William Harvey Research Institute MSc in Forensic Medical

Transcription

Unintentional Asphyxial Deaths in Adolescence
Autoerotic Asphyxia and Asphyxial Games as Part of the Same Syndrome
Andrés Rodríguez Zorro
William Harvey Research Institute
MSc in Forensic Medical Sciences
Unintentional Asphyxiation Deaths in Adolescents:
Autoerotic asphyxia and asphyxial games as part of the same syndrome
Forensic Pathology
Student ID: 100511332
Monday, September 3th, 2012
Supervisor: Professor Peter Vanezis
Word count: 19.575
Dissertation submitted to Queen Mary University of London in partial
Fulfillment of the requirements for the Master of Science degree
Beneficiario Colfuturo 2011.
CONTENTS
LISTE OF TABLES
3
ACKNOWLEDGMENTS
4
1.0 ABSTRACT
5
2.0 METHOD OF UNDERTAKING THE LITERATURE SEARCH
6
3.0 INTRODUCTION
7
3.1 Definition of autoerotic asphyxia
3.2 Definition of asphyxial games
3.3 History
3.4 Neurophysiology of neck compression asphyxias
3.5 Characteristics of autoerotic asphyxiation
3.6 Characteristics of asphyxial games
3.7 Aims
7
8
9
12
16
18
21
4.0 RESULTS
4.1
4.2
4.3
4.4
4.5
Who plays asphyxial games
Who are the victims of autoerotic asphyxia in general population
Who are the victims of autoerotic asphyxiation in adolescence
Who are the victims of asphyxial games
Comparative analysis of asphyxial games and autoerotic asphyxia
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
Table 1: Neurophysiology: agonal sequences in hanging
14
Table 2: Outcome with various techniques of asphyxial games
21
Table 3: Participation rate of students in asphyxial games
27
Table 4: Key characteristics of asphyxial games in living participants
28
Table 5: Risk factors linked to living players of asphyxial games
28
Table 6: Series of fatal cases of autoerotic asphyxia in general population
30
Table 7: Key characteristics of victims of autoerotic asphyxia in general population
32
Table 8: Fatal cases of autoerotic asphyxia in adolescents reported in literature
34
Table 9: Key characteristics of victims of autoerotic asphyxia in adolescents
35
Table 10: Fatal cases of asphyxial games reported in literature
38
Table 11: Key characteristics of victims of asphyxial games
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.
2.0 METHOD OF UNDERTAKING THE LITERATURE SEARCH
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,
PsycARTICLES, PsycCRITIQUES, PsycEXTRA and the Psychology and behavioral
Sciences Collection.
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).
Relevant forensic pathology, psychology, sociology, epidemiology and psychoanalytic
literature related with autoerotic asphyxia, asphyxial games and hypoxiphilia were all
considered.
3.0 INTRODUCTION
3.1 DEFINITION OF AUTOEROTIC ASPHYXIA
Autoerotic deaths have been defined by Byard1, as “accidental deaths occurring
during individual, usually solitary, sexual activity in which a device, apparatus, or prop
used to enhance the sexual stimulation of the deceased in some way caused unintentional
death”.
Typical methods of autoerotic activity leading to death are mostly asphyxia
maneuvers: hanging, ligature strangulation, plastic bag, chemical substances, or a
combination of these. Other asphyxia methods includes: chest compression, positional
asphyxia and drowning.
Atypical methods include electrocution, overdressing/body
wrapping, foreign-body insertion, and other miscellaneous methods2.
Autoerotic asphyxiation syndrome was described by Resnik
3
in 1973 as
"repetitive erotic hanging", also known as asphyxiophilia or hypoxyphilia. It is a
paraphilia in which sexual arousal and achieving orgasm depend on self-strangulation
and suffocation, leading to a loss of consciousness but without actually becoming
unconscious. Compression of the neck and choking sensation heightens the feeling of
pleasure during masturbation. The interference of oxygen to the brain causes hypoxia
that explains the effect.
Hypoxiphilia is classified in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR) - American Psychiatric
Association 2000, as a paraphilia, a subtype of sexual masochism, not otherwise
specified. It is characterized as a “particularly dangerous form of sexual masochism
[that] involves sexual arousal by oxygen deprivation obtained by means of chest
compression, noose ligature, plastic bag, mask or chemical”. 4
This behavior also appears well described in ICD-10 Mental and Behavioral
Classification of Disorders (World Health Organization, 1992) independently of
sadomasochism, classified under the category "Other Disorders of Sexual Preference"
and defined as: "use of strangulation or anoxia for intensifying pleasure sexual”. 5
The syndrome has been recognized throughout history by various cultures but
medical literature did not provide a description until 1856 and 1866 5. Most of the
literature related to it only appeared in forensic pathology publications and was virtually
unknown to much of the medical community in hospitals.
There are few references to the etiology of these practices and it is unclear how
often adolescents incur in the practice. Most publications and literature only mention that
the syndrome is more common in young men, but only a few addresses the syndrome in
adolescents.
It is estimated that between 500 to 1000 deaths per year are related to autoerotic
deaths in the United States 6. In Canada, Sauvageau 7 estimates an incidence of 0.2 to 0.5
cases per million inhabitants per year, showing a very low incidence for this type of
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.
3.2 DEFINITION OF ASPHYXIAL GAMES
Asphyxiation games of self strangulation as practiced by preteens and teens,
called "choking games" in the literature, are another form of voluntary suffocation which
is known to have increased in the last decade mainly in the school population. A recent
report by the Center for Disease Control and Prevention (CDC) in Atlanta defines this
behavior as "self-strangulation or strangulation by another person with the hands or a
noose to achieve a brief euphoric state caused by cerebral hypoxia”.8 The mechanisms
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
Examples of the association between asphyxia, sexual pleasure and excitement
have been described in different cultures and different historical periods. Anthropologists
have reported that Eskimo children hang themselves during certain types of games in
which they seem to mimic asphyxial behavior of adults during intercourse 3. Similarly,
young people of ethnic Yahgans in Tierra del Fuego in southern Chile use ligatures to
induce partial strangulation and excitement while describing having seen bright colors.9
Moreover the children of the Shoshone-Bannock ethnicity in Idaho, United States, play
games like "smoke out", "red out" and "hang up" which are essentially suffocation and
strangulation games. 10
A stone sculpture at the Museum of Anthropology in Mexico City shows a male
teenager with a tight band around the neck, while his penis is erect. The museum notes
that the sculpture represents a teen phallic cult and corresponds to the Mayan culture,
about 1000 AD during the transition from the Late Classic period and the Early Post
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
In the tragicomedy in two acts by Thomas Beckett "Waiting for Godot",
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
and Czech musician Frantiseck
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
In the medical literature the first reference in English (Ryan, 1836)
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
, Litman and Swearinger,
(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,
3
theorized to quantify eroticized, repetitive hangings as a syndrome. He listed 10 features
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.
3.4 NEUROPHYSIOLOGY OF NECK COMPRESSION ASPHYXIAS
According to what Resnick3 postulated in 1972, constriction of the neck:
1. Disrupts the blood flow that supplies oxygen to the brain
2. Increases retention of carbon monoxide
Both hypoxia and hypercapnia affect some particularly sensitive nuclei of the
brainstem and produce a state of semialucinosis accompanied by a lucid and placid
feeling of light-headedness that enhances masturbation. Reinforcing the above, he
mentions that physiologically ejaculatory pleasure is accompanied by breath holding and
contraction of the muscles of the neck.
The most common mechanism used in autoerotic practices according to the
literature reviewed is the compression of the neck of which the most common is hanging.
2
The immediate consequence of bilateral compression of the vascular structures of the
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
reviewed fourteen cases of videotaped hangings: nine autoerotic accidents, four
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
(average 19± 5 seconds) and stopped between 1 minute 2 seconds and 2 minutes 37
seconds (average, 1 minute 51 seconds ± 30 seconds). All results are shown in table 1.
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
Stat of deep rhythmic abdominal
Respiratory movements
Decorticate rigidity
Loss of muscle tone
End of deep rhythmic abdominal
Respiratory movements
Last muscle movement
19 ± 5 s
The findings of Sauvageau et al
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
are consistent with those described by
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
physiology is very similar. Both hypoxia and hypercapnia produce a state of
exhilaration and induce a short but intense lucid semialucinosis that coupled with
the sexual fantasy increase sexual pleasure during masturbation.
In asphyxial games the most widely used mechanism is the compression of
neck vessels: manual strangulation or with clothes when practiced with a partner or
hanging when the individual practices clandestinely. Some variables to the game
add prior hyperventilation which involves hypocapnia.
Once the physiology of hypoxia is understood it is no surprise to learn that
the use of substances such as amyl nitrate (poppers), nitrous oxide and other
inhalants such as 1,1-difluoroethane (HFC-152a) is related to sexual activity. The
intake method of the first substance is by way of an inhaler that induces
metahemoglobinemia and hence low oxygen supply to the brain. It has historically
been associated as a sexual facilitator or "aphrodisiac" and is commonly used
among prostitutes and homosexuals. During the 70 and 80's and times it was
commonly used as a club drug because of the effects of intense lucid semialucinosis
secondary to hypoxia which together with music and other visual stimuli is
perceived as extremely pleasurable. In fact, in the literature reviewed, Bungardt and
Potsch 33, reported a case of autoerotic asphyxiation related to the use of amyl
nitrate in Germany in 2003. In the case of nitrous oxide or "laughing gas", a
substance also used recreationally to obtain euphoria effects, the practice of
inhaling the gas inside a rubber pump and repeatedly reinhaling content is common
in students. 34 This use clearly induces hypoxia and hypercapnia accompanied by
hallucinosis. Sakai
35
reports in recent literature a case in Japan of the autoerotic
death of a 41 year old adult by inhalation of 1,1-difluoroethane (HFC-152a), a
known spray cleaner that produces euphoria. In the series of cases viewed,
autoerotic asphyxiation by other gases such as methane, propane, solvents and
anesthetics is frequently described.
3.5 CHARACTERISTICS OF AUTOEROTIC ASPHYXIATION
According to Byard (1991), autoerotic deaths denotes an unanticipated death
that results while the subject is engaged in solo sexual activity and the arousalenhancing device designed to rescue participants fails. 1 Autoerotic asphyxia deaths
constitute de vast majority of these cases. The most frequently encountered method
was asphyxia by hanging or ligature. 2
Hazelwood 6 describes four mechanisms that interact or contributes in varying
degrees to an autoerotic asphyxia: (1) neck compression, (2) oxygen deprivation,
(3) airway obstruction and (4) chest compression. Participants of autoerotic
asphyxia use combination of these components with intention to heighten sexual
arousal. Participants tend to repeat de practice compulsively and in a solitary and
clandestine context which may result in a loss of control of self rescue mechanism
and accidental death.
The self –rescue device is designed to provide the participant a fail-safe
capability to free himself from the autoerotic act prior to a fatal outcome. The
mechanisms vary from a simple maneuver of standing erect to control neck
compression to complex ligatures between limbs and neck controlled by body
movements. Shields et al (2005)36 identified a slipknot as the most common rescue
device in cases of autoerotic deaths by ligature asphyxia. In a study of 16 cases,
slipknot had been used by 84.6% of the victims who still had the ligature about the
neck at autopsy.
The incidence of autoerotic asphyxias demonstrates particular characteristics.
Resnick (1972) listed 10 features including: (1) an adolescent or young male; (2)
ropes, belts and binding materials so that the constriction of the neck can be
controlled voluntary (3) evidence of masturbation; (4) partial or complete nudity;
(5) usually a solitary act; (6) repetitive behavior designed to produce no visible
marks; (7) no apparent wish to die; (8) presence of erotic literature. Resnick
mentioned
other
two
elements
less
frequent:
(9)
binding
of
body/genital/extremities and (10) presence of female attire. Resnick summarize his
“erotized repetitive hanging syndrome” as adolescent or young male who
participate in a solitary masturbatory act using a binding apparatus that
compresses the neck. 3
Supporting the Resnick features, Hazelwood et al 6 discusses 12 characteristics
of autoerotic death to be taken into account at the scene:
1. Location: a secluded or isolated location such a locked room, attic,
basement, garage, workshop, motel room, places of employment during non
business hours, wooded areas, and summer residences.
2. Victim position: most commonly the victim´s body is partially supported by
the ground such that she/he is suspended upright with only the feet touching
the surface.
3. Injurious agent: most common was a ligature compressing the neck
4. Self rescue mechanism: any provision that the victim has made to reduce
or remove the effects of the injurious agent such as a slip knot or knife for a
ligature
5. Bondage: refers to the use of physically restraining materials or devices that
have sexual significance for the user (this characteristic is often responsible
for the misinterpretation of these deaths as homicidal versus accidental).
6. Sexual masochistic behavior: the deceased sometimes inflicts pain upon
his/her genitals, nipples, or other body parts.
7. Attire: The victims are occasionally dressed in one or more articles of female
clothing (the family often alters the scene due to shame, embarrassment or
impulse).
8. Protective padding: the victim is found with soft material between the
ligature and adjacent body part to prevent abrasions and bruising.
9. Sexual paraphernalia: vibrators, dildos and fetish item such as female
garments, leather, and rubber items are found on or near the victim.
10. Props: items such as mirrors, pornography magazines, pornography
websites, photographs and films.
11. Masturbatory activity: the deceased may or may not engage in manual
masturbation during the fatal autoerotic activity and the presence of seminal
fluid has to be interpreted carefully. In some cases it is not a useful clue in
determining whether death is due to autoerotic misadventure.
12. Evidence of previous experience: elicited from relatives and associates,
permanently affixed protective padding, suspension-point abrasions,
witnessed events, complexity of injurious agent and collected materials.
3.6 CARACTERISTICS OF ASPHYXIAL GAMES
Reference to choking games in the medical literature and in particular psychiatric
literature is very limited. Only in the last decade, there has been a boom around the
phenomenon possibly due to cases published on the Internet, the press and television. In
fact before 2000 there is no reference to these deaths in the Medline database. The first
scientific paper reviews of these practices in adolescents (D Le, AJ Macnab)
37
only
appears until 2001 where there is a retrospective review of cases of self-strangulation
with towel dispensers in Canadian schools.
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,
emergency medicine and public health.
Very recently French author Michel Gregory (2006) 39 at the Psychopathology of
Childhood and Adolescence Service at Robert Debré Hospital, in Paris, described the
violent games played by children and adolescents and classified them into aggression and
oxygenation games. The first set corresponds to heteroagression games where physical
violence is used, usually by group of young people against a victim (bullying). The
second group is the objective of this review and includes all games involving
asphyxiation type of maneuvers with subsequent strangulation and suffocation which
result in cerebral hypoxia, i.e. unintentional suffocation (most of them self-inflicted).
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.
Seizures due to hypoxia (55%) were documented in 36 videos and 25 (38%)
showed no signs of convulsion; in the remaining 4 videos it was impossible to establish
with certainty the possibility of seizure due to an observer blocking the camera. Seizures
were more frequent in those videos that used the technique of "sleeper holder" compared
to the other methods (P <.001). In these cases the seizures were documented in 21 of the
24 cases (88%). Seizures occurred in 3 of the 4 videos among those who curled up and
then stood up, hyperventilated and then applied Valsalva or held their breath,. The
seizures were less frequent in cases of snuggling or bending followed by standing and
then in the chest or neck. Within this group, seizures occurred in 11 of 27 cases (41%).
When pressure was applied to the neck or chest while the person stood without curling
previously, only in 1 of 8 cases showed seizure. Both the older participants and younger
had the same risk of seizures. The complete results are shown in Table 2.
Table 2. Outcome With Various Techniques of Asphyxial Games. From: Linkletter M,
Gordon K, Dooley J. The “choking game” and YouTube: a dangerous combination. Clin
Pediatr.2010; 49(3):274-279.
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
6
3
1
75
25
0
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.
The purpose of this study is
•
Outline any issues relevant to asphyxial games in adolescence and describe
their characteristics, the profile of its practitioners and potential risk factors.
•
Examine comprehensive literature of all fatal cases involving unintentional
asphyxia in adolescents (autoerotic deaths asphyxiation and asphyxia
games) reported in medical journals and publications to determine the
characteristics of these practices in this population in particular, and to find
possible commonalities or differences between them.
•
Review literature in psychology and psychoanalysis to understand the
etiology of asphyxial behavior and its implications.
•
Make a critical analysis of literature in forensic pathology, psychology,
psychoanalysis and discuss whether both behaviors (adolescent autoerotic
asphyxiation and choking games) might correspond to a single syndrome or
may be considered as separate entities.
•
Increase awareness about unintentional asphyxia for health professionals,
forensic pathologist and educational establishments in order to gain a better
understanding of the situation.
•
Cite some recommendations for further studies in the area and the
development of measures to prevent these deaths.
4. RESULTS
4.1 WHO PLAYS ASPHYXIAL GAMES
Macnab et al. (2009) 41 conducted a study based on surveys taken among 2504
students in grades 4 to 12 with ages between 9 and 18, from 8 schools and of higher
education in Texas (USA) and 2 in Ontario (Canada). The average age of
respondents was 13.7 years (SD: 2.2), median age 13. In this study 68% of young
people had heard about the game and 58% of these were men. A total of 45% knew
someone who practiced the game and 6.6% admitted had participated in such
games. Of these 93.9% practiced it with someone else. 40% of respondents did not
perceive any risks with the playing of games. Of 6.6% who admitted having carried
out the practice, 55% were men. Of those who had carried out the practice 94% did
so with someone else being present.
An interesting result is that all girls who have played the game accepted
having had company. Ten young men (11%) did so alone. 58% of respondents who
said they practiced choking game reported continuing to do so. The percentage of
children who continued to participate in these games varied according to age. The
highest percentage (6-10%) was within the range of 15 to 17 years. The researcher
was struck by the discovery that even though one of the schools surveyed had
recently suffered the death of a student by asphyxiation games and five of the
schools were located in a state where two victims were reported, 95 of the
respondents agreed to continuing to play the game and more than a third knew the
game before publications informing of deaths by the press and television.
In the U.S., Ramowski et al. (2010) 42 and Public Health Division of Oregon
surveyed the school population of 8 schools. In 2008, all 647 schools and higher
education were taken into account in the study. A sample of 114 schools with a total
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.
Ramowski et al. (2012) 45 discussed a further follow-up survey conducted in
Oregon in 2008. He sampled 5348 schoolchildren aged 12 to 15 years. In this
review, 22% of 8th grade students reported that they had heard information about
the games, 1.2% admitted to having helped someone during the game and a 6.1%
accepted having played the game alone. The study found no significant differences
regarding sex nor concerning rural compared to urban population. Youth with
better academic performance were less likely to participate than those with lower
grades. The most important advance in this study was to assess bivariate regression
models between health risk factors for and the playing of games of suffocation. The
results showed that the latter are significantly associated with six risk factors:
mental health disorders, substance abuse, exposure to violence, sexual activity,
malnutrition and gambling.
When doing a multivariate analysis no differences were found in predictive
risk factors between men and women. Sexual activity and substance use was
common in both sexes. But for women the strongest predictor was the sex: young
women who were sexually active were given 4 times more to playing the games of
suffocation than those without sexual initiation. (OR: 3.97 [95% CI :2.4-66]). Other
predictors were substance abuse (OR: 2.11 [95% CI :1.4-3 0.3]) and gambling (OR:
1.72 [95% CI :1.3-23]). In the case of men substance abuse was the strongest
predictor of choking game (OR: 3.87 [95% CI :1.9-7 .7]), followed by sexual activity
(OR: 3.01 [95% CI: 1.5-3.1]). Although some young people admitted to the carrying
out the practice only once, most participants (64%) had done it at least twice and a
fifth of them more than 5 times. The above result shows a clear tendency to
repetition in the practitioners. Recalling what Macnab documented regarding the
association between gender and repeated practice alone, a tendency to repetition
while being alone was more predominant in males. The study only took into
account 8th grade students between 12 and 15, which is not very large range.
Lastly, it is worth the study conducted by Linkletter et al (2010)39 is quoting
again. As mentioned above, videos about practitioners of asphyxiation games on the
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.
Table 3.Participation rate of students in asphyxial games
Study
Macnab et al (2009)
Participation rate %
6.6
Dake et al (2010)
9
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.
Table 4. Key characteristics of asphyxial games living participants
•
•
•
•
Frequency tend to increase with age
Game is played mostly in group
Repetition associated with solitary practice
No significant gender differences in survey participants. However, females tend to
play in group. Repetition and solitary practice is linked to male
•
•
In video records evidence, mostly of participants are male.
Not perceived as a life-risk behavior
Table 5. Risk factors linked to living players of asphyxial games
Dake et al (2010)
Ramowski et al. (2012)
Being older >15 years
Poor nutrition
Exposure to physical violence
Exposure to physical violence
Substance abuse
Substance abuse
Sexual activity
Sexual Activity
Non 2 parent family
Gambling
Low academic performance
Low academic performance
Mental health issues
Mental health issues
4.2 WHO ARE THE VICTIMS OF AUTOEROTIC ASPHYXIA IN GENERAL
POPULATION
Using the tools described in the section on methods there are multiple allusions to
series of cases related to autoerotic asphyxiation and unintentional deaths by
asphyxiation. As explained above, the study focuses on the study of all types of
unintentional asphyxia in preadolescent and adolescent populations.
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%.
Table 6. Series of fatal cases of autoerotic asphyxia in general population.
Reference
Year
Country
Period
Number
of cases
Sex
Age
Mean
Age
Type of asphyxia
I/O
Emplacement
Walsh et al47
1977
USA
19581973
43
M
14-75
<30: 77%
All forty three neck ligature compression
43 ND
43ND
Hazelwood et al6
1983
USA
19701978
70
66M
- 4F
9-77
26.5
Forty-four hanging; six neck compression; 12 airway
obstruction, four chest compression; two oxygen
exclusion with gas or chemical replacement
70ND
70ND
Diamond52
1990
USA
ND
8
M
15-59
ND
Six hanging; one plastic bag; one smothering (pillow)
7I
One public location; ND for the
rest
Blanchard and
Hucker50
1991
Canada
19741987
117
M
16-76
26
117
ND
117 ND
Tough et al53
1994
Canada
19
M
15-50
28
19I
19 ND
Behrendt and
Modvig49
1995
Denmark
19781989
19331990
Ninety-three hanging; seven plastic bag + gas or
solvent; six ligature strangulation; five plastic bag;
three hanging + plastic bag; one chest compression;
one gas or volatile solvent: one ligature strangulation +
plastic bag
Eighteen hanging, one inhalation of solvent
46
M
10-71
31
Twenty hanging; 14 plastic bags, six gas or substance
inhalants, two strangulation, two positional asphyxia,
two non asphyxia deaths
80%I
58% bedroom or living room,
14% bathroom, 8% adjacent
room
Bretmeier et al51
2003
Germany
(Hannover)
19781997
17
M
16-76
36.8
Seven asphyxia by strangulation; four suffocation, one
asphyxia by drowning, four non asphyxia deaths
14I
Eleven apartment, one car, one
jail cell, one hotel room
Shields et al46
2005
USA
19932001
16
M
14-59
38.3
Twelve hanging, four ligature strangulation
15I
Five bedroom, four basement,
two home, two cabin, one
garage, one front hall
Janssen54
2005
Germany
(Hamburg)
19832003
40
M
13-79
<39: 50%
Seventeen hanging; three ligature strangulation;
suffocation in eleven cases; two thoracic compression;
One positional asphyxia; Six non clear differentiated.
37I
Byard48
2012
Australia
20012007
44
42M2F
10-69
<39:52%
Hanging in forty cases; four non asphyxia deaths
44ND
Indoor: Bedrooms, bath, cellar,
hotel room. Outdoor: Cabin of
sex cinema, bridge, rubbish
container.
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.
Summary of key characteristics of victims of autoerotic asphyxial in general population
are shown in table 7.
Table 7. Key characteristics of victims of autoerotic asphyxia in general population
Age
In all series there are adolescents reported. Mostly of victims are
compressed in adolescence and young adults.
Gender
Mostly of victims are male
Type of asphyxia
Marked prevalence of neck compression asphyxias, mainly hanging.
Emplacement
Predominant indoors scenes
Context
Solitary, secrecy, clandestine activity.
4.3 WHO ARE THE VICTIMS OF AUTOEROTIC ASPHYXIATION IN
ADOLESCENCE
Reports of 15 cases of deaths of adolescents from 1988 to 2005 were found in
Canada, USA, United Kingdom, Bulgaria, Denmark and Germany. (Shown in Table 8).
The first case was reported by Byard and Braumwell (1988) 55 in Canada, an unusual
case of a female involved with transvestite fetishism. Sheehan et al (1995)56 makes a
detailed review of nine cases occurred between 1975 and 1985 in the state of Minnesota.
Two reported cases were not considered for this study. The first did not have clear
autoerotic features (only describes the shaving of pubic hair as a sign of sexual activity).
The second was excluded because it involved a 20 year old (the study includes only cases
up to 19 years of age according to the definition of adolescence and the World Health
Organization).
Kirksey et al (1995)57 published two fatal cases of boys who arrived in full
cardiopulmonary arrest to Emergency Department of University Hospital in San Antonio
(Texas). Henry (1996) 58 describes a death of 12 years old boy in the midlands UK in
1977 firstly taken as suicide with transvestite fetishism component. The scene was
modified: the mother and aunt decided to redress the boy in his underpants, his normal
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.
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.
Table 8. Fatal cases of autoerotic asphyxia in adolescents reported in literature.
Reference
Year
Country
Sex
Age
Method
Type of asphyxia
I/O
Emplacement
Type paraphilia
Byard and
Bramwell55
1988
Canada
F
19
Ligature neck compression
Ligature Strangulation
I
Bedroom
Transvestite Fetishism
Sheehan et al56
1988
USA
M
13
Hanging
I
Home
Bondage
Sheehan et al56
1988
USA
M
14
Hanging
I
Bedroom
Voyeurism (mirror)
Sheehan et al56
1988
USA
M
14
Plastic bag - Propane inhalation
Suffocation
I
Garage
Sheehan et al56
1988
USA
M
14
Hanging
I
Basement
Sheehan et al56
1988
USA
M
16
Hanging
I
Basement
Sheehan et al56
1988
USA
M
16
Hanging
I
Bathroom
Voyeurism (mirror)
Sheehan et al56
1988
USA
M
16
Hanging
I
Home
Kirksey et al57
1995
USA
M
13
Hanging
I
Bedroom
Bondage
Kirksey et al57
1995
USA
M
17
Hanging
I
Home
Henry58
1996
UK
M
12
Hanging
I
Home
Doychinov et al59
2001
Bulgaria
M
18
Hanging
I
Bedroom
Behrendt et al60
2002
Denmark
F
17
Plastic bag
Suffocation
I
Bedroom
Bondage
Koops et al61
2004
Germany
M
16
Ligature Strangulation
I
Bedroom
Shields et al46
2005
USA
M
17
Gas (butane) inhalation
Suffocation
I
Home
All cases (100%) occurred in indoors scenarios like homes, mainly in bedrooms
(42.8%). Other places described were bathrooms, garages and basements. In all cases
deaths occurs in a context of solitary activity.
4.3.5 Type of paraphilia
Interestingly, it was found that documented paraphilia occurred in early
adolescence. In 12 cases (80%) at least one of these types were established. The most
common paraphilia is fetishism / transvestitism where there were a total of 7 cases
(46.6%) reported; bondage with 3 cases (20%) and voyeurism with two cases (13.3%)
followed. In three cases (20%) did not report any paraphilia, however pornography,
nudity and / or masturbation were evident. As mentioned in the age analysis, there seems
to be a direct correlation between increasing age and the type of paraphilia involved.
Summary of key characteristics of victims of autoerotic asphyxia in adolescents are
shown in table 9.
Table 9. Key characteristics of victims of autoerotic asphyxia in adolescents
Age
Deaths are documented in both: early and late adolescence
Gender
Almost all victims are male
Type of
asphyxia
Marked prevalence of neck compression asphyxias, mainly hanging.
Emplacement
Context
Solitary, secrecy, clandestine activity.
Paraphilias
Paraphilias are common in adolescence and tend to increase with age
4.4 WHO ARE THE VICTIMS OF ASPHYXIAL GAMES
For author Michel39 the magnitude of this phenomenon is very difficult to assess
because it is a type of game played outside adult control. The consequence of this
practice is often interpreted in terms of accidents, but still many are wrongly classified as
suicides. The numbers are contrasting and controversial. In France parent associations
speak about figures ranging from 90 to 200 fatal cases. On the other hand the
Croissandeau report conducted in 2002 by the General Inspectorate of Education in this
country found only a dozen cases since 1990. 62
According to the report the victims were aged between 11 and 15 years; most of
them in elementary school and a few in high school. High school students involved had
initiated the practice in elementary grades. All fatal cases reported were male. All the
victims apparently engaged in group play during middle school or holiday activities.
However, the author notes that in his clinical experience they have identified that the
practice of these games alone in the home and are an indicator of a severity and
seriousness to which we must pay close attention. According to the study most of the
deaths occur precisely at home.
The Croissandeau study posits three different types of practitioners:
1. Occasional: those motivated by curiosity or are driven by peer pressure.
2. The regulars: Very given to experiment and search for new sensations. They
are repeating the game and practice it at home alone.
3. Suicides: Subjects with fragile personality. The most unusual group yet at high
risk of accident and death.
In the present study, the number of articles reporting cases of choking games is
quite small. Only five references that meet the inclusion criteria proposed in this study
are shown. A total of 12 fatalities were reported. See Table 10.
The first of these references is by the Canadian Authors D Le and Macnab
(2001)37 who describe hangings of children and adolescents related to towel dispensers,
within their schools. Both used the Med LARS method and reviewed cases published in
the newspaper and checked reports of Medical Examiners in the period between 1966
and 2000. Of a total of five cases reported, one survived. The remaining four are
included in this study.
The second reference Burch et al. (1995) 63 is a very peculiar case that occurred in
St. Charles County, Missouri (USA) in which the victims, two children under 7 and 8
years respectively, placed a shoelace around the neck and consented to be sodomized by
two other minors of 10 and 13 years respectively. The case was included in the study
because victims themselves voluntarily placed the ligature around the neck. The case is
interesting because it shows a clear association between asphyxial games and a sexual
component at an early age.
Andrew (2007) 64 describes three cases in the state of New Hampshire (USA) in
which three males of school age, 9, 13 and 11 respectively, appeared hanging inside their
rooms. The first had been seen by his sister several times playing with a string around the
neck in his room. In the second case the child's mother brought to the medical examiner's
office emails that involved the child in the practice of game known as "space monkey".
In the latter case, which occurred just six weeks after the second, the child had
knowledge of the game. The author mentions two other highly suspicious cases involving
school children age 12. Both of these were classified by the office of medical examiner
as suicide in one case and as undetermined in the other. For this reason they were not
included in his review.
Table 10. Fatal cases of asphyxial games reported in literature.
Reference
Year
Country
Sex
Age
Method
Type of
asphyxia
I/O
Emplacement
Burch et al63
1995
USA
M
7
Ligature neck
compression
Ligature
Strangulation
O
Wood
Burch et al63
1995
USA
M
8
Ligature neck
compression
Ligature
Strangulation
O
Wood
D Le- Macnab37
2001
Canada
M
11
Ligature neck
compression
Hanging
I
School Bathroom
D Le- Macnab37
2001
Canada
M
7
Ligature neck
compression
Hanging
I
School Bathroom
D Le- Macnab37
2001
Canada
M
7
Ligature neck
compression
Hanging
I
School –
Bathroom
D Le- Macnab37
2001
Canada
M
9
Ligature neck
compression
Hanging
I
School –
Bathroom
D Le- Macnab37
2001
Canada
M
12
Ligature neck
compression
Hanging
I
School –
Bathroom
Andrew64
2007
USA
M
9
Ligature neck
compression
Hanging
I
Bedroom
Andrew64
2007
USA
M
13
Ligature neck
compression
Hanging
I
Basement
Andrew64
2007
USA
M
11
Ligature neck
compression
Hanging
I
Bedroom
Egge65
2010
USA
F
12
Ligature neck
compression
Hanging
I
Bedroom
BarberíaMarcalain66
2010
Spain
M
15
Ligature neck
compression
Hanging
I
Bedroom
Egge (2010) 65 published the only article that documents a female victim, which
occurred in Los Angeles (California).
It also corresponded to hanging inside her
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.
In the last of these cases Barberia-Marcalain et al.66 describe a case in the
Autonomous Community of Catalonia involving a 15 year old found inside his room on
one knee with his elbows on a cushion and neck placed inside a loop in a "U" shape
which was attached to the top of the bunk bed. At the time of death the teenager was
playing with the loop to gradually compress the neck while playing video games with a
handheld console.
The investigation found another reference in Spanish by Baquero et al. (2011) 67
who mentions the occurrence of 8 cases of choking game deaths between August 2009
and 2010 in the province of Rosario in Argentina. Because a description of the cases and
the characteristics of the scene are not described, the story was not considered for this
study. However, it does provide relevant information regarding a trend of occurrences of
multiple cases in a short period of time, which may have been influenced by the media
and the Internet.
The largest study in this review of cases related to fatal “choking games” was
conducted by Toblin et al, 8 members of the division for the Prevention of Unintentional
Injury Prevention at Center for Disease Control in Atlanta (United States) in 2008. The
authors analyzed the deaths of young people between 6 and 19 years of age, between
1995 and 2007, using as source the LexisNexis® method based on reports of articles
published in newspapers across the United States. They initially found a total of 106
deaths related to suffocation games of which 20 items were ruled out due to suspected
suicide as provided by the medical examiner's office; one because the age of the victim
was not clear and 3 due to having autoerotic elements (to my mind a bias in the research).
They documented a total of 82 deaths related to choking games. The earliest
documented cases date from 1995. Three or fewer deaths occurred in the period between
1995 and 2004, but 22 deaths occurred in 2005, 35 in 2006 and 9 in 2007. Seventy-one
(86.6%) of the 82 dead were male. The reported 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 age distribution of
deaths related to asphyxia games during the period 1995-2007 differs substantially from
5.101 young people aged 6-19 years whose deaths were attributed to suicide hanging /
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.
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.
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
Barbería-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
Deaths are documented in both: early and late adolescence
Gender
Almost all victims are male
Type of
asphyxia
All cases are related with neck compression asphyxias, mainly hanging.
Emplacement
Context
Solitary, secrecy, clandestine activity. Previous knowledge of the game.
4.5 COMPARATIVE ANALYSIS OF FATAL CASES OF ASPHYXIAL GAMES
AND AUTOEROTIC ASPHYXIA
To identify common elements in each of the variables a comparative analysis
follows of those variables taken from articles describing cases of fatal choking games
among teenagers, a series of cases analysis of fatal choking games conducted by the
Center for Disease Control and Prevention CDC in Atlanta, articles found relating to fatal
cases of autoerotic asphyxiation in adolescents and the series of cases of auto erotic
suffocation in general (adult and teenagers).
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).
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
In all series are
adolescents reported.
Mostly of victims are
compressed in
adolescence and young
adults.
Deaths are documented
in both:
early and late
adolescence
Deaths are documented
in both:
early and late
adolescence
Gender
Mostly of victims are
male
Almost all victims are
male
Almost all victims are
male
Type of
asphyxia
Marked prevalence of
neck compression
asphyxias, mainly
hanging.
Marked prevalence of
neck compression
asphyxias, mainly
hanging.
All cases are related
with neck compression
asphyxias, mainly
hanging.
Predominant indoors
scenes
Predominant indoors
scenes
Emplacement Predominant indoors
scenes
Context
Solitary, secrecy,
clandestine activity.
Release mechanism
Solitary, secrecy,
Release mechanism
Solitary, secrecy,
Previous knowledge of
games.
Paraphilias
Very common
Present from early
adolescence
N.A ?
5.0 DISCUSSION
5.1 ETIOLOGIC THEORIES
Traditional conceptualization of autoerotic asphyxiation and other paraphilia is
based on psychoanalytic concepts relating to Freud’s theory of psychosexual
development. As mentioned previously, Resnik (1972)3 described the autoerotic
asphyxiation as "eroticized repetitive hangings." He stresses that the intention is not to
produce death and that there are attempts to hide the marks or grooves of the neck
pressure. The author reviewed clinical reports and found other commonalities that he
describes as "upward displacement of castration anxiety" (e.g. the penis into the neck). In
this scheme the penis is represented by the neck, which is symbolically "castrated".
Ejaculation then calms anxiety, which symbolizes having survived castration.
Resnik explains sexual asphyxiation as a result of castration anxiety; possibly
arising from conflicts early in the oral psychosexual development produced by a mother
breastfeeding her child so enthusiastically that partial asphyxiation or suffocation is
associated with the pleasure of being nurtured. The newborn may experience
asphyxiation by the act of the mother compressing its face to her breast before receiving
milk, or when the baby holds its breath while crying before being properly nursed. The
author believes that these many be early determining factors to searching for similar
sensations in later stages of life (e.g. pleasurable experiences induced by hypoxia, anoxia,
hypercapnia by neck compression, partial suffocation or other methods).
Resnik theorizes that the infant suffers a conflict (virtually life and death)
between the pleasurable sensation of breastfeeding and the threat of suffocation, which
he/she relates to a pleasant feeling. Resnik believes that the behavior may represent
conflicts over separation from the mother, symbolizing both the desire for oral
gratification and the fear of remaining too dependent on the mother. "Immobilization and
asphyxia contribute to fantasies of feeding, reunion and rebirth”. In his theory, Resnik
also considers the eroticization of death as related to separation anxiety. Death is a
symbol of "leaving and Returning, Appearing and disappearing, dying and being
reanimated". A patient of Resnik’s described a "smothering by white billows" in early
childhood dreams. The author does not mention any cases where there was no
breastfeeding. There are no references to autoerotic asphyxiation in bottle-fed babies in
the review.
Danto (1980) 68 suggest that the perversion reenacts (on a unconscious basis) the
male victim´s feelings of emasculation (castration) by his mother (or via the mechanism
of displacement by another dominant appearing female) who is seen as a powerful
woman who controls her son´s masculinity: if he “dies” while he is wearing female attire
symbolically and on a fantasy level his (unconscious) linkage is that it is his mother who
“dies” (i.e. is put to death). In Danto´s view, the fantasy creator identifies with the victim.
In analyzing 177 cases of death from autoerotic asphyxiation in Canada,
Psychiatrists Blanchard and Hucker (1990)50 found that those practitioners who were
partially or completely cross dressing at the time of death frequently exhibited two
additional practices: anal stimulation with dildos, vibrators or the like, and mirrors or
pictures of themselves during autoerotic asphyxiation episodes that triggered death. It is
well known to pathologists that transvestite sex typically employs a lot of time
contemplating their feminine appearance in mirrors.
Gutheil (1954) 69 called this tendency the "mirror complex". Both authors report
clinical experience with some transvestites that stimulate themselves anally while
masturbating, and this activity is accompanied by the fantasies that their body is that of a
woman and their anus a vagina. Blanchard (1989)70 coined the very appropriate term of
"autogynephilia" to refer to the erotic excitement that a man feels in seeing an image of
himself as a woman. Blanchard's findings confirm Danto's in the sense that the
autogynephilia and inserting objects via the anus within the context of autoerotic
asphyxia are a way of killing the woman who controls their masculinity. In other words,
the castration complex postulated by Resnick above.
Cowel (2009) theorized that in fully developed autoerotic asphyxia, the male
enactor assumes the role of a willing- or unwilling- sacrificial “victim” of a female who
is perceived as being imperious and indifferent to the victim’s 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 Freud´s 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.
5.2 SOCIOLOGICAL VIEW: THE ORDEAL OR THE RADICAL CONFRONTATION
WITH DEATH
The trial by ordeal or judicium Dei was in a legal practice that lasted until the late
middle Ages in Europe. It was a procedure based on believes that God would decide the
guilt or innocence of a person or a thing (book, work of art) accused of sin or breaking
the law.
The practice was related to fire where the accused would hold a hot iron or put
his/her hands to fire. Sometimes the defendants were subject to a Middle Age version of
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 actor’s 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.
5.3 CONFRONTATION TO RISK IN ADOLESCENCE
For Le Heuzey, 75 the most dangerous games (including choking) are integrated
within the field of risk taking behavior which mostly occurs in adolescence, precisely
where variety of behaviors become evident ranging from the practice of extreme sports to
alcohol and drugs, driving a motorcycle without a helmet, racing cars and unprotected
sexual encounters. During adolescence, “thrill–seeking” behavior is probably the norm.
In this respect the findings by Braush et al.
76
as documented by the department of
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.
Le Hauzey 75 explains these behaviors by different mechanisms:
1. Search the new: The young tend to seek out new experiences outside of
everyday life, to leave behind the routines of childhood and to experiment
forbidden sensations.
2. Search or giddy thrills: The author describes the notion of pleasure as being
very much a part of the scarf game. One of his patients notes: "When I play I feel
fine, I feel no more pain, I suspend myself and everything is happiness." Some
teens recognize the perception of sexual pleasure when they practice the game
alone. For others the pleasure is given by the loss of consciousness with its
hallucinatory sensations. According to sociologist Le Breton in his book
"Passions du Risque" 71-73 mentioned before, these risk confrontation experiences
unfold in four successive phases:
a. Risk taking (vertigo): In this stage the adolescents are aware of the
danger. They discover that death can be tested and surpassed. So in this
game they can overcome their anxiety of the unknown, and instead of
being passive in the face of this anxiety, the teenager will on the contrary
provoke and overcome it. This preliminary stage is a way to prove to
themselves and to their peers that they are capable of doing anything to
confront danger.
b. The confrontation: They do not measure themselves against another
individual but only against themselves. They are their own adversary and
can overcome fear and control their body.
c. Whiteness: The third stage for some young people is to experience their
own demise. It is the state of turning in on oneself, or that of absence or
coma. At this stage the experience is so strong that the youth is in a
situation of loss of consciousness or disappears symbolically. According
to some young people’s reports, this experience may be related to Near
Death Experiences (NDE). The feeling of depersonalization and elevation
are commonly described in asphyxia games.
d. The rebirth -survival: Surviving is a victory over oneself and over
death. This is the ordalic aspect of these behaviors. As explained above,
ordalic practices related to defying death to give more meaning to life and
to validate oneself before one’s peers. For the author it is a form of death
and resurrection. The boundary between risk behavior and suicidal
behavior is often vague: a life-game, flirting with death or definite
intention of ending life. One of Le Heuzey’s asphyxia participant patients
says: "It is the danger, the risk that gives me pleasure." From which can be
deducted that in these cases death is not the ultimate goal, instead, death is
an instrument, the means by which the individual restores his/her sense of
identity.
3. Addiction Drug-Free: The pursuit of the sensation of pleasure and vertigo
once experienced leads to repetition of the game. The practice then evolves as
true addictive behavior: there is a need to play more frequently and increasingly
take more risks. Anxiety appears if the game cannot be repeated. Author Michel
even speaks of a form of "risk addiction" and the emergence of some degree of
dependency.
4. Search for recognition by peers: To belong to a peer group one needs to pass
certain trials. This need to be recognized by others, to be admitted into the group,
leads young to accept putting their lives at stake. Courage is a characteristic
associated with the strongest and often the fact of being stronger means being
able to torment the weak and thus be recognized and respected by others.
5.4 CHILDHOOD ROPE SYNDROME
The term was coined by Rosenblum25 appears in 1979 to explain a possible link
between these practices with what he later called "Adolescent sexual Syndrome". While
not referenced by this name in search applications or in articles, there are a number of
publications that speak about accidental hangings in children and adolescents. These
items were found by cross-referencing other articles described in the methods section.
In the United States Clark et al. (1993) 77 conducted a review of all hangings in
children in Marion (Indiana) and Franklin (Ohio) counties during a period from 1985 to
1990 for ages 2 to 13. While the paper documents five cases of clear accidental hangings
among preschoolers and three clear suicides, it describes a group of 4 cases in which the
manner of death was classified as undetermined. All these cases were males, ranging
from 6 to 12 year olds, who were found inside their rooms fully clothed and had no
history of depression or dysfunction of the family. The practices were held in closed
quarters or in moments of parental absence, which suggests a context of premeditation
and secrecy.
In the United Kingdom Nixon et al (1995) 78 reviewed the deaths by suffocation,
choking and strangulation in England and Wales between 1990 and 1991. The authors
used the information available at the Office of Population Censuses and Surveys (OPCS)
and reviewed in detail records of HM coroners' offices and death certificates. The author
classifies accidental deaths by hanging in two groups: the first from 1 to 7 years which
correspond to deaths with ligatures around the neck with ropes or clothes in the house
and a second group of 8 to 14 year olds that were classified as "self Initiated hanging"
where the child was involved in some kind of game. Only one case is classified as
autoerotic asphyxiation because of the characteristics of the scene. During this period the
study describes a total of 21 cases of involuntary youth hangings between 8 and 14. All
the victims in this group were male. In the first group the proportion male / female is 3:
1. It is noteworthy that the authors have documented a high number of cases (21) in the
population under study in such a short period (only two years).
Also in the United Kingdom, Wyatt et al (1998) 79 makes a retrospective study of
hangings of children in Scotland over a period of 12 years. He reports a total of 12
hangings of which half are classified as accidental hangings. Within this group he
describes cases between 4 and 14 year olds, two with full suspension and 4 with
incomplete suspension. Five of the 6 cases of accidental hangings apparently are related
to “experimental behavior” involving the use of ligatures around the neck. All cases
including non-accidental were carried out in absence of parents and it is very striking that
10 of the victims are male.
Personally, I do not think these findings strange. I agree with Rosemblum in as
much as there are children (mainly male) who participate in asphyxia practices in order
to find some type of pleasurable sensation, and it is common. The suspension with
curtain ropes or other ligatures is a common practice. Male children also find pleasure in
other asphyxia maneuvers such as confinement in small spaces, games with bags over
their heads and even extrinsic compression of the thorax.
5.5 PART OF THE SAME SYNDROME
According to the literature reviewed, the epidemiological studies, psychoanalytic
theories and the results of this study that show how the victims, whether adolescents and
adults, of both asphyxia games and autoerotic asphyxiation are predominantly male, use
same method and type of asphyxia, concur as to place of occurrence, share elements of
compulsivity, premeditation and secrecy associated with the search for some form of
pleasure as well as share several risk factors associated, suggests the existence of a single
syndrome that develops into a model of development in stages or phases. In each it
becomes evident that there exist conflicts in the oral development leading to "childhood
rope syndrome" and this in turn evolves into the practice of asphyxial games associated
with masturbation during adolescence, then to an adolescent autoerotic syndrome and
eventually ends up in a flowery sadomasochistic bondage adult syndrome.
In line with that suggested by Rosenblum25, who suggested a lineal model
(excluding asphyxial games) it is not necessary for an individual to develop the entire
sequence as there may be entrance and exit doors at any point of the sequence. One may
be defined as the moment in which the conduct is adopted, which can occur during
childhood or pre-adolescence as rope game (childhood rope syndrome); in
preadolescence as an asphyxial game later as associated with masturbation or during
adult life as part of a complex sadomasochistic bondage syndrome.
Exit may be defined as the time when the behavior stops either by accidental
death in the case of children and adolescents, by resolution (spontaneous or through
psychotherapeutic intervention) or accidental death in adults or through the suicide.
The essence of the developmental model is that evolution is based on behavioral
adaptation to psychosexual, physical and social reality needs. According to Rosenblum25,
basically, the person develops deviant sexual needs as a response to intrapsychic conflict,
and so is able to then adapt to the reality imposed by physiological behavior
(asphyxiophilia) or die in the process. The form of adaptation is in turn limited by their
environment or social realities (e.g., gets a partner involved and protects him in his
paraphilia). The degree to which this adaptation succeeds or fails, both physiologically
and emotionally will determine whether the person lives or dies. In other words if the
individuals misjudge their physical tolerance to asphyxia, cannot find a partner to protect
them or fall into depression, they die. The failures in the management of physiological
needs (e.g. extended compression of the neck to prolong the pseudo halucinant effect)
lead to accidental death, and failure to meet emotional needs (e.g. develop into a picture
of depression) end up in suicide.
Under this scheme just as many individuals do not fully develop the sequence and
may enter at any stage, there will be individuals who develop through all stages
consecutively.
Based on Rosenblum’s principles, I propose a new modified linear sequential
model of four stages:
1. The Childhood Rope Syndrome
2. Asphyxia games associated with masturbation
3. Adolescent Autoerotic Asphyxia
4. Adult Autoerotic Asphyxia (fetishist / bondage Syndrome)
This model includes both the choice of sequencing of the four stages and the
choice of various in/out gates at each stage. Exit gates are still open through resolution
(either individually or through treatment or psychotherapy) or death understood as a
failure of mechanisms to adapt.
Entrance to the first stage, Childhood Rope Syndrome, would be highly
influenced by the conflicts in the oral phase of psychosexual development. Visual
influences cannot be ruled out because the literature has reported that children will try
these practices after seeing hangings in films, television programs or in more recent
times, influenced by websites. Religious influence cannot be ruled out either. I will
discuss these later. I do not believe that the majority of deaths related to accidental
hangings in children occur in males and that the fatal event has taken place in the absence
of parents is only a coincidence. In my opinion the rope childhood syndrome is a
component of the game as is getting some form of pleasure. However it is not overtly
sexual. Perhaps practitioners act as inductors or diffusers of these practices to school-age
peers. At this stage the ordalic and risk behaviors existing in adolescence are not present.
Several practitioners at phase 1 who adapted to Rope Childhood Syndrome and
did not did accidentally die will move on to include the sexual component in their games
by the time to reach pre-adolescence and when exposed to certain risk factors will evolve
into phase two of the sequence: Asphyxia Games Associated with Masturbation. Some of
the practitioners, probably less influenced by conflicts of the oral phase or those who
improve their home environment only reach this stage and find an exit at this stage as a
resolution (suspension from practice). Others on the contrary will be exposed to new risk
factors and evolve to phase three: Adolescent Autoerotic Asphyxia.
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
Oral Phase Conflicts
Adaptated and modified from Rosemblum s. Faber M. The adolescent
sexual asphyxia syndrome. J Am Acad Child Psychiatry. 1979; 18:546558.
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. Ramowski’s 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
is a failure in physiological adaptation, or suicidal if there is a fault in emotional
adjustment.
Supporting the “developmental model” Curran et al. (1980) 83 claim that each
individual develops his or her own autoerotic asphyxia techniques, which become
embellished and elaborated over time. As the same as other investigators, they found that
to one degree or another, fatal cases presented a characteristic profile syndrome. They
described stages ranging from early “sex play” (asphyxia games) to complex suspension
activities in later adolescence and adulthood, including nudity, and, unlike females, with
paraphernalia consisting of mirrors, pornography, bondage and fetichist/transvestite
articles such a female clothing. They did not consider asphyxia games as a failed form of
autoerotic asphyxia but rather a simpler, less elaborate, non ritualized activity without the
need for escape mechanism, pornography, and cross-dressing, which are typical of fully
developed autoerotic asphyxia, yet their description of stages suggest a possible link
between early and later forms and then supports the developmental model propose firstly
for Rosemblum25.
Another interesting study that supports the developmental model as mentioned
above, was carried out by Blanchard and Hucker (1991)50 in Canada. They took a total of
117 cases of autoerotic asphyxia victims between 1974 and 1987 in the provinces of
Alberta and Ontario in Canada. Multiple regression models for bondage and fetish
variables / transvestism versus age through correlation coefficients were used. The results
showed that as age increases the proportion of exhibiting behaviors such as bondage or
fetish / transvestitism or both increases significantly. The data from the study show that
older practitioners of autoerotic asphyxiation exhibit a higher probability of involving
transvestitism and bondage in their practices. This finding is consistent with the notion
that practitioners gradually developed increasingly complex masturbatory ritual practices
over time and would agree with the concept of adaptation raised in the developmental
model.
Previous studies (Hazelwood et al 1983)6, also showed a large proportion of
practitioners of autoerotic asphyxiation simultaneously engaged in one or more
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
whiteness and rebirth proposed by Le Breton72 in his theories of confrontation of risk to
which is added a significant erotic component (sadist / masochist). Edelheit (1974)90
speculated that identification with Christ and erotic fantasies related to the crucifixion are
almost universal in our culture (at least Western culture). He has found manifestations of
this phenomenon in many patients regardless of gender, race and even religious choice.
In a case described by Eber and Wetli (1985)81, he possesses two photographs of the
victim involved in erotic practices and the poses are very similar to classical paintings of
Christ crucified (e.g. The Crucifixion of El Greco). Hanging can represent Christ on the
cross, after which after whiteness (semi unconscious status from compression of the
neck) he is reborn almighty, next to God.
Lubin (1959) 91 tells of a preteen patient in whom he shows how the unconscious
identification with Christ is a factor in the development of fantasy and sexual behavior.
The early fantasy during masturbation of this patient was to have all four extremities tied,
then crucified and masturbated violently by a friend. It is to be remembered that the
crucifixion is in fact a kind of positional asphyxia. Supporting this view Money (1993)92,
suggested that autoerotic asphyxia is probably overrepresented among persons with strict
religious backgrounds.
5.6 RISK OF DEATH
In the first and second phases of the sequence death would come almost
exclusively from a failure in physiologic adaptation and, as mentioned above, would
mean a type of accidental death. It is easy to understand that infants and pre-teens do not
understand the physiology or the implications of neck compression. Nor has he/she
developed the concept of protecting the neck or some other mechanism to control the
compression. This would explain why in cases of children and teens the type of ligature
is very basic (in some cases simply a rope in U shape without any knot) and without
padding.
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 Bogotá (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.
It revealed close links between asphyxia practices and disorders in
psychosexual development and their integration with sociological components as well as
theories of confrontation with risk in adolescence.
I was struck by the very low number of publications in journals of psychiatry and
psychoanalysis regarding regular practitioners of autoerotic asphyxiation. One
explanation put forth by professionals is that these patients usually do not consult any
therapist. When they do consult, they tend to not return for further psychotherapy. There
are also ethical limitations to not publishing these cases in scientific articles.
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
and retinal hemorrhages
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.
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William Harvey Research Institute MSc in Forensic Medical

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