The stranglers’ greatest hit: A brief overview of autoerotic asphyxiation

Hypoxyphilia (more commonly known as ‘autoerotic asphyxiation’ and less commonly known as ‘asphyxophilia’) is a rare and potentially life threatening paraphilia where a person seeks to reduce supply of oxygen to the brain during a heightened state of sexual arousal. Restricting the oxygen flow causes a build of carbon dioxide. This increase in carbon dioxide brings about feelings of giddiness and pleasure which when accompanied by masturbation can heighten the sexual sensations. Typically, this is achieved by chain, leather belt, rope noose or plastic bag either alone or with a partner and often results in death. Deaths occur due to the loss of consciousness caused by partial asphyxia. High profile deaths (by hanging) have included the Australian INXS singer Michael Hutchence, the US actor David Carradine, and the English MP and television reporter Stephen Milligan.

Although asphyxia from hanging has been described most frequently, a review of autoerotic asphyxiate deaths by Dr Roger Byard (Adelaide Women and Children’s Hospital, Australia) concluded that a wide variety of other lethal situations have been reported. Other hypoxyphilia variants that have been reported include: the use of plastic bags, chemical substance, food, electrocution, water submersion, and power hydraulics, etc.

There is some disagreement as to how common such deaths are. The American Psychiatric Association estimates that one in a million deaths are caused this way. The American FBI estimates there to be a mortality rate of 1000 deaths per year in the States. In a review of the literature, Dr Jane Uva (Wright State University, USA) estimated the mortality rate as being anywhere between 250 and 1000 deaths per year in the United States. Most hypoxyphiliacs are male with one Canadian study published in the British Journal of Psychiatry reporting only one of 117 accidental hypoxyphilic deaths as involving a female. In general, hypoxyphiliacs are white middle-aged males, although there are cases in literature of women or men up to 87 years of age.

There is limited data available but the goal seems to be to increase orgasm intensity. This bears some relationship with those who use amyl nitrate (which reduces brain oxygenation). It has been said that this type of behaviour may be a dangerous variant or manifestation of sexual masochism with its ritualised bondage themes. The person often keeps diaries and may watch themselves in mirrors or video record themselves. A German study of 40 accidental autoerotic deaths published in the journal Forensic Science International, reported that the bodies of hypoxyphiliacs are typically discovered naked and/or with genitalia in hand. Pornographic and/or other paraphilic material and/or sex toys are often present. Furthermore, the individuals will have ejaculated shortly before their death. The literature also shows that hypoxyphilia has also been associated with other paraphilias including masochism, transvestitism, bondage, and fetishism.

In one of the few studies of hypoxyphiliacs that are still alive, Dr Stephen Hucker (University of Toronto, Canada) surveyed over 100 participants via the Internet. He reported that 71% engaged in various masochistic activities, and 31% also took sadistic roles. Furthermore, 66% reported using bondage, 44% used clamps on themselves, 14% used electrical stimulation, and 37% self-flagellated. With regards to the act itself, the highest level of arousal was reported to be to obstruction of breathing. However, loss of control and loss of consciousness were also important in increasing sexual arousal. The lowest sexual arousal ratings were for pain and humiliation.

Finally, a recent review – again written by Hucker – in relation to the new DSM-V paraphilia classification, he surveyed over 100 practitioners who have expertise in treating paraphilic activity. Hucker recommended that the term ‘hypoxyphilia’ should be abandoned in favour of the term ‘asphyiophilia’ as there is little empirical evidence to indicate that the effects of oxygen deprivation per se are the primary motive for the paraphiliiac’s behavior. He argued that the behaviour is sexual arousal to restriction of breathing.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Behrendt, N., Buhl, N. & Seidl, S. (2002). The lethal paraphilic syndrome: Accidental autoerotic deaths in four women and a review of the literature. International Journal of Legal Medicine, 116, 148-152

Blanchard, R. & Hucker, S.J. (1991). Age, transvestism, bondage, and concurrent paraphilic activities in 117 fatal cases of autoerotic asphyxia. British Journal of Psychiatry, 159, 371-377.

Bogliolo, L.R., Taff, M.L., Stephens, P.J., & Money, J. (1991). A case of autoerotic asphyxia associated with multiplex paraphilia. American Journal of Forensic Medicine and Pathology, 12, 64-73

Burgess, A.W. & Hazelwood, R.R. (1983). Autoerotic deaths and social network response. American Journal of Orthopsychiatry, 53, 166-170

Byard, R. (1994). Autoerotic death — characteristic features and diagnostic difficulties. Journal of Clinical Forensic Medicine, 1, 71-78.

Cooper, A. J. (1996). Auto-erotic asphyxiation: Three case reports. Journal of Sex and Marital Therapy, 22, 47–53.

Hucker, S.J. (2008). Sexual masochism: Psychopathology and theory. In Laws, D.R. & O’Donohue, W.T. (Eds.), Sexual Deviance: Theory, Assessment and Treatment. pp.25-263. New York: Guildford Press.

Hucker, S.J. (2011). Hypoxyphilia. Archives of Sexual Behavior, 40, 1323-1326.

Janssen, W., Koops, E., Anders, S., Kuhn, S. & Püschel, K. (2005). Forensic aspects of 40 accidental autoerotic death in Northern Germany. Forensic Science International, 147S, S61–S64.

Martz, D. (2003). “Behavioral treatment for a female engaging in autoerotic asphyxiation”. Clinical Case Studies, 2, 236–242.

Tough, S., Butt, J. & Sanders, G. (1994). Autoerotic sexual asphyxial deaths: Analysis of nineteen fatalities. Canadian Journal of Psychiatry, 39, 157-160.

Uva, J.L. (1995). Review: Autoerotic asphyxiation in the United States. Journal of Forensic Sciences, 40, 574–581.