Protecting Civil and Human Rights

DHS’s Secret Reports on ICE Detention

New Records Confirm Abuses, Medical and Mental Health Care Failures, and Extensive Use of Solitary Confinement at Immigrant Detention Centers Across the Nation
(Illustration: Renzo Velez / POGO)

Note: The following investigation contains mentions and details of suicide and sexual assault.

Previously confidential records from within the Department of Homeland Security’s (DHS) Office for Civil Rights and Civil Liberties (CRCL) confirm years of inadequate medical care, extensive use of solitary confinement, mistreatment of transgender individuals, shortcomings in rape and sexual assault prevention and response, inaccessible services, and other problems disclosed by people detained by Immigration and Customs Enforcement (ICE). The Project On Government Oversight (POGO) is making dozens of these reports public after a nearly five-year Freedom of Information Act (FOIA) legal battle ended with a judge ordering the department to release the records.

Overseeing a Sprawling Detention Network

Experts and advocates say keeping reports like these from CRCL secret undermines the effectiveness of that office, which provides policy recommendations and investigates complaints for DHS. This institutional secrecy has limited CRCL’s impact and allowed problems, many of which are systemic in nature, to fester, enabling abuse and putting lives at risk. By refusing to fulfill FOIA requests or make CRCL’s reports public, DHS can conceal problems for years, if not indefinitely.

Many of the confirmed issues in these reports are only now being made public as a result of litigation — in some cases, roughly a decade after the allegations were made. The newly disclosed reports reveal deficiencies at facilities across the nation: in California, Florida, Georgia, Michigan, New York, and Texas. (NPR News also spent years litigating against DHS for the same kinds of records and found similar problems nationwide in a story published last week.)

The records span the Obama and Trump administrations and shed light on longstanding systemic problems within ICE’s sprawling detention complex, which is locking up significantly more people than it did just two years ago.

As of this July, ICE was detaining over 30,000 people — a number that has doubled since President Joe Biden’s inauguration but decreased from the record high of 55,000 people detained under President Donald Trump in 2019. According to the American Immigration Council, people detained by ICE are overwhelmingly from Mexico, El Salvador, Guatemala, Honduras, and other parts of Latin America. ICE’s detention complex stretches across at least 120 facilities, owned and operated by a mixture of companies and local, state, and federal agencies. The vast majority of people ICE detains are concentrated in a few dozen of the largest facilities. Facilities ICE uses to detain individuals are often converted prisons or currently operating prisons or jails.

Many of the confirmed issues in these reports are only now being made public as a result of litigation — in some cases, roughly a decade after the allegations were made.

Recently, House and Senate lawmakers introduced a bill — the Dignity for Detained Immigrants Act — seeking reforms and aiming to limit the number of people detained by ICE. “Our immigration system has allowed for the unjust treatment of immigrants and stripped them of their humanity and due process,” said Senator Cory Booker (D-NJ) in an April statement announcing the bill. “We must respect and protect the basic rights of immigrants detained in the United States.”

The reports obtained by POGO were prepared by subject matter experts contracted by CRCL and tend to contain more details than the summaries of complaints that CRCL makes public. In addition to sharing their investigative findings in these reports, CRCL’s contracted experts also made recommendations. These recommendations typically call for more qualified medical staff at ICE detention facilities, more discerning use of solitary confinement, broader use of interpreters, and better training for staff at these facilities.

However, according to advocacy groups, the root problem is the entire apparatus of detention built by ICE. Johannes Favi, a Freedom Fellow at Detention Watch Network, said, “Detention itself is harmful. Why put people in detention for a simple documentation issue that could be resolved by a desk appearance?” Favi, a Beninese migrant who previously spent 10 months detained on behalf of ICE, also explained, “There should be no detention — period. Detention destroys families and affects the very fabric of our communities.”

It is unclear to what extent DHS has even implemented expert recommendations from CRCL’s reports, but the documents reviewed by POGO reveal a pattern of ignoring reforms proposed by CRCL, as well as those from other oversight offices such as the DHS Office of Inspector General. At the Karnes County Residential Center in Texas (now the Karnes County Immigration Processing Center), CRCL found a pattern of ICE failing to provide adequate translation assistance for medical services in December 2014, then found the same issues in May 2015 and again in July 2016. A CRCL expert also found Karnes to be repeatedly not in compliance with ICE’s sexual assault prevention and response standards. The Karnes facility is run by the GEO Group, a private prison contractor.

DHS did not respond to POGO’s numerous requests for comment. In an emailed comment, GEO Group stated that it “strictly complied” with the DHS’s Family Residential Standards and that it mandates “zero tolerance towards all forms of sexual abuse and sexual harassment.”

Reports of Sexual Assault

Sexual assault while in ICE detention is a prevalent and ongoing problem. According to a report by Freedom for Immigrants, DHS’s Office of Inspector General received over 33,000 complaints of sexual or physical abuse between January 2010 and July 2016 (the period covered in the CRCL reports). Over 40% of those complaints were filed against ICE — more than any other DHS component. Of the 33,000 total complaints, DHS opened investigations into fewer than 1% of those reports.

One of the previously confidential CRCL reports describes the sexual assault of a minor at the Karnes detention center in Texas. CRCL’s report not only confirmed the assault, it also found that Karnes’ policy of housing minors 12 years and older separately from their parents enabled the assault and that ICE officials failed to respond appropriately once a report of the assault was made. These violations ran afoul of detention standards and the Prison Rape Elimination Act, according to the report.

“There was a delay in the reporting of the incidents because the mother of the victim was fearful that reporting the incident would have a negative impact on the family’s immigration case, or cause problems with other residents,” the report stated.

Similar to federal prisons, DHS has regulations in place to prevent and report sexual abuses. However, in 2022, a Senate subcommittee on investigations found audits to comply with the Prison Rape Elimination Act within federal prisons failed to identify a culture of abusing female inmates at four facilities. It also found the Office of Inspector General, which investigates sexual assaults reported to it, had an enormous backlog of cases, with some open for over five years. The Senate subcommittee ultimately found the Bureau of Prisons had an inability to investigate and close internal affairs complaints in a timely manner and that it failed to hold wrongdoers accountable for their actions. At ICE’s West Texas Detention Facility — the site of some of the most egregious confirmed problems in CRCL’s reports — the CRCL expert found that the point person for stopping and preventing sexual abuse and assault “is not currently well-prepared to oversee SAAPI [sexual abuse and assault prevention and intervention] allegations,” finding that her “log for tracking the SAAPI allegations is inadequate.” Yet the CRCL expert still relied on this person’s records to examine claims that a Somali migrant had been sexually assaulted by a staff member, determining it to be “not substantiated.”

Language Barriers and Inaccessibility

In their reports, CRCL experts frequently cite ICE’s persistent language barriers with migrants, particularly Indigenous migrants from Central America, as an aggravating factor in misconduct complaints. ICE and its contractors frequently fail to provide resources in the native language of the people being detained. Often, communication barriers lead to or compound other problems.

At the South Texas Family Residential Center, the CRCL expert found that migrants who spoke K’iche’, a Mayan language indigenous to Guatemala, and other Indigenous languages cannot communicate effectively at [the facility].

At the South Texas Family Residential Center, the CRCL expert found that migrants who spoke K’iche’, a Mayan language indigenous to Guatemala, and other Indigenous languages “cannot communicate effectively at [the facility].” DHS experts found the failure to provide language access means ICE cannot meet the standards it needs to prevent sexual assault and suicides or provide medical care to people being detained. Without language resources such as interpreters, detained people sign away their legal rights on documents they do not understand. CRCL found that “women are asked to sign documents that they have no understanding of what they are signing and invalidates any legal purpose of the signature.”

In Michigan, at the St. Clair County Jail, CRCL investigators found that detained people who were Muslim were unable to properly observe Ramadan, the holiest month in the Islamic calendar, because of language barriers. They found that “[St. Clair County Jail] relies heavily on the electronic Telemate tablet system for inmates and detainees to request service” but that Telemate was inaccessible to the Somali Muslims requesting Ramadan observance. The Telemate system in general did not “provide access in the multitude of languages used by the detainee population,” which often forced the “detainees [to] help each other in using the system to make requests for services.”

ViaPath did not return a request for comment.

Insufficient Health Care and Unsound Conditions

Poor medical care for people being detained was a recurring theme in records obtained by POGO. CRCL found examples that included detained individuals being transferred without their complete medical history, a senior medical administrator being unaware that they were even in charge, and an excessively high number of patients for the amount of staff available.

Professor Nicole Hallett, director of the University of Chicago Law School’s Immigrants’ Rights Clinic, described ICE as an agency which frequently ignores or delays medical care for migrants. “Detainee medical complaints are often ignored. Even if the detainee has a lawyer, it might take calls to multiple offices over weeks or months before ICE will respond,” she said. “Complaints often have to be escalated to supervisors and sometimes lawyers must make litigation threats in order to get care for their clients.”

According to CRCL’s reports, at the Santa Ana City Jail in California, a transgender woman detained by ICE reported that staffers misgendered them and asked them uncomfortable questions about their transition. Patients were also made to wait, sometimes for months, for hormone replacement therapy because the only physician available visited the jail for just four hours each week. Transgender patients were also warned by doctors that if they missed doses of their hormone replacement therapy for any reason, including side effects, they would permanently lose access to their treatment. In another case, an HIV-positive person made “an informed refusal to take HIV medication” and was told by staff at the jail that “the refusal to take the HIV medications would also cause hormone therapy to be withheld.” CRCL found no medical justification for this practice.

CRCL also documented inadequate mental health services with alarming frequency and specificity. In one report, Stewart Detention Center in Lumpkin, Georgia, reported that the facility planned on having “a single mental health practitioner to cover the nearly 1,800 detainees” in May 2017. Stewart Detention Center, run by the private contractor CoreCivic, is one of the largest ICE detention centers in the country. CRCL concluded that staff at Stewart couldn’t adequately meet prisoner needs as a result of the high number of patients. The inability to properly track medical history and charts of people being detained was a persistent issue, with CRCL’s experts finding physicians unable to provide care due to incomplete intake practices and poor record-keeping systems, which negatively impacted the care received by detained people.

In an emailed statement to POGO, CoreCivic stated that the responsibility to provide medical care at Stewart was entirely within DHS’s control. CoreCivic wrote, “Prior to November 2018, CoreCivic did not provide medical or mental healthcare services or staffing at Stewart Detention Center. The federal government's ICE Health Service Corps (IHSC) was solely responsible for contracting, staffing and oversight of any medical and mental health services provided at Stewart, as well as management of the medical clinic facilities.”

At the West Texas Detention Facility, freshly arrived ICE detainees were often sent without their complete prescription records, leaving up to half of them “at risk for a possible psychotic or deteriorating mental health event.” That CRCL report also found “intake mental health assessments were not meaningful,” and were often grossly inaccurate. Additionally, the West Texas Detention Facility used an electronic medical records system that was not searchable and had so many shortcomings “it is nearly impossible to reconstruct a clinical timeline in an efficient manner.” Much of the information in it was “completely inaccurate,” creating a “considerable legal liability for the facility.”

Cleanliness was a significant problem at some facilities, such as Stewart Detention Center. “The medical clinic at Stewart among was [sic] the dirtiest medical spaces I have ever seen in a U.S. detention facility,” one report said. “We found pills on the floor in the hallways.”

At the West Texas Detention Facility, CRCL experts found numerous issues including overcrowding, drinking water that wasn’t clean, and “extremely dirty” and unsanitary conditions rife with rodents and insects. They also uncovered a collapsing roof that allowed rainwater to pour into the facility’s housing units.

Other problems documented in the reports go beyond deficient medical care. At the Krome detention center in Florida, CRCL documented medical staff force feeding migrants on hunger strike. Force feeding individuals on hunger strike has been condemned by the medical establishment and compared to torture by the UN Commission on Human Rights.

Last fall, for the first time, The Intercept released video of the U.S. government force-feeding a detainee. That person, Ajay Kumar, was in ICE detention at the El Paso Service Processing Center in Texas, run by the company Global Precision Systems. “This is not humanity. This is totally against humanity,” Kumar told The Intercept.

Solitary Confinement

The extensive, prolonged, and improper use of solitary confinement was frequently cited by CRCL investigators as a major deficiency at ICE facilities across the country. Within ICE facilities, isolation from the general population is usually not referred to as “solitary confinement” in documents. Rather, it is referred to by terms such as “administrative and disciplinary segregation,” “medical isolation,” “segregated housing,” and “special management units” (some of these terms specify the purpose of the isolation). All involve an individual’s separation from the general population, sometimes for the safety of a detained person.

However, numerous experts say prolonged isolation can lead to or exacerbate mental health issues — and can increase suicide risks — unless there are compelling reasons to keep a person isolated. “Efforts should be made to swiftly return detained people to their prior housing status, when they are no longer determined to be suicidal or have stopped exhibiting active symptoms of mental illness,” one CRCL report says.

The extensive, prolonged, and improper use of solitary confinement was frequently cited by CRCL investigators as a major deficiency at ICE facilities across the country.

Favi of Detention Watch Network described how the threat of deportation pushed detainees toward self-harm. “Everyone has a breaking point,” he explained, referring to the enormous strain possible deportation placed on detainees, particularly around days that ICE is known to schedule final removals. As he described it, “I’ve met people who living here for 40 years, they’ve almost paid off their house and then suddenly they are deported to nothing. To a country where they have no family, no house, no foundation.”

Several people being detained at the West Texas Detention Facility told CRCL they were afraid to seek out medical care because of the risk of being placed in medical isolation cells. Some who were placed in isolation because of suicide risks were held in solitary for prolonged periods of time, and the cells they were held in “are not suicide resistant.”

One report at that facility documents two chilling confirmed examples of overuse of medical isolation. One involved a migrant woman who was being deported without her child around the same time and in the same region where the Trump administration quietly began its pilot family separation policy in the Border Patrol’s El Paso, Texas, sector. “The detainee was placed into suicide watch on 10/22/2017 after reporting being deported without her daughter,” the report states. “She remained on suicide watch in a suicide resistant gown for five days: three days after all thoughts of self-harm had dissipated.”

In another case, a migrant was placed in medical isolation because he exhibited suicidal ideation. But within a day, the report states, there were no more concerning signs. Yet he was kept in isolation for 16 more days.

At the Stewart Detention Center in Georgia, solitary confinement for long periods “is cause for significant concern,” according to Azadeh Shahshahani, the legal and advocacy director at Project South, an advocacy group. “Two migrants died at Stewart by suicide after being held in solitary for prolonged periods.” ­­­

Attorney Andrew Free, a former attorney and family advocate, recently wrote about the real-world impact of keeping CRCL expert findings secret. He wrote that had the expert findings on Stewart Detention Center been made public, “it’s possible that we could have saved Efrain Romero de la Rosa’s life.”

De la Rosa’s death was similar to that of another detainee, Jean Jimenez-Joseph, in May 2017. Both had mental illness, and both took their own lives after being held in isolation. “The records CRCL has been sitting on all this time concluded that neither CoreCivic nor ICE took the steps experts recommended after Jean died that would potentially prevent another similar death,” Free wrote. Free independently obtained some of the same records on Stewart as POGO.

A 2017 CRCL expert report obtained and reported by POGO in 2019 found that the GEO Group-run ICE detention center in Adelanto, California, kept an “alarming” number of detained people with serious mental illnesses isolated for “shockingly” long periods. Data obtained by POGO showed that the Adelanto facility kept two people in continuous solitary confinement for more than a year each. But even short-term use of solitary confinement can exacerbate mental health issues. “Detainees with serious mental disorders should only be housed in administrative segregation as a last resort, as that environment is not conducive to improving mental health status,” that report stated.

After CRCL released this report and two others on Adelanto to POGO in 2019, the office refused to provide POGO with any more expert reports for nearly four years, until a federal judge ordered the release of more reports earlier this year.

At the Theo Lacy Facility in Orange County, California, CRCL investigators found the facility issued a blanket denial of all rights for migrants in a special management unit, including religious practice and access to the law library. Facilities may limit access to certain activities, but because access to religious expression is a legally protected activity, there must be individualized reasons for limitations. Instead, nearly every justification for suspending their rights was identical, which raised concerns to CRCL that a blanket denial of rights was a first resort by staff applied with little justification. Likewise, migrants at the Stewart Detention Center were placed in segregated housing in many situations with “no documentation” about what made the segregation necessary.

The use of solitary confinement doesn’t seem to be applied proportionately among different racial groups. ICE places migrants from majority-Black countries in solitary confinement at disproportionate rates — a racial disparity similar to that seen in U.S. prisons. University of California researchers found in a 2020 study that “solitary confinement cases involving immigrants from Africa and the Caribbean are vastly overrepresented” in ICE detention. Although immigrants from Africa and the Caribbean made up just 4% of people detained by ICE from 2013 to 2017, they represented 24% of those placed in isolation.

A more recent November 2022 report by the UndocuBlack Network, Black LGBTQIA+ Migrant Project, Black Alliance for Just Immigration, and Freedom for Immigrants similarly found that Black people detained by ICE file disproportionate complaints of abuse in detention centers. Among the report’s findings were that “in a few facilities in Alabama, Georgia, and Louisiana, Black migrants were almost twice as likely to experience abuse inside detention than other non-Black migrants” and that “Black non-binary migrants were 3.5 times more likely to experience abuse in detention.” The report’s analysis was based on analyzing nearly 17,000 calls made to Freedom for Immigrants’ National Immigration Detention Hotline over six years, covering 2016 through 2021. The report notes that CRCL “does not currently distinguish complaints from immigrants in ICE detention by race.”

“Being detained as an immigrant and having to fight for my freedom, I have faced discrimination based on my race,” said Marlissa, a woman who is described as a 22-year-old from the Bahamas, in a statement announcing the report. The statement omitted her last name, noting that she was then detained at the Baker County Detention Center in Florida. “I have faced a lot of racism, a lot of disrespect, and a lot of unfairness in this system. I was threatened with solitary confinement after officers used racial slurs against me,” she said. “Being detained, it’s like you have no say and you have no rights. It’s as if they look at you like you’re beneath them, and the door is just being slammed in your face like you’re an animal.”

Undermining Oversight and Accountability

Every year, CRCL receives hundreds of complaints about DHS, with nearly all of them relating to detention. When investigating complaints, CRCL can find the grievance “substantiated” if the office both finds evidence that the issue occurred as described and that the action by ICE violated detention standards.

However, CRCL often notifies ICE facilities ahead of time that it intends to visit and investigate complaints. This raises questions regarding how realistic the facility’s environment is during these visits, compared to days the facility does not know to prepare for the presence of CRCL’s experts.

“Many of these site visits are announced in advance and there are no surprises and by this very nature, CRCL site visits means many of these claims will be unsubstantiated,” Hallett told POGO. “It also means for the inspection process, many of the facilities know and are able to prepare to obfuscate and evade accountability.”

Some of the complaints reviewed by a CRCL expert regarding the West Texas Detention Facility included claims that facility staff, including then-Warden Michael Sheppard, used racist language and physically assaulted people. The CRCL expert concluded that those claims were unfounded, according to the report. The expert’s fact-finding included reviewing available video footage, as well as reviewing after-action records and interviewing staff.

CRCL often notifies ICE facilities ahead of time that it intends to visit and investigate complaints. This raises questions regarding how realistic the facility’s environment is during these visits, compared to days the facility does not know to prepare for the presence of CRCL’s experts.

While the CRCL expert’s report found that use-of-force incidents at the facility were “well documented,” they also found that Sheppard’s after-action reviews did not include “the participation and input from the other facility managers” and only contained unclear language about outcomes, such as “I gained control of the detainee,” without any details about how that outcome came to be.

Professor Hallett, director of the Immigrants’ Rights Clinic, explained to POGO, “With respect to the unsubstantiated claims, those are claims where CRCL couldn’t corroborate them, not that it didn’t happen.”

In their report on the West Texas Detention Facility, the CRCL expert wrote, “The attitude and demeanor we observed was not punitive, rather, it was one more towards assisting the detainees where ever [sic] possible… Name-calling would seem out of character for the staff at WTDF based on what we observed on-site.” The expert added that “while it is possible that officers acted inappropriately by making threats and using unprofessional language, we did not find evidence of that or that the environment at WTDF is conducive to that type of conduct.”

In August 2018, at the time of these complaints, the West Texas Detention Facility was operated by the company LaSalle Corrections and overseen by Warden Sheppard. In October 2022, Sheppard was charged with manslaughter for shooting migrants near the border.

Outreach attempts to LaSalle Corrections for comments were unsuccessful.

Harmful and Unnecessary Secrecy

Despite the Freedom of Information Act’s “presumption of openness” and the clear public interest in releasing these reports, DHS does not proactively disclose these records or allow the public to easily request them. In response to POGO’s FOIA lawsuit, DHS fought to keep the records secret by arguing CRCL’s expert reports were “predecisional,” and thus could be withheld under the deliberative process privilege as the government was still deliberating internally on what to do in response. Government agencies can withhold requested records under certain legal exceptions, such as the deliberative process privilege, but POGO’s attorneys successfully challenged DHS’s withholdings as improper, specifically the subject matter experts’ investigative findings.

Then-senior CRCL official Scott Shuchart called for greater transparency at CRCL in a 2019 report, which said, “Congress must demand that CRCL be more transparent with people who file complaints with the office and ensure that it can make meaningful, independent reports to Congress and the public on its activities as well as the DHS’s responses to its recommendations.” He also wrote that “Congress can clarify that the DHS is not to hide CRCL’s completed work behind deliberative-process privilege,” which it attempted to do during POGO’s FOIA lawsuit.

Despite the Freedom of Information Act’s presumption of openness and the clear public interest in releasing these reports, DHS does not proactively disclose these records or allow the public to easily request them.

POGO has advocated previously to Congress for more transparency at CRCL and for strengthening CRCL’s authority. Additionally, there is no requirement that DHS components take remedial action on expert findings or any statutory deadlines for implementing change when they do concur with CRCL’s recommendations. In keeping these reports secret, the public is unable to learn what — if any — actions DHS ultimately took to improve facility conditions and address serious issues.

Hallett told POGO that none of CRCL’s recommendations are legally enforceable, and this, coupled with the lack of transparency, makes the office relatively toothless. “The lack of transparency goes hand in hand with the lack of enforcement power,” she said. If “CRCL is not going to have enforcement powers, then they should at least be required to make their recommendations public,” she said. “Shining sunlight on problems allows external parties to push for reform.”

Advocates and policy experts POGO spoke to described their frustration with CRCL, finding it to be an office with little power and few incentives to change. They also expressed little hope that this office, which operates too secretly, could be reformed, especially without outside pressure from the public or Congress.

“We need an agency that acts as an actual watchdog and has the power, the will, and the ability to effectuate change,” Project South’s Shahshahani said.

Resources if you or someone you know needs help

The 988 Suicide and Crisis Lifeline is a hotline for individuals in crisis or for those looking to help someone else. To speak with a trained listener, call 988. Visit for crisis chat services or for more information.

RAINN is the nation's largest anti-sexual violence organization. RAINN created and operates the National Sexual Assault Hotline in partnership with more than 1,000 local sexual assault service providers across the country. If you or someone you know has been sexually assaulted, help is available. Chat online at or call someone who can help at 800-656-4673.

Editor’s note: We have updated this piece to more accurately reflect the name of the ICE facility in Karnes County, Texas. The facility no longer detains families.