Farm assist? A brief look at ‘tractor sex’

One of my good friends, Dr. Mike Sutton, recently sent me a story he’d come across with the headline “Suffolk man had sex with 450 tractors”. Given my academic interest in paraphilias and fetishism, I decided to try and track down the original source of the story and found that it was first published by the Suffolk Gazette back in 2015. According to the news report:

“Ralph Bishop, 53, was found by police with his trousers around his ankles “interfering” with a tractor parked in a field outside Saxmundham. He was arrested on suspicion of outraging public decency, and admitted to having had sex with around 450 tractors all over the Suffolk countryside. When officers searched his terraced home they found a collection of more than 5,000 tractor images on his laptop. The photos showed Bishop had a special desire for John Deere and Massey Ferguson tractors, particularly green ones. A police insider said: “We couldn’t believe it when we found him in the field. He was wearing a white t-shirt and Wellington boots and very little else. He was clearly in state of high excitement at the rear of the machine. Thankfully nobody else was around, but the field is close to a village primary school so we had to arrest him and educate him about the error of his ways. He told us he was particularly ‘in to’ axle grease and the presence of this around the back of tractors was all too much for him.” Bishop, twice divorced, was released without charge on condition he sought psychological help. He was put on the sex-offenders’ register. “He is also banned from the countryside and is now forbidden to go within one mile of a farm,” the police insider added. “So he has to live and remain in the middle of Ipswich to comply with that. However, we are watching him because we are worried about the safety of several street-cleaning machines.” Another policeman added: “He’ll also need to keep away from the town’s gardens – if he takes a fancy to a lawn mower he might find he loses more than just his liberty.”

Since the publication of this story, it has been re-reported dozens of times including the Daily Star and has even had follow-up stories (also in the Suffolk Gazette) – just type in the words ‘Ralph Bishop’ and ‘tractor’ and you’ll see what I am referring to. Given that I have written a number of articles on what has been termed ‘objectum sexuality’ (involving individuals who have sexual relationships with cars, trains, and bicycles) I wouldn’t have been overly surprised to hear of such a story, but the story is a hoax. My suspicions were raised by some of the alleged quotes from the nameless police officers in the story but the real clue to the story being a hoax (along with the follow-up stories) was that these stories were written by a ‘Crime correspondent’ called ‘Hugh Dunnett’ (‘whodunit’).

Despite the story being a hoax I decided to see if there were any real examples of ‘tractor sex’. A quick bit of Googling demonstrated that there is certainly a niche market for pornographic videos featuring individuals having sex in tractors including Porn Hub and elsewhere (please be warned that clicking on these links leads directly to sexually explicit material). I also found the occasional admission in online forums of individuals who had sexual fantasies concerning tractors but these appeared to be nothing more than isolated dreams rather than being a fetish that was enacted. I also discovered that there is a sexual practice colloquially known as a ‘Kentucky Tractor Puller’. According to online sources, the description is as follows:

“The act of a male and a male or male and a female preforming anal sex. During sex the receiver clenches their butt-cheeks tightly and runs with the penis still in the buttocks”.

I then went onto Google Scholar, and a just published 2018 paper appeared after I had typed in the words ‘tractor sex’. A paper in the journal Medical Journal Armed Forces India by Antonio Ventriglio and colleagues entitled ‘Sexuality in the 21st century: Leather or rubber? Fetishism explained’. Unfortunately, I was disappointed by what I found. In the very first paragraph of the paper, the authors repeated the hoax story:

“In the UK, in early October 2015, a man was arrested for having had sex with 450 tractors. According to the news report, he was found to have over 5000 tractor images on his laptop. He had a special desire for John Deere and Massey Ferguson tractors, particularly the green ones. He was into axle grease, which apparently turned him on sexually. He was placed on the Sexual Offenders’ Register”.

Although academics (including myself) can be fooled by hoaxes, the authors of the paper clearly didn’t even check out the original source. In fact, the authors cited the article that appeared in the Daily Star but if they had continued to read the story to the very end, they would have seen the fact that even the newspaper believed the story to be a hoax.

I then found a 2016 paper by Brian Holoyda and William Newman in the International Journal of Law and Psychiatry entitled ‘Childhood animal cruelty, bestiality, and the link to adult interpersonal violence’. I knew the word ‘tractor’ appeared in the paper but I had no idea in what context. I emailed Dr. Holoyda who sent me the paper. I had been expecting to read that there was some kind of bestial act relating to a tractor but this wasn’t the case. It cited a paper published in a 1963 issue of the American Journal of Psychiatry by Dr. John Macdonald which related sadistic acts by a farmer (the so-called ‘homocidal triad‘) towards animals:

“Macdonald described some patients who were “very sadistic,” including one patient who “derived satisfaction from telling his wife again and again of an incident in which he assisted in the birth of a calf by hitching the cow to a post and tying a rope from the presenting legs of the calf to his tractor,” the result being that he “gunned the motor and eviscerated the cow” (p. 126). He claimed that “in the very sadistic patients, the triad of childhood cruelty to animals, fire setting and enuresis was often encountered” (p. 126–127), though he never explicitly stated how many patients had a history of these comorbid behaviors. Macdonald reported that within six months of his study, two patients killed a person, neither of whom he identified as having a history of animal cruelty (or enuresis or fire setting, for that matter), and that one patient with schizophrenia committed suicide”.

I ought to add that bestial acts by farmers is not uncommon. The Kinsey Reports (of 1948 and 1953) arguably shocked its readers when it reported that 8% of males and 4% females had at least one sexual experience with an animal. As with necrophiliacs who are often employed in jobs that provide regular contact with dead people, the Kinsey Reports provided much higher prevalence for zoophilic acts among those who worked on farms (for instance, 17% males who had worked on farms had experienced an orgasmic episode involving animals). A more recent reference by Dr. Anil Aggrawal outlining his new typology for zoophilia (which I overviewed in a previous blog) noted the cases of what he described as opportunistic zoosexuals who have normal sexual encounters but who Aggrawal argued would not refrain from having sexual intercourse with animals if the opportunity arose. Aggrawal claims that such behaviour occurs most often in incarcerated or stranded persons, or when the person sees an opportunity to have sex with an animal when they are sure no-one else is present (e.g., farmhands). Aggrawal claims that opportunistic zoosexuals have no emotional attachment to animals despite having sex with them.

Thankfully, I did manage to locate one paper in the academic literature where tractors were inextricably linked with paraphilic behaviour. In 1993, a paper by P.E. Dietz and R.L. O’Halloran entitled ‘Autoerotic fatalities with power hydraulics’ published in the Journal of Forensic Sciences. They reported two case studies of men who used “the hydraulic shovels on tractors to suspend themselves for masochistic sexual stimulation”. One of the men was an objectophile (although the authors didn’t call him that – I am using Dr. Amy Marsh’s definition in a 2010 paper on objectum sexuality in the Electronic Journal of Human Sexuality to classify him as such). This man actually developed a romantic attachment to his tractor, and went as far as giving his tractor a name and writing poetry about it. Unfortunately, the man “died accidentally while intentionally asphyxiating himself through suspension by the neck, leaving clues that he enjoyed perceptual distortions during asphyxiation”.

The second case was a man who was found dead in a barn lying on his front pinned under the hydraulic shovel of his tractor. His body was covered with semen stains and there was evidence of masochistic sexual bondage. His clothes were folded neatly away nearby. He was found naked except for a pair of women’s red shoes (with 8 inch heels), knee high stockings and tape duct wrapped around his ankles. Ropes led from his feet to the tractor which when raised would lift his inverted body causing complete suspension. It is not known exactly what happened but it is likely that the engine stalled and he was crushed underneath the tractor shovel. He died of positional asphyxiation by chest compression. This was an atypical autoerotic fatality because he did not purposely use asphyxiation but it did cause his death.

Dr. Mark Griffiths, Distinguished Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Aggrawal, A. (2011). A new classification of zoophilia. Journal of Forensic and Legal Medicine, 18, 73-78.

Dietz, P. E., & O’Halloran, R.L. (1993). Autoerotic fatalities with power hydraulics. Journal of Forensic Science, 38(2), 359-364.

“Dunnett, H.” (2015). Suffolk man ‘had sex with 450 tractors’. Suffolk Gazette. Located at: https://www.suffolkgazette.com/news/suffolk-man-sex-with-tractors/

Holoyda, B. J., & Newman, W. J. (2016). Childhood animal cruelty, bestiality, and the link to adult interpersonal violence. International Journal of Law and Psychiatry, 47, 129-135.

Kinsey, A. C., Pomeroy, W. B., Martin, C.E., Gebhard, P.H. (1953). Sexual Behavior in the Human Female. Philadelphia, PA: W.B. Saunders Company.

Kinsey, A. C., Pomeroy, W. B., Martin, C.E., (1948). Sexual Behavior in the Human Male. Philadelphia, PA: W.B. Saunders Company.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Macdonald, J. M. (1963). The threat to kill. American Journal of Psychiatry, 120(2), 125-130.

Marsh, A. (2010). Love among the objectum sexuals. Electronic Journal of Human Sexuality, 13, March 1. Located at: http://www.ejhs.org/volume13/ObjSexuals.htm

Rawle, T. (2015). Perv who romped with 450 TRACTORS caught with 5,000 racy pics of farming vehicles. Daily Star, October 21. Located at: https://www.dailystar.co.uk/news/latest-news/471306/Pervert-tractor-sex-fetish-farm-vehicles-arrested

Ventriglio, A., Bhat, P. S., Torales, J., & Bhugra, D. (2018). Sexuality in the 21st century: Leather or rubber? Fetishism explained. Medical Journal Armed Forces India. Epub ahead of print. https://doi.org/10.1016/j.mjafi.2018.09.009

Dying for it: Bizarre autoerotic deaths (Part 2)

In my previous blog I examined some of the most bizarre autoerotic deaths reported in the medical forensic literature. Here are another five.

Case 1: Autoerotic death by aerosol propellant

Source: Medicine, Science and the Law. Personal details:  32-year old white US man. Single. Computer programmer.

• Bizarre death event: Found dead in bed with cassette recorder next to him. He was wearing headphones which playing “snorting” horse sounds. There was also a can of aerosol propellant. At the end of the bed was a large painting of a male strapped to the hind legs of a horse who was being anally penetrating by the horse. The horse was ridden by a leather-clad woman. He was also wearing some kind if homemade masturbatory device. His death was recorded as cardio-respiratory failure consistent with aerosol propellant abuse (death by misadventure). Self-administration of the chemical agent to modify the sensations of masturbation. He was covered in dry semen stains.

Case 2: Autoerotic death by clothing

Source: Medicine, Science and the Law. Personal details:  25-year old Japanese male. Single.

• Bizarre death event: Man found dead in his bed one morning. naked except for clothing wrapping his head and underpants which were pulled down. He was covered in dry semen stains. He had put a black skirt on his face and then pulled a second skirt upside down over his head and turned down the bottom of it. He then put a plastic bag over these two garments followed by a pair of tights. The legs of the tights were used to tie a knot around the bottom of the skirts. He then wrapped a third skirt around all of this. Death was due to suffocation.

Case 3: Autoerotic death by hanging (female)

Source: Handbook of Forensic Pathology. Personal details:  19-year old white female. Single. College student.

• Bizarre death event: Woman was found dead in her bedroom hanging from the hinge of her closet door dressed as an Oriental “harem girl”. A window sash cord was tied around her body in a complicated fashion and she was also wearing a blindfold and mouth gag (made from the belt of her dressing gown). Next to her lay an underground magazine (this was folded out and showed a bizarre dance involving a clock – the minute hand being a nude male who would make love with the other figure on the hour), a paperback Hitchcock book which explained her fantasy. The paperback contained the story about an Oriental harem master. In this story the harem master provides girls to his lord who stored them by hanging them around his walls on hooks

Case 4: Autoerotic death by vacuum cleaner

Source: American Journal of Forensic Medicine and Pathology. Personal details: 57-year old white US male. Single. History of heart disease and chronic pancreatitis

• Bizarre death event: Man was found naked slumped over his vacuum cleaner after a neighbour wondered why the vacuum cleaner had been on continuously for a long time. The man was found leaning against the dining table with his testicles, buttocks and thighs tightly bound with women’s tights. Near the table was a jar of urine, jars of lubricant and a wooden table leg covered in fecal excrement. The man was covered in burns from the vacuum cleaner. No defect was found in the vacuum cleaner. The man basically had a heart attack while engaged in autoerotic activity. The wooden table leg had been used in an attempt to stimulate orgasm via anal penetration. His wife had caught him masturbating with the vacuum cleaner before (they hadn’t had sex for five years). The death was classed as natural rather than accidental.

Case 5: Autoerotic death by hydraulic tractor shovel

Source: Journal of Forensic Sciences. Personal details:  62 year-old US white male. Married. Farmer.

• Bizarre death event: Found dead in a barn lying on his front pinned under the hydraulic shovel of his tractor. His body was covered with semen stains and there was evidence of masochistic sexual bondage. His clothes were folded neatly away nearby. He was found naked except for a pair of women’s red shoes (with 8 inch heels), knee high stockings and tape duct wrapped around his ankles. Ropes led from his feet to the tractor which when raised would lift his inverted body causing complete suspension. It is not known exactly what happened but it is likely that the engine stalled and he was crushed underneath the tractor shovel. He died of positional asphyxiation by chest compression. This was an atypical autoerotic fatality because he did not purposely use asphyxiation but it did cause his death.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK 

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Byard, R. W. (1994). Autoerotic death—characteristic features and diagnostic difficulties. Journal of Clinical Forensic Medicine, 1(2), 71-78

Cordner, S.M. (1983). An unusual case of sudden death associated with masturbation. Medicine, Science and the Law, 23(1), 54-56

Dietz, P. E., & O’Halloran, R.L. (1993). Autoerotic fatalities with power hydraulics. Journal of Forensic Science, 38(2), 359-364.

Ikeda, N., Harada, A., Umetsu, K., & Suzuki, T. (1988). A case of fatal suffocation during an unusual auto-erotic practice. Medicine, Science and the Law, 28(2), 131-134.

Imami, R. H., & Kemal, M. (1988). Vacuum cleaner use in autoerotic death. American Journal of Forensic Medicine and Pathology, 9(3), 246-248.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Sauvageau, A., & Racette, S. (2006). Autoerotic deaths in the literature from 1954 to 2004: A review. Journal of Forensic Sciences, 51(1), 140-146.

Dying for it: Bizarre autoerotic deaths (Part 1)

In previous blogs I have examined many different sexual paraphilias that have ended up in death for individuals engaged in such practices. Many of these are from autoerotic asphyxiation but also from other sexual practices such as electrophilia and anaesthesiophilia. Today’s blog takes a brief look at some of the most bizarre autoerotic deaths reported in the medical forensic literature.

Case 1: Autoerotic death by car

Source: Journal of Forensic Sciences. Personal details: 40-year old white US male airline pilot. Married and father of two children.

• Bizarre death event: A man left his home at 6am in the morning and told his wife that he was going shooting in the country. He was found naked except for a large-link 10-foot chain harness secured around his body. (The harness was tied around the man’s neck in a moderately tight loop and bolted. The chain then went down his chest and was tied into another loop around his waist. This was tied to the bumper of the car) at 7.30am in the morning in a remote area crushed against the left fender of his car (equivalent of a VW beetle). The engine was still running, ignition was on and the driver’s door was still open. The steering wheel was tied so that it would go round in anti-clockwise circles. His clothes were in the boot of the car. Reconstruction of the events leading to his death showed that he was either being dragged round by the car or following the car producing feelings of asphyxia. When he had finished his sexual turn-on he had tried to approach the car door but had forgotten to undo the chain from the bumper. The chain had got tangled up in the car’s axle and the man was found strangled to death by the chain.

Case 2: Autoerotic death by hanging (male)

Source: American Journal of Forensic Medicine and Pathology. Personal details: 57-year old white US male. Single.

• Bizarre death event: Early one winter’s morning, two joggers found a partially clothed man hanging from a tree five inches from the ground. He was hanging from a rope tied round his neck but also had two other loops of rope harness around his thighs which also encircled his chest. His neatly folded clothes lay two feet away along with lipstick and a jar of Vaseline. He was wearing a woman’s brown wig and a stuffed white bra. He also wore a pair of men’s red underpants, a pair of tights and a pair of high-heeled women’s shoes. He was also found to have a carrot protruding from his anus. Basically his seat harness slipped and he asphyxiated himself on the ropes.

Case 3: Autoerotic death by blankets

Source: American Journal of Forensic Medicine and Pathology. Personal details: 60-year old white US male. Single. Diagnosed schizophrenic and had various sexual compulsions. Well educated former teacher.

• Bizarre death event: After being reported missing from work by his employer, a man was found dead rolled up in 14 different blankets which had been sewn together (the two outermost layers were found fixed with adhesive tape in various places which raised the possibility of murder). Inside the blankets he was dressed in two pairs of hotpants, a pair of long johns and a vest. The body was wet and his hands and arms were outstretched above his head. They found a plastic bag over his penis into which he had ejaculated. He was masturbating while inside the blankets but he had become too hypoxic and died. He was immobilized inside the blankets and was unable to free himself. Over the last few years he had bought an astonishing number of blankets by mail order (over 60 found in his apartment most of which seemed to have some ritual or obsessive meaning by the way were laid out. No pornography was found in the place.

Case 4: Autoerotic death by dental anaesthetic

Source: American Journal of Forensic Medicine and Pathology. Personal details: 59-year old white US male. Single. Antiques dealer

• Bizarre death event: Found dead in his locked apartment. He was seated in front of a dental anaesthetic machine with the anaesthetic face-mask over his face. He was sucking on a rubber teat similar (but much bigger) than a baby’s feeding bottle. There were other anaesthetic machines around the apartment as well as a lot of sexual literature (magazines, photographs, paintings, manuscripts all concerned with his elaborate fetish some of which included photographs of himself in these situations). He was wearing a rubber type apron, three woollen cardigans, a woman’s blouse and two pairs of women’s trousers and a pair of women’s bloomers.

Case 5: Autoerotic death by electrocution

Source: Medicine, Science and the Law. Personal details: 36-year old UK male. Gay (with partner). Unemployed ex-television engineer

• Bizarre death event: Man found dead with a wire cradle applied to his scrotum with another loop of wire (end folded over) inserted into his Vaseline-lubricated anus. The wires were connected to the two terminals that supplied the loudspeaker within the television. When switched on, these wires carried a current of 0.6 amps at 2.2 volts (a quarter of the current needed to light a small torch). The body had two significant injuries. One on the right side of his face (entrance mark of the current), and the other over the left side of his scrotum (where the loop of the wire had been). Unfortunately, one of the wires had broken off resulting in a cessation of the stimulating activity. The man looked inside the back of the open TV set and his face came into contact with an exposed metal cap which zapped 2500 volts through him. The metal cap was the only live part of the television set and it was this that killed him.

(Part 2 can be found here).

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Eriksson, A., Gezelius, C., & Bring, G. (1987). Rolled up to death: An unusual autoerotic fatality. American Journal of Forensic Medicine and Pathology, 8(3), 263-265.

Hazelwood, R. R., Burgess, A. W., & Groth, A. N. (1981). Death during dangerous autoerotic practice. Social Science & Medicine. Part E: Medical Psychology, 15(2), 129-133.

Hiss, J., Rosenberg, S. B., & Adelson, L. (1985). ” Swinging in the park”: An investigation of an autoerotic death. American Journal of Forensic Medicine and Pathology, 6(3), 250-255.

Klintschar, M., Grabuschnigg, P., & Beham, A. (1998). Death from electrocution during autoerotic practice: case report and review of the literature. American Journal of Forensic Medicine and Pathology, 19(2), 190-193.

Leadbeatter, S. (1988). Dental anesthetic death: An unusual autoerotic episode. American Journal of Forensic Medicine and Pathology, 9(1), 60-63.

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Minyard, F. (1985). Wrapped to death. Unusual autoerotic death. The American Journal of Forensic Medicine and Pathology, 6(2), 151-152

Rupp, J. C. (1973). The love bug. Journal of Forensic Science, 18(3), 259-262.

Sauvageau, A., & Racette, S. (2006). Autoerotic deaths in the literature from 1954 to 2004: A review. Journal of Forensic Sciences, 51(1), 140-146.

Hoovers and shakers: Another look at vacuum cleaner sex

In a previous blog I briefly looked at the medical literature relating to penile injuries arising from autoerotic interactions from vacuum cleaners. While researching that blog I also came across other literature that had examined vacuum cleaners being used for sexual purposes that I thought I would make another interesting blog. A number of references in the psychological literature make reference to particular types of people using vacuum cleaners as a source of sexual stimulation for masturbatory purposes. For instance, in a 2005 chapter by Lynne Moxon about sexuality and Asperger Syndrome (i.e., an autism spectrum disorder typically characterized by major difficulties in social interaction and non-verbal communication) noted that among Asperger’s sufferers:

“Lack of awareness of the use of the imagination for sexual fantasy can lead to the use of more physical forms of stimulation, such as the vibration of washing machines or public transport, or the use of vacuum cleaner pipes, holes in chair backs, socks, bottles and more unusual items, such as TV remote controls and golf clubs. Females unaware of the use of sex toys have used deodorant cans, scissors, keys and candles”.

In a 2013 study by Dr. Remigiusz Kijak published in the journal Sexuality and Disability, 133 people (mainly older age teenagers with ages ranging from 17 to 25 years) with mild intellectual disability were surveyed about their sexuality and sexual practices. Dr. Kijak reported that:

“During the studies it has also been determined that 7 % of the studied teenagers stimulate themselves in an untypical manner. The teenagers studied admitted to masturbating with tools, certain objects or to masturbating in a way other than a natural one. The study subjects masturbate using grease, food, furniture and even vacuum cleaners. Such masturbation can be determined as dangerous, mainly due to the fact that it fixes a certain, repeatable chain of strange rituals, often impossible to use in a partner relationship, and may result in a pleasure decrease”. 

As noted in my previous blog on the use of vacuum cleaners as a masturbatory aid, most writings on the topic concern penile injuries that have come to the attention of medics when things go wrong. However, there are a couple of case studies in the forensic literature that have featured vacuum cleaners in autoerotic deaths. In 1988, Dr. R.H. Imami and Dr. M. Kemal published a paper in the American Journal of Forensic Medicine and Pathology about a 57-year old white American male with a history of heart disease and chronic pancreatitis. The man was found naked slumped over his vacuum cleaner after a neighbour wondered why the vacuum cleaner had been on continuously for a long time. The man was found leaning against the dining table with his testicles, buttocks and thighs tightly bound with women’s tights. Near the table was a jar of urine, jars of lubricant and a wooden table leg covered in faecal excrement. The man was covered in burns from the vacuum cleaner. No defect was found in the vacuum cleaner. The autopsy revealed that the man had a heart attack while engaged in the autoerotic activity. The wooden table leg had been used in an attempt to stimulate orgasm via anal penetration. His wife had caught him masturbating with the vacuum cleaner before (and they hadn’t had sex for five years). The death was classes as natural rather than accidental.

In 1994, Dr. Clive Cooke, Dr. Gerard Cadden and Dr. Karin Margolius published a paper concerning four “unusual fatalities where death occurred during autoerotic practice”. Three of the four accidental deaths (electrocution, hanging, and courgette inhalation) involved young to middle-aged men. However, it is the fourth case that is of interest here. This involved an elderly man that (like the previous case) had heart disease. The authors reported that:

“The naked body of this 77[-year] old widower was found in the bathroom of his home…Adjacent to the body, and switched on and working, were a vacuum cleaner and a hair dryer. A pair of men’s underpants was impacted in the hose of the vacuum cleaner. Autopsy examination showed the body of an elderly man of normal build. There was no evident injury; in particular there were no apparent marks of electrical injury. Internal examination showed enlargement of the heart with extensive ischemic fibrous scarring of the thickened left ventricular myocardium. Extensive calcified coronary arteriosclerosis was present, with no thrombosis. There was no significant valvular disease. The lungs were mildly congested and there was benign hypertensive nephrosclerosis. Toxicological analysis was unremarkable. The vacuum cleaner and hair dryer, together with the electric circuitry of the house, were assessed by an electrical inspector and cleared of malfunction. The cause of death was therefore believed to be combined arteriosclerotic and hypertensive heart disease. The scene examination suggested the likelihood that the electrical appliances were being used autoerotically”.

In their discussion of this particular case, Cooke and colleagues noted that sudden autoerotic deaths due to a natural disease process (e.g., heart disease) have seldom been reported in the forensic literature. To their knowledge, only two previous case reports had been published prior to their own study – both males who after autopsy:

“…showed significant arteriosclerotic cardiovascular disease. One was the case of a 61 [-year] old man who died whilst bound with chain restraints; a vibrator was nearby [Hazelwood, Dietz & Burgess, 1981]. The second case was of a 57 [-year] old man whose body was found naked alongside a running vacuum cleaner; the testicles, thighs and buttocks were tightly bound with pantyhose [Imami & Kemal, 1988]. Such deaths are probably less frequent than sudden natural death associated with heterosexual or homosexual activity, particularly if with a novel partner [Malik, 1979]”.

Finally, the only other vacuum cleaner-related autoerotic death I located in the forensic literature was a 2005 case study report by Dr. Andrew Hitchcock and Dr. Roger Start in the Journal of Clinical Forensic Medicine. This was actually a case of hypoxyphilia where the device built to cut off the oxygen supply involved a vacuum cleaner. More specifically, the paper reported:

“A case is reported of a 36-year-old man who died following occlusive entrapment within a device for the purpose of hypoxyphilic gratification. The device was constructed in his own home using instructions found on his home computer down-loaded from the Internet. The device comprised a tough plastic cocoon large enough to accommodate an adult human and incorporating a system of plastic piping connected to a household vacuum cleaner for the evacuation of air within the cocoon. The mechanism of death was thought to be traumatic asphyxia after examination of the deceased and re-construction of the apparatus with the body in situ”.

The prevalence of autoerotic acts involving the use of vacuum cleaners is unknown as only those cases that result in serious genital injury and/or death come to the attention of medics and/or forensic scientists. As noted in my previous blog, the number of cases that are being reported is on the decrease but this may be because the topic is less novel than it used to be and may not be seen by journal editors as worthy of publication.

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

Further reading

Benson, R. (1985). Vacuum cleaner injury to penis: A common urologic problem? Urology, 25(1), 41-44.

Citron, N.D., & Wade, P.J. (1980). Penile injuries from vacuum cleaners. British Medical Journal, 281(6232), 26.

Cooke, C.T., Cadden, G.A., & Margolius, K.A. (1994). Autoerotic deaths: Four cases. Pathology, 26(3), 276-280.

Hazelwood, R.R., Dietz, P. E., & Burgess, A.W. (1981). The investigation of autoerotic fatalities. Journal of Police Science & Administration, 9, 404-411.

Hitchcock, A., & Start, R.D. (2005). Fatal traumatic asphyxia in a middle-aged man in association with entrapment associated hypoxyphilia. Journal of Clinical Forensic Medicine, 12, 320-325.

Imami, R. H., & Kemal, M. (1988). Vacuum cleaner use in autoerotic death. American Journal of Forensic Medicine and Pathology, 9, 246-248.

Kijak, R. (2013). The sexuality of adults with intellectual disability in Poland. Sexuality and Disability, 31(2), 109-123.

Klintschar, M., Grabuschnigg, P., & Beham, A. (1998). Death from electrocution during autoerotic practice: Case report and review of the literature. American Journal of Forensic Medicine and Pathology, 19, 190-193.

Malik, M. O. (1979). Sudden coronary deaths associated with sexual activity. Journal of Forensic Sciences, 24, 216-220.

Moxon, L. (2005). Diagnosis, disclosure and self-confidence in sexuality and relationships. In D. Murray (Ed.), Coming out Asperger: Diagnosis, Disclosure and Self-Confidence (pp. 214-229). London: Jessica Kingsley Publishers.

Rossi, M., Cascini, F., & Torcigliani, S. (1991). [Penile injuries caused by masturbation with a vacuum cleaner. Description of a case and review of the literature]. Minerva Urologica e Nefrologica, 44(1), 43-45.

Hot flat mate: The unusual case of co-existent pyrophilia and crush fetishism

Over the Christmas period, I was at a family wedding in the Cotswolds when by chance I came across Dr. Raj Persaud’s 2003 book From The Edge of the Couch (subtitled ‘Bizarre psychiatric cases and what they teach us about ourselves’) for sale in a charity shop in nearby Moreton-in-Marsh. As it was selling really cheaply I decided to buy it (even though this was the book where a number of the cases Dr. Persaud recounted were plagiarized from other people’s work).

One of the more interesting case studies in the book concerned a 1998 case study published by Dr. R.S. Shiwach and Dr. J. Prosser in the Journal of Sex and Marital Therapy. The paper concerned the treatment of an “unusual case of masochism” (where the individual gained sexual arousal and pleasure from being burnt (i.e., pyrophilia) and crushed (i.e., ‘crush fetishism’) that often meant he was in dangerous and potentially life threatening situations. As the authors summarized:

“Masochistic sexual activity is potentially dangerous, rarely reported voluntarily, and hard to treat. [Our paper] describes a masochist patient who received sexual gratification from being burnt or crushed. Anti-androgen medication [leuprolide acetate], serotonin uptake inhibitor [fluoxetine], and psychodynamic psychotherapy along with sexual education and social-skills training and aversive behavior therapy [covert sensitization and olfactory aversion] were all tried over a period of 9 months. The response was measured by effects of treatments on the frequency of erotic fantasies and masturbation”.

The male masochist was a single 38-year-old man that turned up at a hospital burns unit for treatment to extensive burns on his lower body (around 20% of his total body area) before being referred to the psychiatric unit. His pyrophilic urges and interest in being crushed were long-standing and dated back to mid-adolescence. The incident that led to the hospital admission had involved one of the man’s regular ways of gaining sexual arousal which was to set fire to refuse collecting trucks (i.e., ‘dumpsters’) while he was inside of them and simultaneously masturbating. Dr. Persaud’s reported that:

‘[The man] would then masturbate before getting out [of the dumpster]. His burns had occurred when a plastic dumpster melted and turned over. His first sexual experience at age 15 [years] had occurred when he curled himself up in an oven and ejaculated – an adventure that had been prompted by having been threatened as a child with being roasted ‘like a pig’ as a punishment. A social isolate, he enjoyed watching videos and reading about people being burned at the stake or crushed. He had also attempted autoerotic asphyxia, but relinquished this as ‘too dangerous’”.

The recollection of ejaculating while inside an oven appears to be a critical event in the acquisition and development of the man’s unusual sexual preferences. As Dr. Persaud noted:

“[The man remembered] entering a big unlit oven out of curiosity and liking the warmth and sense of suffocation but did not realize he had ejaculated until the third such instance. He remained a socially isolated virgin and gave a history of sexual disinterest in males or females and of ignorance of sexuality in general…Twice he came close to self-immolation after pouring gasoline on himself…he denied getting any pleasure out of seeing other people suffer…he worked in places where he could have easy access to large waste disposers, ovens, and box compactors”.

Consequently, Dr. Persaud thought (as I do) that learning theory best explained this man’s etiology and that psychoanalytic factors like guilt and punishment may have also been important. This particular case was also reported in a 2006 paper by Dr. D.J. Williams (i.e., ‘Different [painful) strokes for different folks) in the journal Sexual Addiction and Compulsivity. Williams noted that the man had been arrested on a number of different occasions for climbing into refuse collecting dumpsters and had also broken his pelvis as a consequence of being crushed by a box compactor. Williams noted that: “clearly, most experts would agree that acting out fantasies in these dangerous situations posed a significant risk of severe physical harm and death, not to mention being illegal”. Dr. Persaud’s account also more specifically reported that:

‘[The man] would climb into refuse collecting trucks and ejaculate at the sensation of being crushed, only escaping at the last possible minute. He admitted masturbating almost daily to deviant sexual fantasies or to pictures of fire, people being burned or crushed, and even just the sight of chimneys. Recently he had been climbing into a large dumpster, pouring alcohol on the refuse and setting it on fire. He managed to masturbate and get out of the refuse bin with minor burns twice, but the plastic dumpster eventually melted and overturned, causing the injuries he now had”.

Despite the many different pharmacological and psychological interventions, none appeared to have any long-lasting effect. The first intervention was pharmacological and involved being injected weekly with an anti-androgen. This treatment resulted in a decrease of his fetishistic sexual fantasies and an overall decrease in his sex drive. However, the man didn’t like the fact that his sex drive has been significantly inhibited and asked to be taken off the medication. He also took anti-depressants over an 18-week period and then had aversive behaviour therapy (olfaction aversion) and psychodynamic therapy, social skills training, and sexual education. He was discharged after 34 weeks of treatment but on follow-up had resumed his fetishistic behaviour. Drs. Shewach and Prosser concluded that: “Anti-androgens and aversive behavior therapies may be the most effective treatments for such cases, at least in the short-term, although the underlying social deficits and the need to reshape the sexual behavior ought to be addressed in the long-term”.

One of the observations that Dr. Persaud made about this case was that the masochism in this case did not involve psychological humiliation or any interaction with other people in the man’s life. I would also add that most of the focus and commentary in this particular case has been on the pyrophilic aspects rather than the crush fetishism aspects. This may be because there has been far less in the medical and clinical literature on crush fetishism than pyrophilia. However, this is not the only case where crush fetishism has been associated with another sexual paraphilia. At the end of last year, my case study of eproctophilia (i.e., sexual arousal from flatulence) in the Archives of Sexual Behavior involved an eproctophile that was also a crush fetishist.

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

Further reading

Balachandra, K. & Swaminath, S. (2002). Fire fetishism in a female Aasonist? Canadian Journal of Psychiatry, 47, 487-488.

Bourget, D. & Bradford, J.M.W (1987). Fire fetishism, diagnostic and clinical implications: A review of two cases. Canadian Journal of Psychiatry 32, 459-462.

Griffiths, M.D. (2013). Eproctophilia in a young adult male: A case study. Archives of Sexual Behavior, 42, 1383-1386.

Litman, L.C.  (1999). A case of pyrophilia. Canadian Psychological Association Bulletin, February, 18-20.

Persaud. R. (2003). From The Edge Of The Couch. London: Bantam Press.

Quinsey, V.L., Chaplin, T.C. & Upfold, D. (1989). Arsonists and sexual arousal to fire setting: Correlation unsupported, Canadian Journal of Behavior Therapy and Experimental Psychiatry, 20, 203-209.

Shiwach, R. S., & Prosser, J. (1998). Treatment of an unusual case of masochism. Journal of Sex and Marital Therapy, 24, 303-307.

Williams, D. J. (2006). Different (painful) strokes for different folks: A general overview of sexual sadomasochism (SM) and its diversity. Sexual Addiction and Compulsivity, 13, 333-346.

Water meeters: An overview of aquaphilia

Following a previous blog I wrote on psychrocism and sexual arousal from ice, it got me wondering what other sexual behaviours might involve water. In a comprehensive list of paraphilias in the books Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices (by Dr.Anil Aggrawal) and the Encyclopedia of Unusual Sex Practices (by Dr. Brenda Love), a number of water-related paraphilias and sexual behaviours were listed. The list included:

• Aquaphilia: Sexual arousal from water and/or watery environments including bathtubs or swimming pools (and sometimes called hydrophilia)
• Albutophilia – Sexual arousal from water
• Ablutophilia – Sexual arousal from baths or showers
• Antiohilia – Sexual arousal from floods
• Coitobalnism —Sex in a bath tub
• Coitus a unda – Sex under water
• Bidetonism – The use of water spray from a bidet as a genital sexual stimulant for women while masturbating.

In her sex encyclopedia, Brenda Love has a section devoted to having sex in and/or under water (i.e., coitus à unda) and can include masturbation, oral sex and/or penetrative sex in any number of water-based situations (e.g., bath, shower, swimming pool, lake, ocean, etc.). She also says that such activities can include fellatio where the partner holds hot water in his or her mouth. She also highlights a number of other activities that come under the generic banner of ‘water sex’. These include:

• Sexually based ‘entertainment’ hosted in pubs, bars and/or restaurants (e.g., wet T-Shirt or jock-strap competitions, naked women swimming inside large aquariums)
• The use of water as a lubricant to facilitate insertion of bodily parts (e.g., fingers, toes) or sex toys into various bodily orifices
• The use of baby baths along with the addition of child’s bath toys for those who derive sexual pleasure from being an adult baby (i.e., infantilism).

She also claims that Tiberius Caesar had a passion for aquatic sex. She claims Caesar trained young boys (that he called ‘minnows’) to swim after him and come up from below to nibble and suck on his genitals. Other cultures aren’t so liberal. For instance, Dr. Aggrawal notes that in Hinduism – and according to the ‘Laws of Manu’ (i.e., the words of Brahma, the Hindu god of creation – “A man who has committed a bestial crime, or an unnatural crime with a female, or has had intercourse in water, or with a menstruating woman shall perform a Samtapana Krikkhra” (i.e., a 24-hour fast where no food can be consumed whatsoever).

Other psychologists and scientists (e.g., Dr. Viren Swami and Dr. Adrian Furnham in their book The Psychology of Physical Attraction; Dr. Katherine Ramsland and Dr. Patrick McGrain in their book Inside the Minds of Sexual Predators) define aquaphilia (like Dr. Aggrawal and Dr. Love) as a form of sexual fetishism that involves sex in (or under) water but extends the definition to include images of people swimming or posing underwater. According to Wikipedia, the term “aquaphile” was “first used by Phil Bolton, when he created the ‘Aquaphiles Journal’ – an online magazine for followers of the underwater erotica scene published in the 1990s”.

Another more unusual water-related paraphilia is hypoxyphilia. Autoerotic asphyxiates use a variety of methods to restrict their oxygen supply including partial hanging, the use of plastic bags or masks over the face, chest compression, and submerging under water (known in the clinical and forensic literature as “aqua eroticum”). Reports of water-related hypoxyphilic deaths are exceedingly rare but have been documented.

The term “aqua-eroticism” was first used in a 1984 paper – in the journal Medicine, Science and the Law – by Dr. S. Sivaloganathan. However, the use of the term here solely related to hypoxyphilia (i.e.. autoerotic asphxiation). While there have been hundreds of papers and articles about hypoxyphilia, to my knowledge only two papers have been published involving submersion under water. These very rare occurrences have come to light when things have gone drastically wrong (i.e., death for the person engaging in the activity). As with hypoxyphilic activity more generally, underwater submersion while holding one’s breath produces the same effects of oxygen deprivation via other methods (e.g., hanging, self-strangulation).

In the case documented by Dr. Sivaloganathan, a man was found drowned with a stone tied to his ankle (to weigh him down in the water). He was also assumed to have transvestite tendencies as he found dressed in women’s clothes. It was assumed to be an example of autoerotic asphyxia given that it seemed to be a very peculiar way to be swimming or committing suicide. The act of swimming in the opposite sex’s clothes with a weight tied to the leg also had many key features of deliberately induced danger as a method of increasing the arousal level. There is always the possibility that other similar types of incident may have occurred but have been labelled as suicide rather than death by misadventure.

The second case in the academic literature was reported by Dr. A. Sauvageau and Dr. S. Racette in the Journal of Forensic Sciences. Here, the evidence for autoerotic asphyxiation was more clear cut. During the summer, a man aged 25 years was found dead in a lake, submerged underneath his boat. Despite being the height of summer, he was wearing a hockey helmet, a snowmobile suit, and ski boots. However, underneath these clothes he was found to be wearing a self-constructed plastic bodysuit over his naked body from head to toe with a separate plastic tube wrapped around his genitals. Furthermore, there were clear bondage elements. Around his wrists, ankles, knees and waist he was tightly bound in a mixture of mesh and chains (all of which were padlocked to his groin). The only air supply was a black tube joined to his mouth and sealed to the suit by silicone. The man’s air supply system comprised an open plastic container floating on the lake to his mouth.

Although such elaborate bondage suggests a second party may have been involved, the crime scene investigators established that the man could have put on the harness. The victim’s clothing and water submersion appeared to facilitate a masochistic scenario. The investigation also established that the dead man had been an active member of an online hypoxyphiliac website. The authors noted:

“The victim was found completely submerged, with an air tube running from his mouth to a floating plastic container. However, he’d apparently miscalculated, using a tube too narrow for both the intake and expulsion of air. Rather than giving him the right degree of hypoxia for a heightened erotic experience, his air supply was significantly fouled with carbon dioxide, killing him”.

The coroner ruled the death as accidental (i.e., autoerotic asphyxia from re-breathing, caused by the faulty self-constructed air-supply device). Clearly this latter case has overlaps with sadomasochism and bondage. In fact, there are dedicated websites for ‘water bondage’ (where women are gagged and bound and submerged into “helpless submission”). For instance, at waterbondage.com:

“Water bondage is where rope bondage, fetish and BDSM meet breath control, immersion, water sex, predicament bondage, and more. Women are bound, dunked, sprayed and drenched, then dildo fucked and tortured with vibrators until they cum. With the most elegant rope bondage around, Water bondage has extreme bondage, breath play, punishment, domination, BDSM, fetish, submission, pain, and real female orgasms”

The only other sexually related water fetish or paraphilia that I have come across is liquidophilia. Various online articles (such as the not-so-imaginatively-titled Dirty Mag website) mention this behaviour and all define it as a paraphilia in which individuals derive sexual pleasure and arousal from immersing their genitals in some kind of liquid. Although most liquidophiles use water (e.g., taking a bath would be highly erotic for such people), any liquid can apparently be used. It has also been claimed that some liquidophiles have a preference for liquids that resemble bodily secretions (e.g., milk).

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

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Dirty Mag (2011). Fetish fix: Liquidophilia. September 12. Located at: http://dirtymag.com/fetish-fix-liquidophilia/

Love, B. (2001). Encyclopedia of Unusual Sex Practices. London: Greenwich Editions.

Sauvageau A. & Racette S. (2006). Aqua-eroticum: An unusual autoerotic fatality in a lake involving a home-made diving apparatus. Journal of Forensic Sciences, 51, 137-9.

Sivaloganathan S. (1984). Aqua-eroticum – A case of auto-erotic drowning. Medicine, Science and the Law, 24, 300-302.

Swami, V. & Furnham, A. (2008). The Psychology of Physical Attraction. London: Routledge.

Ramsland, K.M. & McGrain, P.N. (2010). Inside the Minds of Sexual Predators. Santa Barbara, CA: ABC-CLIO.

Wikipedia (2012). Aquaphilia (fetish). Located at: http://en.wikipedia.org/wiki/Aquaphilia_(fetish)

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.