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

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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 described stages rang- pediatrician to inquire about “choking games” or the more elaborate AEA syndrome. (Physicians may ing from early “sex play” (asphyxial be unaware that choking may engender feelings of pleasure, erection, and even orgasm.) 2. Hesitant/tangential responses to a sexual history (in an adolescent) do not confirm AEA but may games) to suspension activities in warrant additional inquiry (eg, “Do you ever play with death?” “Have you ever experienced giddiness or later adolescence and adulthood, in- sexual stimulation if you are temporarily deprived of oxygen by choice or accident when roughhousing, cluding nudity, and, unlike females, inhaling a substance, or playing a choking game?” “Do you engage in risk-taking related to sexual with paraphernalia consisting of stimulation or behavior?”). 3. Is there evidence in the physical examination that an orifice has been repeatedly subjected to foreign- mirrors, pornography, bondage, and body insertion? transvestite/fetishist articles such as 4. Are there unusual, unexplained urogenital, vaginal, or anal injuries? female clothing. Atypical features were 5. Does the child or adolescent express concerns about sexual matters? 6. Do abrasions found on limbs, wrists, ankles, or trunk suggest bondage or binding activities during noted in 10% of cases that did not nec- masochistic practices? Is there ornamental piercing of intimate body parts? essarily involve asphyxiation, includ- 7. Are there erythematous or ligature marks on the penis or base of the scrotum? ing unintentional electrocution (car- 8. Do family members express concern about choking games that they have observed or heard about whether in their adolescent or their friends? diac arrest), whole-body wrapping (hyperthermia), foreign-body inser- tion (air embolism), and aquatic sub- mersion (drowning). They did not con- that involve spirituality, sexuality, or Scotland, reported 30 deaths from sider asphyxial games as a forme death. The practice of AEA can involve 1984 to 1988, all from plastic bag as- fruste of AEA but rather a simpler, less all 3. phyxiation, aged 13 to 81 years. Byard elaborate, nonritualized activity with- et al13 studied 8 rarely reported out the need for escape mechanisms, METHODS deaths in females and found dis- pornography, and cross-dressing, which By accessing PubMed-Medline, I found tinctive differences vis-a`-vis males. are typical of fully developed AEA, yet 112 articles on AEA from 1950 to 2008, Among scant child and adolescent lit- their description of stages suggests a most in English, others in world litera- erature, Friedrich and Gerber14 took ex- possible link between early and later ture. Published principally in forensic tensive histories from 5 adolescent male forms. medicine/pathology, legal medicine, practitioners; each demonstrated child- DISCUSSION and toxicology journals, the great hood experiences with choking associ- majority describe fatal cases (often ated with egregious physical and sexual Areas of Consensus initially but erroneously considered abuse. The terror felt by children and ad- suicides.) Rare reports from AEA survi- Investigators agree that autoerotic be- olescents who, with fading conscious- havior has a childhood or adolescent vors; classics of world literature and ness, suddenly realize that escape mech- drama; discussions with colleagues in onset; that males outnumber females anisms have failed and that death is general pediatrics, emergency and imminent is unimaginable. family medicine, psychiatry, and child TABLE 3 Characteristics of Fatal AEA Cases psychology; referenced citations; and Herman Melville described the erotici- zation of hanging in “Billy Budd” as did Partial or complete asphyxiation while often but relevant psychoanalytic literature were not always engaged in masturbatory activity all considered. The following representa- Heinz Ewers in “Alraune.” In Thomas Neck constriction by ligature or rope, Beckett’s “Waiting for Godot,” Vladimir asphyxiation by plastic bag and masks often tive sample of case reports is illustrative with inhalants (nitrous oxide, trichloroethane, of age range, gender weighting, clinical and Estragon discussed stimulating butane, chloroform, and others) manifestations, course, and geographic ways of alleviating their boredom by Partial or complete nudity hanging themselves while waiting for Binding of head, trunk, extremities, or genitals distribution. Insertion of dildos or other objects per rectum Godot.15–17 Marquis de Sade described Sauvageau and Racette10 in Canada, by (or vagina) AEA in the same erotica in which sa- Pain, real or simulated, associated with using Medline and all possible key occasional evidence of self-mutilation 18 words in their search of the literature dism is eponymous. Pornography or bondage literature Curran et al19 claim that each individ- Mirrors positioned so that “victims” may see from 1954 to 2004, found 408 published themselves in the predicament in which they fatal cases ranging in age from 9 to 77 ual develops his or her own AEA tech- have placed themselves (or were placed in years. Shields et al11 found 40 acciden- niques, which become embellished their erotic fantasy) and elaborated over time. Like other Transvestic elements, usually fetishist articles of tal fatalities in Hamburg, Germany, be- feminine clothing (eg, undergarments, tween 1983 and 2003, all male, 13 to 79 investigators, they found that to one de- brassieres, dresses) years of age. Jones et al12 in Edinburgh, gree or another, fatal cases presented Adapted from ref 19.

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(as much as 50:1); and that it is a clan- ences induced by hypoxia/anoxia/hy- dominant–submissive, and sadomas- destine, often solitary, potentially le- percapnia by means of neck compres- ochistic themes. It is no wonder that thal practice usually without suicidal sion, partial suffocation, or other the complexity and persistence of this intent among youthful practitioners. methods). It is possible that pleasur- activity is mystifying to practitioners No biological or genetic markers have able sensations in the infant/child and its etiology obscure to research- been identified. Postmortem findings from being playfully tossed in the air ers! Whether a mirror-image of these are consistent with cerebral anoxia and caught by an adult (usually father) scenarios occurs with female practi- and physical findings related to its in- may also bear a relationship to later tioners is unknown; however, it is im- duction (eg, rope, ligature, suffoca- sexually stimulating experiences dur- portant to note that most estimates of tion). Money20 suggested, however, ing suspension and hanging. autoerotic behavior among females ϳ that because certain medications have Resnik theorized that there is a (vir- are low ( 4% in series of fatal cases), been modestly beneficial in treating tual life and death) conflict for the in- although they may be biased by cul- paraphilias, there could be an ana- fant between pleasurable sensations tural or societal taboos about ac- tomic and neurochemical basis for from unrelieved breastfeeding and the knowledging and reporting autoerotic these behaviors. threat of suffocation, itself also associ- behavior among women: a clinician ated with pleasurable sensations (one would be well advised to include fe- males, young or older, in contemplating Etiologic Theories individual described recurrent, dis- the presence of autoerotic behavior. Traditional conceptualizations of AEA turbing childhood dreams to me of be- (and other paraphilias) rely on psycho- ing “smothered by white billows”). Core Dynamics analytic concepts related to Freud’s Resnik did not address nonbreastfed In fully developed AEA, the male enac- theory of psychosexual development. infants; I found no references to AEA tor assumes the role of a willing—or Resnik,6 for example, described AEA as among practitioners who had been unwilling—sacrificial “victim” of a fe- “eroticized repetitive hanging,” noting bottle fed. male who is perceived as being impe- no apparent wish to die and attempts rious and indifferent to the victim’s to ensure that no visible mark would Forensic Pathology struggle to comply with her fantasied be detectable (suggesting conceal- 24 Danto noted that up until 1980, there demands. AEA can thus be understood ment rather than suicidal intent). He was only one report of a female and as a reenactment (or “acting out”) of reviewed other clinicians’ case re- suggested that “the perversion reen- powerful feeling-states originally re- ports and found common themes that acts (on an unconscious basis) the lated to a female (mother or surro- he regarded as “upward displacement male victim’s feelings of emasculation gate). This “plot,” dimly understood if of castration anxiety” (ie, from the pe- by his mother (or via the mechanism of at all by the reenactor, may also repre- nis to the neck); others included oral displacement by another dominant- sent a symbolic death for lustful sadism,21 conflicts over oral incorpo- appearing female) who is seen as a thoughts and guilt-inducing masturba- ration by the mother and issues of sep- powerful woman who controls her tory behavior (ie, punishment before aration/individuation, conflicts over son’s masculinity: if he ”dies“ while he pleasure!). In “surviving” the play- 22 bisexuality, identification of the male is wearing female attire, symbolically acting death ritual, the individual enactor with the aggressor (mother or and on a fantasy level, his (uncon- emerges, time after time, sexually a female surrogate) according to Lo- scious) linkage is that it is his mother gratified and physically intact with a 23 wenstein, and conflicts or guilty anx- who “dies” (ie, is put to death.) In Dan- sense of relief, triumph, and con- iety over masturbation with or without to’s view, the fantasy creator identifies tempt/resentment (ie, “You think I incest fantasies. with the victim. I concur with Danto, have died for you, but actually I killed Resnik speculated that the neonate and an elaboration of this scenario is you!”). AEA also involves a desire for could feel smothered during unre- that when the sacrificial victim be- control over the anxiety of life versus lieved breastfeeding as well as during comes the simultaneous murderer of death: the closer the reenactor ap- breath-holding while crying yet both his heartless seducer, the helpless- proximates yet cheats death, the associated with pleasurable sensa- ness and powerlessness that he him- greater the sexual excitement. It is in- tions. He opined that these might be self once felt is inflicted on her. Wesse- deed a curious state of affairs that the the earliest determinants of the lius and Bally26 described just such a reenactor is the producer, director, search for similar sensations in later case in which hate/rage for both par- choreographer, judge, actors, and wit- life (ie, heightened sensual experi- ents was combined with male–female, ness in his or her unique, personalized

PEDIATRICS Volume 124, Number 5, November 2009 1321 Downloaded from www.aappublications.org/news by guest on September 25, 2021 drama. In essence, AEA reenacts a “life Interventional Options rotid arteries.30 Literary works such as story” of unmanageable childhood Although it is unrealistic to expect gen- “Waiting for Godot” and “Billy Budd” trauma/conflicts. In Freud’s view, the eral pediatricians to become experts could be used in schools as incidental repetition would be a compulsive but in the management of complex biopsy- vehicles to discuss the peril associ- futile attempt to resolve those con- chosocial disorders such as AEA, famil- ated with asphyxial games (in a man- 26 flicts. “Learned helplessness” and de- iarity with this paraphilia will be help- ner that does not encourage experi- moralization could also be temporarily ful in identifying and discouraging mentation but that would be no more 27 relieved by the exhilaration of AEA. child/adolescent choking games that “suggestive” than instruction on “safe sex” and condom use in primary Vicissitudes can progress to fully developed AEA. Uva,28 for example, recommended pre- grades). When opportunities present, The normal developmental process of ventive strategies such as including pediatricians should be encouraged to separation-individuation from parents AEA in national or state electronic speak to youngsters, parents, and can be difficult for a child with a injury data systems, including such teachers about choking games in the controlling, demanding, or possessive practices in school sex education pro- course of advocating other healthy life- mother and with a father or surrogate grams for students and parents, and style choices such as those on nutri- who is devalued, ineffective, passive, discouraging television producers tion, immunizations, exercise, avoid- distant, or hostile. Under such circum- from sensationalizing AEA. She would ance of addicting substances, and stances, the male child’s unhappy, un- also teach mothers of newborns how routine helmet and seatbelt use. stable (unconscious) identification is to breastfeed infants properly to avoid with both a powerful, demanding, and Comorbidities of mood, anxiety, or sub- partial asphyxiation and the hypothe- intimidating female and a distant, stance abuse disorders can “unmask” sized suffocation cycle (a technique threatening, or devalued male; if the paraphilias (AEA) and should be generally taught to mothers who are male child witnesses maternal abuse, treated. Although anlage of AEA are breastfeeding). then the identification with her will most likely found among unmanage- also be one of protectiveness. These In some adult male paraphilics, reduc- able early childhood conflicts that de- identifications are repressed, and the tion of the sex drive with an antiandro- flect and disturb the usual develop- child/adolescent is left with an unsta- gen, such as medroxyprogesterone ac- mental course, they may be repressed ble sense of who he or she “really is.” etate (to lower testosterone levels), by unconscious defense mechanisms. has been used successfully.20 selective Humiliation and debasement also Intercurrent scholastic, peer, or family serotonin reuptake inhibitors, amyl ni- seem important in AEA exemplified by stressors (including violence and trite, and lithium carbonate have been nudity expressing the reenactor’s low abuse) and pubertal hormonal changes used with modest benefit in some self-image (accentuated in adoles- together with idiosyncratic factors in adult paraphilics, perhaps most effec- cence but reflecting narcissism and the child/adolescent can overwhelm tively when attention-deficit disorder, exhibitionism as well) acted out before defenses, and AEA would then be man- a comorbid mood disorder, or obsessive/ a female and a fantasied “witness” ifested. Perhaps these are among the compulsive disorder is present.27,29 It is (father?). The erotic tension is height- reasons that some asphyxial gamers ened when the reenactor fantasizes not recommended that any of these treatments for AEA be used in children develop the full AEA syndrome and oth- that his or her own personal status ers do not. is either superior or inferior to that or adolescents, because no large-scale of the female images (a dominance– double-blind studies have been con- Beyond consciousness-raising and ed- submission scenario). From this per- ducted on medication use for that ucational opportunities, pediatricians spective, pornography is not only an purpose. would be well advised to consult with aid to arousal but also transforms os- Educational content about AEA should child psychiatrists or child psycholo- tensibly bizarre behavior into a veiled be included in medical, nursing, and gists who have experience in treating and poignant replication of highly con- psychology curricula and for residents sexual disorders if additional thera- flicted relationships with key figures in primary care fields, psychiatry, and peutic interventions are thought nec- from that person’s past. Practiced emergency medicine. It should be em- essary. Interruption of a progression long enough, fantasied relationships phasized that choking practices are from choking games to fully developed can erode, replace, or avoid entirely the capable of causing unconsciousness AEA may require not only medication need/desire for a mature relationship of in 7 seconds with as little as 7 pounds for comorbidities but also attention to mutuality with an actual partner. of pressure on the carotid sinus or ca- Burgess’s aforementioned psychoso-

1322 COWELL Downloaded from www.aappublications.org/news by guest on September 25, 2021 ARTICLES cial dimensions of issues for survivors (act out) intense feeling-states derived ucational efforts to lift the veil of si- and those who have observed auto- from distortions of very early develop- lence on these practices would not be erotic behavior but do not know what ment. Whenever and however it be- preventive but rather would lead to to do about it. Longer term treatment gins, sexual exhilaration produced by imitative experimentation by thrill- may consist of individual psychother- hypoxia/anoxia/hypercapnia, identifica- seeking, troubled children or teens. apy for the child/adolescent as well as tion with females by cross-dressing, sa- That premise seems unrealistic, be- psychoeducation and family psycho- domasochistic scenarios, humiliation, cause AEA seems to be more common therapy. This is indicated when one or and debasement, as well as “plot” than previously thought and, like other both parents deny the behavior, feel- embellishments and paraphernalia, high-risk activities among this age ing embarrassed and defensive when seem to be characteristic of AEA, es- group, should be discouraged by med- confronted by this disturbing problem in pecially in males, more so with ad- ical professionals. their offspring. Therapeutic interven- vancing age. tions must be employed skillfully lest pa- The momentary exhilaration that AEA ACKNOWLEDGMENTS rental anger and rejection aggravate the provides often leads to a lifetime of I thank Robert W. Williams, MLS, MA problem, driving the practitioner deeper shame, mystification, self-condemnation, (Associate Professor of Libraries and into his or her solitary reenactments—or self-isolation, and hopelessness that reference librarian, Joan C. Edwards worse. can end in suicide. In recognizing AEA School of Medicine, Marshall Univer- and when possible interrupting its sity), and Trudi F. Jamison (secretary, CONCLUSIONS course, a pediatrician may save a Office of Graduate Medical Education, I believe that AEA represents a compul- young life or at least alleviate a secret Joan C. Edwards School of Medicine) sion to reenact and thereby discharge burden. It has been suggested that ed- for invaluable help. REFERENCES

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