When Self-Pleasuring Becomes Self-Destruction: Autoerotic Asphyxiation Andrew P. Jenkins, Ph.D., CHES, EMT1 1Associate Professor, Health Education, Central Washington University Corresponding author: Andrew P. Jenkins, Associate Professor, Health Education Programs, Central Washington University, Ellensburg, WA 98926, phone: 503.963.1041; email: [email protected] Abstract Autoerotic is presented in literature review form. Etiology, prevalence statistics, and a profile of AEA participants is provided. The author identifies autoerotic asphyxia as a form of sub-intentional suicide. Warning signs of AEA are presented. Possible sources of mis-information are given. Prevention and education recommendations for administrators, faculty, and parents are provided. A suggested reading list is provided. A part time computer programmer and full- many of the common primary components of time mother comes home from the office early autoerotic asphyxia cases. on Friday afternoon to share a video and a The purpose of this article is to provide the reader pizza with her 15 year old son, Lance. His with information regarding this dangerous behavior bedroom seems unusually quiet on this and to provide a framework in which to place it in the afternoon. Absent is the din of his favorite context of adolescent sexuality, suicide, and education. Smashing Pumpkins CD. She saunters down The literature in this area is somewhat limited with the hallway while calling his name, pushes virtually no articles appearing in the health and open his bedroom door and then collapses on education journals directed at prevention of this the floor in a flood of emotions launched by behavior. This paper provides an objective overview a graphic scene displayed in the room before of the behavior, the typical practitioner, a list of her. contemporary sources of AEA information, and some suggestions for AEA prevention and education in Lance’s lifeless, semi-nude, bluish-white body schools. hangs by the neck from the closet rod. The The most common motivation for adolescent AEA floor is littered with pornographic magazines, appears to be thrill seeking and/or sexual a bottle of hand lotion, and several articles of experimentation in combination with a pseudo- women’s underclothing. Though he hangs masochistic fantasy of and pain (Blanchard & from a bar that would only meet him at eye Hucker, 1991). The risk of sudden death may also level, his knees are bent and his full weight serve to increase the sexual pleasure by adding a strong hangs from the Disney necktie he wore to his component of mortal danger. eighth grade graduation. The knot cinched Strangulation is most often applied by a single up to his larynx resembles the bow that one ligature in the form of a noose or slip-knot around the typically uses to ties one’s shoes. The first neck (Hazelwood, 1983). Props, women’s clothing, two fingers of his lifeless right hand still grip pornographic magazines, and sexual aids are nearly one bow of the knot. always present in some degree during AEA behavior Introduction (Clark, 1996, Garza, 1995). Slang terms for AEA are “scarfing” and in sadomasochistic (S&M) and bondage Autoerotic asphyxia (AEA), the practice of using oriented sadomasochistic (BDSM) circles, the terms “breath ” and the definitive “terminal sex” strangulation to enhance the pleasure of masturbating, describe self or partner inflicted sexual asphyxiation annually claims the lives of between 250 and 1,000 (Wiseman, 1998). young American men (Garza-Leal, & Landrom, 1991, Wesselius & Bally, 1983). It is, without question, the Incidence/Prevalence most disturbing and unthinkable of sub-intentional The actual incidence of AEA is likely underreported. adolescent suicides. The case provided above is a According to forensic researchers Burgess and description of an actual incident which represents Hazelwood (1983), teen-aged AEA victims are most

The International Electronic Journal of Health Education, 2000; 3(3):208-216 http://www.iejhe.siu.edu Self-Pleasuring Jenkins often found by parents, or other relatives who, because victims are usually well adjusted, non-depressed, high of the graphic, highly emotional, and often shocking achievers (Uva, 1995). circumstances under which the victims are found, may The Practice clean up or alter the death scene. Additionally, EMS Despite the potential for a fatal episode, suicidal intent personnel and police investigators are often ignorant of is not usually evident. The apparent intent is sexual the signs and indicators of AEA behavior and hence, pleasure not self destruction. Practitioners of AEA the autoerotic asphyxiation case is often officially perform the behavior in order to enhance their sexual reported as an intentional teen suicide (Kirdsy, Holt- pleasure through hypoxic euphoria induced by Ashley, Williamson, & Garza, 1995). Sadly, it may strangulation (Dietz & Halloran, 1993, Lowery, & often be easier for parents and relatives to deal with Wetli, 1982). Normally, the strangulation device is teen suicide resulting from depression or drug abuse used to occlude blood-flow to the brain which creates than from this puzzling form of sexual behavior. varying degrees of hypoxic euphoria, diminished ego Denial and repression on behalf of parents and controls, giddiness, light-headedness, and exhilaration, relatives can be expected and likely contributes to the all of which may enhance sensations and under-reporting of AEA cases (Kirksey, et al. 1995). orgasm intensity (Resnik, 1972). According to LeVay Data from the Centers for Disease Control & (1999), the decreased cerebral blood flow may be Prevention (CDCP) (1991) indicates that suicide rates similar to the acute cerebral hypotension induced by (all types) for young Americans 15-19 years of age the illicit use of amyl and butyl nitrates known as have increased four-fold from 2.7 per 100,000 in 1950 “poppers.” The net effect of these practices is to 11.3 per 100,000 in 1988 and between 1980 and decreased cerebral inhibition of the lower centers of 1992 a total of 67,369 persons aged less that 25 years the brain where sexual feelings are based (LeVay, committed suicide (CDCP, 1995). Suicide is the 1999). The risk of sudden death increases second leading cause of death among young people substantially when AEA behavior involves the ages 15 to 19 years according to the American combined use of inhalents or other drugs and self- Psychiatric Association (2000). is the second strangulation (Gowitt & Hanzlick, 1992). The practice most common method of suicide among males (Baker, of self-strangulation may also induce or enhance O'Neil, & Ginsburg, 1992). . The spontaneous of hanged men When reviewing these data it should be noted that have been observed and documented in erotic and non- AEA deaths represent a significant proportion of the erotic literature for centuries (Joergensen, 1995). overall adolescent suicide rate. Despite the possibility The involvement of the ligature and strangulation of protective family members and misdirected may be symbolic or purely functional. The extent and investigations, conservative estimates place AEA timing of the strangulation may also vary between deaths as high as 6.5 % of adolescent suicides and at AEA practitioners: Some practitioners strangle least 31% of all adolescent (Clark, 1996). themselves throughout the encounter from beginning Therefore, up to 4,379 teens and young adults may through orgasm and beyond while other practitioners have taken their lives in the past decade through the apply the neck ligature initially to induce cerebral practice of autoerotic asphyxia. hypoxia and subsequent euphoria, and then, at the AEA is most commonly seen in adolescent males peak of orgasm, they release the ligature as the flood of 13-20 years of age although cases of female AEA oxygen-laden blood to the brain is said to enhance deaths have been documented (Hazelwood, 1983, orgasm and create an even greater sense of euphoria Byard & Hucker, 1993). The age range spans from 9 and sexual pleasure. to 80 years of age for male practitioners of AEA (Uva, In nearly all cases a “safety” or “escape system” is 1995). Deceased victims of the practice are most often built into the strangulation tool hence, in virtually all white, middle-class unmarried males (Lowery & Wetli, cases of accidental death, it is the failure of the safety 1982). Although one might presume that practitioners mechanism that results in the expiration of the victim of this bizarre and dangerous behavior suffer mental (Garza-Leal & Landron, 1991). Thus, it is the opinion illness, this is usually not the case. The adolescent of the author that AEA should neither be classified nor approached as other forms of adolescent suicide.

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Autoerotic asphyxia therefore, fits best in the accompanying behavior. There does not appear to be classification of sub-intentional suicide, the purposeful sufficient evidence to conclude that practitioners have participation in behaviors which have a high a proclivity toward homosexuality, nor does AEA likelihood of death or serious injury (e.g. DWI, related transvestitism appear to be correlated with “chicken” games, gang fighting, bridge walking, etc.) sexual orientation. AEA practitioners do not appear to (Smith, 1980). Consequently, AEA prevention efforts suffer from gender identity confusion. It may be that should be modified from those used to prevent most some investigators and have become biased in their other forms of adolescent suicide. profile of the average AEA user as a transvestite due to Autoerotic asphyxia is not classified by the the fact that a hanged man in woman’s underclothing American Psychiatric Association (APA) as a separate makes a more obvious and lasting image of autoerotic syndrome or disorder but may best fit the APA asphyxia than subtle cases which may be mistaken for description of paraphilia. The Diagnostic and intentional suicide. Statistical Manual of Mental Disorders (DSM-IV, Distinguishing AEA cases from other suicide 1994) defines as meeting the following cases may at times be difficult. In the early 1980’s FBI criteria: “…recurrent, intense sexually arousing case researchers Hazelwood, Blanchard, and Burgess fantasies, sexual urges, or behaviors generally (1981) identified six defining characteristics of AEA involving 1) non-human objects, 2) the suffering or typical death scenes for use by police investigators: humiliation of oneself or one’s partner, or 3) children 1) Evidence of asphyxia produced by strangulation or other non-consenting persons” (522-523). The term either by ligature or hanging, in which the asphyxiophilia is sometimes used to describe position of the body or presence of protective practitioners of “breath play” but the term does not mean such as padding about the neck, indicate apply exclusively to practitioners of AEA but includes that the death was not obviously intended. sex partners. Dutch forensic researchers have 2) Evidence of a physical mechanism for obtaining supported the classification of accidental AEA deaths or enhancing and dependent on as lethal paraphilia with or without non-lethal either a self-rescue mechanism or the victim’s paraphilia and props (Behrendt & Modvig, 1995). judgement to discontinue its effects. Though AEA is found primarily among males, 3) Evidence of solo sexual activity. females do participate in AEA behaviors as well but in 4) Evidence of sexual fantasy aids, props, or far smaller numbers. There are also differences pornography. between the techniques of male and female 5) Evidence of prior dangerous autoerotic practice. practitioners of AEA. Males tend to use a wider range 6) No apparent suicide intent. (p. 404) of practices, be involved in fetishes, and have a greater Profile of an AEA Victim tendency toward transvestitism and other paraphilias As stated earlier in this paper, most practitioners of than do females (Uva, 1995). Females are more likely AEA are adolescent and young adult males. Seventy to be found naked, and dead from a single ligature percent of AEA victims are under the age of 30 (Uva, around the neck with no special clothing props or 1995). Most AEA practitioners are white, middle class sexual aids other than electric vibrators or non- individuals although Black and Hispanic male case powered dildoes. These differences between the sexes studies have appeared in the literature. Although there may also lead to an underreporting of cases of female are no reliable predictors of AEA behavior, some AEA deaths due to the less obvious evidence of AEA psychologists have postulated a positive correlation behavior among self-strangled females (Byard, Hucker, between a patient history of early child abuse, sexual & Hazelwood, 1990). abuse, and strangulation and AEA behavior (Friedrich Although not all cases of male AEA involve & Gerber, 1994). transvestitism, the wearing of women’s clothing and Apart from a learned association of sexuality and undergarments or using them as props was common in strangulation or sadomasochistic interests, the 26% of male AEA cases investigated by Hazelwood, et behavioral motivations may also be linked to simple al. 1983. Thus, transvestitism in itself should not be thrill seeking which is very common among teens and considered a risk factor to AEA behavior but as an young adults (Uva, 1995). The risk of death and the

The International Electronic Journal of Health Education, 2000; 3(3):208-216 http://www.iejhe.siu.edu 210 Self-Pleasuring Jenkins danger of being caught may in fact enhance the behaviors or symptoms. A single factor by itself may “taboo” nature of masturbation and thus the AEA not warrant concern but if a combination of signs is behavior. Though the practice of self-strangulation is evident, concern is warranted. Warning signs include likely painful and therefore considered masochistic but are not limited to: when combined with sexual self-pleasuring, only 1) unexplained marks on necks 11.8% of deceased AEA victims may be diagnosed as 2) often but not always women’s clothing and/or sexual masochists based on other evidence of their pornography in closet, under bed preference toward masochistic sexual practices 3) short ropes, padded ropes, neckties tied in odd (Hazelwood et al, 1983). As AEA practitioners age knots they are more likely to present multiple paraphilias 4) bloodshot eyes such as bondage and transvestitism according to 5) complaints of headaches Blanchard and Hucker (1991). 6) locks on bedroom doors It should be emphasized that actual suicidal desire Evidence of repetitive hanging such as is lacking in the majority of AEA cases—that there is unexplained marks on the neck or broken or multiple no real desire to die. This fact is most evident from the rope abrasions on closet rods from repeated hangings inclusion of padding of the ligature and the obvious are likely the best and most salient indicators of AEA escape mechanisms such as slip knots and suspension behavior parents and teachers may observe. Parents points lower than the body height (Resnik, 1972). and teachers should also be alert for signs of interest in Additionally, rarely do teen-aged AEA practitioners , and/or bondage and rope play. This engage in suicidal ideations, talk of suicide with loved may appear as a general attitudinal change or a distinct ones, or display any of the typical adolescent suicide proclivity toward outward symbols of bondage/sado- warning signs such as giving away possessions, saying masochism such as heavy rope or leather collars worn good-byes, etc. (American Foundation for Suicide about the neck. Body piercing, while increasingly Prevention , 2000, Jenkins, 1997). Autoerotic popular in fad culture, should not be dismissed entirely asphyxia deaths are nearly always the result of failed for its overt S&M overtones. This is particularly true attempts at self-rescue (Tough, Butt, & Sanders, 1994). for the piercing of sexually sensitive areas such as the Only in a few cases (2% or less) is there actual suicide nipples, labia, and scrotum. intent as evidenced by notes left by the deceased Although AEA behavior in adolescent males is (Hazelwood, Dietz, & Burgess, 1983). Further, suicide thought to be primarily a thrill-seeking behavior, it notes left behind in AEA fatalities may actually be may also be a precursor to the development of a contingency plans in case of accidental death or part of sadomasochistic and/or bondage/ (BDSM) the sadomasochistic fantasy and therefore may not be sexual identity. It should be noted at this juncture that regarded as genuine suicide notes. The possibility, the relative healthfulness of S&M and B&D forms of however, should not be over-looked that the AEA sexual expression have been discussed and debated practitioner may harbor at some level, suicidal intent within the human sexuality literature and thus are (Johnston & Huws, 1997). beyond the scope of this paper. The destructiveness Warning Signs for Parents and and lethality of the link between S&M practices and autoerotic asphyxia should not be ignored. To place it Teachers in perspective, one should note that while not all Parents and teachers should be made aware of warning practitioners of BDSM participate in AEA, all signs of AEA behavior. Note that with the exception deceased practitioners of AEA died as a result of of ligature marks on the neck, each of these signs bondage behaviors. should be taken in light of other signs and related

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Dangerous Education potentially dangerous information on the World Wide Masturbation is generally a solitary behavior and is not Web is available and copius. Investigation for this widely discussed between teenagers. Accompanying paper uncovered WWW website articles titles, Please fetishes paraphilia are less likely to be talked about. Be Tender When You Cut Me Down, “When All is Said Nonetheless, word of mouth remains one of the more and Done, Life Kills Your Ass,” (Society for Human common ways young adults learn of autoerotic Sexuality, 1998) and alluring advertisements for the asphyxia (Winterburn, 1991). In addition to peers, book, “SM 101: A Realistic Introduction” (Wiseman, pornography and non-pornographic magazines, 1998). television, and movies are all possible sources for Some websites such as one titled “Black Plague” sexual information and misinformation (Li, & Davey, feature collections of hundreds of grizzly images of 1996. These media may also present intentional and death, hangings, and openly extol the “pleasures” of non-intentional promotions of AEA. A decade ago, and sexual behaviors that lead to death some investigators expressed concern regarding which is euphemistically called “snuffing” televised portrayals and reports of AEA in that (Blackplague, 1998). However, in many instances, the resultant “copycat” strangulations may occur (Dietz, sexual pleasure and death connection is neither skirted 1989, O’Halloran & Lovell, 1988). In 1987 nor clouded in euphemisms. One essay, found at the magazine was sued for contributing to the death of an Black Plague (1998 website professes that adolescent boy who read the feature article, “Orgasm “…being reminded of death should be erotic of Death” in Hustler magazine. According to court for most of us. We should get moist and hot reports, he was found dead, hanging nude from his and hard at the thought of it.” and regarding closet rod with an issue of Hustler magazine open to orgasm, “One has only to take a small the article which described in detail the procedure and further step to recognize that this pleasures to be achieved from autoerotic asphyxia transcendence of time and space is a form of (Turner, 1998). psychic death. To be swallowed up by Presently, with more children watching blackness is an exquisite pleasure. It is to increasingly more hours of television without the know ecstasy, but it is also to die.” benefit of adult supervision and interpretation, the risk of teens seeing TV programs, videos, or reading While this sort of macabre erotic essay may be magazine features that involve AEA, experimenting intended for adult readers, it can easily be accessed and with AEA and other thrill seeking behaviors is a internalized by adolescent viewers who may be reasonable cause for concern. Even the renowned searching for answers to questions they may have AEA researcher Robert Hazelwood has come forward about their emerging and often confusing new sense of to denounce the use of television as a medium for sexuality. education about AEA; so high is the risk of mis- Although many of these websites and web-based education of teens in the behavior (Hazelwood, 1989). articles may include mention of the dangers of AEA, The most contemporary source of AEA they give a much more persuasive and appealing information may be Internet. With the prevalence of message regarding the possible benefits and pleasures home computers and teen-aged World Wide Web of the behavior with descriptions of “orgasmic (WWW) access increasing daily comes the risk of mis- fulfillment,” and “extreme pleasure” and extol the education through the WWW. As disturbing as it may pleasurable benefits of bondage and rope play websites seem to most parents and educators, there are even solicit and encourage the sharing of stories such numerous world wide websites dedicated to sexual as “Did anyone have any good bondage experiences sadomasochism, fetishism, and other sexual paraphilia while growing up?” (Stories, 1998) all of which may including autoerotic asphyxia. Currently, the WWW serve to educate and legitimize the association of search engine Yahoo produces over 550 “hits” when strangulation and sexuality. The inexperienced the simple term “bondage” is entered in its search adolescent mind and libido may be unable to mode. Some BDSM sites even advertise openly, distinguish between sexual fantasy and reality, sexual “Newbies welcome” (KPOG, 1998). Clearly, access to titillation and actual sexual practice.

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Prevention community education may be the most effective In light of the fact that risk-taking plays a significant preventative strategy for health educators to coordinate part in the appeal of AEA behavior, any warnings and implement to lower the incidence of this self- found in erotic magazines or at erotic websites may destructive practice. actually serve to promote AEA behavior and at the Although AEA involves components of sexual very least, they are likely as ineffective as warning behavior, it is the opinion of the author that AEA labels on cigarette packages at dissuading adolescent prevention education is best presented as part of males from smoking. It may therefore be prudent to suicide prevention lessons as part of a comprehensive direct educational efforts as much toward parents and health education program. Presenting AEA as part of school personnel as to adolescents who may, a section on sexuality may lead to a misunderstanding inadvertently, be inspired to experiment with the that AEA is an innocuous variation of expression of behaviors. This tentative assumption has been human sexuality and not an extremely dangerous previously presented in health education literature behavior. At best, AEA results in brain damage (Betchtel, Westerfield, & Eddy, 1990, McNab, 1986) secondary to cerebral hypoxia and at worse, it results though no specific program reviews have yet been in death. It should be stressed to young adults that published in the common health education journals. AEA can not be practiced safely and without Prevention of website visitations by students may be immediate harm and impending death. Therefore it near impossible without close monitoring by teachers. may be most prudent to present AEA prevention There are several screening softwares and services education from the standpoint of safety, risk reduction, available such as Bess (Bess, 1998), Safeplaces and sub-intentional suicide prevention. (Safeplaces, 1998), Searcholpolis (1998), and Parent and teacher association meetings which Surfwatch (Surfwatch, 1999) but the effectiveness of focus on the warning signs and symptoms, as well as these programs is still limited and should not be the relative risk of mis-education, should be organized. expected to take the place of adult supervision. Guest speakers who specialize in sexual paraphilia High school students and others often discover may be helpful as well as police detectives and autoerotic asphyxia quite by accident in American representatives from local ’s offices. Do not literature. Autoerotic asphyxia is described in the assume, however, that specialists in general counseling classic play by Samual Beckett (1954) “Waiting for possess expertise in this area. Be certain to inquire Godot” where the character Estragon suggests to directly regarding their experience and background in Vladimir, “What about hanging ourselves?” and autoerotic asphyxia. Further, it is the opinion of this Vladimir responds, “Hmmm. It’d give us an author, that no health educator and/or PTA personnel erection.” Some discussion follows between the two attempt to broach the etiology of this tragic and bizarre characters and then Estragon exclaims, “Let’s hang paraphilia before expanding their own educational ourselves immediately!” Although the Beckett’s intent background in autoerotic asphyxia less they themselves with this dialog was likely humor and farce, this scene become unknowing purveyors of mis-education and may serve to idealize the erotic aspects of self-hanging unwarranted fears. to the adolescent student. Practitioners who are discovered by teachers or Certainly, student oriented education aimed at parents should receive immediate counseling and/or preventing or lowering risks to AEA behavior should therapy. In some cases mere sexual experimentation be presented in the health education classroom and adolescent risk taking are the only behaviors however, there are significant and feasible venues in involved but in other cases, the development of AEA other secondary school classes. Rather than sheltering paraphilia is much complex and may require more students from the aforementioned scene in Becket’s extensive psychotherapy. Treatment of AEA play, Waiting for Godot, it could be used as an paraphilia may include drug treatment in addition to opportunity for the drama and health education psychotherapy. Some limited success has been seen teachers to combine efforts to reveal the realities of with the use of psychotherapeutic drugs such as AEA behavior. This type of in-class, cross-curricular lithium carbonate in the treatment of AEA paraphilia education in combination with parental and disorder (Cesnik & Coleman, 1989).

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The following reading list is offered as a point of Blanchard, R., & Hucker, S.J (September, 1991). beginning for professional preparation for teacher, Age, transvestitism, bondage, and concurrent student, and parent education. Well-designed public paraphilic activities in 117 cases of autoerotic and school educational efforts based on accurate asphyxia. British Journal of Psychiatry, 159, 371-377. information is likely the best way to control this tragic Byard, R.W., Hucker, S.J., & Hazelwood, R. R form of sub-intentional suicide among teenagers. (March 1993). Fatal and near-fatal autoerotic Suggested Reading List asphyxia episodes in women. American Journal of Bechtel, L. S., Westerfield, C., & Eddy, J. M. Forensic Pathology, 14(1) 70-73. (1990). Autoerotic fatalities: Implications for health Byard, R.W., Hucker, S.J., & Hazelwood, R. R. educators, Journal of Health Education, 21(1), 38-42. (December, 1990). A comparison of typical death Ernulf, K. E., Innala, S. M. (December, 1995). scene features in cases of fatal male and female Sexual bondage: A review and unobtrusive autoerotic asphyxia with a review of the literature, investigation, Archives of Sexual Behavior, 24(6) 631- Forensic Science International, 48(2), 113-21. 647. Behrendt, N. & Modvig, J. (September, 1995). Hazelwood, R.R., Dietz, P., & Burgess, A. (1983). The lethal paraphiliac syndrome: accidental autoerotic Autoerotic fatalities, Lexington, MA: Lexington deaths in Denmark 1933-1990. American Journal of Books. Forensic Medical Pathology, 16(3). Turvey, B.E. (1995). An objective overview of Burgess, A. W. & Hazelwood, R. R. (1983). autoerotic fatalities. Available from Knowledge Autoerotic asphyxial deaths and social network Solutions, 1271 Washington Avenue #274, San response, American Journal of Orthopsychiatics, Leandro, CA 94577-3646 or at WWW.corpus- 53(1), 166-171. delicti.com/auto.html. Cesnik, J.A., & Coleman, E. (1989). Use of lithium carbonate in the treatment of autoerotic References asphyxia. American Journal of Psychotherapy, 43(2). American Foundation for Suicide Prevention Centers for Disease Control & Prevention (2000) [WWW site]. URL http://www.afsp.org/index- (September 20, 1991). Attempted suicide among high 1.htm (visited March 28, 2000). school students in the United States, 1990, Mortality American Psychiatric Association (1994). The and Morbidity Report, 40(37), 633-635. Diagnostic and Statistical Manual of Mental Centers for Disease Control & Prevention (April Disorders, Fourth Ed. American Psychiatric 21,1995). Suicide among children, adolescents, and Association, Washington, DC. young adults in the United States, 1980--1992, American Psychiatric Association (2000). Teen Mortality and Morbidity Report, 44(15),. suicide at APA On-Line [WWW site]. URL Clark, M. (January, 1996). The autoerotic http://www.psych.org/public_info/teen.html (visited asphyxiation syndrome in adolescent and young adult March 27, 2000). males, [WWW document] . URL Baker SP, O'Neill B, Ginsburg M. (1992). The http://members.aol.com/bj022038/index.html (visited injury fact book. New York: Oxford University Press. 1998, June 2). Bechtel, L. S., Westerfield, C., & Eddy, J. M. Dietz, P. E., & O’Halloran, R. (1993). Autoerotic (1990). Autoerotic fatalities: Implications for health fatalities with power hydraulics, Journal of Forensic educators, Journal of Health Education, 21(1), 38-42. Sciences, 2:359-364. Beckett, S. (1954). Waiting for Godot. New Dietz, P. E (1989). Televised inspired autoerotic York: Grove Press. asphyxiation, Journal of Forensic Sciences, 34(3), 58. Bess, (1998). An internet retriever for kids, Friedrich, W., & Gerber, P. (September, 1994). families, and schools. [WWW site]. URL Auterotic asphyxia: the development of a paraphilia. http://www.bess.net (visited November 18, 1998). Journal of the Academy of Child and Adolescent Black Plague (1998) Black Plague Website Psychiatry, 33(7), 970-974. [WWW site]. URL http://www.blackplague.org Garza-Leal, J.A., & Landron, F.J. (Nov., 1991). (visited September 22, 1998). Autoerotic asphyxial death initially misinterpreted as

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