Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CONTENTS
LISTE OF TABLES
ACKNOWLEDGMENTS
1.0 ABSTRACT
3.0 INTRODUCTION
7
8
9
12
16
18
21
4.0 RESULTS
4.1
4.2
4.3
4.4
4.5
23
28
32
36
41
5.0 DISCUSSION
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
Etiologic theories
Sociological view: the ordeal or radical confrontation with death
Confrontation with risk in adolescence
Childhood rope syndrome
Part of same syndrome
Risk of death
Limitations
Recommendations
6.0 REFERENCES
44
46
48
51
52
61
63
65
67
LIST OF TABLES
14
21
27
28
28
30
32
34
35
38
41
Table 12: Comparison between fatal cases of autoerotic asphyxia and asphyxial games
43
Acknowledgments:
My sincere thanks to Professor Peter Vanezis for his commitment and dedication
as a teacher in each of his presentations during the program, for sharing his experience
and knowledge in the practice of autopsies and for his guidance in addressing the subject
of this dissertation. It is an honor to have been a pupil of the highest authority in the field
of forensic pathology in the UK. Thanks to the entire faculty of the Masters program and
at Barts and the London School of Medicine and Dentistry; to life for giving me a second
chance and allowing me to grow personally, academically and professionally during my
year at fascinating London.
1.0 ABSTRACT
OBJECTIVES: Unintentional asphyxia among preadolescents and adolescents by compression of the
neck and other means of inducing hypoxia / anoxia in order to get exhilarating effects are not new or
uncommon behaviors and can lead to death by accident. Medical science has described autoerotic
asphyxiation and more recently asphyxial games choking games as different entities. This study
addresses both behaviors to understand the characteristics of how these practices are presented as well
as the risks factors to them in order to determine if there are substantial differences between the two
practices, or if instead they are related behaviors. Accurate knowledge of these behaviors based on
scientific evidence will facilitate the understanding of the etiology and manifested features and
facilitate the implementation of preventive measures to avoid such deaths.
METHODS: A retrospective study of fatal cases published in recognized scientific journal articles of
both autoerotic asphyxiation and choking game behaviors in the adolescent population was made.
Articles on sociology, psychoanalysis and psychiatry as well as studies previously published case
series and epidemiological studies to assess student population etiological factors and risk factors
associated with behaviors were included in this review. Features of both behaviors, such as
prevalence, age distribution, gender, type of asphyxia and place of occurrence are presented.
RESULTS: The results are consistent in all variables analyzed for both behaviors. Most practitioners
are men. Cases of both behaviors in preadolescence show a tendency to increase with age. The most
frequent type of asphyxia identified was hanging conducted in private quarters. Psychiatric and
psychoanalytic literature identifies common elements between male castration complex, failed oral
psychosexual development and the practice of asphyxia in its integration with sociological theories of
risk and confrontation ordeal in adolescence. The review of epidemiological studies reveals common
elements in the development of both practices in terms of risk factors.
CONCLUSIONS: The evidence suggests a link between both practices and allows to theorize that
they are part of the same syndrome. Integrating psychoanalytic and sociological concepts as well as
the risk factors suggests a linear sequential model of development in four stages: childhood syndrome
rope, asphyxial games associated to masturbation, Adolescent autoerotic asphyxia and Adult
Autoerotic Asphyxia fetishist / bondage Syndrome. Death is explained in each of the stages as failed
physiological and emotional adaptation mechanisms. It is important to disseminate knowledge of
these practices among health professionals and further studies should be carried out in regarding
deaths by hanging in children and adolescents.
The analyses were based on an extensive search of electronic databases available through
the Queen Mary University of London and British Library. The databases included both:
medical
and
psychological
publications:
PubMed
(Medline),
PsychINFO,
The terms used for the search were: choking game, asphyxial games, self strangulation
games, sexual asphyxia, autoerotic asphyxia, autoerotic asphyxiation, autoerotic
fatalities, autoerotic death, hypoxiphilia, asphyxiophilia, sexual asphyxia syndrome,
adolescent sexual asphyxia, adolescent asphyxia, unintentional asphyxia, voluntary
asphyxia.
All published studies and articles available were reviewed and the papers considered for
the revision were:
1. Studies of series of fatal cases of autoerotic asphyxia in general population
2. Case reports of voluntary asphyxia deaths in late infants, preadolescents and
adolescents (age between 7 and 19 years).
3. Studies of both: asphyxial games and autoerotic asphyxia in preadolescents and
adolescents. Other autoerotic deaths (non asphyxial) were excluded.
4. Peer reviewed journals and articles
5. Publications in English, French or Spanish. Other languages were excluded.
6. Articles published prior to 1990 were excluded to ensure that current and salient
data were presented (with the exception of some early influential papers).
3.0 INTRODUCTION
in 1973 as
practice. However, these figures should be interpreted with caution given that most cases
are not due to fatal asphyxia. They are carried out in secret as a form of sexual
experimentation (some "different" sexual behaviors are seen as a taboo even by society)
and are not described to the medical personnel who assist at emergency services.
Additionally, in fatal cases, these deaths are mistakenly labeled as "suicide" by
authorities who remove evidence from the body, forensic pathologist and even by the
family itself.
used mainly include compression of neck vessels manually or with ligatures to reach a
state of euphoria and other effects linked to hypoxia. There are variations of this practice
consisting of vagal stimulation using the Heimlich maneuver (compression of the carotid
sinus) or maneuvers that incite hyperventilation with subsequent chest compression to
induce presyncope. These sensations are perceived as pleasurable and lead to repetition.
These games bear suggestive names: "Black Hole", Black Out, Flatlining,
Funky Chicken, Space Monkey, Suffocation Roulette, Gasp, Tingling and
Knock Out. French calls them "reve blue" (blue dream), reve indien (Indian dream),
jeu du cosmos (cosmos game), jeu des poumons (lungs game) and the best known of
all is jeu du foulard (scarf game). Spanish cites juego de la asfixia (asphyxial game)
o juego del desmayo (fainting game). Some young people even refer to them as the
"drug of good children", in allusion to the pleasurable effects and excitement produced
by some drugs.
3.3 HISTORY
classic. It is known that the Maya believed that the souls of individuals who hung
themselves went straight to paradise where Ixtab, the goddess of the hanged, received
them. The representation of the Maya goddess in manuscripts shows her in a kneeling
position with a rope around the neck, ankles tied and nipples visibly erect.
In the literature the autoerotic maneuvers have been described since the 1600s. In
those days sexual asphyxia was used as a technique to cure impotence. 3. The Marquis de
Sade places the practice of erotic hanging in ancient Celtic culture. His description is
clearly referenced in his novel Justine published in France (1791). 11
Herman Melville describes the eroticization of hanging in his novel of strong
homoerotic content "Billy Budd" published in 192410. Heinz Ewers cites the legend of the
origin of the mandragora calling to mind the semen produced during the hanging in
"Alraune".
12
published in 1952, Vladimir and Estragon discuss ways to alleviate boredom using
stimulants by hanging himself while waiting for Godot. 13Finally in the fictional novel by
Thomas Harris "Hannibal", published in 1999 and made into a film in 2001, the character
Mason Verger practiced autoerotic asphyxia by hanging while Hannibal Lecter makes
him inhale a popper (amyl nitrite) and suggests cutting his face with a piece of glass,
then feeding the pieces of meat to the dogs. 14
For centuries it has been well known that prostitutes were aware of sexual
asphyxia. In England there were brothels with a reputation for choking which were used
to enhance the pleasure of their customers. The "Hanged Men's Club" during the
Victorian era in London was recognized because of the practice of controlled hangings to
satisfy the sexual fantasies of their clients. 15 Also in London the cases of the deaths of
Huguenot writer Peter Anthony Motteux in 1798,
16
Koczwara author of "The Battle of Prague" in 179117 have been connected to practices of
autoerotic asphyxiation. Among more recent cases there are those of the Australian
Michael Hutchence, renowned vocalist of rock group INXS, in Sydney 1997 18and that of
the American actor David Carradine in Bangkok in 2009. 19
20
gives
examples of suffocation "to excite the venereal appetite", and in 1856 the French
psychiatrist DeBoismont described the association between hanging, erection and
ejaculation. He described the interesting case of a boy of 12 years who was found
suspended by a rope tied to a rack and feet flat on the verge of a manger. His father cut
the cord quickly and was able to revive him. The boy later said that he had no desire to
end his life but he had felt an irresistible urge to carry out the practice of risk. 21
In 1936 Ellis described the "urge to strangle the object of sexual desire" and drew
attention to the fact that some young individuals obtain pleasure from fantasizing about
being strangled. 22 In 1947 the following case report in the text Keith Simpson's Forensic
Medicine: "A naked youth found in a lavatory was half hanging off the edge of the seat,
the turgid penis and sperm dribbling from the neck suspended by a rope to the inlet pipe
of the cistern above. Several front pages of pictures of nudes were laid out in a half ring
in front of him on the floor. Death was due to vagal inhibition and must have taken place
suddenly, without warning. These cases must not be mistaken for suicides; they are
accidental deaths ". 23
From the second half of the twentieth century there are multiple reports of cases
of deaths related to autoerotic asphyxiation in adolescents mainly published in forensic
pathology. In 1953, Stearns 9, published a review of 97 suicides of young people and
found that up to 25% of these corresponded to apparent unmotivated suicide, accidental
deaths and / or sexual hanging. The relationship between transvestism and hanging was
later explored by Shankel and Carr (1956) 24, in the first case presentation of a live
practitioner sexual asphyxia to appear in the literature was a teenager. Rosenblum25
mentioned for first time the term Adolescent Sexual Asphyxia Syndrome and cited
three case reports [Edmonton, (1972)
26
, Herman, (1974)
27
(1972) 28] of adolescents who survived a hanging. Of these three case reports presented
by Edmonson one shows a teenager whose behavior was clearly sexual. Resnick,
including being adolescent or young men. This finding was supported by Hazelwood and
colleagues (1983) in an analysis of 132 postmortem cases. 6.
Most current literature references related to this topic are published in journals of
forensic pathology and psychiatry but did not emphasis in adolescents. Due to the limited
distribution and availability of these items, the subject is unknown and misunderstood by
much of the medical community and society.
neck over the carotid sinus is primarily a loss of consciousness due to cerebral hypoxia.
Compression can be performed by placing a ligature around the neck, which compresses
the vascular structures (arterial and venous) and is designed to give the person control
over the pressure and thus provides a mechanism to stop or release the pressure. Other
variables may be manual or ligature strangulation produced by a second person.
Transient cerebral hypoxia combined with physical impotence and the fact of putting
oneself at risk to the limit of death increases sexual gratification. Yet this method reduces
self-control and impairs judgment, which may result in accidental death because of the
victim's inability to operate the rescue mechanism provided.
Multiple studies show that pressures as low as seven pounds is sufficient to
induce unconsciousness quickly: under 15 seconds in some cases. Sauvageau et al (2011)
29
suicides and one homicide. With time 0 representing the start of the hanging, he observed
a rapid loss of consciousness (Average 10 3 seconds) in all cases. Loss of
consciousness was thoroughly evaluated through observation of the face in association
with body tone.
The next event documented reported seizures after loss of consciousness in all
cases (Average 14 3 seconds in all cases). In the following seconds (Average 19 5
seconds), decerebration rigidity was observed, with full extension of the upper and lower
extremities, extension of the hips and knees, adduction of the legs, internal rotation of the
shoulders extension of the elbows, hyperpronation of the distal parts of the upper limbs,
with finger extension at the metacarpophalangeal joints and flexion of the
interphalangeal joints.
After the decerebrate rigidity, the author describes two phases of decorticate
rigidity. This postural attitude is characterized by marked extensor rigidity of the legs
(the same to the one observed in decerebrate rigidity), but combined with rigidity of the
flexors of the arms: the arms appears flexed and bend on the chest, with the hands
clenched into fists. The first phase occurs relatively rapid (beginning around 21 seconds,
Average: 40 16 seconds). It was followed by a second and sometimes a third phase of
decorticate rigidity.
The apparent loss of muscle tone varied between 1 min 38 sec and 2 min 45 sec
(average: 1 minute 17 seconds 25 seconds) with a last isolated muscle movement
occurring between 2 minutes 15 seconds and 4 minutes 12 seconds. For respiratory
response, the following sequence was observed: deep rhythmic abdominal breathing
attempts with contraction of the diaphragm begin between 13 seconds and 32 seconds
Table 1. Neurophysiology. Agonal sequence in Hanging. From: Sauvageau et al. Agonal sequences in
14 filmed hangings with comments of the role of the type of suspension, ischemic habituation, and ethanol
intoxication on timing of agonal responses. Am J Forensic Med Pathol. 2011;32(2):104-107
Average Time
Loss of consciousness
Convulsions
Decerebrate rigidity
10 3 s
14 3 s
19 5 s
19 5 s
38 15 s
1 min 17 s 25 s
1 min 51 s 30 s
4 min 12 s 2 min 29 s
29-30
Rossen et al. (1943) 31 who conducted a study with 85 male volunteers between the
ages of 17 and 31 who were asphyxiated with an inflatable sleeve on the neck. Loss
of consciousness was documented in ranges of 5 to 11 sec.
Other less common forms of autoerotic asphyxiation deaths are in order of
frequency: suffocation by placing a bag over the head, chest compression and /or
abdomen and chemical asphyxiation and/or suffocation by displacement
(inhalation of aerosols, anesthetics, or chemical vapors) 2. There are reported cases
of positional asphyxia. Almost anecdotally, Sauvageau32 describes a case of
autoerotic drowning of a 25 year old in a rare case that occurred in a lake involving
restriction of the body and the use of homemade diving contraption. In all cases the
35
marks; (7) no apparent wish to die; (8) presence of erotic literature. Resnick
mentioned
other
two
elements
less
frequent:
(9)
binding
of
37
only
The origin of the term "choking games" is not clear, but appears as a term in
keywords in scientific articles. In this respect Katz and Toblin (2010)38 has suggested
using the term "strangulation activity" rather than the colloquial "choking games"
pointing out the etiological type and wishing to reflect the potential risk to life inherent to
this behavior. The more correct term is probably unintentional death by asphyxiation as it
allows to not only include deaths by strangulation, but by other types of asphyxia. Only
in the last decade asphyxia games have been referenced in publications on pediatrics,
The author describes what has been termed "initiation or experimentation phase"
which usually occurs in groups within the recreation area or the bathrooms of schools in
the absence of adults. There is no defined role for the victim who later becomes the
aggressor making the practice often consensual and reciprocal: the choked becomes
strangler and vice versa. Many young people often agree to participate in the game, often
under pressure from peers. The most common practice known as "jeu du foulard",
literally "the scarf game" (curiously scarves are rarely used) is to provoke an initial
hyperventilation through repeated bending of the knees followed by strong inspirations
(hypocapnia). Then one of the participants compresses the carotid neck to trigger the
effect of cerebral hypoxia (strangulation). The hallucinatory sensations are: being lifted
off the ground, depersonalization, seeing brightly colored circles, etc. The game is
repeated many times by increasing the time of compression. There are some variations of
the game involving compression of the sternum or the rib cage (Valsalva maneuver) as in
"tomato stake" or "frog game".
Linkletter et al (2010) 40 conducted an interesting study based in assessment of asphyxial
games videos available in the web site YouTube. For searching purposes they used the
street names of asphyxia games most commonly utilized by students: Choking game,
Space Monkey, Flatliner, Space Cowboy, Suffocation roulette, Sleeper hold,
Rising Sun, etc. They identified a total of 65 videos between October 22 and
November 2, 2007 from postings to YouTube. The technique used varied substantially:
The most common practice involved the individual squatting or bending, followed by
standing quickly. Then a partner (the chocker) applied pressure to the chest until loss of
consciousness. At least 27 videos (42%) were related with this practice.
The second most common practice was sleeper hold. In this practice, the choker
applied pressure to the neck of the subject wrapping an arm or a forearm around and
compressing the neck by standing behind. This practice was documented in 24 cases
(37%). The next most common practice: involved a compression on the chest or neck of
a standing subject, was used in 8 cases (12%). In two cases there was a variant of this
technique in which the subject added hyperventilation. The last method described with 4
cases (6%) involved only an individual who squatted and hyperventilated then stood
rapidly and perform a Valsalva maneuver or breathe holding.
Techniques Used
Squat/bend at waist,
hyperventilate,
stand quickly; choker
applies
pressure on
neck/chest
Sleeper hold
Stand,
hyperventilate; choker
applies pressure on
neck/chest
Squat, hyperventilate,
stand quickly,
Valsalva
maneuver/hold breath
Age
(Years)
12 >
18
18
42
13
14
Percentage
With
Seizure
41
37
15
11
8
13
2
88
10
8
90
4
0
75
25
Frecuency
(%)
Percentage
Without
Seizure
48
Porcentage
Unclear if
Seizure
11
3.7 AIMS
If the number of adults who practice autoerotic asphyxia is unknown, much more
so is the number of preteens and teenagers involved in asphyxial games. Only in the last
decade the issue gained widespread communication through the media in a kind of
boom, especially in newspapers and television programs. Unfortunately the approach
taken by the media is too sensationalist and distorts the understanding of the syndrome
by the society, educators, families and even the medical community itself.
Some authors believe that autoerotic asphyxia in adolescents is an entity distinct
from asphyxia games because of the sexual component found in the former, which is
accompanied by masturbation and paraphilia such as sadism-masochism and the
restriction. However other authors consider that there is a close link between both
practices and that the games are nothing more than the early stage in the development of
one or more paraphilia in adolescence and adulthood.
Cite some recommendations for further studies in the area and the
development of measures to prevent these deaths.
4. RESULTS
of 10,642 participants was selected. The objective was to assess the familiarity and
participation in this activity. The results indicated that 36.2% of 8th grade students
had heard of the choking game, 30.4% had heard of someone close who participated
and 5.7% acknowledged having participated. Young people in rural areas were
significantly more likely to practice than those in urban areas. The practice of games
of suffocation was higher in those at high risk of developing mental illness and in
adolescents who had a history of substance abuse.
Dake et al. (2010) 43 conducted a study in Ohio between autumn 2008 and
autumn 2009. They did a total of 3408 surveys in 192 classrooms in 88 state
schools. They established two categories of schools: middle school and high school.
The prevalence of activity in high school students was double that of middle school
(11% vs. 5%) which shows the practice increasing with age. As for the sex
distribution the study shows a higher prevalence for males in both middle school
students as well as in high schools. The investigation showed a participation rate of
9%.
The evaluation of the prevalence of choking games in middle school ages
(12-15 years) indicate that these were significantly more likely to be found in
students with the following characteristics: age (25% for 15 years age), live in
single-parent families (9%) and receive low grades (Ds and Fs) (17%). Additionally,
the asphyxial games were significantly higher in students who reported the
following risks: exposure to physical violence (15% -22%), mental health issues
(12-30%) and substance use (21% -37%).
Because previous research had shown that selected demographic
characteristics (e.g. gender and age) affect the prevalence of participation in
asphyxia games, the researchers decided to monitor the effects of demographic
variables and risk factor adjusted to odds ratios (AOR) and confidence intervals of
95%. The variables most significantly associated with participation in games of
suffocation for middle school students were: being over (15 years old) (AOR = 25.3),
marijuana use in the last 30 days (AOR = 19.9), cigarette smoking in the last 30 days
(AOR = 14.9) and consumption of alcohol in the last 30 days (AOR = 12.2).
High School students (14-18 years) involved in choking games share several
common features with those in middle school. These participants were more likely
to be male (14%), with families with a stepparent (17%) and students with low
grades (Ds and Fs) (27%). In relation to association behavior, the following were
associated with high prevalence of behavioral choking game: having more than 4
sexual partners (22%), exposure to physical violence (22% -33%), mental health
issues (16% -30%) and substance use (18% -29%).
An analysis of the adjusted odds ratios (AOR) for demographic variables
showed a total of 23 variables significantly related to high school students involved
in asphyxial games. The variables most closely related to choking games were: age
(compared with middle school students) (AOR :7.0-9 .6), being forced to have sex
(AOR = 4.5), inhalant use (AOR = 3.4) , mental health issues (AOR = 3.2) and
excessive alcohol consumption in the last 30 days (AOR = 3.0).
The study is complete (it should be noted that Dake took a broader age range
than that used by Ramowski and Macnab) and reduces the risk of bias by
controlling the five demographic variables with adjusted odds ratios and confidence
intervals of 95%. Whether the practitioner of the games was alone or accompanied
at the time of practice was not taken into account in this study and is one of its
limitations.
Le Heuzey (2011) 44 cites a survey conducted in the school population in
France between 746 students, of whom 70% had knowledge of the game, 10% had
practiced it and 3% habitually practiced it (all male). The year that the survey was
conducted is not mentioned. The games were practiced by children from 5 to 17
years with a mean of 12 years.
website YouTube were evaluated. With a total sample of 65 different videos there
were 10 cases (15%) where only the practitioner and a companion were present. In
the remaining 55 observers were shown watching the game. A total of 110
participants / observers were identified in the 65 videos to be mostly men (n = 99,
90%). The estimated age of the participants was 12 to 18 years in 35 of 65 videos
(64%) and over 18 years in the remaining 30 (46%). The activity usually took place
in a private quarter.
Linkeletter, also measured the "popularity" of the videos and found that a
total of 65 videos in the study were seen 137,550 times. The average video was
viewed by 2,670. Three weeks after the collection of data the percentage of visitors
had increased by 61%, at this point the number of viewers had increased to 279,240
with an average of 4296 views per video. One video in particular that shows the
practice of the game by several young men in a dormitory and in which two
participants have seizures was viewed 27,507 times. The 65 videos were marked as
"favorites" a total of 721 times with an average of 11 times per video.
Participation rate in all series are shown in table 3.
Participation rate %
6.6
Dake et al (2010)
Le Heuzey (2011)
10
Ramowski (2012)
6.1
Summary key characteristics of living participants of asphyxial games and risk factors
related are shown in tables 4 and 5.
Poor nutrition
Substance abuse
Substance abuse
Sexual activity
Sexual Activity
Gambling
It is noteworthy that during the research three extensive reviews of the general
literature on autoerotic deaths were found. Two of them Uva (1994)15 and Shields
(2005)46 focus on autoerotic asphyxiation and one of them Sauvageau (2006)2 on
autoerotic deaths, including deaths different from asphyxia. These reviews included
studies of series and reports of fatal cases cited in the present study. However, they did
not focus on the adolescent population. In reviewing these articles no connection with
asphyxia games was found nor mentioned. The articles were taken into account to
facilitate the search for series of cases of autoerotic asphyxiation, which included
adolescent population, and to review concepts, general literature and corroborate results.
The aim is to identify whether there were teenagers among deaths classified as
autoerotic asphyxiation as well as age groups found in each of the studies, their
frequency and to evaluate the variables of sex, kind suffocation involved and the place
where asphyxiation is practiced. A total of 10 studies of series of cases that involved
autoerotic asphyxiation in the general population were found. The results are shown in
Table 6.
The studies are quite comprehensive and include several countries:
USA,
Germany, Denmark, Canada and Australia. The oldest corresponds to Walsh47 published
in 1977 and the most recent Byard48 (Australia), published in 2012. Some include long
periods of evaluation as presented by Behrendt49 in Denmark who studied a 57-year
period between 1933 and 1990. The study with the highest number of cases was
conducted by Blanchard and Hucker50 in Canada between 1974 - 1987 for a total of 117
cases.
4.2.1 Gender
All studies show an almost absolute prevalence of males. In fact, with the
exception of studies by Hazelwood (1983) 6 and Byard (2012) 48 who report a few cases
of women, all reported victims are male. In Hazelwood the percentage of women is only
5.7% and in Byard only 4.5%.
Year
Country
Period
Number
of cases
Sex
Age
Mean
Age
Type of asphyxia
I/O
Emplacement
Walsh et al47
1977
USA
19581973
43
14-75
<30: 77%
43 ND
43ND
Hazelwood et al6
1983
USA
19701978
70
66M
- 4F
9-77
26.5
70ND
70ND
Diamond52
1990
USA
ND
15-59
ND
7I
Blanchard and
Hucker50
1991
Canada
19741987
117
16-76
26
117
ND
117 ND
Tough et al53
1994
Canada
19
15-50
28
19I
19 ND
Behrendt and
Modvig49
1995
Denmark
19781989
19331990
46
10-71
31
80%I
Bretmeier et al51
2003
Germany
(Hannover)
19781997
17
16-76
36.8
14I
Shields et al46
2005
USA
19932001
16
14-59
38.3
15I
Janssen54
2005
Germany
(Hamburg)
19832003
40
13-79
<39: 50%
37I
Byard48
2012
Australia
20012007
44
42M2F
10-69
<39:52%
44ND
4.2.2 Age
All groups show victims in the age of adolescence. Hazelwood's study (1983)6
shows victims as young as nine; Behrendt and Modvig (1995) 49 and Byard (2012) 48
from ten year-olds. Blanchard and Hucker (1991)50 and Bretmeier et al. (2003)51 report
ages of initiation at 16.
The results show that in all studies the age range is quite wide and extends from
the preteen / teens to adult group. However when analyzing the average age it is
surprising that the vast majorities are in the group of adolescents and young adults. In
fact in all studies provided that more than 50% of victims were under age 40. Blanchard
and Hucker (1991)50 and Hazelwood (1983)6 show median ages of 26 and 26.5 years
respectively. Walsh (1977) 47 shows that 77% of victims were under 30 years.
4.2.3 Type of asphyxia
Studies show a marked prevalence of asphyxia by neck compression and within
these mainly hanging; ligature strangulation and suffocation followed. In some cases
such as the study by Walsh (1977)47, 100% was due to neck compression. In Hazelwood
(1983)6, 62% were by hanging, 8.5% by strangulation (a 70.5% consolidated to
asphyxiation by neck compression). Blanchard and Hucker (1991)50 group the greatest
number of cases by hanging at 79%.
4.2.4 Place of occurrence
While some of the series of cases analyzed do not take this detail into account,
those that do clearly show a predominance of closed scenarios within the home (indoors).
Diamond (1990) 52, Tough (1994) 53, Bretmeier et al (2003)51, Shields et al (2005)46 and
Janssen (2005) 54 show that over 80% of cases occur in such places. In the study by
Behrendt and Modvig (1995)49 the prevalence of closed spaces is 80%. The most
common scenarios are bedrooms followed by bathrooms, basements and garages.
Gender
Type of asphyxia
Emplacement
Context
night wear, before summoning help. Shields et al. (2005)46 reported a total of 11 cases of
which two are adolescents. One case is dismissed because it corresponds to an autoerotic
death involving electricity but no asphyxia maneuvers. Findings like bondage and
transvestite fetishism were described. Single cases were reported by Doychinov et al
(2001) 59, Behrendt et al (2002) 60 y Koops et al (2004)61. Listed below is the analysis of
sex, age, and type of asphyxia, place of occurrence and add the variable type of
paraphilia associated with the practice of asphyxiation.
4.3.1 Gender
There is absolute predominance of male patients with a total of 13 victims
(86.6%) and only two females (13.3%). (6.5:1 male: female ratio).
4.3.2 Age
Ages range from 12 to 19 years. Mean age is 15.4 years and the median 16 years.
It should be remembered that within the series of autoerotic asphyxiation cases there are
reported cases since age 9. The age analysis of the most relevant information points to a
direct correlation across age variables associated with type of paraphilia. In this review
paraphilias are describe as early as 12 years. Henry (1996) 58 described a case of a young
boy of 12 years with fetishism / transvestitism. Sheehan et al (1988)56 also show a case
of fetishism / transvestitism in a 13 years old boy. As age increases transvestite fetishism
seems to appear, a finding consistent with the study of Blanchard et al (1991)49 who
showed in a series of 119 cases that the proportion of bondage and fetish / transvestitism
increased with age.
4.3.3 Type of asphyxia
Asphyxia by neck compression was the method most commonly appearing in 12
cases (80%). Of these 10 (66.6%) correspond to hanging and 2 ligature strangulation
(13.3%). In the remaining three cases (20%) the asphyxia type corresponds to
suffocation.
Year
Country
Sex
Age
Method
Type of asphyxia
I/O
Emplacement
Type paraphilia
Byard and
Bramwell55
1988
Canada
19
Ligature Strangulation
Bedroom
Transvestite Fetishism
Sheehan et al56
1988
USA
13
Hanging
Home
Bondage
Sheehan et al56
1988
USA
14
Hanging
Bedroom
Voyeurism (mirror)
Sheehan et al56
1988
USA
14
Suffocation
Garage
Sheehan et al56
1988
USA
14
Hanging
Basement
Sheehan et al56
1988
USA
16
Hanging
Basement
Sheehan et al56
1988
USA
16
Hanging
Bathroom
Voyeurism (mirror)
Sheehan et al56
1988
USA
16
Hanging
Home
Transvestite Fetishism
Kirksey et al57
1995
USA
13
Hanging
Bedroom
Bondage
Kirksey et al57
1995
USA
17
Hanging
Home
Transvestite Fetishism
Henry58
1996
UK
12
Hanging
Home
Transvestite Fetishism
Doychinov et al59
2001
Bulgaria
18
Hanging
Bedroom
Transvestite Fetishism
Behrendt et al60
2002
Denmark
17
Plastic bag
Suffocation
Bedroom
Bondage
Koops et al61
2004
Germany
16
Ligature Strangulation
Bedroom
Transvestite Fetishism
Shields et al46
2005
USA
17
Suffocation
Home
Transvestite Fetishism
Gender
Type of
asphyxia
Emplacement
Context
Paraphilias
Year
Country
Sex
Age
Method
Type of
asphyxia
I/O
Emplacement
Burch et al63
1995
USA
Ligature neck
compression
Ligature
Strangulation
Wood
Burch et al63
1995
USA
Ligature neck
compression
Ligature
Strangulation
Wood
D Le- Macnab37
2001
Canada
11
Ligature neck
compression
Hanging
School Bathroom
D Le- Macnab37
2001
Canada
Ligature neck
compression
Hanging
School Bathroom
D Le- Macnab37
2001
Canada
Ligature neck
compression
Hanging
School
Bathroom
D Le- Macnab37
2001
Canada
Ligature neck
compression
Hanging
School
Bathroom
D Le- Macnab37
2001
Canada
12
Ligature neck
compression
Hanging
School
Bathroom
Andrew64
2007
USA
Ligature neck
compression
Hanging
Bedroom
Andrew64
2007
USA
13
Ligature neck
compression
Hanging
Basement
Andrew64
2007
USA
11
Ligature neck
compression
Hanging
Bedroom
Egge65
2010
USA
12
Ligature neck
compression
Hanging
Bedroom
BarberaMarcalain66
2010
Spain
15
Ligature neck
compression
Hanging
Bedroom
Egge (2010) 65 published the only article that documents a female victim, which
occurred in Los Angeles (California).
bedroom. The victim was resuscitated and transferred to an intensive care unit where
brain death evolved. In this case one of her cousins and classmate testified to having
played with her at compressing the neck with garments in the past.
suffocation during the same period. The finding confirms that they are completely
different phenomena.
In 70 deaths where information provided was sufficient, 67 cases (95.7%)
occurred when the victim was alone. In 42 cases with complete information, 39 (92.9%)
parents of the victims said they were not aware of the practice until their children had
died.
4.4.1 Gender
Of the 12 documented cases, 11 (91.6%) were male, a finding similar to the series
of cases studied by the CDC in Atlanta (86.6%). Only Egge's article (2010) 64 describes
the case of one female victim.
4.4.2 Age
Cases from 7 to 15 years with an average of 10.8 years were described with
standard deviation of 2.4 and a median of 10 years. The epidemiological study of the
CDC reported the age range was 6 to 19 years with a mean age of 13.3 years (standard
deviation: 2.1) and a median of 13. The data are consistent in both sets of cases.
4.4.3 Type of asphyxia
All articles show related cases of choking by compression of the neck (100%).
Ten of them (83%) are by hanging, and two of them (16.6%) with ligature strangulation.
The study of the CDC in Atlanta does not discriminate the type of asphyxia. However it
is clear that most choking games published in the media in U.S. territory correspond to
neck compression maneuvers since the study defined cause of death as auto
strangulation.
4.4.4 Place of occurrence
Indoors were the most prevalent. Ten of the scenes (83%) occurred in youngsters
home, more precisely in their rooms. Only two cases (16.6%) occurred in open scenes
(two cases already mentioned that occurred in a forest). However 100% of the cases took
place secretly, while children were alone; in a similar finding to that reported by the CDC
in Atlanta shows that in 95.7% of cases the victims were alone at the time of play. A
striking finding is that in the most recent cases, Andrew (2007) 64, Egge (2010)65 and
Barbera-Marcalain (2010)66, siblings and playmates reported that there was prior
knowledge of choking games. In a case reported by Andrew (2007) 64 tightening the neck
with ropes were of long standing behavior.
Summary of key characteristics of victims of asphyxia games in adolescence are
shown in table 11.
Table 11. Key characteristics of victims of asphyxial games
Age
Gender
Type of
asphyxia
All cases are related with neck compression asphyxias, mainly hanging.
Emplacement
Context
4.5.1 Gender
In analyzing the gender variable all studies show a marked predominance of
males versus females. All groups document prevalence above 86% for males. The
prevalence of males is also very marked in autoerotic asphyxiation in adults.
4.5.2 Age
The three groups show fatal cases at an early age in childhood and
preadolescence. Autoerotic deaths are reported cases of victims as young as 9 years. The
CDC group samples cases occurring from age 6 and cases of fatal choking games there
is one reporting a victim of age 7. All studies situate the maximum age in adolescence,
after puberty, and are consistent. The results show that the deaths of the first three groups
range from childhood / preadolescence and extend through adolescence. Recall that in
adults the deaths occur in young adults (mostly between 3rd and 4th decade of life).
4.5.3 Type of asphyxia
In all groups asphyxia by neck compression dominate: 80% in autoerotic
asphyxiation adolescent (the same pattern is observed in auto erotic asphyxiation in
adults). In asphyxial games all fatalities (100%) are reported to be by compression of the
neck. In adults the majority of victims asphyxia corresponds to compression of the neck.
The most common type of asphyxia in all groups was hanging.
4.5.4 Place of occurrence and status of the victim
The articles relating to deaths by autoerotic asphyxiation in both adults and
teenagers always discard the presence of a second person when assessing the manner of
death consequently the victim must have been alone in all cases. The scenes are mostly
indoors and occur within the home. In the case of the choking game, 10 of the 12 cases
the children were alone at home. In the 2 remaining cases of fatal choking games, the
victims were not alone (there was consensual sexual activity with two children) and the
act was carried out in a forest, however the practice was performed in a clandestine
manner. In CDC group 95.7% of the deaths occurred while the victim was alone.
A profile comparison between fatal cases of autoerotic asphyxia and asphyxia games are
shown in table 12.
Table 12. Profile comparison between fatal cases of autoerotic asphyxia and asphyxial
games
Autoerotic asphyxia
(General)
Autoerotic asphyxia
(adolescents)
Asphyxial games
Age
Gender
Type of
asphyxia
Marked prevalence of
neck compression
asphyxias, mainly
hanging.
Marked prevalence of
neck compression
asphyxias, mainly
hanging.
Predominant indoors
scenes
Predominant indoors
scenes
Solitary, secrecy,
clandestine activity.
Release mechanism
Solitary, secrecy,
clandestine activity.
Release mechanism
Solitary, secrecy,
clandestine activity.
Previous knowledge of
games.
Paraphilias
Very common
N.A ?
5.0 DISCUSSION
is perceived as being imperious and indifferent to the victims struggle to comply with
her fantasized demands. For the author, the autoerotic asphyxia can thus be understood as
a reenactment (or acting out) of powerful states originally related to a female (mother
or surrogate). This plot, dimly understood if at all by the reenactor, may also represent
a symbolic death for lustful thoughts and guilt inducing masturbatory behavior (i.e.,
punishment before pleasure). In surviving the play acting death ritual, the individual
emerges, time after time, sexually gratified and physically intact with a sense of relief,
triumph and contempt/resentment (i.e., you think I have died for you, but actually I
killed you). 71
The author suggests that autoerotic asphyxia involves a desire for control over the
anxiety of life versus death: the closer the reenactor approximates, yet cheats death, the
greater the sexual excitement. For him: it is indeed a curious state of affairs that the
reenactor is the producer, director, choreographer, judge, actors and witness in his or her
unique, personalized drama. In essence the autoerotic asphyxia reenacts a life story of
unmanageable childhood trauma conflicts. In psychoanalytical Freuds view, the
repetition would be a compulsive but futile attempt to resolve those conflicts.
As we will see this description and Resnik's postulates are consistent with the
ordalic behavior defined by Charles-Nicolas and mentioned by Le Breton72 in his
sociological theories of risk confrontation.
water boarding. If he/she survived or was not too hurt, it was understood that God had
considered him/her innocent and should not receive any punishment. In this sense ordalic
behavior makes reference to trial by ordeal which "puts life up to God" that is, the victim
risks his/her life voluntarily.
In physical activity or high-risk sports, symbolic play with death is more or less
defined and easily understood. However, it is not easy to understand the desire to play
with death, of entering its territory. That is the foundation of the ordeal, i.e. a form of
deliberate play with death. In the author's words: There is no intention of actually dying,
but rather of testing out their personal determination, of finding an intensity of being, a
moment of supreme being, giving voice to a cry or expressing suffering, and sometimes
all this is intermingled with a quest which often only takes on a meaning in the aftermath
of the event. 73
For Le Breton, assuming a risk taking is ambivalent in that it is a lucid act of
willpower, of asserting self-confidence, which distinguishes it from outright blindness or
a firm will to die. It entails an evaluation of the actors own resources as he/she leaps into
action; a calculation, perhaps intuitive, of the probability of success, but it also relies on a
wager that mixes in a rather confused way the ability of the actor in this kind of situation
with the perception that he/she has of his own "luck", his/her particular talent to escape
the worst.
The author quotes an interesting example of swimmer Guy Delage, well known
for having crossed the Atlantic Ocean swimming 10 hours a day for two months from
Cape Verde islands to the Caribbean. For the author, Guy Delage typifies the passion for
risk shown in these testimonies and is a clear example that abounds in which followers
describe that the extent of the symbolic confrontation with death is a commonplace of
which they usually come out winners. "Death is a magnetic pole for me ... I learned to
live near her, to face her, very often included it as a plausible hypothesis in my projects
... Of course, there's a game ... I like to touch death without ever reaching it; this game
gives me a subtle extreme pleasure. This permanent vision of what it is to escape her
releases adrenaline flows... therefore, pleasure. Before jumping in to gain the other side
of the Atlantic by swimming he wrote postcards to friends, "The Atlantic, will it allow
me to get to the other side? If not, my relatives will receive on this insignificant piece of
paper my last affectionate thoughts towards them. The most interesting thing in this
example is that Guy Delage rejects any suicidal intent. "I love life terribly. I know every
corner, all the possibilities. I seek to broaden the fields of the wrappings of my life,
turning it like a bubble, inflating it to the limit of its ability without letting it explode.
The game is to come within setting off the explosion without actually having it go off.
My extraordinary experiences allow me to enjoy a life of intense passions. 74
The concept of ordalic behavior and its application in forensic pathology at the
time of defining the manner of death is interesting. In some academic settings the
determination of manner of death in risk behavior such as autoerotic asphyxiation,
Russian roulette and heavy drug use has long been discussed. Some forensic pathologists
and Latin American psychiatrists believe they are a form of suicide as they are
considered from some point of view "self-destructive behavior." In some cases, the
consensus has been to label this type of violent deaths as indeterminate. But
understanding the principle that ordalic behaviors is a means of defying death and beget
some kind of satisfaction is important. Deaths of this kind in my opinion should be
treated as accidents.
76
psychology at Illinois in 2011 are interesting. She found that adolescents who practice
self-inflicted asphyxia are more likely to experience other risk behaviors than those who
do not practice them.
Accidental
Death
Accidental
Death
Depression
Accidental
Death
Adaptation
Adaptation
Accidental
Death
Adaptation
2. Asphyxial
Games
Associated to
Masturbation
Resolution
1. Childhood
Rope Syndrome
Suicide
Death
4. Adult Autoerotic
Asphyxia Syndrome
3.Adolescent
Autoerotic
Asphyxia
Resolution
Resolution
Risk Factors
Genital Phase
Conflicts
Factors related to both practices are essentially the same as those shown in this
paper. Rosenblum and Faber25 mentioned factors such as exposure to violence and sexual
activity in their study of living autoerotic asphyxiation practitioners. The linear
epidemiological study carried out by Ramowski et al. in Oregon (USA) (2008-2012)42,45
among high school students through a survey showed that some factors related the
practice of asphyxiation games were exposure to violence, sexual abuse and premature
contact with alcohol and drugs. The epidemiological study of Dake et al.43 also among
school practitioners of asphyxiation games (2010) identified exactly the same variables
as well as mental health issues. Shankel and Carr (1956)80, Rosenblum and Faber (1979)
25
and more recently Eber and Wetli (1985)81 mentioned dominant and / or punitive
mothers, academic problems and absence of the father as common features in adolescents
practicing autoerotic asphyxiation. Dake et al. (2010)43 also describes homes with no
father and academic problems as a factor associated with the choking game.
However, in this model not necessarily all the teenagers involved in these
practices come from phase one. A significant number enter directly through the pre-teen
and teenager door. Conflicts in the genital phase of psychosexual development as well as
history of sexual abuse would have the greatest weight as risk factors.
Psychiatrists Friedrich and Gerber (1994) 82 recounted in great detail 5 cases of
teenagers (still living) involved in asphyxia autoerotic (all male) and identified common
factors. Again physical abuse, sexual abuse and further strangulation history, risk taking
behavior and learning through a friend are mentioned. The last three components are
clear in asphyxial games: they are a form of strangulation activity, they are learned
behavior and as explained above correspond to a risk taking behavior. Additionally the
first two (physical abuse and sexual abuse) may explain the conflicts in the genital phase
of psychosexual development and promote direct entry in adolescence. Studies of Dake
(2010) 43 and Ramowski (2012)45, also identified drug use and gambling as risk behaviors
common among practitioners of the asphyxia game.
If to this model the sociological concepts of Le Breton73 about ordalic behavior
and risk behaviors that are manifested strongly in adolescence are added, it bears to posit
that young people exposed to the factors of intrapsychic conflict mentioned above and in
contact with the asphyxial game while testing the effects on the brain, make this their
favorite tool when challenging death.
The severity of the factors affecting psychosexual development (mainly related to
sexual abuse) will depend on the speed in developing through the sequence, i.e. the speed
of moving from one game associated to masturbation (phase two) to the Adolescent
Autoerotic Syndrome (phase three) of the developmental model. This would explain the
findings of this study where sophisticated components of fetish and bondage appear at
ages are as young as 12.
From the model it is understood that contact with the choking games or its
occasional practice would not necessarily lead to the child developing the asphyxia
games associated masturbation or subsequent Adolescent Autoerotic Syndrome. As
mentioned in the theoretical framework many of the children agree to participate in the
games as a form of being accepted to the group in response to peer pressure. In this
situation if the adolescent has no associated risk factor (e.g. no changes in any phase of
psychosexual development), the child will tend not to repeat the practice and if he/she
does so it will probably be repeated in groups with the company of friends. Recall that
epidemiological studies showed that most respondents, practitioners of games
asphyxiation, performed them in the company of another person. The real point of
entrance is where the practice becomes single, repetitive, and clandestine and integrates
the pleasure and / or sexual (masturbation) components.
This brings to mind that in his epidemiological study Macnab (2009)41 showed
that all women who took part in the game did so in the company of another person and
that those who admitted to being regular practitioners mostly were men and did so while
being alone. Ramowskis study45 showed that at least 64% of those men practicing the
game repeated it. This result would explain what has been documented in the present
study where the vast majority of victims of both autoerotic asphyxiation and asphyxiation
games in adolescents are males. Since men tend to play the game repeatedly in solitary
plus the additional sexual component, the group as a whole is more predisposed to failure
in the physiological adaptation to asphyxia and therefore show more accidental deaths.
Recalling the castration complex as postulated by Freud and Resnick3, from the
psychoanalytic point of view, it maybe posited that men are somehow more prone to
exhibiting disorders of the oral phase and because men are more exposed to risk factors
such as exposition to violence, sexual activity and substance abuse, they are in fact more
vulnerable to develop the syndrome. All epidemiological studies support the theory of
sexual motivation in these games played out repeatedly and in solitaire; as in Macnab
(2009)41, Dake (2010)43 and Ramowski (2012)45 who identified sexual activity as a risk
factor directly related to the playing of games of asphyxia.
While death as a result of asphyxia games practiced in groups is a potential risk, it
rarely occurs according to the results of present study. The probability of death increases
with solitary, repetitive and clandestine practices associated with the pleasure
component. If we recall the sexual response cycle (SRC), it is hypoxia and sexual fantasy
which act as cortical desinhibitors causing compression of the neck to be dangerously
prolonged and affect the sense of perception to the point where the rescue mechanism
provided will not be activated.
Somewhere between the third and fourth the choking technique and the rescue
measure swill tend to become more sophisticated (the ordalic component of confronting
risk and defying), and other paraphilias, especially fetish / transvestism , bondage and
sadism / masochism will also appear. The physiological and emotional adaptation will
determine whether the person survives. As mentioned above, according Rosemblum25
emotional adjustment at this stage is limited by the environment or the individual's social
reality. In this sense depending on whether the person finds a partner to participates in
asphyxial maneuver, the risk inherent in the practices will be reduced. On the other hand
emotional security give by having an accomplice will prevent the victim from falling into
depression. Given the above step 4 is not necessarily autoerotic and can become erotic
asphyxiophilia involving a second person. Exit doors are again individually resolution or
as a result of treatment, (psychotherapy - psychotropic drugs) or death: accidental if there
paraphilia episodes at the time of death. These findings are consistent with the consensus
that exists in psychiatric clinical practice on the presence of a paraphilia tending to
facilitate the appearance of other ones. (Eg Wilson and Gosselin (1980)84; Buhrich and
Beaumont (1981)85, Freund et al. (1986)86; Lang et al. (1987)87; Abel et al (1988)88.
Some authors even posit an association between specific paraphilia and paraphilia that
are true syndromes.
Several explanations have been suggested to explain the general tendency of
paraphilia to appear in clusters. Abel et al. (1988)88 hypothesized that the absence
negative consequences of their first experience of paraphilia by the practitioner will
cause him/her to be less inhibited when incorporating other fantasies about other
paraphilia. Bancroft (1989)89 stresses the tendency of paraphilia to occur simultaneously
suggests that the conditions necessary for development of a particular type of paraphilia
may facilitate the development of others. He conjectures that this can potentially curb
some characteristics of the central nervous system that underlie the individual's sexual
learning. This conjecture is equivalent to the notion psychiatric paraphilia diathesis.
In reviewing the psychoanalytic literature there appears reported a case consistent
with this model and the concepts previously reviewed. Eber and Wetli (1985)81 made a
detailed description of a patient of his who later died at age 34 during an autoerotic
hanging inside a hotel room. The patient reported that his behavior began in
preadolescence. From a psychoanalytic point of view the therapist identified conflicts
with the mother, narcissistic personality elements and sadomasochistic elements. Two
aspects prove interesting. Firstly while being aware of the practice the wife becomes
intolerant of compulsiveness of the aberration, so the patient begins to practice
asphyxiation in secret in a hotel room. The second point is the patient's identification
with Christ's passion and resurrection from adolescence. In the first aspect of the
behavior compulsiveness and intolerance of the couple causes a disruption in the
physiological adaptation to asphyxia and produces the exit sequence of accidental death.
The second point which is the description of the death and resurrection of Christ
fits, in my opinion, the concept of ordalic behavior, more precisely the stages of
In phase three teens in the model will be better adapted physiologically. They will
know the technique, wear more elaborate knots (sliding), used padding and develop a
complex rescue measure. Despite this, the majorities of deaths are to be explained by
failures in physiological adaptation and thus are accidental deaths.
Medical literature suggests that the practitioners of autoerotic asphyxia are
usually depressed adolescents and their older counterparts are more prone to depression.
Consequently one can infer that the risk of suicidal instead of accidental death increases
with age. Taking into account the processes of adaptation mentioned by Rosenblum25,
this could be explained by the fact that adults find a partner who protects them while
performing the procedure (physiological adaptation) and are therefore less likely to die
from unintentional suffocation (accidental). On the contrary, as adolescents and younger
adults are more likely to carry out the act alone, they are at an increased risk of
unintentional death.
Death in mature and older adults would most likely occur because of emotional
maladjustment whether caused by the difficulty of finding a mate who agrees to
participate in the perversion, the difficulty of maintaining a one who will accept the
compulsive behavior or the loss of such a person. Emotional maladjustment results in a
suicide-type exit. It is likely that a significant number of practitioners of autoerotic
asphyxiation end up committing suicide. However in the absence of tools such as
psychological autopsy is almost impossible to distinguish which suicides may be related
to these practices.
My assessment is supported by the findings in the review of the bibliography
presented here in which the majority of cases happen among adolescents and young
adults. Deaths of mature adults and seniors will be labeled simply as suicide and not be
tied to any practices of autoerotic asphyxiation. The study conducted by the CDC in
Atlanta comparing the choking game deaths to deaths by suicide in adolescents shows a
clear trend of suicide increasing in direct proportion to age.
A complex and unusual exit door to the model may be in the form of autoerotic
suicide, first described by Hazelwood (1983)6 in two cases in which all the Fetish /
transvestite paraphernalia accompanied by bondage and masochism but with a clear
antecedent of depression and / or existence a suicide letter present at the scene. More
recently, Bhardwaj et al. (2004) 93 described a case in New Delhi - India of a 22 year old
subject with evidence of fetishism / transvestitism, no apparent rescue measure or
protection in the neck and with a history of depression and a marriage described as
dysfunctional. Benomran et al. (2007) 94 described the case of suicide in Dubai (UAE) of
a 35-year-old man found in suspension in an open area with evidence of masking and
bondage. This exit would be unusual only in adulthood in stage four of the proposed
model when the individual has achieved a high degree of sophistication in the technology
and has developed several paraphilia but flawed in emotional adjustment, so falls into
depression and commits suicide.
5.7 LIMITATIONS
One of the major limitations in conducting this study was the small number of
articles found for both autoerotic asphyxiation in adolescents and choking games. It is
very striking that while the Atlanta CDC reports a total of 82 fatal cases in the period
from 1995 to 2007 in the United States, 8 only 6 cases appear reported in the literature.
Two of them were not categorized as games but as adolescent sexual asphyxia.
As mentioned earlier references to choking games are very recent (much of them
in the last decade) and it is possible that there is still no widespread knowledge of this
practice among health professionals working with adolescents (pediatricians) and among
those addressing related deaths (Forensic pathologist). In this regard McClave et al.
(2009)95 conducted a survey of pediatricians and general practitioners and found that
only a third of the professionals had knowledge of the games and did not recognize that
practice of choking games could be an activity potentially life threatening to adolescents.
In the same study, only 52.3% were able to identify 3 of 10 clinical warning signs that
commonly described these practices.
Deaths reviewed by Andrew (2007)64 showed two cases where the initial
conclusion was suicide. It was only thorough subsequent information provided to the
medical examiner that the manner of death was modified. In the first case the mother
found e-mails referring to the practice of the games and in the second case the practice
came to light after review by the Child Fatality Review Team. Articles were found to be
minimal or non-existent when reviewing published articles of fatal case descriptions of
personal, family and the behavior of the victim. The descriptions were limited to the
description of characteristics pertaining to the discovery of the body and findings
regarding internal examination at autopsy.
When conducting a survey among 28 coworkers of the group practicing forensic
pathology autopsies daily at the National Institute of Legal Medicine and Forensic
Sciences in Bogot (Colombia), only two colleagues had heard of the practice. The lack
of knowledge about these practices on the part of researchers and police who arrive at the
death scene as well as the professionals who perform autopsies coupled with the failure
to integrate the personal history of the victim to their findings, cause the deaths to be
wrongly labeled as suicides or in some cases as undetermined deaths.
A review sociological, psychiatric and psychoanalytic literature was essential in
this study.
The last limitation found was that in the series of fatal cases autoerotic
asphyxiation reviewed, researchers excluded choking and asphyxia games as well as
those of autoerotic asphyxiation. In many of the articles the existence of cases with
elements of both practices is tacitly suggested -i.e. reference to asphyxial games and
partial nudity but without the paraphernalia specific to pornography or autoerotic death
due to paraphilia. The authors did not consider most of these cases. To my mind this is a
bias that represents one of the causes that has prevented or limited research in this
direction. Only psychiatrists who analyze cases and study the distortions in psychosexual
development in living people based on psychoanalytic theories suggest the existence of a
link between the two practices and publish their findings in scientific journals.
5.8 RECOMENDATIONS
For future research in this area I suggest a detailed review of reports and series of
cases of hangings in children, preadolescents and adolescents. The results of this study
and several of the articles reviewed strongly suggest that some of the cases initially
labeled as suicide and many labeled as accidents or undetermined deaths are related to
games or even asphyxiation autoerotic asphyxiation.
In cases where psychiatrists and psychoanalysts have addressed the issue of
autoerotic asphyxiation but have not published their findings in scientific journals,
information could be obtained through personal communication to explore their
experience in each case, omitting of the patient's identity. This would preserve the ethical
principles of confidentiality and disclosure. The psychoanalytic view is essential for a
better understanding of these behaviors and to conduct any investigation in the future.
Regarding fatal cases, it would be helpful that during the visit to the scene of the
crime a multidisciplinary team that included the research coordinator (State of Local
attorney - coroner), a pediatric professional, psychologist or psychiatrist, a social worker,
as well as a forensic pathologist member of the family and the school were present. The
team would be responsible for identifying potential risk factors (exposure to physical
violence, sexual abuse, substance abuse, gambling, etc.) as well as exploring any contact
with choking games. In some cases it might be necessary to return to the scene to try to
identify related evidence while bearing in mind the possibility of some overlooked sexual
component. In all cases the psychological autopsy report should be shown.
Future studies can be done using the research methods used by the CDC in
Atlanta (LexisNexis) where the likely event may be located through press releases and
then corroborated by the official reports of the death through the office the medical
examiner or competent authority by country. Another source of information may be the
web sites of "choking game awareness" which report related deaths (also used in the
study by CDC Atlanta). In all cases it is essential to corroborate the information with the
official report of the case, including the results of the autopsy.
Also awareness of these practices among health care professionals should be
promoted, especially among those who are in contact with the exposed population -i.e.,
pediatricians, nurses, psychologists and child psychiatrists as well as school authorities.
Health personnel should be alert to identify warning signs that indicated the existence of
behavior. In this regard they should pay attention to pictures in recurrent epileptic
manifestations
96-97
, syncope
97-98
, encephalopathy
99
100-101
which are scientific references associated to the practice of asphyxial games in living
patients.
It is also important to disseminate such information among police and research
personnel, and among physicians and pathologists who practice medical legal autopsies.
Regarding the dissemination to parents or the media, it should be transmitted in a prudent
and scientific manner to avoid generating mass hysteria, as demonstrated in the Toblin
study (2008) of the CDC of Atlanta when overexposure by the media and
misrepresentation of information ended up in the appearance of cases in cluster. Parental
supervision is particularly important for young people who engage compulsively and
alone in this activity101. Future research should focus on parental guidance to provide
both supervision and education during this complex stage of life.
6.0 REFERENCES
1. Byard RW, Bramwell NH. Autoerotic death: a definition. Am J Forensic Med Pathol.
1991; 12 (1): 7476.
11. Sade, Marquis de. Justine. In: Lely G, Ed. The Marquis de Sade: A biography.
New York NY: Grove Press; 1962.
12. Ewers H. Alraune. New York, NY: John Day; 1929.
13. Beckett T. Waiting for Godot. New York, NY: Grove Press;1962
14. Harris T. Hannibal. New York NY: Delta; 2005.
15. Uva J. Review: autoerotic asphyxiation in the United States. J Forensic Sci. 1995;
40(4): 574-581.
16. Ober WB. The man in the scarlet cloak. The mysterious death of Peter Anthony
Motteux. Am J Forensic Med Pathol. 1991;12(3):255-261.
17. Ober WB. The sticky end of Frantiseck Koczwara, composer of The Battle of
Prague. Am J Forensic Med Pathol. 1984;5(2):145-149.
18. "Paula challenges Hutchence verdict". BBC News (BBC). 10 August 1999.
Retrieved 9 December 2010.
19. "Carradine Death 'Erotic Asphyxiation'". Bangkok Post. 2009-06-06. Retrieved
2009-06-05.
20. Ryan M. Manual of medical jurisprudence and state medicine (2nd Ed.). London:
Sherwood, Gilbert & Piper; 1836.
21. DeBoismont A. Du Suicide et de las Folie Suicide [original in French]. Paris.
France: Germer Bailliere;1856.
22. Ellis H. Studies in the psychology of sex (Vol 1 pp 152-153). New York: Random
House. 1936.
34. Nq J, OGrady G, Pettit T, Frith R. Nitrous oxide use in first year students at
Auckland University. Lancet. 2003; 361:1349-1350.
35. Sakai K, Maruyama-Maebashi K, Takatsu A. Fukui K. Sudden death involving
inhalation of 1,1 difluoroethane (HFC-152a) with spray cleaner: three cases
report. Forensic Sci Int. 2011; 20(1-3):58-61.
36. Shields LB, Hunsaker DM, Hunsaker JC III. Autoerotic asphyxias part I. Am J
Forensic Med Pathol.2005; 26(1):45-52.
37. Le D, Macnab AJ. Self strangulation by hanging from cloth towel dispensers in
Canadian schools. Inj Prev. 2001;7(3):231-233
38. Katz KA, Toblin RL. Language matters: unintentional strangulation activity and
the choking game. Arch Pediatr Adolesc Med. 2009; 163(1):93-94.
39. Michel G. Dangerous and violent games in child and adolescent: the example of
aggressive and self-asphyxiation games [original in French]. J Pediatr Pueric.
2006; 19:304-12.
40. Linkletter M, Gordon K, Dooley J. The choking game and YouTube: a dangerous
combination. Clin Pediatr.2010; 49(3):274-279.
41. Macnab AJ, Deevska M, Gagnon F, Cannon WG, Andrew T. Asphyxial games or
the choking game: a potentially fatal risk behavior. Inj prev. 2009;15(1):45-4942. Ramowski SK, Nystrom RJ, Chaumeton NR. Choking game awareness and
participation among 8th graders-Oregon, 2008. MMWR Morb Mortal Wkly Rep
2010; 59:1-5.
43. Dake JA, Price JH, Kolm-Valdivia N, Wielinski M. Association of adolescent
choking game activity with selected risk behaviors. Acad Pediatr. 2010;
10(6):410-416.
44. Le Heuzey MF. Dangerous games in schoolchildren. [Article in French].Arch
Pediatr 2011; 18:235-237.
45. Ramowski SK, Nystrom RJ, Rosenberg KD, Gilchrist J, Chaumenton NR. Health
risk of Oregon eight-grade participants in the choking game: Results from a
population-based survey. Pediatrics 2012; 129:846-851.
46. Shields LB, Hunsaker DM, Hunsaker JC III. Autoerotic asphyxias part II. Am J
Forensic Med Pathol 2005; 26(1):53-62.
47. Walsh FH, Stahl CJ, Unger HT. Autoerotic asphyxia deaths: a medico legal
analysis of 43 cases. Legal Medicine Annual 1977; 157-182.
48. Byard RW, Winskog C. Autoerotic death: incidence and age of victims A
population based study. J Forensic Sci 2012; 57(1):129-131.
49. Behrendt N, Modvig J. The lethal paraphiliac syndrome accidental autoerotic
death in Denmark 1933-1990. Am J Forensic Med Pathol 1995; 16(3):232-7.
50. Blanchard R, Hucker SJ. Age, transvestism, bondage and concurrent paraphilic
activities in 117 fatal cases of autoerotic asphyxia. Br J Psychiatry1991; 159:371377.
51. Breitmeier D, Mansouri F, Albrecht K, Bhm U, Trger HD, Kleemann WJ.
Accidental autoerotic deaths between 1978 and 1997 Institute of Legal Medicine,
Medical School Hannover. Forensic Sci Int 2003:137:41-44.
52. Diamond M, Innala SM, Ernulf KE. Asphyxiophilia and autoerotic death. Hawaii
Med J 1990; 49(1).11-6, 24.
53. Tough SC, Butt JC, Sanders GL. Autoerotic asphyxia deaths: Analysis of
58. Henry RI. Suicide by proxy: a case report of juvenile autoerotic sexual asphyxia
disguised as suicide. A common occurrence ?. J Clin Forensic Med 1996;
3:55.56.
59. Doychinov ID, Markova IM, Staneva YA. Autoerotic asphyxia (a case report).
Folia Med (Plovdiv) 2001; 43(4):51-53.
60. Behrendt N, Buhl N, Seidl S. The lethal paraphiliac syndrome: accidental
autoerotic deaths in four women and review of the literature. Int J Legal med
2002; 116(3):148-152.
63. Burch PM, Case ME, Turgeon R. Sexual asphyxiation: An unusual case
involving four male adolescents. J Forensic Sci 1995; 40(3):490-491.
64. Andrew A, Fallon K. Asphyxial games in children and adolescents. Am J
Forensic Med Pathol 2007; 28(4):303-307.
65. Egge MK, Berkowitz CD, Toms C, Sathyavagiswaran L. The choking game: a
cause of unintentional strangulation. Pediatric Emerg Care 2010; 26(3):206-208.
66. Barbera-Marcalain E,
78. Nixon JW, Kemp AM, Levene S, Sibert JR. Suffocation, choking, and
strangulation in childhood in England and Wales: epidemiology and prevention.
Arch Dis Childhood 1995; 72: 6-10.
79. Wyatt JP, Wyatt PW, Squires TJ, Busutill A. Hanging deaths in children. Am J
Forensic Med Pathol 1998; 19(4):343-6.
80. Shankel LW, Carr AC. Transvestism and hanging in a male adolescent. Psychiat
Quart 1956; 30:478-493.
81. Eber M, Wetli CV. A case of autoerotic asphyxia. Psychoterapy 1985; 22(3):662668.
82. Friederich WN, Gerber PN. The development of a paraphilia. J Am Acad Adolesc
Psychiat 1994; 33(7):970-974.
83. Curran W, McGarry A, Petty C. Autoerotic asphyxiation in modern legal
95. McClave JL; Russell PJ, Lyren A, ORiordan MA, Bass NE. The chocking game:
Physician perspectives. Pediatrics 2010; 125:82-7.
96. Ullrich NJ, Bergin AM, Goodkin HP. The choking game: Self induced hypoxia
presenting as recurrent seizure like events. Epilepsy and behav 2008; 12:486-488.
97. Andrew TA, Macnab A, Russel P. Update on The Choking Game. J Pediatr.
2009; 155:770-80.
98. Shlamovitz GZ, Assia A, Ben-Sira L, Rachmel A. Suffocation roulette: a case
of recurrent syncope in an adolescent boy. Ann Emerg Med 2003; 41:223-226.
99. Senanayake M; Chandraratne KA, De Silva S, Weerauriya DC. The choking
game: self strangulation with a belt and clothes rack. Ceylon Med J. 2006;
51(3):120.
100.
associated with self applied ketamina. Int J Legal Med. 2002; 116: 113-6.
104.
105.