Hypoxyphilia was first introduced into the Diagnostic and Statistical Manual in the revision of its third edition and has been included in subsequent editions, always as a subtype of Sexual Masochism. In DSM-IV-TR (American Psychiatric Association, 2000), it is characterized as a “particularly dangerous form of Sexual Masochism [that] involves sexual arousal by oxygen deprivation obtained by means of chest compression, noose, ligature, plastic bag, mask, or chemical.” The behavior is also described in the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organization, 1992), separately from Sadomasochism, under Other Disorders of Sexual Preference, simply as the “use of strangulation or anoxia for intensifying sexual excitement.”

Whether hypoxyphilia should remain a subcategory of Sexual Masochism in DSM-5 or given a place among the specifically named paraphilias is one of the central concerns to be addressed in this report. If it is given a separate identity, a further issue would be the criteria that should be required for the diagnosis.

Background Literature on Hypoxyphilia

Examples of an association between asphyxia and sexual arousal have been described in other cultures and historical periods. The earliest medical reference in English (Ryan, 1836) mentioned examples of asphyxiation “to excite the venereal appetite” and, for a century thereafter, reports in the medical and scientific literature almost exclusively concerned fatalities and the need to distinguish them from suicides and homicides, which they may resemble (Dietz, 1983).

Perhaps surprisingly, Krafft-Ebing (1886) did not refer to hypoxyphilia, or deaths that may result from it, though he described sexual masochism as “the wish to suffer pain and be subjected to force” and “the affected individual, in sexual feeling and thought, is controlled by the idea of being completely and unconditionally subject to the will of a person…of being treated by this person as by a master, humiliated and abused,” though he restricted his description to heterosexuals. Among other pioneers of sexology Ellis (1936) drew attention to the fact that some individuals, often women, may derive sexual pleasure from fantasizing about or actually being strangled. Hirschfeld (1948) also noted that the “motif of strangulation recurs again and again in extreme cases of masochism.”

Since these early descriptions there have appeared only sporadic accounts of living individuals who have asphyxiated themselves to produce sexual arousal, but there has been a steady and increasing stream of articles, and two books, regarding fatalities and mention is nowadays consistently made of these “accidental autoerotic deaths” in textbooks on forensic medicine and pathology (e.g., Dolinak, Matshes, & Lew, 2005; Saukko & Knight, 2004). However, the latter continue to focus essentially on accurate identification and differentiation from suicides and homicides; the underlying sexual behavior is typically given little attention other than to recognize that an unusual sexual predilection is involved.

Evidence found at an autoerotic death scene, and elsewhere among the deceased’s belongings, can usually provide information relevant to sexological diagnosis. Such evidence may include: cross-dressing of the body; clips, clamps, or electrodes on sexually sensitive parts; presence of objects such as dildos, vibrators, broom handles, and so on, in the rectum; ligatures (sometimes in an unusually complex arrangement) extraneous to any asphyxiating mechanism; inhalation of gases, vapors, etc.; whips, paddles, and so on; garments made of plastic, rubber, fur, etc.; and the contents of pornographic magazines, photographs, videos, and personal diaries. Sexual masochism and sadism, fetishism, and transvestic fetishism are thus the most prominent paraphilias represented but other less common ones may also be noted (see, e.g., Blanchard & Hucker, 1991; Hucker & Blanchard, 1992).

More information, especially with respect to sexual fantasies and other sexual activities and interests, can be obtained when a living practitioner is available for interview. Unfortunately, published reports have typically involved single cases or very small samples and provide tantalizingly meager details of the behavior involved though theoretical speculations and treatment suggestions often predominate (Friedrich & Gerber, 1994; Money, Wainwright, & Hingsburger, 1991; Quinn & Tuomey, 1998; Thompson & Beail, 2002; Wesselius & Bally, 1983). Nevertheless, among these reports, evidence of the common associated paraphilias is usually found. As with fatal cases, transvestic and other types of fetishism are commonly described, along with more typical elements of sexual sadism and sexual masochism, with other paraphilias also sometimes mentioned.

Among the small samples of individuals who asphyxiate themselves for sexual purposes, Litman and Swearingen (1972) gained access to nine hypoxyphiliacs through an advertisement in an underground newspaper. van Lunsen (1991) obtained six cases following contacts made after the airing of a television program about the subject. Friedrich and Gerber (1994) described five adolescent males who had been evaluated for other mental health reasons.

In these studies, the rich fantasy lives of living hypoxyphiliacs was described, often in considerable detail. Unambiguous masochistic themes, such as being raped or beaten, humiliated or made to be subservient and obedient to a master, were commonly reported and being in a dangerous situation was described as erotically exciting by others.

Observations from a series of 15 patients who presented to the present author over approximately 30 years of clinical practice are in accord with the above findings (Hucker, unpublished data). Clearly, masochistic themes were present in all the cases (being raped, physically abused or humiliated). Being in a risky or perilous situation was a recurrent fantasy in three cases; sadistic themes were represented in seven and autogynephilic fantasies in three others. One described being sexually aroused by thinking about choking and another of being “totally helpless.” For most, being choked, strangled or suffocated was a particularly potent stimulus for their sexual arousal.

With the advent of the Internet, a new avenue for exploring sexually anomalous behavior and interests has become available. Though there are limitations to this method, it has enabled researchers to gain confidential access to individuals who likely would not otherwise have been interviewed (Kim & Bailey, 1997). I conducted a study of living hypoxyphiliacs using a website (autoeroticasphyxia.ca) set up specifically for this purpose. During the course of one year, over 130 individuals responded by completing an online questionnaire. Excluding those who did not complete the questionnaire properly and those that were apparently not hypoxyphiliacs (despite completing the questionnaire), 115 were accepted. In addition to completing the questionnaire (which provided opportunities to add further information), several respondents contributed very detailed descriptions of their behavior, sexual interests, and fantasies. No other source provides similar information on such a large group of self-identified hypoxyphiliacs.

The sample comprised 91 men and 24 women. The proportion of women contrasts with the study of fatalities already mentioned (Blanchard & Hucker, 1991) in which there was only one woman. The rarity of women among fatalities has been repeatedly noted (Behrendt, Buhl, & Seidl, 2002; Byard, Hucker, & Hazelwood, 1990). Fifty-four percent of the sample were married or living common-law. Fifty-five percent were heterosexual, almost 7% homosexual, and 32% bisexual, with 5% unsure of their sexual orientation. Seventy-five percent reported using bondage during asphyxiation or at other times, 44% used clips or clamps, 37% reported transvestic fetishism, 17% used electrical stimulation, 64% reported various fetishes, and 35% used flagellation. Seventy-one percent viewed themselves to be masochistic and 36% as sadistic (some endorsed both behaviors). A number of other sexually anomalous behaviors were also reported. Once again, the overlap with transvestic fetishism, bondage, and fetishism was consistent with the published literature. However, a statistical analysis of data from this sample found no support for the suggestion that hypoxyphilia be assigned a category separate from other types of masochistic behavior.

In recent studies of Sexual Masochism based both on clinical samples (Freund, Seto, & Kuban, 1995) and consensual S & M practitioners (Alison, Santtila, Sandnabba, & Nordling, 2001), hypoxyphilia was represented in about 15% of the subjects, further suggesting that it belongs naturally among the wide variety of masochistic behaviors.

Sadomasochistically inclined individuals, especially members of social clubs catering to their sexual interests, appear to be generally high functioning and successful people who mostly do not regard themselves as mentally disordered and only a minority engaged in behavior likely to result in serious harm (Moser & Levitt, 1987; Sandnabba, Santtila, & Nordling, 1999; Santtila, Sandnabba, Alison, & Nordling, 2002; Williams, 2006). On the other hand, there are individuals who have received from a partner, or inflicted upon themselves, physical injuries (including asphyxiation) sufficient to justify hospital treatment or that have resulted in death (Hucker, 1985).

Conclusions and Recommendations

  1. 1.

    The diagnostic criteria for Sexual Masochism that are currently laid out in DSM-IV-TR (American Psychiatric Association, 2000) include the presence of fantasies, urges or real (not simulated) behaviors involving “being humiliated, beaten, bound, or otherwise made to suffer” (p. 573). Hypoxyphilia is identified in the accompanying text as a “particularly dangerous form of sexual masochism …[that] involves sexual arousal by oxygen deprivation” (p. 572).

    However, from the literature and my own clinical experience and investigations concerning motivations for self-strangulation, suffocation, etc., it is not clear that the sexual arousal is, in fact, the result of oxygen deprivation (hypoxia) as such. Rather, it appears that these individuals primarily obtain sexual arousal by restricting their breathing, which secondarily results in the subjective experiences of oxygen lack. The term “asphyxiophilia” is the recommended alternative term, as it better reflects this main motivation and has already entered the professional literature (Money, 1986).

  2. 2.

    Asphyxiophilia, though its essence can be clearly defined, does not appear from the available research to be sufficiently distinct from other types of masochistic behavior to justify being given a separate category or code with its own diagnostic criteria in DSM-5.

  3. 3.

    The behavior is however sufficiently well known, both because of its unusual nature and the potential to result in a well-recognized mode of accidental death, that it is worthy of continued inclusion, by name, under the general rubric of Sexual Masochism. Behaviors referred to as electrophilia and anaesthesiophilia (Seidl, 2004) could also be mentioned by name under this category. The criteria for Sexual Masochism might also use specifiers (as is currently the case with pedophilia), namely asphyxiophilia, electrophilia, anaesthesiophilia, bondage, etc. For example: Sexual Masochism, asphyxiophilia and bondage, non-exclusive type (i.e., also involved in conventional sexual activities).

  4. 4.

    The arguments for and against the removal of paraphilias entirely from the DSM are well known (e.g., Moser & Kleinplatz, 2005). It does appear that most self-identified sadomasochists, who have been surveyed through clubs, internet sites, etc., are high functioning and successful individuals who otherwise show no psychopathology. It is recommended that masochistic behaviors that potentially entail physical harm or death be identified as “Dangerous Masochism” (Freund, unpublished) and that the less extreme varieties be relieved of the stigma of mental disorder.