Prevalence of Sexual Strangulation/Choking Among Australian 18-35 Year-Olds.

In Australia, strangulation has been explicitly criminalized in all states and territories. However, it continues to be a "normalized" sexual practice despite its potentially fatal consequences and associated short and long-term sequelae. This research aimed to establish the prevalence of strangulation during sex and examine predictors of positive perceptions toward sexual strangulation in Australia. Confidential, cross-sectional online surveys were conducted with 4702 Australians aged 18-35 years. Participants were 47% cis-men, 48% cis-women, and 4% trans or gender diverse. A total of 57% reported ever being sexually strangled (61% women, 43% men, 79% trans or gender diverse) and 51% reported ever strangling a partner (40% women, 59% men, 74% trans or gender diverse). Differences were found across genders on all variables of sexual strangulation, including frequency of engagement, level of pressure on the neck, consequences, wanting and enjoyment, and how consent was given/received. However, when split by gender, sexual orientation of men and women revealed further differences in behaviors, consequences, and wanting, particularly among straight and bisexual women. After accounting for exposure to strangulation in pornography and previous experience of sexual strangulation, positive perceptions of being strangled (R2 = .51) and strangling a partner (R2 = .53) were predicted by ratings that it could be done safely and social normative factors. These findings suggest strangulation is common during sex among young Australians. Non-stigmatizing education strategies are needed to engage with young people so they have a better understanding of the risks involved and how to negotiate consent and safety regarding sexual strangulation.

#ChokeMeDaddy: A Content Analysis of Memes Related to Choking/Strangulation During Sex.

Recent research indicates that some young people initially learn about sexual choking through Internet memes. Thus, a qualitative content analysis was performed on 316 visual and textual memes collected from various social media websites and online searches to assess salient categories related to choking during sex. We identified nine main categories: communication, gendered dynamics, choking as dangerous, choking as sexy, sexualization of the nonsexual, shame and worry, romance/rough sex juxtaposition, choking and religious references, instructional/informational. Given that memes, through their humor, can make difficult topics more palatable and minimize potential harm in the phenomenon they depict, more concerted, synergistic effort that integrates media literacy into sexuality education programming on the potential risks that may ensue for those engaging in sexual choking is warranted.

Fatal Choking Due to a Slug: A Death Driven by Folklore.

The use of animals for therapeutic purposes is based on traditional beliefs, family pressure, and watching others appear to be cured. We report an unusual case of a 47-y-old man who choked to death after consuming a live slug. During autopsy, a 9.5-cm slug was found impacted in the tracheobronchial tree. History provided by the family revealed that the deceased consumed slugs in the belief that this would relieve his symptoms of chronic arthritis. We report this rare case to highlight the possible ill effects of such practices.

Mealtime difficulties in adults with mental health conditions: an integrative review.

BACKGROUND: Dysphagia and choking are highly prevalent in adults with mental health conditions. However, there is scant research considering the personal experience of dysphagia for this population. AIMS: To understand the evidence-base for strategies to involve the patient in recognition, assessment and treatment of mealtime difficulties. METHODS: This integrative review synthesised the literature on the experience of dysphagia in patients with mental health conditions. Patient consultation led to co-designed search terms and eligibility criteria for a systematic search of five scientific databases following Prisma guidance. Quality assessment of the eligible studies and reflexive thematic analysis were completed. RESULTS: 31 studies were included for review. These included case reports, literature reviews and cross-sectional studies. Quality of evidence was weak and no intervention studies were identified. There was scant detail regarding the personal experience of dysphagia or choking. Themes identified related to biomedical perspectives, influencing factors presented without context, and decision-making led by clinicians. CONCLUSIONS: Guidance on mental healthcare calls attention to under-diagnosis of physical co-morbidities and advocates patient inclusion. However, the patient voice in this population is rarely described regarding dysphagia. Further inclusive research is indicated to explore the impact of dysphagia and choking, and implications for interventions and outcome measures.

Did Jesus Die by Suffocation?: An Appraisal of the Evidence.

A majority of medical and lay articles regarding crucifixion, and specifically the crucifixion of Jesus Christ, now state that suffocation was the primary cause of death from crucifixion. An in-depth analysis reveals that this theory is based on a form of torture unrelated to crucifixion and that no evidence directly linking suffocation to crucifixion has been published. Indeed, a thorough review of available ancient evidence from literature, artwork, graffiti, and modern archeology and re-enactment studies reveals no evidence in favor of suffocation and much evidence against suffocation as the cause of death in typically-portrayed crucifixions, and particularly for the crucifixion of Jesus Christ. Researchers are encouraged to look elsewhere for the most likely cause or causes of death from crucifixion. It may be time to abandon the idea that suffocation was the primary cause of death in crucifixion.

How safe is BDSM? A literature review on fatal outcome in BDSM play.

A noteworthy number of people are interested in BDSM (bondage and discipline, dominance and submission, sadism, and masochism). Fatal outcomes while participating in BDSM activities occur. The aim of this literature review is to give a better insight into potential dangerous BDSM play by summarizing published data on BDSM fatalities. A literature search was conducted. It was searched for non-natural death related to BDSM activity. Seventeen cases were found. The age of the deceased ranged between 23 and 49 years (mean age 34.9 years). Strangulation in the course of erotic asphyxiation was the most common cause of death (88.2%). In 13 cases, a toxicology report for the deceased was mentioned, of which in eight cases (61.5%) toxicology analysis was positive. In four of these cases, the BDSM partner was also tested positive with the same substance. Drugs or alcohol was involved in 64.3% of fatal BDSM play. In nine cases, the level of experience in BDMS activity of the deceased and the partner was described, and in all of them, the deceased and the partner were not new to BDSM play. Fatal outcomes of BDSM plays are rarer than autoerotic fatalities and natural deaths related to sexual activities. Safeguards and education on medical aspects exist in the BDSM communities. If they are followed by the practitioners, the risks of BDMS play can be reduced. Cases of non-natural death connected to BDSM are rare incidents and can be prevented.

Acute or chronic pulmonary emphysema? Or both?-A contribution to the diagnosis of death due to violent asphyxiation in cases with pre-existing chronic emphysema.

The diagnosis of death due to violent asphyxiation may be challenging if external injuries are missing, and a typical acute emphysema (AE) "disappears" in pre-existing chronic emphysema (CE). Eighty-four autopsy cases were systematically investigated to identify a (histo-) morphological or immunohistochemical marker combination that enables the diagnosis of violent asphyxiation in cases with a pre-existing CE ("AE in CE"). The cases comprised four diagnostic groups, namely "AE", "CE", "acute and chronic emphysema (AE + CE)", and "no emphysema (NE)". Samples from all pulmonary lobes were investigated by conventional histological methods as well as with the immunohistochemical markers Aquaporin 5 (AQP-5) and Surfactant protein A1 (SP-A). Particular attention was paid to alveolar septum ends ("dead-ends") suspected as rupture spots, which were additionally analyzed by transmission electron microscopy. The findings in the four diagnostic groups were compared using multivariate analysis and 1-way ANOVA analysis. All morphological findings were found in all four groups. Based on histological and macroscopic findings, a multivariate analysis was able to predict the correct diagnosis "AE + CE" with a probability of 50%, and the diagnoses "AE" and "CE" with a probability of 86% each. Three types of "dead-ends" could be differentiated. One type ("fringed ends") was observed significantly more frequently in AE. The immunohistochemical markers AQP-5 and SP-A did not show significant differences among the examined groups. Though a reliable identification of AE in CE could not be achieved using the examined parameters, our findings suggest that considering many different findings from the macroscopical, histomorphological, and molecular level by multivariate analysis is an approach that should be followed.

Self-ligature strangulation by multiple cable ties.

This article reports an autopsy of a 39-year-old deceased male who had done suicidal strangulation using multiple self-locking cable ties. The deceased used seven ligatures, constricting at a different level around the neck to accomplish the suicidal strangulation. Each ligature was made up of two cable ties attached to each other. The detailed autopsy examination and crime scene investigation confirm the manner of strangulation as suicidal. Suicidal strangulation is uncommon but not rare. Varying ligature materials and different locking methods were used for this purpose. The present case is remarkable because of the use of multiple self-locking zip cable ties as ligature material.

Diverse Sexual Behaviors in Undergraduate Students: Findings From a Campus Probability Survey.

BACKGROUND: Probability-based surveys of college students typically assess sexual behaviors such as oral, vaginal, and anal sex. Little is known about the broader range of sexual behaviors in which students engage. AIMS: In a random sample survey of undergraduate students, we aimed to: (1) describe how recently participants had engaged in solo and partnered sexual behaviors, (2) examine how frequently participants enacted certain rough sex sexual behaviors (e.g., light spanking, hard spanking, choking, slapping, and others), (3) assess participants' frequency of experiencing certain rough sex behaviors, (4) describe participants' frequency of threesome/group sex, (5) assess the characteristics of participants' experiences with choking during sex; and (6) examine choking and face slapping in regard to consent. METHODS: A confidential, online cross-sectional survey of 4,989 randomly sampled undergraduate students at a large U.S. university. OUTCOMES: Participants reported having engaged in a broad range of solo and partnered sexual activities, including rough sex behaviors. RESULTS: The most prevalent general sexual behaviors were solo masturbation (88.6%), oral sex (79.4% received, 78.4% performed), penile-vaginal intercourse (73.5%), and partnered masturbation (71.1%). Anal intercourse was the least prevalent of these behaviors (16.8% received, 25.3% performed). Among those with any partnered sexual experience, 43.0% had choked a partner, 47.3% had been choked, 59.1% had been lightly spanked and 12.1% had been slapped on the face during sex. CLINICAL TRANSLATION: College health clinicians and educators need to be aware of the diverse and evolving range of solo and partnered sexual behaviors reported by students. In addition to counseling students about pregnancy and sexually transmitted infection risk, clinicians might assess patients' engagement in diverse sexual behaviors, such as choking/strangulation during sex, given the risk for serious outcomes including death. STRENGTHS AND LIMITATIONS: Strengths of our research include the large sample size, use of random sampling, high response rate for college populations, broad range of behaviors assessed, and novel data on choking during sex. Among our limitations, we did not assess to what extent the experiences were wanted, pleasurable, or appealing to participants. Except for in relation to choking and slapping, we also did not assess issues of consent. CONCLUSION: Participants reported engaging in diverse sexual behaviors, some of which have important clinical implications, are understudied, and warrant further research. Herbenick D, Patterson C, Beckmeyer J, et al. Diverse Sexual Behaviors in Undergraduate Students: Findings From a Campus Probability Survey. J Sex Med 2021;18:1024-1041.

Hanging disguised as bondage: accidental or suicidal death?

The concept of autoerotic asphyxiation refers to the use of devices or substances intended to enhance one's arousal by inducing cerebral hypoxia, which can involuntarily lead to death. Although in most cases death occurs accidentally, it is nonetheless true that the same devices might be used by the practitioners in order to attempt suicide. The case of a 34-year-old practitioner of autoerotic asphyxiation found dead in his apartment with bondage-like ligatures and masking is reported here. The case raised some issues concerning the accidental or suicidal nature of the act. The aspects taken into account in the management of the case are discussed, along with a compared approach to the data provided by literature.

Neck injury and conjunctival petechiae in a woman who underwent cardiopulmonary resuscitation and subsequently died from meningococcal sepsis.

Cardiopulmonary resuscitation (CPR) can create a range of unusual lesions and injuries, which may complicate forensic evaluation. Although potentially sinister findings, neck injury and conjunctival petechiae may also be seen in patients who have undergone CPR. We report a case of an individual with subcutaneous bruising and hemorrhage in the deep structures of the neck and florid conjunctival petechiae at autopsy that can be explained by cardiopulmonary resuscitation and meningococcal sepsis.

Lung transplantation following death by drowning: a review of the current literature.

While multiple donor characteristics have been cited as ideal for lung transplantation, there are minimal widely accepted exclusion criteria. One criterion that many centers view with hesitation is death by drowning. However, recent literature suggests such donors may result in acceptable outcomes following transplantation. This review highlights a case of a patient who underwent a successful bilateral lung transplant from a donor following a drowning event. A review of the current literature is presented, concluding with a new proposed set of favorable donor criteria following death by drowning.

Manual and instrument asphyxiation/strangulation: Examining perpetrator and victim characteristics.

Asphyxiation and strangulation are predominant murder methods, with ligature and hands being common weapons in such attacks. This study examines a broad sample with the goal of establishing statistical significance between manual and instrument asphyxiation/strangulation and both victim and offender characteristics. Two hundred cases of perpetrators who strangled or asphyxiated at least one victim on or after 1970 were randomly selected from the Radford-FGCU Serial Killer Database. Descriptive analysis and association tests were performed for characteristics of the perpetrators, victims and crimes. In 68% of the cases, perpetrators only targeted women. The primary murder motives were sadism (36%) and intense emotions (22%), which were statistically associated with the perpetrators' relationship with their victims, serial killing and motive of asphyxiation. There was a relationship between the perpetrators' favoring the use of manual or ligature strangulation/asphyxiation and their ethnicity, prior history of abuse and the victims' racial/ethnic group. Findings highlight the variety of contexts in which strangulation takes place, ranging from sexually or sadism motivated homicide and intimate partner violence. Moreover, the predominance of manual or ligature asphyxiation/strangulation among different racial/ethnic groups may have implications in legal processes, as well as in risk and threat assessments.

Delayed respiratory distress after thyroidectomy-another challenge for us: a case report.

Background: Delayed airway obstruction and the resulting severe dyspnea with acute distress are rare but life-threatening postoperative thyroidectomy complications. Unfortunately, if not adequately attended to on time, they could cost a patient's life. Case Description: A 47-year-old female patient who underwent thyroidectomy was left at the end of surgery with a tracheostomy, because of tracheomalacia and recurrent laryngeal nerve injury. Within the next ten days, her health condition gradually worsened. She complained of unexpected symptoms of shortness of breath, airway compromize and neck inflammation even with the existing tracheostomy tube. In face of new onset dyspnea, without giving proper attention to the postoperative course of this complicated patient, the consulting otorhinolaryngologist decided to decannulate the patient on the sixth postoperative day. This precipitated the presentation of an extensive neck infection with resultant total bilateral vocal fold immobility, followed by life-threatening airway obstruction, due to an unintentionally forgotten gauze in peritracheal space during thyroidectomy. In critical condition, the patient was successfully intubated with Rapid Sequence Induction, which enabled ventilation, oxygenation and saved the patient's life. After definitively securing the airway, she underwent tracheostomy with tracheal re-cannulation. After a prolonged antimicrobial course and achieving voice rehabilitation, the patient was decannulated. Conclusions: Post thyroidectomy dyspnea is possible even with tracheostomy in place. The decision-making in the management of a thyroidectomy patient is of paramount importance not only intraoperatively, but also in the postoperative period and the gland surgeon expertise is of supreme value for avoiding life-threatening complications. In case of postoperative complaints, the patient should be referred first to the gland surgeon and only thereafter to other medical consultants. Disregarding a variety of factors like patient characteristics, risk factors and comorbidity, available diagnostic tools and specific recovery profile could cost the patient's life.

Homicidal burial - Forensic issues.

A young woman was buried in a sitting position in sandy soil in a shallow grave. PMCT showed filling of the upper airways with radio-opaque material consistent with soil, with autopsy dissection confirming the presence of soil in the mouth, pharynx, upper oesophagus, larynx, trachea and main bronchi. Death was due to upper airway occlusion by soil. Live burial as a type of homicide is extremely rare. Issues that need to be clarified include whether the victim was alive at the time of burial, the level of consciousness/awareness of the process, whether restraints or drugs were used and the speed with which death occurred. Possible mechanisms of death include smothering, choking and positional/compression asphyxia.

Effects on oral tissues of asphyxiation caused by cervical compression: The pink teeth phenomenon in Kato's studies (1941).

The effects on oral tissues of asphyxiation caused by cervical compression were investigated in 203 rabbits by Kiyotoshi Kato, who published four papers in classical Japanese in Kokubyo Gakkai Zasshi (now The Journal of the Stomatological Society, Japan) in 1941. The aim of this review is to summarize and disseminate the enormous amount of experimental data (reprint permission in English has been obtained from the journal). Based on the experimental models of hanging, strangulation with an external force equal to body weight, and strangulation with an external force equal to 1/10th body weight, the macroscopic and histological findings of the oral region immediately after death, including the respiratory condition until death and ocular conjunctival petechiae, were obtained and compared with 4 cases of human strangulation. Strangulation after each of four physical conditions (anesthesia, starvation, alcohol intake, and bleeding) was also investigated. Experiments were performed to investigate the effects of tracheal obstruction, cervical vein ligation, common carotid artery ligation, cervical nerve amputation, or combinations thereof. In the discussion focusing solely on tooth discoloration, it was suggested that the presence of pink teeth at a stage when putrefaction has little or no effect might be a finding indicative of death from asphyxiation caused by cervical compression. This review provides detailed data on the condition of oral tissues after asphyxiation caused by cervical compression and is expected to be used not only for elucidating the mechanism of the pink teeth phenomenon but also for conducting other forensic research.

Structural brain morphology in young adult women who have been choked/strangled during sex: A whole-brain surface morphometry study.

INTRODUCTION: Being choked/strangled during partnered sex is an emerging sexual behavior, particularly prevalent among young adult women. Using a multiparameter morphometric imaging approach, we aimed to characterize neuroanatomical differences between young adult women (18-30 years old) who were exposed to frequent sexual choking and their choking naïve controls. METHODS: This cross-sectional study consisted of two groups (choking [≥4 times in the past 30 days] vs. choking-naïve group). Participants who reported being choked four or more times during sex in the past 30 days were enrolled in the choking group, whereas those without were assigned to the choking naïve group. High-resolution anatomical magnetic resonance imaging (MRI) data were analyzed using both volumetric features (cortical thickness) and geometric features (fractal dimensionality, gyrification, sulcal depth). RESULTS: Forty-one participants (choking n = 20; choking-naïve n = 21) contributed to the final analysis. The choking group showed significantly increased cortical thickness across multiple regions (e.g., fusiform, lateral occipital, lingual gyri) compared to the choking-naïve group. Widespread reductions of the gyrification were observed in the choking group as opposed to the choking-naïve group. However, there was no group difference in sulcal depth. The fractal dimensionality showed bi-directional results, where the choking group exhibited increased dimensionality in areas including the postcentral gyrus, insula, and fusiform, whereas decreased dimensionality was observed in the bilateral superior frontal gyrus and pericalcarine cortex. CONCLUSION: These data in cortical morphology suggest that sexual choking events may be associated with neuroanatomical alteration. A longitudinal study with multimodal assessment is needed to better understand the temporal ordering of sexual choking and neurological outcomes.

Heads or tails first? Evolution of fetal orientation in ichthyosaurs, with a scrutiny of the prevailing hypothesis.

According to a longstanding paradigm, aquatic amniotes, including the Mesozoic marine reptile group Ichthyopterygia, give birth tail-first because head-first birth leads to increased asphyxiation risk of the fetus in the aquatic environment. Here, we draw upon published and original evidence to test two hypotheses: (1) Ichthyosaurs inherited viviparity from a terrestrial ancestor. (2) Asphyxiation risk is the main reason aquatic amniotes give birth tail-first. From the fossil evidence, we conclude that head-first birth is more prevalent in Ichthyopterygia than previously recognized and that a preference for tail-first birth likely arose in derived forms. This weakens the support for the terrestrial ancestry of viviparity in Ichthyopterygia. Our survey of extant viviparous amniotes indicates that fetal orientation at birth reflects a broad diversity of factors unrelated to aquatic vs. terrestrial habitat, further undermining the asphyxiation hypothesis. We propose that birth preference is based on parturitional mechanics or carrying efficiency rather than habitat.

Medical line entanglement: The unspoken patient safety hazard of medical devices.

BACKGROUND: In February 2022, the US Food and Drug Administration published a safety communication regarding the risk of strangulation from enteral feeding delivery sets. When it comes to the causes of accidental strangulation or asphyxiation, it is common knowledge that household items, such as window blind cords, are potential hazards. However, many people may not expect that medical devices may pose similar risks because of medical line entanglement (MLE). METHODS: A survey of clinicians from pediatric acute care and outpatient facilities and caregivers of patients with medical lines was conducted with a goal to understand if clinicians and caregivers are aware of MLE, if healthcare facilities have policies and procedures related to the prevention of MLE, and if education about the risks of MLE is provided to caregivers when they first receive a medical device. RESULTS: The survey was shared through clinician organizations and patient advocacy groups. Responses were received from 191 clinicians and 117 caregivers. A majority of clinicians reported awareness of the risk of entanglement; however, few received direction from their employer on managing these risks. Caregivers (N = 106) reported that their child had experienced MLE, however only 9% of those caregivers recalled receiving any education on MLE from their healthcare providers. CONCLUSION: This survey demonstrates the need for healthcare facilities to develop programs for managing risks of MLE and for healthcare teams and caregivers to discuss prevention methods whenever an at-risk patient is sent home with a medical device that poses a risk for entanglement.