Federal immigration officials are force-feeding six immigrants through plastic nasal tubes during a hunger strike that’s gone on for a month inside a Texas detention facility, The Associated Press has learned.

U.S. Immigration and Customs Enforcement says 11 detainees at the El Paso Processing Center have been refusing food, some for more than 30 days. Detainees who reached the AP, along with a relative and an attorney representing hunger strikers, said nearly 30 detainees from India and Cuba have been refusing to eat, and some are now so weak they cannot stand up or talk.

Another four detainees are on hunger strikes in the agency’s Miami, Phoenix, San Diego and San Francisco areas of responsibility, said ICE spokeswoman Leticia Zamarripa on Wednesday.

The men say they stopped eating to protest verbal abuse and threats of deportation from guards. They are also upset about lengthy lock ups while awaiting legal proceedings.

In mid-January, two weeks after they stopped eating, a federal judge authorized force-feeding of some El Paso detainees, Zamarripa said. She did not immediately address the detainees’ allegations of abuse but did say the El Paso Processing Center would follow the federal standards for care.

ICE officials say they closely monitor the food and water intake of detainees identified as being on a hunger strike to protect their health and safety.

The men with nasal tubes are having persistent nose bleeds, and are vomiting several times a day, said Amrit Singh, whose two nephews from the Indian state of Punjab have been on hunger strike for about a month.

“They are not well. Their bodies are really weak, they can’t talk and they have been hospitalized, back and forth,” said Singh, from California. “They want to know why they are still in the jail and want to get their rights and wake up the government immigration system.”

Singh’s nephews are both seeking asylum. Court records show they pleaded guilty to a misdemeanour charge in September after illegally walking across the border near El Paso.

There have been high-profile hunger strikes around the country at immigration detention centres in the past, and non-consensual feeding and hydration has been authorized by judges in court orders. Media reports and government statements don’t indicate immigration detainees actually underwent involuntary feeding in recent years, opting to end their hunger strikes when faced with nasal intubation. ICE did not immediately respond to queries about how often they are force-feeding detainees.

To force-feed someone, medical experts typically wind a tube tightly around their finger to make it bend easily, and put lubricant on the tip, before shoving it into a patient’s nose. The patient has to swallow sips of water while the tube is pushed down their throat. It can be very painful.

The El Paso detention facility, located on a busy street near the airport, is highly guarded and surrounded by chain-link fence.

Ruby Kaur, a Michigan-based attorney representing one of the hunger strikers, said her client had been force-fed and put on an IV after more than three weeks without eating or drinking water.

“They go on hunger strike, and they are put into solitary confinement and then the ICE officers kind of psychologically torture them, telling the asylum seekers they will send them back to Punjab,” Kaur said.

Eiorjys Rodriguez Calderin, who on a call from the facility described himself as a Cuban dissident, said conditions in Cuba forced him and other detainees to seek safety in the U.S., and they risk persecution if they are deported.

“They are restraining people and forcing them to get tubes put in their noses,” said Rodriguez, adding that he had passed his “credible fear” interview and sought to be released on parole. “They put people in solitary, as punishment.”

Those “credible fear” interviews are conducted by immigration authorities as an initial screening for asylum requests.

ICE classifies a detainee as a hunger striker after they refuse nine consecutive meals. Federal courts have not conclusively decided whether a judge must issue an order before ICE force-feeds an immigration detainee, so rules vary by district and type of court, and sometimes orders are filed secretly.

In Tacoma, Washington, where immigration detainees have held high-profile hunger strikes in recent years, courts have ordered force-feeding at least six times, according to court records. In July 2017, a federal judge refused to allow ICE to restrain and force-feed a hunger striking Iraqi detainee who wanted to be housed with fellow Iraqi Chaldean Christians detained Arizona facility.

Since May 2015, volunteers for the non-profit Freedom for Immigrants have documented 1,396 people on hunger strike in 18 immigration detention facilities.

“By starving themselves, these men are trying to make public the very suffering that ICE is trying keep hidden from taxpayers,” said Christina Fialho, director of the group.

While court orders allowing force-feeding have been issued in cases involving inmates, Fialho couldn’t recall a situation when involuntary feeding actually occurred in immigration detention facilities because the inmates opted to eat.

The force-feeding of detainees through nasal tubes at Guantanamo Bay garnered international blowback. Hunger strikes began shortly after the military prison opened in 2002, with force-feeding starting in early 2006 following mass refusals to eat.

After four weeks without eating, the body’s metabolic systems start to break down, and hunger strikers can risk permanent damage, including cognitive impairment, said Dr. Marc Stern, a correctional physician at the University of Washington in Seattle who has previously consulted with the Department of Homeland Security.

“You can become demented and lose co-ordination, and some of it is reversible, some of it isn’t,” Stern said. “The dangers are not just metabolic. If you are very weak, you could very simply get up to do something and fall and crack your skull.”

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.”

Garance Burke And Martha Mendoza, The Associated Press