Eight cases of autoerotic asphyxia deaths on Oahu are reviewed. Distinguishing features typically separate these deaths from intentional suicides or homicides. The sexual nature of these incidents is a salient feature of the death. The etiology of the practice is unknown but worth investigation.


Several recent forensic events in Hawaii and national media1,2 have brought increased general and professional awareness to the practice of accidental death accompanying solitary sexual arousal and masturbation. Such practices have been termed sexual or autoerotic asphyxia, hypoxophilia, or asphyxiophilia. Asphyxiophilia is the desire for a state of oxygen deficiency in order to elicit or enhance sexual excitement and orgasm.3 In a metropolitan community with a relatively small but diverse ethnic population (around 1 million) and one which often views itself, and is viewed by others, as away from the major concerns and problems of larger Mainland communities, it seems quite appropriate to review the occurrence of autoerotic death in Honolulu and to see how it compares with cases elsewhere.

A most recent case in Honolulu illustrates the practice of asphyxiophilia and some of the medicolegal as well as sexological questions surrounding it. The case involved the finding of an adult who had hanged himself from a bamboo “tree,” located in an accessible but relatively secluded area of an Oahu forest. The body was determined to have several classic signs of asphyxiophilia.4-8 One such sign was an elaborate mechanism for creating the hypoxia. In this case, the decedent had nestled one bamboo pole in a notch of a live 3-inch diameter bamboo tree. This notch was about 6 feet above the ground. At the junction he had attached a one-fourth-inch thick rope and a nylon stocking forming a sliding loop into which he had placed his neck. Two snap hooks were located in the rope sling, one on each side of the neck, where theoretically they could easily be opened as quick-release safety devices. Chlorophyll stains on the stocking, as well as wear and tear marks on the support structure, indicated repeated use.

Medical authorities were faced, as they often are in such cases, with determining if this was an instance of homicide, suicide or accidental death. To help in resolving the problem both a physical autopsy and a psychological autopsy were conducted. This involved an investigation and an interview with all those individuals who might have had knowledge of the deceased and his behavior.

The physical findings were typical for hanging; the medical examiner’s report showed that the decedent had died of asphyxia several days prior to discovery. The police investigation and psychological study revealed that the decedent was a graduate of a religious high school on the Mainland and for many years had been a successful local businessman without known drug or alcohol abuse. He was described by neighbors and friends as stable and “a nice guy.” For at least a year and a half he had practiced mutual sexual asphyxiation together with his wife. These incidents were always at his bidding but his partner did not seem to be an unwilling participant. They included use of the bamboo devices mentioned above, as well as manual strangulation at home.

Audiotapes, manuscripts of short stories, erotic magazines, as well as personal writings found in the decedent’s house, revealed fantasies or at least interests that included consensual sadomasochism, bondage, rape of women and homosexual behavior. He and his wife had occasionally engaged in light sadomasochism that included the use of handcuffs. The decedent had said to his wife, on several occasions, that asphyxiation gave him a “peaceful, high feeling.” There was, however, no evidence, knowledge or report of past homosexual practice, involuntary or abusive sex or rape. Indeed, the decedent had no criminal record for assault or other crime and had often voiced homophobic sentiments.

We have summarized all known cases of asphyxiophilia in Honolulu during the period 1977 to 1988. Consultation with the Medical Examiner’s office led us to believe that diagnosis and identification of the practice of asphyxiophilia might not have been accurate prior to 1977.

Method and results

In order to investigate the occurrence of asphyxiophilic deaths in Honolulu. we contacted the Honolulu Examiner’s Office. The jurisdiction of this office comprises the City and County of Honolulu. Honolulu County includes the island of Oahu and accounts for approximately 80% of the State of Hawaii population. The Medical Examiner’s records revealed 8 cases of asphyxiophilia from January 1977 through December 1988. We analyzed these case reports and compiled the results. Data analyses addressed several major issues and are presented in tabular form (Tables 1-4).

Asphyxiophilia in Honolulu County (1977-1988)
Cases (N = 8)
Table 1: Demographic Characteristics
1. Age  
Range = 15-59
Median = 36.5
Mean = 36.9
2. Sex
  a. male
  b. female
3. Marital status
  a. single
  b. married
  c. separated, widowed or divorced
  d. not mentioned
4. Living arrangement
  a. living alone
  b. living with sex partner
  c. living with relatives
  d. living with roommate
5. Ethnicity
  a. Caucasian
  b. Hawaiian or part-Hawaiian
  c. Japanese
  d. Chinese
  e. Black
  f. mixed or other


Asphyxiophilia in Honolulu County (1977-1988)
Cases (N = 8)
Table 2: Physical Characteristics at Scene

1. Asphyxiation mechanism (maybe more than one)
          a. pressure to the neck, hanging 6
  b. airway obstruction (e.g., pillow) 1
  c. oxygen deprivation (e.g., plastic bag) 1
  d. chest compression 0

2. Asphyxiation devices (maybe more than one)
  a. noose to adjust airflow, hanging 7
  b. plastic bag over the head 1
  c. blankets, pillow, etc 1
  d. elaborate devices suspended from above 6

3. Inferred position of body during asphyxiation act
  a. standing or kneeling 6
  b. sitting 1
  c. lying 1

4. Safety devices apparent (maybe more than one)
  a. device to loosen the ligature 2
  b. knife 0
  c. adjusting body position loosens ligature 3
  d. automatic self-rescue mechanism 0
  e. none, not apparent, not recorded 4

5. Padding to avoid rope burns
  a. apparent 3
  b. not apparent 1
  c. not recorded 4

6. Location of body when found
  a. private, hidden 2
  b. private, not hidden 5
  c. public, hidden 1
  d. public, not hidden 0

7. Evidence of repetitive behavior
  a. physical evidence (e.g., rope marks) 1
  b. verbal reports 3
  c. signs (e.g., rope burns, blood shot eyes) 2
  d. not recorded 2


Asphyxiophilia in Honolulu County ( 1977-1988)
Cases (N = 8)
Table 3: Sexual Characteristics

1. Erection when found
          a. apparent 0
  b. not apparent 0
  c. not recorded 8

2. Signs of semen
  a. found 1
  b. not found 1
  c. not recorded 6

3. Sexual paraphernalia apparent at scene
  a. dildo 1
  b. vibrator 1
  c. mirror 2
  d. other 1
  e. not apparent 1
  not recorded 4

4. Sexual-explicit material
  a. apparent at scene 2
  b. not apparent at scene 2
  c. found elsewhere 3
  d. not recorded 2

5. Body attire when found
  a. nude 5
  b. partially nude 0
  c. dressed 1
  d. unusual attire (e.g., women’s attire, leather) 4

6. Other sexual characteristics
  a. bound (other than ligature) 1
  b. cross dressed 4
  c. homosexual or bisexual interest 4
  d. other (e.g., sex offender) 1
  e. not apparent 1
  f. S& M or B&D evidence (other than for asphyxia) 1


Asphyxiophilia in Honolulu County (1977-1988)
Cases (N = 8)
Table 4: Other Investigative Findings

1. Drugs
          a. alcohol (percentage> .1%) 2
  b. “poppers” (amyl nitrite) 0
  c. other drugs (e.g., freon) 1
  d. not apparent 2
  e. not recorded 4

2. Previous depression
  a. yes 1
  b. no evidence of depression or death wish 5
  c. not recorded 2

3. Letters or notes left behind
  a. saying death was accidental 1
  b. saying death was intentional 0
  c. not apparent 1
  d. not recorded 6

4. Other hidden signs of autoerotic behavior
  a. yes 2
  b. no indications 6
  c. not recorded 0

5. Suspicion or evidence of foul play
  a. yes 0
  b. no 8

All cases were male. The mean age at death was 37 years, the oldest individual being 59. Only 1 teenager, age 15, was reported.

Safety devices, both simple and elaborate, were often present to prevent death. In 2 of our cases, there was a device that could be used to loosen the ligature, and in 3 cases, simply standing or adjusting the body position would loosen the ligature. As death probably came unexpectedly and rapidly, these practitioners of asphyxiophilia were unable to avail themselves of the intended safety guards.

Typically, the decedents were found in places where it would be unlikely that they would be interrupted during the act, such as in private rooms or apartments with the doors often locked from the inside. Seven of our cases were found in such private locations. The 8th case, described in the introduction, was found in a public but hidden location.

Evidence in 6 of the 8 cases indicated the behavior was repeated time after time. No suicide letters or other correspondence were found in these cases.

Innumerable elaborate devices to effect the hanging, constructed of rods and ropes, were apparent in 6 of our cases. Devices in the neck noose had often been attached to adjust the airflow. To these, some subjects also tied their hands or feet. In only one of our cases was binding of limbs, as separate from attachment to the noose or hanging device, a finding. In other cases, the method used to achieve hypoxia was simple. One individual died with a plastic bag containing freon gas encasing his head. Another smothered himself with a pillow.

Five of our 8 cases were found nude; the remaining 3 were “cross-dressed.” One of the nudes wore female pumps. Sexual artifacts, such as dildoes or vibrators, and sexual-explicit materials were often found near the bodies, suggesting these objects were used to stimulate and enhance the sexual activity; the presence or absence of erection was not recorded in any of the cases; seminal emission was noted in only 2 cases.

Although all cases were investigated for the possibility of homicide or suicide, all 8 cases were determined to be accidental. There was no evidence or suspicion of foul play in any of our cases. Investigation was made difficult in 2 cases, however, in that relatives or friends had tried to hide the evidence. This was so in the case we described in the introduction.


The classic signs of asphyxiophilia were apparent in our model case, such as evidence of repetitive behavior, the presence of intended (even if ineffectual) safety devices, and the padding to avoid pain, rope burns or actual injury. It is also typical that the decedent was described as happy and successful, without signs of alcohol or drug abuse and without any reason to suspect suicide or homicide. One somewhat unusual finding, however, was that in this particular case it was done in an open, albeit secluded, locale (see also references 8 and 9). Although his wife had refused him sex earlier that evening, prolonged sexual deprivation is not necessarily a motive. Among our cases were incidents where prior to the death, the individuals were known to have had marital coitus daily and extramarital sex at least several times a week. Several also were known to masturbate and to pick up tourists or prostitutes for sexual liaisons.

The 8 cases reported in this study occurred during an 11-year period, 1977 through 1988. Using 1980 census data, this corresponds to a frequency of 0.7 deaths per million inhabitants per year in Honolulu County. Using the same correction for under-reporting as in similar studies,3,7 we conservatively estimate the mortality in Honolulu County due to asphyxiophilia as 1-2 deaths per million inhabitants per year (we do not have comparable data for other counties in the State of Hawaii). A rough estimate of the United States mortality rate from autoerotic death, for the same period of time, is 250-1000 deaths per year,7,10,11 which corresponds to a frequency of 1-4 deaths per million inhabitants per year. In comparison, the autoerotic mortality rate in Scandinavia has recently been estimated as 1-2 deaths per million inhabitants per year.3 Of course, these figures in no way indicate how widespread is the practice of asphyxiophilia. These estimates represent those who die while doing it.

Demographically, the Honolulu cases are somewhat different from those found elsewhere. Generally, asphyxiophilia is most common among young males aged 12-25 years, with a preponderance in the 12-17 subgroup.8,9,12,13 However, it has also been reported among middle-aged and older men. Here, however, the cases are all male, but substantially older than that reported in other general samples. The reasons for the age difference seen here are not apparent. Female cases, of which there were none reported in our study. are relatively rare in general. They have been estimated as 4% of all cases reported, and only a few have been described in any detail.14-16

Evidence that the behavior was repetitive was apparent in 6 of our 8 cases. Such repetitive behavior is often indicated by letters present at the scene that reveal that the danger of death is known to the practitioner, thus relieving family or authorities of the need to look for a motive.11 No letters or notes were found among our cases. This suggests the individuals felt there was insufficient danger to themselves or reason to warn others of the practice.

The prevalence of nudity and cross-dressing in our study is not an uncommon finding in asphyxiophilia victims and it corresponds to findings elsewhere.6-8,12 The literature frequently describes bodies found with unusual clothing on the victim, such as women’s underwear, women’s attire, rubber or plastic underclothes and mackintoshes.4-8 The reasons for these fetishistic features are not understood. Nudity is often associated with eroticism but cross-dressing is more difficult to interpret. Most normal individuals are not aroused by their own or other’s cross-dressing. It may be an indication of transvestism, fetishism, masochism, or a variety of other phenomena. Therefore, caution is necessary when drawing inferences about this phenomenon. Sufficient evidence exists, however, that cross-dressing per se need not characteristic of either homosexuality or bisexuality.17-19

In many reports in the literature, feet, hands and other parts of the body have often been tied.7-9 This was apparent in only one of our local cases. Similar to findings in our cases, sexual artifacts and sexual-explicit materials were often found near the bodies, suggesting the sexual nature of the experience.

Practitioners of asphyxiophilia use different devices to apply partial strangulation. Besides applying manual pressure they may use ropes, chains or leather belts. In most cases, compression of the neck by some type of noose is used to obtain the asphyxiation effect.5,7 In other cases, the effect has been obtained by covering the face with a plastic bag, blankets or a mask. Airway obstruction, chest compression, self-smothering are other methods occasionally used.6,20 Partial asphyxia is said to induce a euphoric effect on the practitioner. How this is learned or developed is not understood. The timing of the effect in relation to orgasm has been reported to vary widely among individuals.7

The dangers associated with asphyxiophilia are many. Obviously faulty construction of the device can lead to injury. Rope burns, dermal abrasions and scarring of the neck are possible, and the intended safety devices may not work. Most critical is the physiological reflex that might be brought about with stimulation of the carotid sinus by a sudden compression or pressure surge. This can cause a rapid drop in blood pressure or bradycardia with sudden cardiac arrest, or unconsciousness within 10 seconds.6,21 It is probably safe to say that most individuals are not aware of such a possible reflex.

It is presently not known whether arterial occlusion, venous occlusion, asphyxia per se, or other factors play the major role in these deaths.22 Individuals with underlying cardiac disease seem particularly vulnerable to reflex carotid sinus stimulation and hypoxia.23

While extensive writings about autoerotic deaths are not rare (e.g. 5-8) and psychodynamic theories associated with the practice abound (e.g. 6 and 8), in reality little is known about why people start to asphyxiate themselves or how this practice becomes eroticized. In one case24 a young man reported that at the age of 14 he saw a cowboy movie that portrayed a hanging. He was sexually aroused while watching the hanging, and later on hanged himself from a tree. Although he lost consciousness and almost died in the first attempt, he found it sexually arousing and periodically continued to hang himself purposefully. One female informant revealed to the senior author that, although she had never practiced asphyxiophilia, she had from early teen age fantasized about being encased in a rubber wet-suit garment that had openings only for her perineum, breasts and mouth. Her fantasy was that when she was being sexually penetrated in all her orifices, she would be without breath, since her mouth would be filled with a penis. And this bondage and coital situation was erotic to her. The closest this fantasy got to reality, however, was only in her thoughts during solitary masturbation. Although highly sophisticated, she had no idea as to the origins of the fantasy or desires.

Eskimo children have been reported to seek unconsciousness as a delightful game.25 One 19-year-old American who engaged in erotic hypoxia wrote about the pleasure he discovered at the age of 9 or 10 while applying manual pressure to his own neck in order to “pass out”.26 Children’s sensations are not necessarily erotic and it is difficult to know to what extent the very young practice asphyxiation for sexual pleasure. It may well be that before the sexual potential is discovered, sensations are mainly different and exciting in general and afterward they shift to being erotic.

Asphyxiophilia has on a few occasions been depicted in theater performances and movies, such as The Ruling Class by Peter Barnes, Waiting for Godot by Samuel Beckett, and In the Realm of the Senses by Nagisa Oshima. The well-known Marquis de Sade wrote of it appealingly in his 1791 book Justine.27 However, we think these depictions are too rare and esoteric to account for the widespread incidence of asphyxiophilia. In the past, the behavior appears to have been self-discovered.26 Recent publicity might be changing this.

The danger itself might be a source of sexual excitement in some practitioners of asphyxiophilia. One frequently reported feature of those involved with asphyxiophilia seems to be an orientation toward masochism or violence and death associated with eroticism. 28,29. However, as accounts of eroticized danger in asphyxiophilia are lacking, it is unknown whether this is a common source of sexual excitement. We ourselves doubt this is so, since few data support this contention. Those involved in asphyxiophilia appear to be generally young, well adjusted and without apparent signs of psychopathology. It is probable that this is solitary play-acting where, as Resnik6 succinctly puts it: “dying, rather than death, appears to be the end-game; this would seem to mitigate against the self-destructive and suicidal nature of the behavior.” It should also be kept in mind that hanging per se, in non-erotic situations, such as in capital punishments, has been known to induce erection and ejaculation in the victim.

Characteristics such as the binding of body parts other than the neck, and use of or presence of sadomasochistic erotica, seem in keeping with the practice but are also difficult to interpret since most such individuals are not known to indulge in asphyxiophilia. At present, there are few reports by practitioners of asphyxiophilia about their own inner experiences or motives.24,26,28,29 More first-person reports would assist in understanding the aberration. It is possible in at least some individuals, as in the case of our model that eroticism has a wide polymorphous base. He and others might have had a strong desire for novel and unique sexual stimulation. It is noteworthy, keeping this in mind, that only 2 of our 8 cases showed evidence of ejaculation. Of course, in the other cases, death might have intervened before orgasm could be expected to occur.

Pathologists and the lay authorities may occasionally misclassify the deaths as suicide or murder instead of accidental.7,12 To our knowledge, only a few cases of homicide have ever been reported wherein the scene has been deliberately set to look like accidental asphyxiophilia.13,28,30 In such instances, we hypothesize that the murderer knew of his own or the private sexual practices of the victim. Specific suspicion or evidence of foul play was not seen in any of our cases. Usually, for the forensic investigator, the problem is one of distinguishing between accidental death and suicide. The risk of misclassification is especially great if the facts are not particularly clear or if evidential material is lacking. This can occur, for instance, when relatives or friends try to hide the true cause or nature of the death by removing evidence.9,11,13 This was so in our model case and one other.

Although it is often difficult to distinguish between accidental asphyxiophilia deaths and suicides, several items might be kept in mind. Victims of asphyxiophilia accidents are typically young, apparently well-adjusted men, lacking evidence of depression or a death wish. Why Hawaii is so different in regard to the age distribution of its victims is not understood but should be kept in mind by local authorities. Other indications of accidental death are the presence of safety devices and padding to avoid marks on the body. Nudity, cross dressing or unusual clothing are also common signs of accidental deaths. Furthermore, letters left behind often indicate if deaths have been accidental or intended. To assist in medicolegal determinations, it would be prudent for investigators to record specifically the presence or absence of suicide notes and other matters.

Medicolegal investigations are often stressful for relatives and friends of the decedents. However, if an asphyxiophilia death turns out to be accidental instead of intentional, physicians and others associated with the case can relieve much guilt among survivors by tactfully giving them this information. Physicians, police and others in authority who are aware of the practice, can assuage the family’s grief by explaining that the death is from a known, even if rare, cause. Knowledgeable agencies, counseling and support groups can also help the bereaved.2,18 Establishing it as an accidental cause of death can also be help in settling insurance claims.

Medical practitioners are encouraged to probe the possibility of asphyxiophilia if suspicious neck abrasions, bloodshot eyes or other signs of strangulation are apparent. Warnings of danger are in order particularly about the carotid.

Medical examiners or authorized investigators are encouraged to record carefully those factors enumerated in Tables 1-4. It is hoped future study and interviews will lead to a better understanding of the phenomenon.

While this was in press. Saunders reviewed the topic of asphyxiophilia and called for educators and therapists to be more outspoken in warning youth and young adults of the dangers of such behavior.31 The authors of this paper second that exhortation.



1. King L: Larry King Live (Television program). Cable News Network. 4 Feb. 1988.

2. Winfrey O: The Oprah Winfrey Show: Autoerotic asphyxia (WLS-TV Transcript #W433). New York: Journal Graphics, 1988.

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4. Camps FE (Ed.): The sexual asphyxias, Chap. 33:520-522. In: Gradwohl’s Legal Medicine. Bristol, Great Britain: John Wright & Sons Ltd, 1976.

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13. Ford, R: Death by hanging of adolescent and young adult males. J Forensic Sci. 2(2):171-176, 1957.

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17. Diamond M: Sex, Gender, Clothes Video (60 min). Produced by S.U.N.Y.-Stony Brook & Long Island V.A. Hospital, [Available from Health Instructional Resources Unit, Univ. of Hawaii], 1976.

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19. Diamond M: The world of sexual behavior: Sexwatching. Gallery Press, New York, 1984.

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21. Reay DT and Eisele JW: Death from law enforcement neck holds. Am J Forensic Med Pathol 3(3):252-258, 1982.

22. Line WS Jr, Stanley RB Jr, Choi JH: Strangulation: A full spectrum of blunt neck trauma. Annals of Otology, Rhinology, and Laryngology, 94(6 Pt 1):542-546, 1985.

23. Thomas JE: Hyperactive carotid sinus reflex and carotid sinus syncope. Mayo Clinic Proc., 44:127-139, 1969.

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25. Freuchen D (Ed.): Peter Freuchen’s book of the Eskimos. Cleveland, OH: The World Publishing Company, 1961.

26. Clark MA and Kerr FC: Case report: Unusual hanging deaths. J Foren Sci 31(2):747-755,1986.

27. De Sade, the Marquis: Justine. The complete philosophy in the bedroom and other writings. Grove Press, New York, 1965.

28. Litmann RE and Swearinge C: Bondage and Suicide. Archives of General Psychiatry, 27:80-85, 1972.

29. Money J: 1988 Lovemaps. The lovemap of asphyxiophilia. Chapter 24, Prometheus Books, N.Y.

30. Wright RK and Davis, J: Homicidal hanging masquerading as sexual asphyxia. J Foren Sci. 21:387-389, 1976.

31. Saunders EJ: Life-threatening autoerotic behavior: A challenge for sex educators and therapists. J Sex Ed & Ther 15(2):82-91, 1989.

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