By Jay Wiseman, 1997, GreeneryPress.com
For some time now, I have felt that the practices of suffocation
and/or strangulation done in an erotic context (generically known as breath
control play; more properly known as asphyxiophilia) were in fact far more
dangerous than they are generally perceived to be.
As a person with years of medical education and experience, I know of no way
whatsoever that either suffocation or strangulation can be done in a way that
does not intrinsically put the recipient at risk of cardiac arrest. (There are
also numerous additional risks; more on them later.)
Furthermore, and my *biggest* concern, I know of no reliable way to determine
when such a cardiac arrest has become imminent.
Often the first detectable sign that an arrest is approaching is the arrest
itself. Furthermore, if the recipient does arrest, the probability of
resuscitating them, even with optimal CPR, is distinctly small. Thus the
recipient is dead and their partner, if any, is in a very perilous legal
situation. (The authorities could consider such deaths first-degree murders
until proven otherwise, with the burden of such proof being on the defendant).
There are also the real and major concerns of the surviving partner's own
life-long remorse to having caused such a death, and the trauma to the friends
and family members of both parties.
Some breath control fans say that what they do is acceptably safe because they
do not take what they do up to the point of unconsciousness. I find this
statement worrisome for two reasons:
(1) You can't really know when a person is about to go unconscious until they
actually do so, thus it's extremely difficult to know where the actual point of
unconsciousness is until you actually reach it.
(2) More importantly, unconsciousness is a *symptom*, not a condition in and of
itself. It has numerous underlying causes ranging from simple fainting to
cardiac arrest, and which of these will cause the unconsciousness cannot be
known in advance.
I have discussed my concerns regarding breath control with well over a dozen
SM-positive physicians, and with numerous other SM-positive health
professionals, and all share my concerns. We have discussed how breath control
might be done in a way that is not life-threatening, and come up blank. We have
discussed how the risk might be significantly reduced, and come up blank. We have
discussed how it might be determined that an arrest is imminent, and come up
blank.
Indeed, so far not one (repeat, not one) single physician, nurse, paramedic,
chiropractor, physiologist, or other person with substantial training in how a
human body works has been willing to step forth and teach a form of breath
control play that they are willing to assert is acceptably safe -- i.e., does
not put the recipient at imminent, unpredictable risk of dying. I believe this
fact makes a major statement.
Other "edge play" topics such as suspension bondage, electricity
play, cutting, piercing, branding, enemas, water sports, and scat play can and
have been taught with reasonable safety, but not breath control play. Indeed,
it seems that the more somebody knows about how a human body works, the more
likely they are to caution people about how dangerous breath control is, and
about how little can be done to reduce the degree of risk.
In many ways, oxygen is to the human body, and particularly to the heart and
brain, what oil is to a car's engine. Indeed, there's a medical adage that goes
"hypoxia (becoming dangerously low on oxygen) not only stops the motor,
but also wrecks the engine." Therefore, asking how one can play safely
with breath control is very similar to asking how one can drive a car safely
while draining it of oil.
Some people tell the "mechanics" something like, "Well, I'm
going to drain my car of oil anyway, and I'm not going to keep track of how low
the oil level is getting while I'm driving my car, so tell me how to do this
with as much safety as possible." (They may even add someting like
"Hey, I always shut the engine off before it catches fire.") They
then get frustrated when the mechanics scratch their heads and say that they
don't know. They may even label such mechanics as "anti-education."
A bit about my background may help explain my concerns. I was an ambulance
crewman for over eight years. I attended medical school for three years, and
passed my four-year boards, (then ran out of money). I am a former member of
the American Academy of Family Physicians and a former American Heart
Association instructor in Advanced Cardiac Life Support. I have an extensive
martial arts background that includes a first-degree black belt in Tae Kwon Do.
My martial arts training included several months of judo that involved both my
choking and being choked.
I have been an instructor in first aid, CPR, and various advanced emergency
care techniques for over sixteen years. My students have included physicians,
nurses, paramedics, police officers, fire fighters, wilderness emergency
personnel, martial artists, and large numbers of ordinary citizens. I currently
offer both basic and advanced first aid and CPR training to the SM community.
During my ambulance days, I responded to at least one call involving the death
of a young teenage boy who died from autoerotic strangulation, and to several
other calls where this was suspected but could not be confirmed. (Family
members often "sanitize" such scenes before calling 911.)
Additionally, I personally know two members of my local SM community who went
to prison after their partners died during breath control play.
The primary danger of suffocation play is that it is not a condition that gets
worse over time (regarding the heart, anyway, it does get worse over time
regarding the brain). Rather, what happens is that the more the play is
prolonged, the greater the odds that a cardiac arrest will occur. Sometimes
even one minute of suffocation can cause this; sometimes even less.
Quick pathophysiology lesson # 1: When the heart gets low on oxygen, it starts
to fire off "extra" pacemaker sites. These usually appear in the
ventricles and are thus called premature ventricular contractions -- PVC's for
short. If a PVC happens to fire off during the electrical repolarization phase
of cardiac contraction (the dreaded "PVC on T" phenomenon, also
sometimes called "R on T") it can kick the heart over into
ventricular fibrillation -- a form of cardiac arrest. The lower the heart gets
on oxygen, the more PVC's it generates, and the more vulnerable to their effect
it becomes, thus hypoxia increases both the probability of a PVC-on-T occurring
and of its causing a cardiac arrest.
When this will happen to a particular person in a particular session is simply
not predictable. This is exactly where most of the medical people I have
discussed this topic with "hit the wall." Virtually all medical folks
know that PVC's are both life-threating and hard to detect unless the patient
is hooked to a cardiac monitor. When medical folks discuss breath control play,
the question quickly becomes: How can you tell when they start throwing PVC's?
The answer is: You basically can't.
Quick pathophysiology lesson # 2: When breathing is restricted, the body cannot
eliminate carbon dioxide as it should, and the amount of carbon dioxide in the
blood increases. Carbon dioxide (CO2) and water (H2O)
exist in equilibrium with what's called carbonic acid (H2CO3)
in a reaction catalyzed by an enzyme called carbonic anhydrase.
Thus: CO2 + H2O becomes H2CO3
A molecule of carbonic acid dissociates on its own into a molecule of what's
called bicarbonate (HCO3-) and an (acidic) hydrogen ion. (H+)
Thus: H2CO3 becomes HCO3- and H+
Thus the overall pattern is:
H2O + CO2 becomes H2CO3 becomes HCO3-
+ H+
Therefore, if breathing is restricted, CO2 builds up and the
reaction shifts to the right in an attempt to balance things out, ultimately
making the blood more acidic and thus decreasing its pH. This is called
respiratory acidosis. (If the patient hyperventilates, they "blow off CO2"
and the reaction shifts to the left, thus increasing the pH. This is called
respiratory alkalosis, and has its own dangers.)
Quick pathophysiology lesson # 3:
Again, if breathing is restricted, not only does carbon dioxide have a hard
time getting out, but oxygen also has a hard time getting in. A molecule of
glucose (C6H12O6) breaks down within the cell
by a process called glycolysis into two molecules of pyruvate, thus creating a
small amount of ATP for the body to use as energy. Under normal circumstances,
pyruvate quickly combines with oxygen to produce a much larger amount of ATP.
However, if there's not enough oxygen to properly metabolize the pyruvate, it
is converted into lactic acid and produces one form of what's called a
metabolic acidosis.
As you can see, either a build-up in the blood of carbon dioxide or a decrease
in the blood of oxygen will cause the pH of the blood to fall. If both occur at
the same time, as they do in cases of suffocation, the pH of the blood will
plummet to life-threatening levels within a very few minutes. The pH of normal
human blood is in the 7.35 to 7.45 range (slightly alkaline). A pH falling to
6.9 (or raising to 7.8) is "incompatible with life."
Past experience, either with others or with that same person, is not
particularly useful. Carefully watching their level of consciousness, skin
color, and pulse rate is of only limited value. Even hooking the bottom up to
both a pulse oximeter and a cardiac monitor (assuming you had either piece of
equipment, and they're not cheap) would be of only limited additional value.
While an experienced clinician can sometimes detect PVC's by feeling the
patient's pulse, in reality the only reliable way to detect them is to hook the
patient up to a cardiac monitor. The problem is that each PVC is potentially
lethal, particularly if the heart is low on oxygen. Even if you "ease
up" on the bottom immediately, there's no telling when the PVC's will
stop. They could stop almost at once, or they could continue for hours.
In addition to the primary danger of cardiac arrest, there is good evidence to
document that there is a very real risk of cumulative brain damage if the
practice is repeated often enough. In particular, laboratory studies of
repeated brief interruption of blood flow to the brains of animals and studies
of people with what's called "sleep apnea syndrome" (in which they
stop breathing for up to two minutes while sleeping) document that cumulative
brain damage does occur in such cases.
There are many documented additional dangers. These include, but are _not_
limited to: rupture of the windpipe, fracture of the larynx, damage to the
blood vessels in the neck, dislodging a fatty plaque in a neck artery which
then travels to the brain and causes a stroke, damage to the cervical spine,
seizures, airway obstruction by the tongue, and aspiration of vomitus.
Additionally, there are documented cases in which the recipient appeared to
fully recover but was found dead several hours later.
The American Psychiatric Association estimates a death rate of one person per
year per million of population -- thus about 250 deaths last year in the U.S.
Law enforcement estimates go as much as four times higher. Most such deaths
occur during solo play, however there are many documented cases of deaths that
occurred during play with a partner. It should be noted that the presence of a
partner does nothing to limit the primary danger, and does little or nothing to
limit most of the secondary dangers.
Some people teach that choking can be safely done if pressure on the windpipe
is avoided. Their belief is that pressing on the arteries leading to the brain
while avoiding pressure on the windpipe can safely cause unconsciousness. The
reality, unfortunately, is that pressing on the carotid arteries, _exactly_ as
they recommend, presses on baroreceptors known as the carotid sinus bodies.
These bodies then cause vasodilation in the brain, thus there is not enough
blood to perfuse the brain and the recipient loses consciousness. However,
that's not the whole story.
Unfortunately, a message is also sent to the main pacemaker of the heart, via
the vagus nerve, to decrease the rate and force of the heartbeat. Most of the
time, under strong vagal influence, the rate and force of the heartbeat
decreases by one third. However, every now and then, the rate and force
decreases to zero and the bottom "flatlines" into asystole --
another, and more difficult to treat, form of cardiac arrest. There is no way
to tell whether or not this will happen in any particular instance, or how
quickly. There are many documented cases of as little as five seconds of
choking causing a vagal-outflow-induced cardiac arrest.
For the reason cited above, many police departments have now either entirely
banned the use of choke holds or have reclassified them as a form of deadly
force. Indeed, a local CHP officer recently had a $250,000 judgment brought
against him after a nonviolent suspect died while being choked by him.
Finally, as a CPR instructor myself, I want to caution that knowing CPR does
little to make the risk of death from breath control play significantly
smaller. While CPR can and should be done, understand that the probability of
success is likely to be less than 10%.
I'm not going to state that breath control is something that nobody should ever
do under any circumstances. I have no problem with informed, freely consenting
people taking any degree of risk they wish. I am going to state that there is a
great deal of ignorance regarding what actually happens to a body when it's
suffocated or strangled, and that the actual degree of risk associated with
these practices is far greater than most people believe.
I have noticed that, when people are educated regarding the severity and
unpredictability of the risks, fewer and fewer choose to play in this area, and
those who do continue tend to play less often. I also notice that, because of
its severe and unpredictable risks, more and more SM party-givers are banning
any form of breath control play at their events.
If you'd like to look into this matter further, here are some references to get
you started:
People with questions or comments can contact me at the GreeneryPress website
or write to me at Greenery Press, 3739 Balboa #195, San Francisco, CA 94121.
Regards,
Jay Wiseman