I hope to post this as a step in a series that help to describe some of my thoughts on how to make erotic tickling in a social context more assuredly ‘safe-sane-and consensual’ as well as fun, for any and all involved. This first posting is not meant simply to alarm, though it may be read that way. Rather, I wanted to put it up as a bit of a wake up call, that “wiitwd” (what it is that we do), can tend to limit, in varying degrees, the amount of oxygen that our play partners (the wonderful ticklees) actually may be taking in during the throes of heavy tickle play, and why it is absolutely necessary to carefully observe and allow for the ticklee’s reactions. Each and every person, each and every partnering will present and require differing play styles. It’s up to the players to be aware and adapt to their partner’s play styles.
I enjoy both tickle play as well as other fetish activities, sm play among them. While I do enjoy both with my play partners, I have always regarded “breath play” as “edge play”. There are several in the BDSM world who have written on the risks and cautions involved with breath play, I have chosen to include Jay Wiseman’s articles here as a well known and respected author of scene educational materials. I include Mr. Wiseman’s articles in their entirety, as snipping from them takes away important considerations, and the impact with which he wrote them. Though many of us might want to deny it from time to time, tickling can be just as intense, and just as serious as any “bondage-bdsm” type play, and must be just with the same respect.
Spenser
Thus:
“The Medical Realities of Breath Control Play (This is a copy of an essay that Jay Wiseman has posted many times in internet newsgroups, particularly soc.subculture.bondage-bdsm)
Hi folks,
As many of you know, the subject of breath control play pops up here from time to time, and I often participate in the resultant threads.
I notice that I repeatedly tend to post the same basic information about the physiology of what's involved, and such "re-inventing the wheel" is unnecessary. I have therefore been working on a basic "position paper" of what's involved for some time, and here it is. Assuming that it's factually accurate (and I cordially invite _informed_ challenge on this point), this will become my "boilerplate" statement on the matter.
Given that "any subject can be written about at any length" it has been a distinct challenge to write this article. I have tried to keep it short enough so that people will actually read it, but also make it long enough to cover what I consider are the important points. I have tried to provide relevant physiological and biochemical information, but not go so deeply into detail that the average reader would get lost. I have tried to provide basic "starting point" references for my points and concerns for those who wish to research this matter further on their own (and I certainly encourage such research), but not to provide such an exhaustive list of citations that the researcher would become overwhelmed. Hopefully, my efforts have been at least adequate. My best wishes to all.
Regards,
Jay Wiseman
Copyright issues footnote: I
wrote this article with the hope that it would be widely read and distributed, and without any particular expectation of financial compensation in return for writing it. Therefore, I consent to the following uses of this essay:
1. It's fine with me if you read it.
2. It's fine with me if you send it, in unaltered form and including the foreword, in private e-mail to appropriate others.
3. It's fine with me if you post it, as mentioned in point # 2, to newsgroups and closed mailing lists.
4. If you put it up on a private, no-fee-to-access, website, please put it up as mentioned in point # 2 and include a link to the Greenery Press website (www.bigrock.com/~greenery).
5. I do require that you get my specific prior permission before putting this article up on a pay-to-access website, putting it in a book offered for sale, or otherwise charge for any sort of access to it.
The Medical Realities of Breath Control Play
Copyright 1997 by Jay Wiseman, author of "SM 101: A Realistic Introduction". All rights reserved.
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 something 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 re-polarization 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-threatening 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. (Sorry, but I can't do subscripts in this program.)
Thus: CO2 + H2O 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 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:
"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 www.bigrock.com/~greenery or
write to me at Greenery Press, 3739 Balboa # 195, San Francisco, CA 94121.
Regards,
Jay Wiseman
(The following essay was originally published, if I remember correctly, on the internet newsgroup soc.subculture.bondage-bdsm in May of 1998.)
Breath Control: Is Epinephrine The "Smoking Gun"?
Hi folks,
I want to share a new thought that I've recently had on this topic. I haven't got much time just now, so this will be brief and preliminary, but I think I just may have a new insight on this matter.
There are five basic categories of people who get choked. (I'll skip suffocation play for now.)
1. People being criminally assaulted.
2. People being arrested by the cops.
3. Martial artists.
4. People doing erotic choking on their partner.
5. People doing erotic choking on themselves.
Most of the people in group # 5 seem to die because they pass out while the noose is still constricting their necks.
Let's set aside group number 4 for the moment, and look at groups 1, 2, and 3.
_Lots_ of documented deaths from even brief periods of strangulation in groups 1 and 2. _No_ reported deaths in group number 3. (Actually, one death in group 3, but even I will agree that one was due to a high dose of hubris.)
So what's the difference?
I don't believe that it's the technique, as is sometimes claimed. Indeed, I still think that the technique, even or perhaps especially when done properly, is a major contributing factor.
What is the essence of the difference between situations 1 and 2, and situation 3?
Try this thought out: Situations 1 and 2 are "real" while situation 3 is "play." A person being choked "for real" is likely to have a far different, and far stronger, fear/anger-type emotional response than a person in situation 3.
In particular, a person in a "real" situation such as 1 or 2 is likely to have a much stronger "flight or fight" response than a person in situation 3 -- and that means that they likely pump a lot more epinephrine (aka adrenalin) into their system.
Small doses of epinephrine strengthen the rate and force of cardiac contraction. Large doses of epinephrine also do the above, but also make the heart more susceptible to sudden, lethal arrythmias such as ventricular fibrillation -- and greatly increase its need for oxygen. (This sudden dumping of a large amount of epinephrine onto the heart can and does occasionally stop it. It's a large part of the reason why someone occasionally "dies of fright.")
There are a large number of documented cases of someone dying suddenly from "merely" having a gun pointed at them or having a "real world" criminal assailant "merely" reach their hands towards the victim's neck. No physical contact at all was involved, yet the person went into cardiac arrest almost immediately. It seems to me that such deaths can quite reasonably be called "epinephrine deaths."
We know that a "proper" choke causes a substantial amount of vagal outflow onto the heart, slowing its rate and weakening its force. The question emerges: Is it plausible that the same amount of vagal outflow onto an "epinephrine-drenched" heart (assault/arrest situations) would cause that heart to be considerably more likely to flop over into ventricular fibrillation than a "non-epinehprine-drenched" heart (martial artists)? IMO, hell, yes! The relevant physiology and pharmacology strongly support such an assertion.
Interestingly enough, _IF_ this line of reasoning is correct, then it would follow that SM-related "play" choking would be a relatively safe activity _compared_to_ the more "real" chokings of actual arrests and criminal assaults.
I dunno yet what to make of this, and I certainly wouldn't want anyone to take this as my final word on the subject or as an endorsement of strangulation play. (Among other things, there are a number of other dangers that I haven't mentioned here.) As I said, these are preliminary musings, not carefully thought out statements. Still, on the question of why is there is such a strong disparity in the deaths rates, little ol' Jay just may be on to something here.
Regards,
Jay Wiseman
I enjoy both tickle play as well as other fetish activities, sm play among them. While I do enjoy both with my play partners, I have always regarded “breath play” as “edge play”. There are several in the BDSM world who have written on the risks and cautions involved with breath play, I have chosen to include Jay Wiseman’s articles here as a well known and respected author of scene educational materials. I include Mr. Wiseman’s articles in their entirety, as snipping from them takes away important considerations, and the impact with which he wrote them. Though many of us might want to deny it from time to time, tickling can be just as intense, and just as serious as any “bondage-bdsm” type play, and must be just with the same respect.
Spenser
Thus:
“The Medical Realities of Breath Control Play (This is a copy of an essay that Jay Wiseman has posted many times in internet newsgroups, particularly soc.subculture.bondage-bdsm)
Hi folks,
As many of you know, the subject of breath control play pops up here from time to time, and I often participate in the resultant threads.
I notice that I repeatedly tend to post the same basic information about the physiology of what's involved, and such "re-inventing the wheel" is unnecessary. I have therefore been working on a basic "position paper" of what's involved for some time, and here it is. Assuming that it's factually accurate (and I cordially invite _informed_ challenge on this point), this will become my "boilerplate" statement on the matter.
Given that "any subject can be written about at any length" it has been a distinct challenge to write this article. I have tried to keep it short enough so that people will actually read it, but also make it long enough to cover what I consider are the important points. I have tried to provide relevant physiological and biochemical information, but not go so deeply into detail that the average reader would get lost. I have tried to provide basic "starting point" references for my points and concerns for those who wish to research this matter further on their own (and I certainly encourage such research), but not to provide such an exhaustive list of citations that the researcher would become overwhelmed. Hopefully, my efforts have been at least adequate. My best wishes to all.
Regards,
Jay Wiseman
Copyright issues footnote: I
wrote this article with the hope that it would be widely read and distributed, and without any particular expectation of financial compensation in return for writing it. Therefore, I consent to the following uses of this essay:
1. It's fine with me if you read it.
2. It's fine with me if you send it, in unaltered form and including the foreword, in private e-mail to appropriate others.
3. It's fine with me if you post it, as mentioned in point # 2, to newsgroups and closed mailing lists.
4. If you put it up on a private, no-fee-to-access, website, please put it up as mentioned in point # 2 and include a link to the Greenery Press website (www.bigrock.com/~greenery).
5. I do require that you get my specific prior permission before putting this article up on a pay-to-access website, putting it in a book offered for sale, or otherwise charge for any sort of access to it.
The Medical Realities of Breath Control Play
Copyright 1997 by Jay Wiseman, author of "SM 101: A Realistic Introduction". All rights reserved.
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 something 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 re-polarization 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-threatening 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. (Sorry, but I can't do subscripts in this program.)
Thus: CO2 + H2O 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 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:
"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 www.bigrock.com/~greenery or
write to me at Greenery Press, 3739 Balboa # 195, San Francisco, CA 94121.
Regards,
Jay Wiseman
(The following essay was originally published, if I remember correctly, on the internet newsgroup soc.subculture.bondage-bdsm in May of 1998.)
Breath Control: Is Epinephrine The "Smoking Gun"?
Hi folks,
I want to share a new thought that I've recently had on this topic. I haven't got much time just now, so this will be brief and preliminary, but I think I just may have a new insight on this matter.
There are five basic categories of people who get choked. (I'll skip suffocation play for now.)
1. People being criminally assaulted.
2. People being arrested by the cops.
3. Martial artists.
4. People doing erotic choking on their partner.
5. People doing erotic choking on themselves.
Most of the people in group # 5 seem to die because they pass out while the noose is still constricting their necks.
Let's set aside group number 4 for the moment, and look at groups 1, 2, and 3.
_Lots_ of documented deaths from even brief periods of strangulation in groups 1 and 2. _No_ reported deaths in group number 3. (Actually, one death in group 3, but even I will agree that one was due to a high dose of hubris.)
So what's the difference?
I don't believe that it's the technique, as is sometimes claimed. Indeed, I still think that the technique, even or perhaps especially when done properly, is a major contributing factor.
What is the essence of the difference between situations 1 and 2, and situation 3?
Try this thought out: Situations 1 and 2 are "real" while situation 3 is "play." A person being choked "for real" is likely to have a far different, and far stronger, fear/anger-type emotional response than a person in situation 3.
In particular, a person in a "real" situation such as 1 or 2 is likely to have a much stronger "flight or fight" response than a person in situation 3 -- and that means that they likely pump a lot more epinephrine (aka adrenalin) into their system.
Small doses of epinephrine strengthen the rate and force of cardiac contraction. Large doses of epinephrine also do the above, but also make the heart more susceptible to sudden, lethal arrythmias such as ventricular fibrillation -- and greatly increase its need for oxygen. (This sudden dumping of a large amount of epinephrine onto the heart can and does occasionally stop it. It's a large part of the reason why someone occasionally "dies of fright.")
There are a large number of documented cases of someone dying suddenly from "merely" having a gun pointed at them or having a "real world" criminal assailant "merely" reach their hands towards the victim's neck. No physical contact at all was involved, yet the person went into cardiac arrest almost immediately. It seems to me that such deaths can quite reasonably be called "epinephrine deaths."
We know that a "proper" choke causes a substantial amount of vagal outflow onto the heart, slowing its rate and weakening its force. The question emerges: Is it plausible that the same amount of vagal outflow onto an "epinephrine-drenched" heart (assault/arrest situations) would cause that heart to be considerably more likely to flop over into ventricular fibrillation than a "non-epinehprine-drenched" heart (martial artists)? IMO, hell, yes! The relevant physiology and pharmacology strongly support such an assertion.
Interestingly enough, _IF_ this line of reasoning is correct, then it would follow that SM-related "play" choking would be a relatively safe activity _compared_to_ the more "real" chokings of actual arrests and criminal assaults.
I dunno yet what to make of this, and I certainly wouldn't want anyone to take this as my final word on the subject or as an endorsement of strangulation play. (Among other things, there are a number of other dangers that I haven't mentioned here.) As I said, these are preliminary musings, not carefully thought out statements. Still, on the question of why is there is such a strong disparity in the deaths rates, little ol' Jay just may be on to something here.
Regards,
Jay Wiseman
