ABSTRACT
Of the various types of abnormal sexual
behavior, or “paraphilias” as defined by medicine, probably the most bizarre
and dangerous is autoerotic asphyxiation, also known as sexual hanging.
Autoerotic asphyxia is the practice of inducing cerebral anoxia, usually by
means of self-applied ligatures or suffocating devices, while the individual
masturbates to orgasm. The most common practitioners of this paraphilia are
adolescent and young adult males. Despite its long documented history, this
bizarre practice is still an enigma for most in society, including medical and
law enforcement personnel. Tragically, the asphyxiator’s sexual practice is
usually first discovered when he dies from accidental hanging.
Survivors of those who die by autoerotic
asphyxiation are puzzled and troubled by what must seem to them bizarre
behavior on the part of individuals whom they believed to be free of abnormal
sexual behavior. The surviving family members and friends are left struggling
with the sudden tragedy of death, along with having to cope with the bizarre,
embarrassing practice of autoerotic asphyxiation. Families are left with
lingering questions of; Why did he do this? Who taught him this? Why didn’t he get help? The grim task of
answering these enigmatic questions is usually left to law enforcement
investigators or medical professionals who, most likely, have only limited
explanation for the autoerotic practice. There are psychoanalytic and
physiological theories that can explain some of the reasons for the practice,
however, families are still left with unanswered questions, along with feelings
of guilt and embarrassment. This paper
will attempt to explain the autoerotic asphyxiation syndrome, and suggest that
through education, counseling and emotional support, family and friends can
gain relief from this emotionally scaring experience.
INTRODUCTION
There
is a portion of self-induced adolescent hanging deaths in which the goal of the
victims was not self-destruction but self-sexual gratification. Although this
behavior may seem unusual, it is far from uncommon. Autoerotic asphyxiation
deaths account for 6.5 % of all self-induced adolescent deaths and 31% of all
adolescent hanging deaths over a ten year period.[1]
It is suggested that the
incidents of autoerotic
asphyxiation deaths are
increasing. For example, in the US in 1979, 250 cases were reported. In 1983,
500-1000 cases were reported in the US, representing a two to four times increase. Autoerotic
asphyxiation deaths have been reported in males as young as 9 and as old as 80
years. The most common age group is
12 to 25 years, with
71% of the victims less than 30 years old.[2]
Due to the social stigma, lack of professional awareness, and few recorded
experiences, the actual number of living asphyxiators is not known.
METHODOLOGY
The autoerotic asphyxiation syndrome has been described as
"eroticized repetitive hanging". Also
known as asphyxophilia
or hypoxyphilia, it is a paraphilia of the
sacrificial type in which sexuoerotic arousal and attainment of orgasm depend
on self-strangulation and asphyxiation up to, but not including, loss of
consciousness.[3]
It has been proposed that the hanging might be used to produce physiological
enhancement of sensation during masturbation, enhancement that is supposed to
take place through interference with the blood supply to the brain, causing
cerebral anoxia that is subjectively perceived as giddiness, lightheadedness,
and exhilaration, which reinforces the mastubatory sensation.[4]
The most common physiological mechanism
by which sexual arousal is obtained is by constriction of the neck. Other less
common forms of autoerotic asphyxia are; compression of the abdomen, placing
a plastic bag over the head,
inhalation of aerosol propellants or chemical vapors, or passing
electrical current through the body.
These less common methods are known as “atypical autoerotic
practices”. Neck constriction,
being most common, is accomplished by
placing some form of ligature around the neck that is designed to give the
victim control of the pressure and provide an escape mechanism. Transient cerebral hypoxia
during autoerotic manipulation combined with physical helplessness and
self-endangerment to the degree that life is threatened, enhances sexual
gratification—but it also weakens the victim’s self control and judgment,
occasionally resulting in accidental death from the failure of or the victim’s
inability to operate previously arranged self-rescue mechanisms.[5]
HISTORICAL
The
practice of autoerotic asphyxia has been documented since the early 1600’s. It
was first used as a treatment for erectile dysfunction and impotency. The idea
for this most likely came from subjects who were executed by hanging. Observers
at public hangings noted male victims developed an erection (priapism) and
occasionally ejaculated when being hung.[6]
Anthropologists have long been aware of asphyxial practices among various
cultures. For example, Orientals often strangle the throat to heighten sexual
pleasure, as do the Yahgans in South America, and the Celts. Eskimo children
play sexual games involving hanging and choking, and the Shoshone-Bannock
Indian children play suffocating games such as “smoke-out” and “hang-up”.[7]
Literary works such as; the Marquis de Sâde’s Justine, Melville’s Billy
Budd and Becket’s Gadot, all
illustrate sexual asphyxiation. The earliest medical publication of
asphyxophilia is in 1856 by the French psychiatrist, DeBoismont. He reported
30% of men who died of hanging had associated erections or ejaculations.[8]
An Austrian encyclopedia of sexuality published from 1928-31 devoted chapters
to strangulation and “penis strangulation” as autoerotic practices. In 1935,
Bloch described the practice of choking women during intercourse, and in 1936,
Ellis described the “impulse to strangle the object of sexual desire”. In 1940,
Vance, Gonzales and Helpburn introduced sexual asphyxia to the forensic
community for the first time by adding a single sentence about the subject in a
textbook on forensic medicine. In 1953, Stearns published a review of 97
suicides occurring among young people in Massachusetts during 1941-1950. He
found 25 of the 97 to be probable suicides in young persons without obvious
motivation, suggesting accidental death or sexual hanging (Stearns 1953).[9]
Most of today’s literature on this topic is written in forensic and psychiatry
journals. Because of the scarcity of these articles, society is for the most
part, unaware of these practices.
VICTIMS
Autoerotic asphyxia is seen in all races, in all parts of the
world, and in all socioeconomic levels. Typically, the asphyxiator is an adolescent or young adult male.
Adult asphyxiators are found to have different characteristic practices from
that of adolescent asphyxiators. Adults tend to be more sophisticated in their
mastubatory ritual and are aware of the death orientation of the practice. This
is probably due to elaboration over time. The adult practice of asphyxophilia
has been named “terminal sex” or “scarfing” in the adult bondage community.
Adult asphyxiators are predominantly heterosexual males and may weave sexual
asphyxia into an elaborate sado-masochistic sexual repertoire involving bondage
and pain.[10]
It is a common assumption that
asphyxiators
also display homosexual behavior. However, studies reveal a low prevalence of recognized homosexuality
among decedents, concluding that autoerotic asphyxiation is not associated with homosexuality.[11]
Autoerotic
asphyxial behavior typically begins during adolescence. Most autoerotic deaths
occur in this age group because the practitioners lack experience and are
unaware of the dangers of hypoxia. Adolescent victims are described as
otherwise well adjusted, high achievers, apparently sexually normal, and not
perceived to be depressed or suicidal by friends and family.[12]
Adolescents are more likely to be experimenting with their sexuality and have
fewer, if any, related paraphilias. Adolescence is said to be a time of risk
taking and experiencing the unfamiliar. For example, male adolescents may
experiment with homosexual behavior, but this does not mean that they are gay,
rather they are “thrill seeking”. In the same manner, the majority of
adolescents who try sexual asphyxia do so just for the experience.[13]
According to Rosenblum, the risks of sexual asphyxia are not well known and it
could therefore be viewed as no more pathological than driving a car or
motorcycle at high speeds.[14]
These types of risk taking behaviors are prevalent among today’s adolescents.
It is not known what becomes of those adolescents who survive their repeated
brushes with death. It is suggested that they simply outgrow the practice, or
they continue until the odds of death catch up with them and they become one of
the rarer adult autoerotic death victims.
Most often, the adult or adolescent
asphyxiator has no known history of
deviant sexual behavior. This practice is revealed only when the
victim dies in an accidental hanging death. Studies have shown that as the age
of the asphyxiator increases, so does the likelihood that the mastubatory
ritual becomes more elaborate and involves other related paraphilias such as
transvestitism and bondage.[15]
Transvestism is the assumption of clothes of the opposite sex for sexual
purposes.[16]
Bondage is the use of ropes, chains, cords, fabric, etc. to constrict the body
in a superfluous manner for the purpose of sexual arousal.[17]
Most death scenes support these findings, revealing the presence of female
clothing, props and bondage materials.
The
“clustering” of paraphilias is thought to occur when the asphyxiator encounters
no adverse effects from his first paraphilic experience, which loosens his
inhibitions about acting out other erotic fantasies.[18]
Bancroft (1989) suggested that the tendency of paraphilias to occur together
suggests that the conditions necessary for the development of one paraphilia
may facilitate the development of others. He conjectured that this potential
might stem from some characteristics of the individual’s nervous system that
underlies sexual learning.[19]
Freund (1976) introduced the concept of “courtship disorder” to explain his
finding that various combinations of paraphilias occur together. He theorized
that courtship disorder results from the failure of some mechanism that
coordinates normal human courtship behavior, and whose dysfunction allows
various components of the normal sequence to erupt in fragmentary and
unmodulated forms.[20]
Another possibility is suggested in the work of LaTorre (1980), who produced an
experimental model for fetishism by showing that males who feel rejected by
women show an enhanced response to women’s clothing and a decreased response to
women.[21]
THE
DEATH SCENE
Autoerotic
hanging victims are usually found by family members, making their deaths
especially traumatic for the finders. The visual memory of the death scene
becomes imprinted in the family member’s mind forever. Impulsively, family
members often hide the evidence of asphyxophilic deaths either out of
embarrassment, or perceived social stigma.[22]
These death scene alterations make investigation and classification of the
autoerotic death more difficult. However, some professionals that have
investigated autoerotic death scenes in the past have little trouble
recognizing the death scene as an accidental, sexual hanging. Researchers have
identified the appearance of sexual activity in conjunction with the process of
induced cerebral anoxia as the basic characteristics of most autoerotic death
scenes.[23]
According
to Hazelwood (1981) the characteristics of most death scenes are:
1. Evidence
of asphyxia produced by strangulation either by ligature or hanging, in which
the position of the body or presence of protective means such as padding about
the neck, indicate that the death was not obviously intended.
2. Evidence
of a physiological mechanism for obtaining or enhancing sexual arousal and dependent
on either a self-rescue mechanism or the victim’s judgment to discontinue its
effects.
3. Evidence
of solo sexual activity.
4. Evidence
of sexual fantasy aids, props or pornography.
5. Evidence
of prior dangerous autoerotic practice.
6. No
apparent suicide intent.[24]
The
circumstances and features of autoerotic deaths are not commonly known and, as
a result, can be misrepresented as suicide or homicide. The fact that most
autoerotic asphyxia victims are found alone in a secluded location, such as a
locked bedroom, garage, or an isolated outdoor area, and the fact that the
victim died of hanging, can lead investigators to classify the death as
suicide. Common features at death scenes such as; a blindfold, a gag, physical
restraints, and other bondage items have lead to mistaken suspicions of
homicide.[25]
Educating law enforcement and medical professionals to identify the autoerotic
death scene will help to accurately document these deaths as accidental.
ETIOLOGY
Families
and friends trying to cope with an autoerotic asphyxia death are left with many
questions about their loved one’s bizarre sexual behavior. The task of
answering these tough questions is usually left to law enforcement
investigators or medical professionals who, most likely, have only limited
explanation for the autoerotic practice. The most enigmatic question is: Why
did he do it? To answer, it must first be understood that “abnormal sexual
behavior” and “sexual perversions” are relative terms used to describe socially
unacceptable or unlawful sexual practices. To the asphyxiator, his ritualistic
hanging is a fixated and necessary sexuoerotic practice. The term sexual
perversion, used to describe autoerotic asphyxiation, suggests a deliberate,
volitional deviation from normal sexuality and that being offered the chance at
normal genital intercourse, the asphyxiator willfully takes the path of
abnormality. Nothing is further from the truth. In most cases, there is no
sexual satisfaction from, or the ability to indulge in, normal sexual behavior.
The asphyxiator is forced into abnormal behavior by the same forces that drive
a normal man into normal sexual activity.[26]
Autoerotic
asphyxia is probably the least understood of the paraphilias. There are many
reasons this practice is so obscure. First, it is difficult to ascertain the
number of practitioners of asphyxophilia due to the social stigma, lack of
professional awareness, and few practitioners recorded experiences.[27]
Also, there have been many studies done on autoerotic death victims, studies
which do not fully reveal past histories of the asphyxiators. Conversely, there
are relatively few studies available on living practitioners.
Mental
health professionals mostly agree that paraphilias, or deviant sexual behaviors
are generally thought to be caused by some form of disruption of the normal
sexual development during adolescence. The asphyxiator may be compelled to
engage in this practice as a result of arrested development during a stage of
sexual development.[28]
In writings by Dr. Ernest Jones (1926) of sexual development, he states that
during early adolescence, males go through the “autoerotic phase”. During this
phase, the adolescent has the tendency toward introversion and a richer life of
secret fantasy, together with a preoccupation of self and the varying degrees
of shyness and self-consciousness.[29]
A traumatic experience during this stage may cause dysregulation and disrupt
the sexual development.
Many
theories have been suggested for the autoerotic asphyxial practice. The usual
causative factors suggested are psychoanalytic. Saunders (1989) suggests
several rationales for the practice, including guilt associated with
masturbation, castration anxiety, and risk-taking/thrill-seeking in general.[30]
In two cases, childhood abuse was suggested as a possible etiological factor.
They suggest that childhood abuse could result in self-defeating activity
relieved by engaging in sexually euphoric behavior.[31]
Money (1989) suggested that autoerotic asphyxia is a sacrificial paraphilia.
This type of behavior occurs in individuals who feel they must atone for their
erotic behavior, thus pairing pleasure with threat or punishment.[32]
Psychoanalytic formulations have viewed victims of autoerotic death in terms of
an eroticization of helplessness, weakness, and a threat to life, which is
overcome through survival thus creating a sense of success.[33]
In
the book, Autoerotic Fatalities
(Dietz et. al., 1983) the authors suggest that the most common psychological
processes underlying autoerotic asphyxia are the desire for the subjective
experience of hypoxia, the acting out of a masochistic fantasy that includes
being abused, tortured, or executed, and the desire to be sexually aroused
through risk-taking. A patient interviewed in connection with the study done by
Dr. Dietz illustrated these processes. The patient indicated that his
autoerotic asphyxiation began at age twelve, though he could not recall how he
first came to use it. He said that in the early years of his practice, he
enjoyed the subjective experience of hypoxia and passing out, which was always
associated with a fantasy that powerful women were doing this to him. Often he
tied himself up or cross-dressed and fantasized that the women had done this to
him as well. His history illustrates the elements of hypoxia-seeking and
masochistic fantasies.[34]
In
1994, Friedrich and Gerber studied five adolescent male practitioners of
autoerotic asphyxia. This is one of the few studies done on living
practitioners. The sample of five living practitioners is, however, thought to
be significantly skewed because of the insufficient number of practitioners
studied, and because there was clinical referral of these cases for other
presenting problems. The authors of this study understand that some teenagers
may try autoerotic asphyxia and then move on with no clear reasons why.
However, they believe that presenting the commonalties of these case histories
will be useful in understanding the etiology of this paraphilia.[35]
Several
characteristics were reported in the five boys studied. They include a history
of choking, physical abuse, sexual abuse, other risk-taking behaviors, and
pairing of sexual arousal with the choking experience. Their behavior was found
to be ritualistic and compulsive and most likely the result of more significant
etiological precursors.[36]
Physical and sexual abuse can be precursors to the abnormal sexual behavior. An
important factor of abuse is dysregulation, including altered psychophysiology
as well as a paired capacity for self-soothing. Persistent dysregulation can
lead to chronic over-arousal and set the stage for repetitive, risk-taking
behaviors driven possibly by the child’s need to undo or master the trauma.[37]
While
these theories are useful in explaining some autoerotic asphyxial behavior by
paired-associate learning[38],
and psychological processes, there still remains questions of how young males
begin the practice. Why the asphyxiator develops this bizarre practice is
mostly unknown. Do these individuals find the pain and humiliation of hanging
stimulating, or are they masochistic, dealing out a degrading punishment to a
victim whose simulated death they witness taking place before them?[39]
A 1990 study in Hawaii concluded, “In reality, little is known about why people
start to asphyxiate themselves or how the practice becomes eroticized.”[40]
It is, however, thought that many asphyxiators learn of the practice by word of
mouth, sex manuals, medical books, pornographic literature, or detective
magazines, as well as through the media.[41]
Another possibility is that asphyxiators begin the practice by accidental
discovery or by self-generated experiences.
INTERVENTION
STRATEGIES
Autoerotic
asphyxia can be a devastating problem for practitioners, especially
adolescents, their families and friends. From a public health perspective, the
most concerning are the adolescent deaths. Most agree there is a need for
intervention, however, there are many barriers to successful intervention. One
is the difficulty in identifying practitioners. Because of the embarrassment or
perceived social stigma, asphyxiators are not likely to visit a clinician for
treatment. Also, for most practitioners, accidental hanging death is the first
presenting sign of autoerotic asphyxiation. Although case studies on autoerotic
death victims are useful, they shed little light on the psychological factors
for starting the practice. Making it even more difficult, teens have the
tendency to live for the present and not see the risks or consequences of their
actions. They therefore are not likely to see their practices as problematic or
life threatening, and thus not seek help.[42]
The
few asphyxiators that seek professional help usually present different problems
for their seeking clinical treatment. When asphyxophilia is diagnosed,
clinicians can recommend drug therapy. This treatment is directed at
substituting the hypoxic effects of hanging with drugs that cause hypoxic
feelings and are less dangerous. However, this treatment has only limited
potential. There is only a portion of asphyxiators whose single goal is the
physical sensation of cerebral anoxia. These cases could be treated by
prescribing medications such as amyl nitrate or lithium carbonate. For other
asphyxiators, the purely physical sensation of anoxia is not the only source of
sexual stimulation. In such cases, the hypoxia may merely be incidental to the
sexual stimulation achieved by the act of self-strangulation or hanging.[43]
For those, education about sexual physiology and its legitimate enhancement
through socially and physically acceptable means could have a preventative
impact.[44]
In
spite of the barriers, there are intervention strategies that are suggested.
Education is thought to be the best chance at intervention. Uva (1995) suggests
many different intervention strategies. One is: including the dangers of
practicing autoerotic asphyxia in school sex education classes. Also suggested,
is education for medical and law enforcement professionals about asphyxophilia
and the need for accurate reporting, regardless of the social stigma. In
addition to education, there is a need to support research aimed at identifying
the risk factors and etiological factors that contribute to the autoerotic
asphyxiation practice. This includes support for the identification of
biomedical, behavioral and environmental risk factors and how they interact
with age.[45]
The
autoerotic death victim’s family and friends must be offered counseling to
understand and cope with the death of their loved one. Counseling can be
provided by professionals dealing with the autoerotic asphyxia syndrome or
through support/focus groups. Education should be directed at the various
disciplines that may encounter the syndrome. This includes the clergy as well
as law enforcement and medical professionals. Families often turn to their
church to answer questions about their loved one’s death. The clergy should be
educated on autoerotic asphyxiation to help families of victims cope with the
guilt and associated emotional trauma of the death.[46]
In
addition to intervention efforts, efforts must be made to limit children’s
exposure to the syndrome. Risk-taking youth experimenting with their sexuality
run a high risk of imitative practices. Limiting children’s exposure to
pornography should be strictly enforced. There is also a need to limit mass
media exposure and coverage of the autoerotic asphyxia syndrome. Dr. Park Dietz
co-author of Autoerotic Fatalities
(Dietz et. al., 1983) has been invited many times to appear on television
discussing the subject. He has refused every time because of his belief that
the media is not a suitable medium for discussion of this syndrome, citing the
high risk of imitative behavior.[47]
In fact, a show on autoerotic asphyxia was aired on May 10, 1988, against Dr.
Dietz’s advice. Since the airing, there have been two adolescent deaths
attributed to the victim’s viewing of the show.[48]
CONCLUSION
The
bizarre nature of an autoerotic asphyxiation death can leave a void in the
lives of the surviving family and friends. When these deaths occur, victim’s
families and friends are left with questions about the bizarre practice of
asphyxophilia. Studies of living practitioners and autoerotic death victims
have suggested some psychological as well as physiological answers to the
questions of why and how the practice starts. Many valid etiological theories
have been put forth, however, each case is unique, and may not have clear
etiological factors. Each family has the need to understand their loved one’s
behavior. Law enforcement and medical professionals should to be able to
explain the autoerotic asphyxia syndrome without being judgmental or bias. They
should be able to direct survivors to support groups in which families and
friends can discuss their tragedy with others who have had similar experiences.
Until there is
an increased awareness of the dangerous practice of autoerotic asphyxiation,
the untimely and tragic death of adolescents and young adults will continue to
occur. Through increased awareness and better documentation of autoerotic
asphyxial practices, society will be better able to understand and cope with
the complex environmental and behavioral factors that lead to this dangerous
syndrome.
[1] W. Sheehan,
“Adolescent Autoerotic Deaths,” Journal of the
American Academy of Child & Adolescent Psychiatry, 27 (May, 1988) p
367.
[2] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 574.
[3] L. Boglioli and M. Taff, Handbook of Forensic
Sexology (New York: Prometheus Books), 1994. p 156.
[4] H. Resnik, “Eroticized Repetitive Hangings”, American
Journal of Psychotherapy, 26 (1972) pp. 4-21.
[5] J. Garza-Leal, and F. Landron, “Autoerotic
Asphyxial Death Initially Misinterpreted as Suicide”, Journal of Forensic
Sciences, 36 (Nov., 1991) p 1758.
[6] S. Tough, J. Butt and G. Sanders, “Autoerotic
Asphyxial Deaths: Analysis of Nineteen Fatalities”, Canadian Journal of
Psychiatry, 39 (April, 1994) p 157.
[7] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 575.
[8] ibid.
[9] L. Boglioli and M. Taff, Handbook of Forensic
Sexology (New York: Prometheus Books), 1994. p 156.
[10] S. Tough, J. Butt and G. Sanders, “Autoerotic
Asphyxial Deaths: Analysis of Nineteen Fatalities”, Canadian Journal of
Psychiatry, 39 (April, 1994) p 158.
[11] L. Boglioli and M. Taff, Handbook of Forensic
Sexology (New York: Prometheus Books), 1994. p 159.
[12] S. Rosenblum and M. Faber, “The Adolescent
Sexual Ashpyxia Syndrome”, Journal of American Academy of Child Psychiatry,
18 (1979) pp. 546-58.
[13] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 577.
[14] S. Rosenblum and M. Faber, “The Adolescent
Sexual Ashpyxia Syndrome”, Journal of American Academy of Child Psychiatry,
18 (1979) pp. 546-58.
[15] R. Blanchard and S. Hucker, “Age,
Transvestitism, Bondage, and Concurrent Paraphilic Activities: 117 Fatal Cases
of Autoerotic Asphyxia”, British Journal of Psychiatry, 159 (Sept. 1991)
p 375.
[16] C. Allen, The Sexual Perversions and
Abnormalities (Connecticut: Greenwood Press), 1949, p 145.
[17] R. Blanchard and S. Hucker, “Age,
Transvestitism, Bondage, and Concurrent Paraphilic Activities: 117 Fatal Cases
of Autoerotic Asphyxia”, British Journal of Psychiatry, 159 (Sept. 1991)
p 371.
[18] ibid. p 376.
[19] J. Bancroft, Human Sexuality and Its Problems,
(London: Churchill Livingstone) 1989.
[20] K. Fruend, Diagnosis and Treatment of
Forensically Significant Anomalous Erotic Preferences, Canadian Journal of
Criminology and Corrections, 18 (1976) pp. 181-189.
[21] R. Latorre, “Devaluation of the Human Love
Object: Heterosexual Rejection as a Possible Antecedent to Fetishism”, Journal
of Abnormal Psychology 89 (1980) pp. 295-298.
[22] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 575.
[23] S. Hucker and R. Blanchard, “Death Scene
Characteristics in 118 Fatal Cases of Autoerotic Asphyxia Compared To Suicidal
Asphyxia”, Behavioral Sciences and the Law, 10 (1992) p 521.
[24] ibid.
[25] R. Hazelwood, P. Dietz, and A. Burgess, “The
Investigation of Autoerotic Fatalities”, Journal of Police Science and
Administration, 9 (1981) p 404.
[26] C. Allen, The Sexual Perversions and
Abnormalities (Connecticut: Greenwood Press), 1949, pp. 55-56.
[27] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 575.
[28] L. Blum, Clinical Psychologist, Delinquency
Control Institute Lecture, February, 1996.
[29] E. Jones, British Journal of Psychology,
13 (1926) pp. 31-47.
[30] E. Saunders, “Life Threatening Autoerotic
Behavior: A Challenge for Sex Educators and Therapists”, Journal of Sex
Education and Therapy, 15 (1989) pp. 82-91.
[31] J. Cesnick and E. Coleman, “Use of Lithium
Carbonate in the Treatment of Autoerotic Asphyxia, American Journal of
Psychotherapy, 43 (1989) pp. 277-286.
[32] J. Money and M. Lamacz, Vandalized Love Maps,
(Buffalo, NY: Prometheus Books) 1989.
[33] R. Litman and C. Swearingen, “Bondage and
Suicide”, General Psychiatry, 27 (1972) pp. 81-85.
[34] P. Dietz, R. Hazelwood, and A. Burgess, Autoerotic
Fatalities, (Lexington, MA: Lexington Books, 1983) pp. 97-98.
[35] W. Friedrich and P. Gerber, “Autoerotic
Asphyxia: The Development of Paraphilia”, Journal of the American Academy of
Child and Adolescent Psychiatry, 39 (April, 1994) p 971.
[36] ibid. p 973.
[37] B. Braun, “The BASK Model of Disassociation”, Disassociation,
1 (1988) pp. 4-23.
[38] W. Friedrich and P. Gerber, “Autoerotic
Asphyxia: The Development of Paraphilia”, Journal of the American Academy of
Child and Adolescent Psychiatry, 39 (April, 1994) p 974.
[39] W. Sheehan,
“Adolescent Autoerotic Deaths,” Journal of the
American Academy of Child & Adolescent Psychiatry, 27 (May, 1988) p
370.
[40] M. Diamond, S. Inalla and K. Ernulf,
“Asphyxophilia and Autoerotic Death”, Hawaii Medical Journal, 49 (1990)
p 15.
[41] L. Boglioli and M. Taff, Handbook of Forensic
Sexology (New York: Prometheus Books), 1994. p 160.
[42] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 580.
[43] R. Blanchard and S. Hucker, “Age,
Transvestitism, Bondage, and Concurrent Paraphilic Activities: 117 Fatal Cases
of Autoerotic Asphyxia”, British Journal of Psychiatry, 159 (Sept. 1991)
p 376.
[44] S. Tough, J. Butt and G. Sanders, “Autoerotic
Asphyxial Deaths: Analysis of Nineteen Fatalities”, Canadian Journal of
Psychiatry, 39 (April, 1994) p 160.
[45] J. Uva, “Autoerotic
Asphyxiation in the United States”, Journal of Forensic
Sciences, 40 (July 1995) p 579.
[46] ibid.
[47] P. Dietz, “Television Inspired Autoerotic
Asphyxiation”, Journal of Forensic Sciences, 34 (May, 1989)
p 528.
[48] ibid.