Review: Autoerotic Asphyxiation in the United States - Library

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Pre-event Event Post-event TABLE 8--Haddon matrix. UVA 9 AUTOEROTIC ASPHYXIATION IN THE UNITED STATES 579 Factors Human Factors Agent or Vehicle Physical Environment Sociocultural Environment 9 Type of clothing 9 Type of footwear 9 Visual acuity 9 Experience & judgment 9 Speed & accuracy of setup 9 Weight of clothing 9 Fatigue 9 Impairment 9 Attention to escape route 9 Size of the practitioner 9 Knowledge of how to hang 9 Clothing weight 9 Preexisting disease 9 Athleticism 9 Genetic makeup 9 Age 9 Physical condition 9 Recuperative power 9 Escape mechanism 9 Padding on rope 9 Center of gravity 9 Energy transfer 9 Control of airway 9 Load weight 9 Noose placement 9 Placement, hardness, and sharpness of contact surfaces 9 Load containment 9 Equipment malfunction 9 Failure of escape mechanism 9 Speed/height of impact 9 Height off the floor 9 Other energy transferring properties is healthy versus pathological, therefore, injury and premature death are unexpected and accidental. The main implementation bodies of these recommendations are highlighted. Federal Government 9 Support epidemiologic surveillance of autoerotic asphyxia to identify circumstances and diagnostic risk factors of these injuries and deaths. 9 Include autoerotic asphyxia in the National Electronic Injury Surveillance System (NEISS). 9 Support analytic studies of major contributors of autoerotic asphyxia, including biomedical, behavioral, and environmental risk factors for injuries and interaction of these risk factors with age. 9 Fund local injury prevention workers and act on the results of surveillance and analytic studies. 9 Develop and disseminate prevention programs. 9 Increase support of clinical trials to test strategies for injury reduction and rehabilitation. State and Local Governments 9 Conduct surveillance of circumstances and specific locations of autoerotic asphyxial injuries/deaths. 9 Develop E-codes specific for autoerotic asphyxiation. 9 Enforce age minimum to purchase pornographic material. 9 Include autoerotic asphyxial practices in the sex education in schools. 9 Discourage TV producers from using TV as a medium for discussing and/or glamorizing autoerotic asphyxiation. 9 Educate police, coroners, forensic pathologists, and medical practioners about autoerotic asphyxiation and the need for accurate reporting regardless of the social stigma. 9 Educate the clergy on autoerotic asphyxia to help families of 9 Access to asphyxial materials 9 Visibility 9 Location 9 Stability of the apparatus 9 Consistency of the ground 9 Isolated location 9 Level of the ground 9 Emergency communication system 9 Distance to emergency care 9 Quality of emergency care 9 Available rehabilitation 9 Attitudes about the severity of the problem 9 Community support for injury prevention 9 Sexuality education for adolescents 9 Parental supervision 9 Sexual partner awareness 9 Awareness of sexual partner 9 Support of trauma care systems 9 Training of emergency medical personnel, police, coroners and forensic pathologists 9 Parents, friends, and lovers' knowledge of first aid 9 Medico-legal ramifications the practitioners to cope and decrease the guilt associated with death and disability. 9 Share the observations of the different disciplines encountering autoerotic death and develop a systematic method of interacting with each other. Private Organizations 9 Educate pharmacists and industrial suppliers of the risks of nitrous oxide. 9 Limit the distribution of nitrous oxide in large quantities to noncommercial individuals. 9 Encourage medical and mental health professionals to increase clinical counseling and identification of autoerotic asphyxia. 9 Enforce businesses not to serve alcohol to underage or intoxi- cated patrons. 9 Enforce E-code utilization by hospital emergency room personnel. 9 Develop support/focus groups for adolescents concerning sexuality and autoerotic asphyxia. 9 Develop anonymous hot lines on sexuality, especially for adolescents. 9 Develop a support network for surviving parents that would distribute accurate information on autoerotic asphyxia. Academic and Research Institutions 9 Conduct analytic studies (including risk facto,s for autoerotic asphyxiation) listed under "federal government" above. 9 Conduct clinical trials to test strategies for hanging injury prevention and rehabilitation. 9 Develop and evaluate innovative interventions. 9 Educate clinicians so parents and patients can be cautioned. 9 Conduct clinical studies of patients who have engaged in such behavior.
580 JOURNAL OF FORENSIC SCIENCES 9 Educate medical students, residents, and nurses that choking sets free in certain individuals feelings of pleasure, erections, and orgasm. 9 Teach mothers of newborns how to feed their babies properly to avoid asphyxiation and the hypothesized strangulation cycle. 9 Provide follow-up care for individual and families to prevent further autoerotic experimentation. 9 Use literary works (such as Waiting for Godot) that are currently read in the school curriculum as tool to discuss sexuality such as autoerotic asphyxia. 9 Study further the medications for treatment options for autoerotic asphyxia such as lithium carbonate, Depo-Provera, and amyl nitrite. 9 Educate psychiatrists and other physicians about such drugs and their possible usage. Conclusions Autoerotic asphyxia can be a devastating problem for practitioners, especially for adolescents, their partners, families, and friends. From a public-health perspective, most concerning is the prevalence of male adolescent practitioners of autoerotic asphyxia who experience a needless lifelong injury or die a premature death. Ideally, we should strive to prevent such tragedies, however, there are foreboding barriers in the way. These practitioners are extremely difficult, if not impossible, to identify. Adolescent practitioners do not want to die and often do not expect an accident to result from their behavior. Clearly, this population is highly unlikely to visit a clinician for treatment or prevention. Compound- ing the problem, adolescents live for the present and do not see the future consequences of their actions. These teens developmen- tally feel that they are omnipotent and immune to death regardless of their actions. Since autoerotic asphyxia only represents a minute fraction of the deaths due to high risk sexual behavior it will not be prioritized highly in this era of limited resources. Furthermore, the data is inconsistent, difficult to quantify, time consuming to collect, and costly. Currently, there is a tremendous lack of awareness and enormous room for policy changes concerning the problem of autoerotic asphyxia. Nonetheless, even if the recommendations are carried through, there is still a question of their effectiveness. Is this just an esoteric public health issue for academia or is it some- thing that can be prevented and/or treated? Since there are limited resources available, the recommendations will be prioritized. The prioritization is based on cost-efficiency, ease of implementation, and acceptability. The following recommendations have been ranked as the highest priorities based on this criteria. Education appears to be the number one priority. This education should be of the disciplines possibly encountering autoerotic asphyxia, including emergency medicine physicians. Next, these disciplines should be encouraged to increase their identification, reporting, and counseling of practitioners, families, friends, and lovers faced with autoerotic asphyxia. Finally, surveillance of the circumstances, risk factors, and prevention strategies should be conducted. Until there is an increased awareness and energy invested into these recommendations, the community will never know the answer to whether or not the recommendations are effective. The morbidity and mortality rates for autoerotic asphyxia will continue to increase as a result of a lack of attention to these recommendations. Subsequently, the increase in premature death and disability will continue to go undetected and be misclassified. References [1] McGinnes, J. M. and Foege, W. H., "Actual Causes of Death in the United States," Journal of the American Medical Association, 1993, Vol. 270, pp. 2207-2212. [2] WHO Collaborating Center in Perinatal Care and Health Service Research in Maternal and Child Care. Unintended Pregnancy and Infant Mortality/Morbidity. Am J Prev Med 1987, Vol. 3, pp. 130-142. [3] American Cancer Society. Cancer Facts and Figures-1993. Atlanta, GA: American Cancer Society, 1993. [4] De Vita, V. T., Hellman, S., et al. Cancer: Principles and Practice ofOncology, vol 1, 3rd ed. Philadelphia, PA. JB Lippincott Co: 1989. [5] Nelson, J. H., Averette, H. E., et al. Cervical intraepithelial neoplasia and early invasive cervical carcinoma. CA Cancer J Clin 1989;39:175-78. [6] Williams, W. W., Hickson, M. A., et al. Immunization policies and vaccine coverage among adults. Ann Intern Med 1988;108:616-25. [7] Alter, M. J., Hadler, S. C., et al. The changing epidemiology of hepatitis B in the United States: need for alternative vaccination strategies. JAMA 1990;263:1218-22. [8] Centers for Disease Control and Prevention. HIVIAIDS Surveillance Report. Atlanta GA: US Dept of Health and Human Services; Feb 1993. [9] Money, J. Lovemaps. New York: Irvington, 1986. [10] Walsh, E IVI., Stahl, C. J., et al. Autoerotic asphyxial deaths: a medico- legal analysis of forty-three cases. Legal Medicine Annual 1977; 155-82. [11] Miller, E. C. and Milbrath, S. D. Medical-legal ramifications of an autoerotic asphyxial death. Bulletin of the American Academy of Psychiatry and Law 1983; 11:57--69. [12] American Psychiatric Association. DSM IIIR. Washington, DC, 1987. [13] American Psychiatric Association. DSM IV.. Washington, DC, 1991. [14] WHO The ICD-IO Classification of Mental and Behavioral Disor- ders. Geneva, 1993. [15] Hazelwood, R. R., Dietz, P. E., et al. Autoerotic Fatalities. Lexington, MA: DC Health (Lexington Books), 1983. [16] Brody, J. E. Autoerotic death of youths causing widening concern. New York Times 1984;17-20. [17] Rosenblum, S. and Faber, M. M. The adolescent sexual asphysia syndrome. J Am Acad Child Psychiatry 1979;18:546-58. [18] Resnick, H. "Eroticized repetative hangings: a form of self-destruc- tive behavior," Am J Psychotherapy. 1972;26:4-21. [19] Hirschfield, M. Sexual Anomalies. New York: Emerson, 1948. [20] DeSade, the Marquis, The Complete Justine, Philosophy in the Bed- room and other Writings. Trans. by Seaver R and Wainhouse A. New York: Grove Press, 1965. [21] Melville, H. Billy Budd, Foretopman in the Shorter Novels of Herman Melville. Greenwich, CT: Fawcett Publications, 1928. [22] Becket, S. Waiting for Godot. New York: Grove Press, 1954. [23] Henry, R. D. Sex hangings in the female. Medico-Legal bull #214 Virginia State Health Dept, 1971. [24] Steams, A. Cases of Probable suicide in young persons without obvious motivation. J Maine Med Assoc 1953;44:16. [25] Harbitz, E Laerebok iretsmedicin [Textbook on forensic medicine], Broggers Boktrykkeris Forlag, Oslo, Norway, 1943. [26] DeBoismont, A. B. Du Suicide et de la Folie Suicide. Pads: Germer Bailliere, 1856. [27] Berlyne, N. and Strachan, M. Neuropsychiatric sequelae of attempted hanging. Brit J Psychiat 1968;114:411. [28] Henry, R. D. Accidental Strangulation during perverse sexual activity. Medico-Legal Bull #58 Virginia State Health Sept, 1955. [29] Gwozdz, F. The sexual asphyxias. Foren Sci Gazette 1970;1:2-3. [30] Litman, R. E., Sweadngen, C. Bondage and Suicide. Arch Gen Psychiat 1972;27:80-80. [31] Rosenblum, S. and Faber, M. M. The adolescent sexual asphyxia syndrome. J Am Acad Child Psyciatry 1979;18:546-558. [32] Wright, R. K. and Davis, J. Homicidal hanging masqueraded as sexual asphyxia. J Foren Sci 1976;21:387-89. [33] Boglioli, L. R., Taft, M. L., et al. A case of autoerotic asphyxia associated with multiple paraphilia. Am J of Forensic Med and Pathol- ogy 1991;12:64-73. [34] Burgess, A. W. and Hazelwood, R. R. Autoerotic asphyxial deaths and social network response. Am J of Orthopsychiatry 1983;53:166-70. [35] Hucher, S. J. Self-harmful sexual behavior. 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