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Autoerotic Asphyxiation: Secret Pleasure—Lethal Outcome?

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Autoerotic Asphyxiation: Secret Pleasure—Lethal Outcome? Autoerotic Asphyxiation: Secret Pleasure—Lethal Outcome? WHAT’S KNOWN ON THIS SUBJECT: Centuries old, AEA first AUTHOR: Daniel D. Cowell, MD, MLS, CPHQ appeared in medical literature in 1856. Etiology is speculative, Departments of Psychiatry and Behavioral Medicine and and the majority of reports deal with fatal cases. Distortions of Graduate Medical Education, Marshall University, Joan C. normal development on the basis of psychoanalytic theories are the Edwards School of Medicine, Huntington, West Virginia most prevalent understanding of the disorder. KEY WORDS asphyxiation, “choking games,” hypoxia/anoxia, lethal, WHAT THIS STUDY ADDS: AEA is little known beyond forensic masochism/sadism, sexual stimulation, suffocation, suicide medicine and is generally regarded as a curiosity rather than a ABBREVIATION medical disorder whose onset is in childhood or adolescence. AEA—autoerotic asphyxiation This study adds understanding of causation and provides guidance to www.pediatrics.org/cgi/doi/10.1542/peds.2009-0730 pediatricians on recognition and management. doi:10.1542/peds.2009-0730 Accepted for publication Jun 4, 2009 Address correspondence to Daniel D. Cowell, MD, MLS, CPHQ, Departments of Psychiatry and Behavioral Medicine, and Graduate Medical Education, Marshall University, Joan C. abstract Edwards School of Medicine, 1600 Medical Center Dr, Suite 3414, Huntington, WV 25701. E-mail: [email protected] OBJECTIVE: Voluntary asphyxiation among children, preteens, and ad- PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). olescents by hanging or other means of inducing hypoxia/anoxia to Copyright © 2009 by the American Academy of Pediatrics enhance sexual excitement is not uncommon and can lead to unin- FINANCIAL DISCLOSURE: The author has indicated he has no tended death. This study addresses autoerotic asphyxiation (AEA) with financial relationship relevant to this article to disclose. the intent of increasing pediatricians’ knowledge of the syndrome and awareness of its typical onset among young patients. AEA is character- istically a clandestine and elusive practice. Provided with relevant in- formation, pediatricians can identify the syndrome, demonstrate a willingness to discuss concerns about it, ameliorate distress, and pos- sibly prevent a tragedy. METHODS: A retrospective study was undertaken of published cases both fatal and nonfatal and included personal communications, refer- enced citations, clinical experience, and theoretical formulations as to causation. Characteristic AEA manifestations, prevalence, age range, methods of inducing hypoxia/anoxia, and gender weighting are pre- sented. All sources were used as a basis for additional considerations of etiology and possibilities for intervention. RESULTS: AEA can be conceptualized as a personalized, ritualized, and symbolic biopsychosocial drama. It seems to be a reenactment of in- tense emotional feeling-states involving an identification and sadomas- ochistic relationship with a female figure. Inept AEA practitioners can miscalculate the peril of the situation that they have contrived and for numerous reasons lose their gamble with death. CONCLUSIONS: Pediatricians should be alert to the earliest manifes- tations of AEA. Awareness of choking games among the young and, of those, a subset who eventually progress to potentially fatal AEA is strongly encouraged among all primary care professionals who may be able to interrupt the behavior. Pediatrics 2009;124:1318–1323 1318 COWELL Downloaded from www.aappublications.org/news by guest on September 25, 2021 ARTICLES Autoerotic asphyxiation (AEA) is a clin- TABLE 1 Impediments to Identification of AEA ical syndrome that is classified in the 1. Patient embarrassment/shame Diagnostic and Statistical Manual of 2. Anticipation that disclosure will result in the physician’s discomfort, provoking judgment, repugnance, condemnation, or rejection (in part, this may represent a projection of his or her own Mental Disorders, Fourth Edition, Text self-condemnation upon the physician). Revision as a paraphilia, not otherwise 3. Paraphilic thoughts/behaviors are experienced by the patient as odd but ego-syntonic and thus not a classified.1 It has been recognized for problem. 4. The physician’s discomfort in taking a sexual history may stem from concerns involving his or her own centuries in many cultures but did not sexuality or paraphilic thoughts or behaviors, resulting in distancing from similar behavior in the appear in medical literature until patient. 18562 and 1866.3 Little is known with 5. The patient’s view that behavior that others regard as deviant (“abnormal”), whether experienced as acceptable or unacceptable to himself or herself, is a private matter that has no bearing in his or her certainty about its etiology or how consultations with physicians for what they regard as purely medical (or even psychiatric) reasons. widely dispersed individuals learn of 6. The physician lacks knowledge of paraphilias and their manifestations, course, and preventive and the practice. It is estimated that there therapeutic options. 7. The sexual behavior of choking games or AEA may (mistakenly) be regarded as “harmless” or are 250 to 1200 deaths annually from “victimless” by either the AEA practitioner or the physician. AEA in the United States, although a 7-year retrospective study by Sau- vageau in one Canadian province sug- gists have recognized them in studies sionals and especially pediatricians be gested a lower incidence of autoerotic of primitive Celtic culture as well as informed about AEA, its manifestations deaths and a higher percentage of fe- among certain Native American and and possible interventions. male and “atypical” autoerotic fatali- Eskimo children who engage in games ties than previously reported in US Impediments to revelation of sexual of risk-taking involving suffocation studies.4 Estimates are almost cer- practices (unusual or otherwise) are called “Smoke Out” and “Red Out.”6 tainly inaccurate, however, because described in Table 1, and findings that Andrew and Fallon7 noted an increase the practice is characteristically en- should raise suspicion are listed in Ta- in lethality among young, risk-taking acted in secret, most cases do not end ble 2. It would be expedient for pedia- adolescents who engage in these as- tricians to be familiar with paraphilias fatally (are therefore rarely reported), phyxial or choking games increasingly the activity is usually unknown to fam- and especially the phenomenon of AEA by using ligatures in solitary circum- in order to use a matter-of-fact, non- ily and friends, and it is generally un- stances. These games are suggestively judgmental approach when inquiring recognized by medical professionals. described: Black Hole, Black Out, about it. Development of tolerance and Troubled youth, of either gender, may Flatlining, Funky Chicken, Space Mon- respect for the great variety of sexual engage in AEA for purposes of sexual key, Suffocation Roulette, Gasp, Tin- experiences, thoughts, and behaviors, experimentation. Authorities may be gling, and Knock Out, among others.8 often culturally conditioned, on the importuned by a decedent’s distraught The authors’ series of 24 fatal cases, part of physicians as well as their pa- family to declare the death a suicide aged 9 to 16, suggests that when these tients is helpful. Even when no form of especially if they have discovered the youngsters see that the activity can be AEA is acknowledged, the patient will death scene; Burgess and Hazelwood5 conducted without drugs, they falsely be comforted by the nature of the detailed the impact on the family in believe that they can create a “safe” questions, which indicate that the pe- such cases that calls for professional high. diatrician is informed about, open to attention. The number of adult practitioners who discussing, and not repelled by an ac- The earliest manifestations of AEA may engage in AEA is unknown, much less tivity about which they themselves may be so-called “choking games” among the number of children and adoles- be curious, troubled, or self-condem- school-aged children, which seem to cents involved in asphyxial games. AEA natory; in time, they may be able to dis- be increasing. These activities are has achieved notoriety in television close their unique story. AEA is a good known among teachers and educa- dramas and “talk shows.” There are, in example of the principle that patients tors from elementary grades through fact, reports of AEA deaths related to are more likely to reveal what is impor- high school (T. LeGrow, PsyD, verbal such programming.9 These portrayals tant to them when they believe that a communication, January 2009), and are not helpful, because they sensa- physician is able to tolerate the infor- “highs” are also produced by vagal tionalize the practice and do not treat mation without risking dismissal, dis- stimulation via a Heimlich-like maneuver it as a little-known but dangerous med- approval, or condemnation. This is (S. Lerfold, MD, verbal communica- ical disorder. For these reasons, it is true of many issues that trouble pa- tion, February 2009). Anthropolo- important that primary care profes- tients and none more so than those PEDIATRICS Volume 124, Number 5, November 2009 1319 Downloaded from www.aappublications.org/news by guest on September 25, 2021 TABLE 2 Clues for Suspecting AEA a characteristic profile or syndrome 1. Bruises of the neck or recurrent syncopal episodes in a child or an adolescent should prompt the (Table 3). They
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