Autoerotic asphyxia 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 misinformation 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-time mother comes home from the office early on Friday afternoon to share a video and a pizza with her 15 year old son, Lance. His bedroom seems unusually quiet on this afternoon. Absent is the din of his favourite Smashing Pumpkins CD. She saunters down the hallway while calling his name, pushes open his bedroom door and then collapses on the floor in a flood of emotions launched by a graphic scene displayed in the room before her.

Lance's lifeless, semi-nude, bluish-white body hangs by the neck from the closet rod. The floor is littered with pornographic magazines, a bottle of hand lotion, and several articles of women's underclothing. Though he hangs from a bar that would only meet him at eye level, his knees are bent and his full weight hangs from the Disney necktie he wore to his eighth grade graduation. The knot cinched up to his larynx resembles the bow that one typically uses to ties one's shoes. The first two fingers of his lifeless right hand still grip one bow of the knot.

Introduction

Autoerotic asphyxia (AeA), the practice of using strangulation to enhance the pleasure of masturbating, annually claims the lives of between 250 and 1,000 young American men (Garza-Leal, & Landrom, 1991, Wesselius & Bally, 1983). It is, without question, the most disturbing and unthinkable of sub-intentional adolescent suicides. The case provided above is a description of an actual incident which represents many of the common primary components of autoerotic asphyxia cases.

The purpose of this article is to provide the reader with information regarding this dangerous behaviour and to provide a framework in which to place it in the context of adolescent sexuality, suicide, and education. The literature in this area is somewhat limited with virtually no articles appearing in the health and education journals directed at prevention of this behaviour. This paper provides an objective overview of the behaviour, the typical practitioner, a list of contemporary sources of AeA information, and some suggestions for AeA prevention and education in schools.

The most common motivation for adolescent AeA appears to be thrill seeking and/or sexual experimentation in combination with a pseudo-masochistic fantasy of bondage and pain (Blanchard & Hucker, 1991). The risk of sudden death may also serve to increase the sexual pleasure by adding a strong component of mortal danger.

Strangulation is most often applied by a single ligature in the form of a noose or slip-knot around the neck (Hazelwood, 1983). Props, women's clothing, pornographic magazines, and sexual aids are nearly always present in some degree during AeA behavior (Clark, 1996, Garza, 1995). Slang terms for AeA are "scarfing" and in sadomasochistic (S&M) and bondage oriented sadomasochistic (BDSM) circles, the terms "breath play" and the definitive "terminal sex" describe self or partner inflicted sexual asphyxiation (Wiseman, 1998).

Incidence/Prevalence

The actual incidence of AeA is likely underreported. According to forensic researchers Burgess and Hazelwood (1983), teen-aged AeA victims are most often found by parents, or other relatives who, because of the graphic, highly emotional, and often shocking circumstances under which the victims are found, may clean up or alter the death scene. Additionally, EMS personnel and police investigators are often ignorant of the signs and indicators of AeA behaviour and hence, the autoerotic asphyxiation case is often officially reported as an intentional teen suicide (Kirdsy, Holt-Ashley, Williamson, & Garza, 1995). Sadly, it may often be easier for parents and relatives to deal with teen suicide resulting from depression or drug abuse than from this puzzling form of sexual behaviour. Denial and repression on behalf of parents and relatives can be expected and likely contributes to the under-reporting of AeA cases (Kirksey, et al. 1995).

Data from the Centers for Disease Control & Prevention (CDCP) (1991) indicates that suicide rates (all types) for young Americans 15-19 years of age have increased four-fold from 2.7 per 100,000 in 1950 to 11.3 per 100,000 in 1988 and between 1980 and 1992 a total of 67,369 persons aged less that 25 years died by suicide (CDCP, 1995). Suicide is the second leading cause of death among young people ages 15 to 19 years according to the American Psychiatric Association (2000). Hanging is the second most common method of suicide among males (Baker, O'Neil, & Ginsburg, 1992).

When reviewing these data it should be noted that AeA deaths represent a significant proportion of the overall adolescent suicide rate. Despite the possibility of protective family members and misdirected investigations, conservative estimates place AeA deaths as high as 6.5 % of adolescent suicides and at least 31% of all adolescent hangings (Clark, 1996). Therefore, up to 4,379 teens and young adults may have taken their lives in the past decade through the practice of autoerotic asphyxia.

AeA is most commonly seen in adolescent males 13-20 years of age although cases of female AeA deaths have been documented (Hazelwood, 1983, Byard & Hucker, 1993). The age range spans from 9 to 80 years of age for male practitioners of AeA (Uva, 1995). Deceased victims of the practice are most often white, middle-class unmarried males (Lowery & Wetli, 1982). Although one might presume that practitioners of this bizarre and dangerous behaviour suffer mental illness, this is usually not the case. The adolescent victims are usually well adjusted, non-depressed, high achievers (Uva, 1995).

The Practice

Despite the potential for a fatal episode, suicidal intent is not usually evident. The apparent intent is sexual pleasure not self destruction. Practitioners of AeA perform the behaviour in order to enhance their sexual pleasure through hypoxic euphoria induced by strangulation (Dietz & Halloran, 1993, Lowery, & Wetli, 1982). Normally, the strangulation device is used to occlude blood-flow to the brain which creates varying degrees of hypoxic euphoria, diminished ego controls, giddiness, light-headedness, and exhilaration, all of which may enhance masturbation sensations and orgasm intensity (Resnik, 1972). According to LeVay (1999), the decreased cerebral blood flow may be similar to the acute cerebral hypotension induced by the illicit use of amyl and butyl nitrates known as "poppers." The net effect of these practices is decreased cerebral inhibition of the lower centers of the brain where sexual feelings are based (LeVay, 1999). The risk of sudden death increases substantially when AeA behaviour involves the combined use of inhalents or other drugs and self-strangulation (Gowitt & Hanzlick, 1992). The practice of self-strangulation may also induce or enhance erection. The spontaneous erections of hanged men have been observed and documented in erotic and non-erotic literature for centuries (Joergensen, 1995).

The involvement of the ligature and strangulation may be symbolic or purely functional. The extent and timing of the strangulation may also vary between AeA practitioners: Some practitioners strangle themselves throughout the encounter from beginning through orgasm and beyond while other practitioners apply the neck ligature initially to induce cerebral hypoxia and subsequent euphoria, and then, at the peak of orgasm, they release the ligature as the flood of oxygen-laden blood to the brain is said to enhance orgasm and create an even greater sense of euphoria and sexual pleasure.

In nearly all cases a "safety" or "escape system" is built into the strangulation tool hence, in virtually all cases of accidental death, it is the failure of the safety mechanism that results in the expiration of the victim (Garza-Leal & Landron, 1991). Thus, it is the opinion of the author that AeA should neither be classified nor approached as other forms of adolescent suicide. Autoerotic asphyxia therefore, fits best in the classification of sub-intentional suicide, the purposeful participation in behaviours which have a high likelihood of death or serious injury (e.g. DWI, "chicken" games, gang fighting, bridge walking, etc.) (Smith, 1980). Consequently, AeA prevention efforts should be modified from those used to prevent most other forms of adolescent suicide.

Autoerotic asphyxia is not classified by the American Psychiatric Association (APA) as a separate syndrome or disorder but may best fit the APA description of paraphilia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) defines paraphilias as meeting the following criteria: "recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) non-human objects, 2) the suffering or humiliation of oneself or one's partner, or 3) children or other non-consenting persons" (522-523). The term asphyxiophilia is sometimes used to describe practitioners of "breath play" but the term does not apply exclusively to practitioners of AeA but includes sex partners. Dutch forensic researchers have supported the classification of accidental AeA deaths as lethal paraphilia with or without non-lethal paraphilia and props (Behrendt & Modvig, 1995).

Though AeA is found primarily among males, females do participate in AeA behaviours as well but in far smaller numbers. There are also differences between the techniques of male and female practitioners of AeA. Males tend to use a wider range of practices, be involved in fetishes, and have a greater tendency toward transvestitism and other paraphilias than do females (Uva, 1995). Females are more likely to be found naked, and dead from a single ligature around the neck with no special clothing props or sexual aids other than electric vibrators or non-powered dildoes. These differences between the sexes may also lead to an underreporting of cases of female AeA deaths due to the less obvious evidence of AeA behaviour among self-strangled females (Byard, Hucker, & Hazelwood, 1990).

Although not all cases of male AeA involve transvestitism, the wearing of women's clothing and undergarments or using them as props was common in 26% of male AeA cases investigated by Hazelwood, et al. 1983. Thus, transvestitism in itself should not be considered a risk factor to AeA behaviour but as an accompanying behaviour. There does not appear to be sufficient evidence to conclude that practitioners have a proclivity toward homosexuality, nor does AeA related transvestitism appear to be correlated with sexual orientation. AeA practitioners do not appear to suffer from gender identity confusion. It may be that some investigators and have become biased in their profile of the average AeA user as a transvestite due to the fact that a hanged man in woman's underclothing makes a more obvious and lasting image of autoerotic asphyxia than subtle cases which may be mistaken for intentional suicide.

Distinguishing AeA cases from other suicide cases may at times be difficult. In the early 1980's FBI cases researchers Hazelwood, Blanchard, and Burgess (1981) identified six defining characteristics of AeA typical death scenes for use by police investigators:

   1.      Evidence of asphyxia produced by strangulation either by ligature or hanging, in which the position of the body or presence of protective mean such as padding about the neck, indicate that the death was not obviously intended.

   2.      Evidence of a physical mechanism for obtaining or enhancing sexual arousal and dependent on either a self-rescue mechanism or the victim's judgement to discontinue its effects.

   3.      Evidence of solo sexual activity.

   4.      Evidence of sexual fantasy aids, props, or pornography.

   5.      Evidence of prior dangerous autoerotic practice.

   6.      No apparent suicide intent. (p. 404)

Profile of an AeA Victim

As stated earlier in this paper, most practitioners of AeA are adolescent and young adult males. Seventy percent of AeA victims are under the age of 30 (Uva, 1995). Most AeA practitioners are white, middle class individuals although Black and Hispanic male case studies have appeared in the literature. Although there are no reliable predictors of AeA behaviour, some psychologists have postulated a positive correlation between a patient history of early child abuse, sexual abuse, and strangulation and AeA behaviour (Friedrich & Gerber, 1994).

Apart from a learned association of sexuality and strangulation or sadomasochistic interests, the behavioural motivations may also be linked to simple thrill seeking which is very common among teens and young adults (Uva, 1995). The risk of death and the danger of being caught may in fact enhance the "taboo" nature of masturbation and thus the AeA behaviour. Though the practice of self-strangulation is likely painful and therefore considered masochistic when combined with sexual self-pleasuring, only 11.8% of deceased AeA victims may be diagnosed as sexual masochists based on other evidence of their preference toward masochistic sexual practices (Hazelwood et al, 1983). As AeA practitioners age they are more likely to present multiple paraphilias such as bondage and transvestitism according to Blanchard and Hucker (1991).

It should be emphasized that actual suicidal desire is lacking in the majority of AeA cases that there is no real desire to die. This fact is most evident from the inclusion of padding of the ligature and the obvious escape mechanisms such as slip knots and suspension points lower than the body height (Resnik, 1972). Additionally, rarely do teen-aged AeA practitioners engage in suicidal ideations, talk of suicide with loved ones, or display any of the typical adolescent suicide warning signs such as giving away possessions, saying good-byes, etc. (American Foundation for Suicide Prevention , 2000, Jenkins, 1997). Autoerotic asphyxia deaths are nearly always the result of failed attempts at self-rescue (Tough, Butt, & Sanders, 1994). Only in a few cases (2% or less) is there actual suicide intent as evidenced by notes left by the deceased (Hazelwood, Dietz, & Burgess, 1983). Further, suicide notes left behind in AeA fatalities may actually be contingency plans in case of accidental death or part of the sadomasochistic fantasy and therefore may not be regarded as genuine suicide notes. The possibility, however, should not be over-looked that the AeA practitioner may harbour at some level, suicidal intent (Johnston & Huws, 1997).

Warning Signs for Parents and Teachers

Parents and teachers should be made aware of warning signs of AeA behaviour. Note that with the exception of ligature marks on the neck, each of these signs should be taken in light of other signs and related behaviours or symptoms. A single factor by itself may not warrant concern but if a combination of signs is evident, concern is warranted. Warning signs include but are not limited to:

1) unexplained marks on necks

   1.      often but not always women's clothing and/or pornography in closet, under bed
   2.      short ropes, padded ropes, neckties tied in odd knots
   3.      bloodshot eyes
   4.      complaints of headaches
   5.      locks on bedroom doors

Evidence of repetitive hanging such as unexplained marks on the neck or broken or multiple rope abrasion on closet rods from repeated hangings are likely the best and most salient indicators of AeA behaviour for parents and teachers to be aware of. Parents and teachers should also be alert for signs of interest in sadomasochism, and/or bondage and rope play. This may appear as a general attitudinal change or a distinct proclivity toward outward symbols of bondage/sado-masochism such as heavy rope or leather collars worn about the neck. Body piercing, while increasingly popular in fad culture, should not be dismissed entirely for its overt S&M overtones. This is particularly true for the piercing of sexually sensitive areas such as the nipples, labia, and scrotum.

Although AeA behaviour in adolescent males is thought to be primarily a thrill-seeking behaviour, it may also be a precursor to the development of a sadomasochistic and/or bondage/discipline (BDSM) sexual identity. It should be noted at this juncture that the relative healthfulness of S&M and B&D forms of sexual expression have been discussed and debated within the human sexuality literature and thus are beyond the scope of this paper. The destructiveness and lethality of the link between S&M practices and autoerotic asphyxia should not be ignored. To place it in perspective, one should note that while not all practitioners of BDSM participate in AeA, all deceased practitioners of AeA died as a result of bondage behaviours.

Dangerous Education

Masturbation is generally a solitary behaviour and is not widely about between teenagers. Accompanying fetishes paraphilia are less likely to be talked about. Nonetheless, word of mouth remains one of the more common ways young adults learn of autoerotic asphyxia (Winterburn, 1991). In addition to peers, pornography and non-pornographic magazines, television, and movies are all possible sources for sexual information and misinformation (Li, & Davey, 1996. These media may also present intentional and non-intentional promotions of AeA. A decade ago, some investigators expressed concern regarding televised portrayals and reports of AeA in that resultant "copycat" strangulations may occur (Dietz, 1989, O'Halloran & Lovell, 1988). In 1987 Hustler magazine was sued for contributing to the death of an adolescent boy who read the feature article, "Orgasm of Death" in Hustler magazine. According to court reports, he was found dead, hanging nude from his closet rod with an issue of Hustler magazine open to the article which described in detail the procedure and pleasures to be achieved from autoerotic asphyxia (Turner, 1998).

Presently, with more children watching increasingly more hours of television without the benefit of adult supervision and interpretation, the risk in the 1990's of teens seeing TV programs, videos, or reading magazine features that involve AeA, experimenting with AeA and other thrill seeking behaviours is a reasonable cause for concern. Even the renowned AeA researcher Robert Hazelwood has even come forward to denounce the use of television as a medium for education about AeA; so high is the risk of mis-education of teens in the behaviour (Hazelwood, 1989).

The most contemporary source of AeA information may be Internet. With the prevalence of home computers and teen-aged World Wide Web (WWW) access increasing daily comes the risk of mis-education through the WWW. As disturbing as it may seem to most parents and educators, there are numerous world wide websites dedicated to sexual sadomasochism, fetishism, and other sexual paraphilia including autoerotic asphyxia. The WWW search engine Yahoo provides 377 "hits" when the simple term "bondage" is entered in its search mode. Some BDSM sites even advertise openly, "Newbies welcome" (KPOG, 1998). Clearly, access to potentially dangerous information on the World Wide Web is available and copius. Investigation for this paper uncovered WWW website articles titles, Please Be Tender When You Cut Me Down, "When All is Said and Done, Life Kills Your Ass," (Society for Human Sexuality, 1998) and alluring advertisements for the book, "SM 101: A Realistic Introduction" (Wiseman, 1998).

Some websites such as one titled "Black Plague" feature collections of hundreds of grizzly images of death, hangings, and openly extol the "pleasures" of necrophilia and sexual behaviours that lead to death which is euphemistically called "snuffing" (Blackplague, 1998). However, in many instances, the sexual pleasure and death connection is neither skirted nor clouded in euphemisms at some websites. One essay, found at the Black Plague (1998 website professes that

      "being reminded of death should be erotic for most of us. We should get moist and hot and hard at the thought of it." and regarding orgasm, "One has only to take a small further step to recognize that this transcendence of time and space is a form of psychic death. To be swallowed up by blackness is an exquisite pleasure. It is to know ecstasy, but it is also to die."

While this sort of macabre erotic essay may be intended for adult readers, it can easily be accessed and internalized by adolescent viewers who may be searching for answers to questions they may have about their emerging and often confusing new sense of sexuality.

Although many of these websites and web-based articles may include mention of the dangers of AeA, they give a much more persuasive and appealing message regarding the possible benefits and pleasures of the behaviour with descriptions of "orgasmic fulfillment," and "extreme pleasure" and extol the pleasurable benefits of bondage and rope play websites even solicit and encourage the sharing of stories such as "Did anyone have any good bondage experiences while growing up?" (Stories, 1998) all of which may serve to educate and legitimize the association of strangulation and sexuality. The inexperienced adolescent mind and libido may be unable to distinguish between sexual fantasy and reality, sexual titillation and actual sexual practice.

Prevention

In light of the fact that risk-taking plays a significant part in the appeal of AeA behaviour, any warnings found in erotic magazines or at erotic websites may actually serve to promote AeA behaviour and at the very least, they are likely as ineffective as warning labels on cigarette packages at dissuading adolescent males from smoking. It may therefore be prudent to direct educational efforts as much toward parents and school personnel as to adolescents who may, inadvertently, be inspired to experiment with the behaviours. This tentative assumption has been previously presented in health education literature (Betchtel, Westerfield, & Eddy, 1990, McNab, 1986) though no specific program reviews have yet been published in the common health education journals. Prevention of website visitations by students may be near impossible without close monitoring by teachers. There are several screening softwares and services available such as Bess (Bess, 1998), Safeplaces (Safeplaces, 1998), Searcholpolis (1998), and Surfwatch (Surfwatch, 1999) but the effectiveness of these programs is still limited and should not be expected to take the place of adult supervision.

High school students and others often discover autoerotic asphyxia quite by accident in American literature. Autoerotic asphyxia is described in the classic play by Samual Beckett (1954) "Waiting for Godot" where the character Estragon suggests to Vladimir, "What about hanging ourselves?" and Vladimir responds, "Hmmm. It'd give us an erection." Some discussion follows between the two characters and then Estragon exclaims, "Let's hang ourselves immediately!" Although the Beckett's intent with this dialog was likely humour and farce, this scene may serve to idealize the erotic aspects of self-hanging to the adolescent student.

Certainly, student oriented education aimed at preventing or lowering risks to AeA behaviour should be presented in the health education classroom however, there are significant and feasible venues in other secondary school classes. Rather than sheltering students from the aforementioned scene in Becket's play, Waiting for Godot, it could be used as an opportunity for the drama and health education teachers to combine efforts to reveal the realities of AeA behaviour. This type of in-class, cross-curricular education in combination with parental and community education may be the most effective preventative strategy for health educators to coordinate and implement to lower the incidence of this self-destructive practice.

Although AeA involves components of sexual behaviour, it is the opinion of the author that AeA prevention education is best presented as part of suicide prevention lessons as part of a comprehensive health education program. Presenting AeA as part of a section on sexuality may lead to a misunderstanding that AeA is an innocuous variation of expression of human sexuality and not an extremely dangerous behaviour. At best, AeA results in brain damage secondary to cerebral hypoxia and at worse, it results in death. It should be stressed to young adults that AeA can not be practiced safely and without immediate harm and impending death. Therefore it may be best to present AeA prevention education from the standpoint of safety, risk reduction, and sub-intentional suicide prevention.

Parent and teacher association meetings, which focus on the warning signs and symptoms, as well as the relative risk of mis-education, should be organized. Guest speakers who specialize in sexual paraphilia may be helpful as well as police detectives and representatives from local coroner's offices. Do not assume, however, that specialists in general counselling possess expertise in this area. Be certain to inquire directly regarding their experience and background in autoerotic asphyxia. Further, it is the opinion of this author, that no health educator and/or PTA personnel attempt to broach the etiology of this tragic and bizarre paraphilia before expanding their own their educational background in autoerotic asphyxia less they themselves become unknowing purveyors of mis-education and unwarranted fears.

Practitioners who are discovered by teachers or parents should receive immediate counselling and/or therapy. In some cases mere sexual experimentation and adolescent risk taking are the only behaviours involved but in other cases, the development of AeA paraphilia is much complex and may require more extensive psychotherapy. Treatment of AeA paraphilia may include drug treatment in addition to psychotherapy. Some limited success has been seen with the use of psychotherapeutic drugs such as lithium carbonate in the treatment of AeA paraphilia disorder (Cesnik & Coleman, 1989).

The following reading list is offered as a point of beginning for professional preparation for teacher, student, and parent education. Well-designed public and school educational efforts based on accurate information is likely the best way to control this tragic form of sub-intentional suicide among teenagers.

This paper was presented at the American Alliance for Health, PE, Recreation and Dance National Conference and Exposition on March 25, 2000 in Orlando Florida. It was also published and copy written in the International Electronic Journal of Health Education.