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Learn More. DSM-5 distinguishes between paraphilias and paraphilic disorders. Paraphilias are defined as atypical, yet not necessarily disordered, sexual practices. Paraphilic disorders are instead diseases, which include distress, impairment in functioning, or entail risk of harm one's self or others. Hence, DSM-5 new approach to paraphilias demedicalizes and destigmatizes unusual sexual behaviors, provided they are not distressing or detrimental to self or others.
Asphyxiophilia, a dangerous and potentially deadly form of sexual masochism involving sexual arousal by oxygen deprivation, are clearly described as disorders. Although autoerotic asphyxia asphyxiation kink been associated with estimated mortality rates ranging from to deaths per year in the United States, in Italy, knowledge on this condition is very poor. Episodes of death caused by autoerotic asphyxia seem to be underestimated because it often can be confounded with suicide cases, particularly in asphyxiation kink Italian context where family members of the victim often try to disguise autoerotic behaviors of the victims.
The current paper provides a review on sexual masochism disorder with asphyxiophilia and discusses one specific case as an example to examine those conditions that may or may not influence the likelihood that death from autoerotic asphyxia be erroneously reported as suicide or accidental injury. In a survey of sexual behavior in the US involving respondents, Hunt [ 3 ] found that 4. Asphyxiophilia is one of the most dangerous conditions associated to SMD and is characterized by the use of various strategies to achieve the level of oxygen depletion needed to enhance sexual arousal, such as self-strangulation, hanging, suffocation with an object like a plastic bag over the head, chest compression, use of gas or volatile solvents, or a combination of these, up to the point of loss of consciousness [ 5 ].
Sometimes, however, this safety release does not function correctly or the individual incorrectly measures the amount of oxygen restriction, which may lead to death or serious brain injury. Estimates of the mortality rate of autoerotic asphyxia range from to deaths per year in the United States [ 6 ].
In a review of all published cases of autoerotic deaths from toHucker [ 7 ] reported that autoerotic death practitioners were predominantly Caucasian males. Most cases of asphyxia were by hanging, ligature, plastic bags, chemical substances, or a mixture of these. Atypical methods of autoerotic activity leading to death ed for about Victims were aged from 9 to 77 years and were mainly found in various indoor locations [ 7 ]. Because of its dangerousness, the DSM-5 paraphilias workgroup decided that this condition merits a specifier and patients be diagnosed with SMD with asphyxiophilia.
Studies of asphyxiophilia survivors indicate that nearly all individuals fantasize about masochistic scenarios as they asphyxiation kink in asphyxia practices [ 8 ]. Asphyxiophilia may be accomplished by a self-induced or assisted cerebral anoxia, usually by hanging, suffocation, or reduction of the oxygen in the inspired air that may be achieved through plastic bags or gas masks that may allow inhaling some anesthetic gases e.
Self-hanging appears the most common method observed among fatal cases [ 10 ]. Asphyxiophilia can be often accompanied with other paraphilias such as bondage and transvestism and a great range of paraphernalia props and devices involved in paraphilia sexual activitiessexual aids or pain-stimulating agents, intimate feminine garments, bondage, locks, pornographic magazines, and rubber items [ 11 ].
The inhalation of anesthetics, inhalants, and solvents sometimes occurs in combination with other appropriate devices like gas masks, anesthetic masks, diving masks, or even anesthetic machines [ 12 ]. The individual may inhale the substances or more often soak a rag with a solvent and then insert the rag in the asphyxiation kink to inhale the fumes. Jones and colleagues [ 13 ] described a case of asphyxiophilia characterized by plastic-bag asphyxiation in combination with inhaled glue spray.
Similarly, Gowitt and Hanzlick [ 14 ] reported two cases which had an involvement of ll-trichloroethane, a compound commonly found in typewriter correction fluid. Fatal masochistic asphyxia tends to be a relatively rare phenomenon and may be caused by the malfunction of apparatus used to provide sexual pleasure. Asphyxiation due to neck compression subsequent to hanging has been reported as the most common form of autoerotic death [ 15 ]. However, differentiation between accidental death and suicide often in cases of suspicion of autoerotic asphyxia becomes difficult due to the unusual methods used by victims [ 15 ].
According to Arun et al. The possibility of homicide should be ruled out in the cases of unusual suicides as well [ 16 ]. The psychological autopsy has been generally accepted in the psychiatric field for evaluating suicide cases for better understanding the social, psychological, and physical conditions of suicide [ 17 ]. Establishing whether the death was accidental or suicidal is quite challenging for the forensic professionals. Some authors established criteria of accidental autoerotic death: solitary, accidental, and caused directly by the abnormal mechanism aimed at asphyxiation kink satisfaction [ 18 ].
Some features differentiating death attributed to autoerotic asphyxia and suicide are presented in Table 1. Several sources in the literature, some dating back more than years, reported the use of life-threatening sexual practices, particularly those related to autoerotic asphyxia [ 19 ].
Recently, increasing evidence has been described by authors on this topic. Ueno and colleagues [ 20 ] reported the case of sexual asphyxial death by of a year-old male, found dead lying on his face in a bed of a truck cab and hanging himself from a window frame using a leather belt. He was completely naked.
There were pornographic and sadomasochistic magazines beneath his face, opened to s depicting nude photographs of a woman. Autopsy findings revealed a ligature mark on the neck and petechial hemorrhages in the conjunctivae, but there were no hemorrhages in the neck muscles or fractures of the hyoid bone or the thyroid cartilage.
The circumstances suggested that the death of the man was accidental and due to asphyxia by hanging performed to enhance sexual gratification during masturbation [ 20 ]. Some evidence also suggested that autoerotic asphyxia presents with characteristics similar to those found in scenes of male cases, despite the fact that autoerotic practices are generally believed to be rarer among females than in males.
Skugarevsky et al. The authors identified four cases, in which the autopsies showed that asphyxiation was the cause of death. In two cases death was determined by suffocation due to strangulation and in the other two by plastic bags placed over asphyxiation kink individuals' head. The authors observed that in one case there was additional evidence at the scene that the deceased had inhaled ether. Despite the fact that growing interest has been dedicated by researchers and practitioners for this topic, features of autoerotic asphyxia seem to be understudied in Italy.
In light of the limited amount of data on cases of death caused by autoerotic asphyxia in the Italian context, the current study described the characteristics of a case of an Italian man who died due to suffocation during an autoerotic practice. Elements of the scene were described in order to provide a rationale for considering this case as a death due to autoerotic asphyxia.
A male aged 47 years and married but without children was asphyxiation kink dead in his house. The corpse was found by the neighbors near the table in the cellar.
The neighbors were alerted by the wife of the man, who had not seen him going back home for dinner. A slipknot was around the neck and the cord was attached to the ceiling beam. The legs were flexed on the thighs and the body seemed to be on his knees, but the knees were suspended a few inches from the floor. The legs were also suspended and crossed, while the feet touched the floor. The hanging was therefore incomplete since the body was not completely suspended from the ground. The man was wearing sporty clothing, white T-shirt with short sleeves, white shorts, cotton socks, sneakers, and pantyhose on the head as a hood.
External examination of the corpse, stripped of clothing, evidenced the absence of the underwear. After the pantyhose and the hood were removed, the presence of a discontinuous groove on the neck was found, consistent with the death due to asphyxiation kink. No external cause injury was observed. An acute mechanical asphyxiation was identified as the cause of death. Reconstructing the scene based on the evidence and the data obtained seemed to support the hypothesis that the subject had achieved sexual pleasure through autoerotic asphyxiation.
A suicide or another cause of accidental death was excluded based on the way the man was dressed. The circumstantial evidence demonstrated that the death occurred while the subject was enacting autoerotic maneuvers. The literature shows the noticeable diffusion of particular methods to reach sexual gratification but the incidents of such practices are underestimated because the cases are reported as suicides.
Ann Burgess [ 22 ] delineated the criteria to correctly diagnose autoerotic accidental death AAD : 1 the asphyxiation being caused by strangling or hanging, body positioning that favors asphyxiation as the cause of death, and the asphyxiation death being accidental; 2 evidence at the crime scene proving that the lifesaving system failed; 3 proof that the sexual activity was solitary in other cases it would be characterized as homicide or assisted suicide ; 4 proof of sexual fantasy materials such as pornography; 5 proof of acts of autoerotic asphyxiation; and 6 missing intent of an apparent suicide.
With regard to the current case, 1 death was caused by mechanical asphyxia acute action of a noose tied around the neck; 2 the suspension of the body was less than the asphyxiation kink of the subject that flexing the legs could voluntarily and independently cause the progressive and gradual tensioning and fastening tightening the noose tied around the neck, checking asphyxia exerted by the loop itself.
Conversely, the extension of the lower limbs would have allowed reducing asphyxia, representing a mechanism of self-protection, but hypoxia has generated a loss of consciousness and muscle relaxation, which prevented maintaining the voluntary control of self-induced condition with the consequent lowering of the body and closing the noose around the neck. When his wife asked him some explanations, he released vague statements and did not want to talk about it. The diagnosis of an AAD appeared correct, since the evidence was similar to the elements outlined in the above-mentioned literature [ 22 ] while the homicidal hypothesis was not probable the entry points of the apartment were closed asphyxiation kink inside and there were no s of a third party presenceand the external examination of the corpse did not evidence s of violence or struggles.
Moreover, evidence for an AAD seemed to be further supported since in the job office of the man the police found a tale, where he described autoerotic sexual practices similar to those related asphyxiation kink the death. On the basis of the familiar testimony and the hypothesis of the investigators, suicide seemed improbable. After police acquaintances the subject seemed to conduct a normal life and did not have a asphyxiation kink case history. The subject was close to his family and did not show homosexual tendencies, and the literature does state that such practices are often enacted by largely heterosexual individuals who lead normal lives.
Episodes of death caused by autoerotic asphyxia seem to be underestimated to date because they often can be confounded with suicide cases, particularly in the Italian context where family members of the victim often try to disguise autoerotic behaviors of the victims. In line with these considerations, it should be highlighted that the current case was found by the neighbors.
In addition, the current case presents with original features compared with case reports since the victim was found wearing pantyhose on the legs, and this feature could be interpreted as a fetishistic behavior based on cross-dressing. However, the lack of information on the psychological anamnesis prevented drawing this conclusion. Moreover, the current case report highlights the importance that a correct and reliable diagnosis of autoerotic asphyxia cases is based on a multidisciplinary staff consisting of legal physicians and investigators who tly work using the literature and their experience.
In conclusion, for cases of autoerotic death we suggest the importance of taking into evidence and elements coming from a variety of sources, including the examination of the victim's psychological history and familiarity, since for the current case father of the victim was suicidal, and the investigation of the death context and environment.
More research and public awareness are needed as to the risks of autoerotic asphyxiation, which needs to be widely recognized as an extremely dangerous sexual practice and should asphyxiation kink be used to achieve sexual gratification. National Center for Biotechnology InformationU.
Journal List Case Rep Psychiatry v. Case Rep Psychiatry. Published online Sep Author information Article notes Copyright and information Disclaimer. This is an open access article distributed under the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract DSM-5 distinguishes between paraphilias and paraphilic disorders. Table 1 Comparison of the characteristics of death due to autoerotic asphyxia and suicide. Open in a separate window. Aims Despite the fact that growing interest has been dedicated by researchers and practitioners for this topic, features of autoerotic asphyxia seem to be understudied in Italy.
Case Report A male aged 47 years and married but without children was found dead in his house. Discussion The circumstantial evidence demonstrated that the death occurred while the subject was enacting autoerotic maneuvers. Conclusions Episodes of death caused by autoerotic asphyxia seem to be underestimated to date because they often can be confounded with suicide cases, particularly in the Italian context where family members of the victim often try to disguise autoerotic behaviors of the victims. Competing Interests The authors declare that they have no competing interests.
References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Krueger R. The DSM diagnostic criteria for sexual masochism. Archives of Sexual Behavior. Hunt M. Sexual Behavior in the s. Shields L.
American Journal of Forensic Medicine and Pathology. Uva J. Review: autoerotic asphyxiation in the United States. Journal of Forensic Sciences. Sauvageau Asphyxiation kink. Autoerotic deaths in the literature from to a review. Hucker S. Sexual masochism. Psychopathology and theory. In: Laws D. Sexual Deviance: Theory, Assessment, and Treatment. Litman R. Bondage and suicide.Asphyxiation kink
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Man dies after solo 'kink' act goes wrong