by Jay Wiseman
Author of "SM 101: A Realistic Introduction"
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 know 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. (Sorry, but I can't
do subscripts in this program.)
Thus: CO2 + H20 <carbonic anhydrase> 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 <> HCO3- and H+
Thus the overall pattern is:
H2O + CO2 <> H2CO3 <> 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 to 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-outlfow-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:
"Emergency Care in the Streets" by Caroline (I'd
recommend starting here.) "Medical Physiology" by Guyton
"The Pathologic Basis of Disease" by Robbins
"Textbook of Advanced Cardiac Life Support" by American Heart
Association "The Physiology Coloring Book" by Kapit, Macey, and
Meisami "Forensic Pathology" by DeMaio and Demaio "Autoerotic
Fatalities" by Hazelwood
"Melloni's Illustrated Medical Dictionary" by Dox,
Melloni, and Eisner
People with questions or comments can contact me at
jaybob@crl.com or write to me at P.O. Box 1261, Berkeley, CA 94701.
Regards,
Jay Wiseman
