponatraemia associated with waterboarding is when the detainee attempts to swallow the water as a counter measure. The CIA uses a saline solution to mitigate the risk of hyponatremia. I assume they mean a 0.9% saline solution as that is the most commonly medically used but there are other concentrations commercially available and saline can be custom mixed to create a specific concentration with the addition of sterile water or starting with a higher concentration saline solution. By using a limited amount of saline (less than 1 liter) and instructing the bottom not to intentionally swallow water the risk of hyponatremia can be reduced. When effective, water boarding produces many involuntary responses and if one of those responses is swallowing the bottom may swallow regardless of being directed not to do so.

Vomit in the Lungs

A further risk is stomach contents, also called emesis, making their way into the lungs. Regarding risks associated with waterboarding, the CIA notes, “a detainee might vomit and then aspirate the emesis”. Aspiration results from the individual being unable to get the vomit out of their mouth, due to position of restraint and potential disorientation or confusion, and the vomit draining into the lungs, leading to pneumonia. The stomach acid in vomit does not discriminate between steak or lung tissue and can cause significant harm. Additionally, stomach acid contains a lot of bacteria that is beneficial in the stomach but harmful when in the lungs. A 2012 retrospective study of deaths associated with aspiration pneumonia found that 30-day mortality of 21%. Admittedly, many of the patients in that study were older and had other illnesses, but regardless. aspiration pneumonia is not a minor side effect. Even if the bottom is otherwise healthy prior to waterboarding and develops aspiration pneumonia, it still might mean time lost at work due to illness. The CIA reports placing detainees on a liquid diet prior to waterboarding to decrease the risk of aspirating vomit. They do not state how long prior to the waterboarding detainees should be on the liquid diet. The decision to place someone on a liquid diet can be a complex issue and requires taking multiple factors into account so that the desired result is achieved without causing harm to the individual. The nutritional solutions given to medical patients placed on a liquid diet are carefully balanced and may be supplemented depending on the individuals history.

Seized Vocal Chords

The final, and most severe risk the CIA identifies is the seizing shut of the vocal chords, called laryngospasm. This is an initially healthy response to perceived drowning because when the chords close, and stay closed, they prevent movement of water from the mouth to the lungs but they also prevent air movement. Most drowning victims experience laryngospasm at some point but for 10-20% of them, the vocal chords stay shut and no water actually enters the lungs, even after death. When that occurs, it is referred to as a dry drowning, as opposed to a wet drowning where water enters the lungs.

When the laryngospasm persists after danger of drowning has passed, it is a harmful process that prevents the individual from breathing. Based on my research, I have not found an effective method to predict who will be in that 10-20% which experience persistent laryngospasm. The treatment for persistent laryngospasm is insertion of a needle in to the windpipe (needle cricothyrotomy) or cutting a hole in the windpipe (tracheotomy). The CIA notes that although there has not been a documented case of it during waterboarding (consensual or non-consensual), it is still a known risk. Therefore, they require a physician with the appropriate equipment to be present during waterboarding. There are a number of Enhanced Interrogation Tactics included in the leaked CIA documents. All of them require medical personnel (Physician Assistant, Paramedic, Nurse, etc) to be present. However, waterboarding is the only one that specifically requires a physician.

Chronic Stress Responses

The CIA and US Military report no documented cases of PTSD or other chronic stress responses being developed following waterboarding. With that said, studies have found that patients with a history of near drowning (what waterboarding attempts to simulate) are more likely to develop a panic disorder than those without a history of near drowning,. One study notes additional research is needed to confirm these findings, but their initial results are statistically relevant. Refugees from Cambodia who suffered torture by waterboarding are much more likely to develop panic disorders than those who did not have that experience. That study notes witnesses of waterboarding are also at risk of developing panic disorders. The National Institutes of Health state that some risk factors for developing PTSD are “Seeing people hurt or killed, Feeling horror, helplessness, or extreme fear,” .simply witnessing a waterboarding could be enough to cause PTSD for some. They also note that “it is likely that many genes with small effects are at work in PTSD,” making it a complex issue with a genetic component that aftercare might not be enough to overcome. It is possible that consent makes a radical difference in how one perceives waterboarding, but that is a theory without research.

Allen S. Keller, M.D., Director of the Bellevue/NYU Program for Survivors of Torture, noted during his testimony before the US Senate regarding waterboarding, “As the prisoner gags and chokes, the terror of imminent death is pervasive, with all of the physiologic and psychological responses expected…” In his testimony, Dr. Keller goes on to state, “Long term effects (of waterboarding) include panic attacks, depression and PTSD.” Dr. Keller’s experiences are with individuals who did not consent to waterboarding and often experienced it as one of many human rights violations during an extended interrogation, torture, and imprisonment.

My opinion is that because water boarding triggers an involuntary response in the body, it is feasible that giving consent to the procedure may not prevent someone from developing a chronic stress response. Additionally, those who have had a previous near drowning experience may be much more likely to have a negative psychological response to even consensual waterboarding. It is worth noting that the members of the US military who underwent waterboarding did give some level of consent (granted completion of the training where the waterboarding occurred in may have been essential to their career so one can question how enthusiastic the consent was), and the military reports none of those individuals developing lasting psychical effects. Based on the documents I’ve read, it’s not clear how long those individuals were tracked, as the documents seem to refer to the duration of the training but not beyond.

Method Variations

The method with the most widely available documentation is also the least practiced, as only three detainees underwent waterboarding with the CIA’s protocol. That method is derived directly from the military’s method but features a greater duration and frequency.

The US Military method was used during Survival, Evasion, Resistance, and Escape (SERE) training for certain service members, who are at higher risk of capture and torture. That method differs from the CIA technique, in that it is done for a shorter duration and typically only once, never more than twice.

The military’s concern about using waterboarding in training is something called “learned helplessness”. Essentially waterboarding is so effective that no one was able to succeed in resisting it, and for effective learning, a student must be able to succeed eventually. Constantly failing at a task defeats them and is counterproductive. Understanding learned helplessness has ramifications for different types of play, including interrogation.

Methods that are visually similar but do not involve much if any water entering the upper airway may not carry the same risk of laryngospasm, but they will carry the same risk of getting some fluid in the lungs. Getting a small amount of sterile, or at least medically clean, water in the lungs will carry less of a risk of pneumonia, but it is hard to say specifically how much less of a risk. Should the bottom vomit while restrained, the waterboarding method used may not matter as the bottom is still at an increased risk of aspiration due to their restrained position. Some individuals will vomit when profoundly scared, and a less “effective” method of waterboarding may (my opinion) make them less likely to vomit. Some tops suggest placing a cloth in the mouth and then pouring a small amount of water on to that as an alternative and potentially safer method. I haven’t found any research regarding this method, so I can’t speak to the overall safety. I am confident that placing a cloth in the mouth risks stimulating their gag reflex and causing them to vomit, potentially leading to aspiration of the vomit. There is also some risk that an unsecured cloth in the mouth could be a choking hazard.

Higher Risk Bottoms

It is worth noting that not everyone will share the same risk profile for water boarding. Due to an individual’s medical history, some individuals may be more likely to experience a problem than others. Below are some of the conditions which should raise your concern.

Chronic Breathing Problems (Asthma or Chronic Obstructive Pulmonary Disease)

Water boarding may trigger an exacerbation of either condition requiring use of a rescue inhaler and possibly emergency treatment depending on the severity of the attack

Heart Problems

Someone with a history of heart disease may develop a rapid heart beat due to the stress of the situation leading to a need for emergency treatment. This rapid heart beat isn’t simply “anxiety” but rather an inappropriate response due to a glitch in the heart so rest might not be enough to resolve the problem. The strain on the heart may leave lasting damage. Additionally, a rapid and irregular heart beat can cause problems outside of the heart by producing blood clots that can travel to the brain.

Individuals who have had a heart attack may place an additional strain on already weakened heart muscle leading to further dysfunction.

Aneurysms

Aneurysms can develop anywhere in the body and are the result of weakened walls of arteries that allow a balloon like bulge to develop. The protrusion is at risk of tearing open allowing the artery to bleed. Many doctors will monitor a patient with aneurysms until it gets worse and requires invasive surgery. Part of the monitoring and management will include maintaining normal or low (but healthy) blood pressures. During water boarding the blood pressure will spike as a result of the fight or flight and could cause an aneurysm to tear which can be fatal, especially when it occurs in the brain or the abdomen.

Compromised immune systems

A number of medications will intentionally suppress the immune system or do so as a side effect. Those with suppressed immune systems will be at significantly increased risk of infection from even minor trauma or a small amount of water entering the lungs.

Diabetes

Triggering the fight or flight response will cause the body to use more glucose for quick energy but for those with diabetes who have a hard time maintaining normal glucose levels may experience low blood glucose. Those low levels can cause confusion, agitation, unconsciousness, and seizures.

Fainting

Almost everyone will faint at some point in their life and often it is harmless and passes quickly. Sometimes people fall when they faint and may suffer an injury then but the fainting itself is rarely harmful. Fainting can be triggered by an external stimuli like seeing blood, being startled, etc or may occur as the result of an internal process such as dehydration or a heart issue. The internal issues are more concerning but also less common. Fainting as a result of external stimuli is a possible risk with many types of play and perhaps a greater risk as the intensity of the play increases, as it does with waterboarding. Consider what would happen should the bottom faint during any given activity. Will they strike their head? Will their restraints begin to restrict their breathing? As a general rule most emergency medical personnel assume fainting episodes are caused by the worst possible things first and then work backwards to less serious causes. Following that reasoning it is generally suggested that anytime someone faints they should be evaluated by a medical provider. There’s no way to say with absolute certainty that any given fainting spell is harmless. Use your best judgment and consider learning more about fainting.

Sexy or Dangerous?

Back to the original question, is waterboarding sexy or dangerous? My opinion is that it can be both, but so is crossing the street in high heels. The real questions should be, does the potential benefit outweigh the potential risks, and what, if any, measures are you willing/able to take to decrease the risks? That decision is ultimately yours. Please realize that if a problem occurs, law enforcement, healthcare providers, and lawyers may be heavily influenced by the negative publicity surrounding waterboarding and may only see it as a heinous means of torture. Therefore, your involvement in an act of torture may carry heavy criminal and civil consequences, regardless of the bottom consenting to it. I subscribe to the Risk Aware Consensual Kink (RACK) model and am not adverse to risk in my play, but in this instance, I believe the risks outweigh the benefits and choose not to engage in waterboarding.

I write this not to preach abstinence but rather stratify the risks and ensure all parties involved are giving informed consent by being fully aware of the associated risks.

CIA Protocol – 2005