Descriptions available in BDSM literature of the risks involved in engaging in breath control play are contradictory. Similarly, more scientific sources tend to neglect various details and aspects relevant to our interest. Thus, for the purposes of our investigation, we shall make use of a considerable amount of more pertinent and useful information drawn from juridical medicine (victims of violent crime/assault and autoerotic accidents), sport medicine (strangleholds in martial sport disciplines) and diving. Hardly any of these sources is 100 percent applicable to our particular situation and it can only be reiterated that there are in actual fact no really reliable data for some aspects of our subject.
Some of what is written on this page may not be that easy to understand. However, anyone who intends to play around with the life-supporting functions of his/her partner's body is urged to take a bit of time to read the text through carefully and to refer to a few medical terms in the glossary [not yet translated].
The carotid-sinus reflex is often described as the only or the most significant danger of breath control play. Actually, fatalities in autoerotic practices occur mostly as a result of too great a pressure applied to the arteries.
The carotid-sinus reflex is triggered at the application of pressure on the carotid artery in the area of the carotid bifurcation (the bifurcation is easily recognised in the diagram. The thick pipe, which parts into two, is the carotid artery; the long thin strands are nerves. The thin short strands are further carotid branches. The long nerve which runs parallel to the carotid is called the 'vagus' and shall be discussed further later on. None of this is to be confused with the neck veins which can often be seen protruding through the skin these are in this instance irrelevant to our investigation).
Sensors situated at this bifurcation monitor the body's blood pressure. In the event of a severe blow or external pressure being applied to the area of these sensors, they immediately lower the blood pressure and reduce the pulse, falsly interpreting the raised local blood pressure as applying to the whole body. For individuals with a hyperactive carotid-sinus reflex, the so-called carotid-sinus syndrome can cause momentary unconsciousness and even a brief cardiac arrest. Such individuals can trigger these effects of the carotid-sinus syndrome simply by wearing a tight necklace, a tight collar or by turning their head.
A synopsis of the carotid-pressure experiment [in German] with an electrocardiogram depicting the triggered cardiac arrest.
The recorded (incidentally anything other than numerous) fatalities seem to have resulted from strikes or kicks to the side of the neck; listed in "Zum traumatischen Karotissinus-Reflextod" ("Lethal Outcomes of Traumatic Carotid-Sinus Reflex") are following examples: kick of a cows hoof to the left side of the neck / a fall onto the floor with neck being struck against the back of a chair / Karate chop against the neck / strikes made to the neck, upper body etc. with a walking stick. We find the following:
"If the external pressure applied to the neck and the carotid-sinus is no more than negligible, cardiac activity will as rule slow down throughout the duration of the pressure applied. Afterwards the regulatory system recovers its original levels and cardiac activity re-adjusts itself. By contrast, injuries to the carotid artery wall, as well as intra-mural bleeding, constitute a lasting stimulation of the nerve receptors which persists throughout and beyond the actual moment of traumatisation even though external mechanical pressure and its immediate effects may have ceased. The post-traumatic and persistent stimulation of the pressure receptors therefore appears to be crucial to the perpetuation of the reflexive action and prevents thereby the spontaneous recovery from the reflexively triggered bradycardia (asystole) or periphal vasodilation with circulatory failure, making death the immediate consequence." (SMZ89)
In "Kann ein Griff an den Hals zum reflektorischen Herztod führen?" ("Can pressure applied to the neck cause a reflex leading to cardiac death?") we find:
"Although a hypersensitive carotid-sinus constitutes a pre-condition for carotid-sinus syndrome, this does not necessarily mean that individuals with hypersensitive carotid-sinus are actually susceptible to the syndrome. Investigations carried out by various authors [ ] have shown that the carotid-sinus reflex becomes more sensitive after the age of 35 and that asystole caused by pressure applied to the carotid-sinus are more likely to occur at 60 years and thereafter; during the course of these authors' investigations, which involved conducting pressure experiments on approx. 8000 individuals between 15 and 95 years of age, there was not one single fatality that may have occurred as a consequence of pressure simulation applied to the carotid-sinus, even though some at risk patients did participate in the experiment. Drawing on the results of his pressure testing experiments on 3507 individuals, of whom 9% were found to have hyper-active sinus reflexes, Franke (1963) comments that from the age of 40 the pathological responsiveness of the carotid-sinus reflex increases in proportion with increasing age. Arteriosclerosis is assumed to be the reason for this connection with ageing." (KU+90)
The authors draw the following conclusion:
"In an actual case, i.e. after pressure is applied to the neck for a short time without apparent injury or petechiae, how is one to answer questions relating to any perceived threat to life? We believe that none of the casuistry which has hitherto characterised the literature on this subject is suitable for the purpose of substantiating with incontestable certainty (necessary for reaching a criminal verdict) the possibility of death occurring as a result of fatal over-stimulation (ie. pressure applied to the neck) of the carotid-reflex. It is therefore highly likely, if not absolutely certain, that such considerations will be ruled out anyway in the case of individuals who do not show any pre-disposition for a hyper-active carotid-sinus reflex as discussed earlier. Even in the case of individuals who do demonstrate such a pre-disposition, the probability of death resulting from the carotid-reflex remains extremely remote." (KU+90)
More details: "Kann ein Griff an den Hals zum reflektorischen Herztod führen?" in a slightly condensed form [in German].
Jay Wiseman (in Wisb and Wisc) turns his attention to the fact that there are no fatalities recorded in connection with martial sport disciplines in which it is common to apply pressure to the carotid arteries (in contrast to the numerous fatalities resulting from the strangleholds used by the police, refer also to Oxygen Deprivation (Anoxaemia) and the Heart and "Deaths Occurring Following the Application of Choke or Carotid Holds"). According to his theory, less catecholamines (diverse stress hormones which influence the function of the heart unfavourably) are released in situations where the victim knows that there is no real danger. His concluding remarks are as follows:
"Exactly what the implications of my hypothesis are for BDSM are not yet clear. Given that I know people who went to prison after their partners died during breath control scenes, I'm certainly not willing to send out a "never mind" message. Plus there are still the issues around a number of related dangers such as strangulation-induced seizures and aspiration. (...)
However, given that BDSM play -- because, again, it is not real in the way that "real" torture is - is closer to the "martial arts" population than the 'assault/arrest' population, there is some reason to (very cautiously) suggest that the risk level would be more comparable to the martial arts population than to the assault/arrest population." (Wisb)
In "Obstructive Asphyxia in Martial Disciplines" we find the following
"A literature search in the field of sports medicine [ ] did not yield one single case of a fatality occurring during the practice of a martial discipline which could be identified as a result of the vagus reflex or the stimulation of the carotid-sinus. Such occurrences are thus at least extremely rare. We are of the opinion that the risk of sudden death of natural cause during the practice of such a sport as judo is much greater than the risk of death resulting from obstructive asphyxiation. [ ]" (MD90)
Die Autoren schlussfolgern:
"Diese Feststellung einer geringen Gefährlichkeit der obstruktiven Asphyxie in der Sportpraxis steht nur scheinbar im Widerspruch zur nicht unerheblichen Gefährlichkeit der obstruktiven Asphyxie in Deliktfällen (...), da hier andere Voraussetzungen gegeben sind. Im Sport sind Sorgfalt des Angreifers, Schutz durch das Reglement, dosierter Krafteinsatz, sofortiges Abbrechen des Angriffs bei Bewußtlosigkeit, eine gute physische Verfassung des Opfers sowie annähernde Kräftegleichheit vorauszusetzen. Bei Straftaten entfällt ein Reglement, die Täter sind nahezu immer den Opfern - zumeist Frauen und Kindern (...) - um ein Vielfaches körperlich überlegen und führen den Angriff mit maximalem Krafteinsatz aus. Hinzu treten eine allfällige Vorschädigung des Opfers (z.B. hohes Lebensalter, schwere kardiovaskuläre Erkrankungen) und toxische Einflüsse (starke Alkoholisierung, Drogen). Der wesentlichste Faktor für den tödlichen Ausgang ist aber unter Berücksichtigung der Erfahrungen in den Kampfsportarten zweifellos die Fortsetzung des Angriffs, also die lange Zeitdauer der obstruktiven Asphyxie, oftmals über mehrere Minuten." (MD90)
SM-Praktiken dürften hier eindeutig in die Kategorie der Sportpraxis einzuordnen sein - abgesehen vielleicht von der "guten physischen Verfassung des Opfers", auf die diese tunlichst selbst achten sollte.
Di Maio and Di Maio also clearly reject the possibility of a healthy individual dying suddenly through carotid-sinus causes in "Forensic Pathology", incidentally one of the few works listed by Jay Wiseman in (Wisa).
"Some articles refer to cases of stimulation of the carotid sinus that have allegedly produced bradycardia, progressing to cardiac arrest and death. Review of the original case reports almost invariably indicates these individuals to be suffering from some severe disease that in itself is capable of causing sudden death." (DiM89)
"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-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." (Wisa)
Information relating to specific cardiac problems which can arise from a combination of several physiological mechanisms can be found here in an excerpt from "Death Following the Application of Choke or Carotid Holds" (DiM89).
Although breath control play and the use of Viagra do not necessarily have to be mutually exclusive, a situation in which the taking of Viagra becomes a matter of necessity can also indicate that breath control play is not advisable: "Erectile dysfunction, ie. the inability to have or sustain an erection, can be the first sign of a more general vascular disease and thus also be an indicator of circulatory problems in the heart. Two small-scale investigations showed that 16-59% of patients who consulted their physician in relation to erectile dysfunction also suffered from an hitherto undetected coronary disease." (VuH)
A local lack of oxygen in the brain is generally the cause of death in hangings (refer also to Background: Theories & Explanations: Hanging [not yet translated]). According to the type of noose used and the way in which it is positioned, the carotid arteries close at a pressure weighing 3.5 to 5 kilogramms. The vertebral arteries, in a less vunerable area, close anywhere between 15 to 30 kilogramms. They cannot, however, ensure that sufficient oxygen reaches the brain.
Lack of oxygen to the brain can cause mild euphoria and, during sex, it can assist in achieving climaxes more quickly and can generally enhance and intensify the experience of orgasm. Although often dismissed by researchers as the dubious practice of 'certain individuals', we are in fact dealing with a general physiological mechanism. It would seem that statements of disapproval are a means of preventing people from throwing aside the journal of forensic medicine and rushing to the laboratory in order to perform experiments of their own. Lack of oxygen to the brain can also be the cause of euphoric and reckless behaviour in high altitudes or while diving. This euphoria is desirable for our purpose; playing alone, however, any impairment to our powers of judgement can lead to fatal consequences.
Cutting off the blood supply to the brain completely by pressing the arteries in the neck leads within seconds to unconsciousness; after three minutes at the most irreversible damage to the brain will ensue. Problems can arise even before that if one is not prepared for the possiblity of one's partner falling unconscious by other causes: injuries incurred by falling, inability to bring your partner into a safe position, inhalation of vomit.
Quote from "Befunde und äußere Umstände bei Todesfällen im 'Schwitzkasten'" ("Attendant circumstances of, and findings relating to fatalities in 'headlocks'"):
"The compression of the neck becomes fatal only if applied for a longer period of time after an unconscious state has already been reached (at least 2-3 minutes for a young and healthy person)" (DPM90)
"Experience in sport has shown that controlled obstructive asphyxiation is possible and as a rule represents no great danger. Observations relating to the length of time it takes for an individual to be rendered completely incapacitated (ie. to reach an unconscious state) give an approximate time of 10 seconds and thus correspond to the findings and bibliographical references of forensic medicine [ ] Experience has shown that temporary loss of consciousness, which can occur in some strangleholds used in judo, is harmless. However, given that obstructive asphyxiation as it occurs in sport activities is low risk, obstructive asphyxiation as an act of grievous bodily harm is to be regarded as nothing other than high risk [ ] since it occurs under quite different conditions. In sport activities it can be assumed that a certain amount of care is taken by the attacking opponent; that safety and protection are guaranteed by the governing rules; that the physical forces involved are applied in a trained and measured fashion; that the activity ceases immediately if one opponent falls unconscious; and that the victim is in good physical condition and of the same strength as the attacking opponent. In cases of actual assault there are no governing rules, the assailants are usually physically much stronger than their victims who are most often women and children [ ] and apply all their physical force in the assault. This is further exacerbated by the possible frailty of the victim (eg. old age, severe cardiovascular illness) and/or the presence of toxic substances (alcohol, drugs). Drawing from experiences in martial sport disciplines, the most significant factor causing death is undoubtedly the duration of the assault, i.e. the duration of the obstructive asphyxiation which often lasts for several minutes." (MD90)
If the blood circulation to the brain is insufficient for more than three or five minutes, the consequent damage can lead to death even after days or weeks. (eg. WAR88, Max87). One of the cases reported in Max87 is of particular practical and legal interest and is described in greater detail in Fatalities in the Presence of a Partner [not yet translated].
For various reasons, restoring the supply of oxygen to the brain within a short space of time is no guarantee that the circulation in the brain will be similarly restored to an adequate level. It can take quite a time for adequate circulation in the brain to be completely restored. (Hen90)
"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." (Wisa)
The Deviants' Dictionary notes:
"It's well known that low level or repeated oxygen deprivation (from, say, high altitudes or in certain medical syndromes where patients' breathing ceases intermittently during sleep) can cause brain damage. Hypoxia destroys neurones (brain cells), which in adults are the only cells in the body that can't be replaced. Wiseman has cited the case of a judo instructor who may have been brain-damaged by frequent sessions as a demonstration model for the carotid strangulation techniques traditional in his sport. [cf. Wise, K.P.] Checkmate's consultant Tattoodoc points out that the cerebral cortex is the most demanding of oxygen, so hypoxia 'affects the highest centres of the brain first'.
To get this in perspective, we have many billions of neurones and the brain can work with much fewer than its natural endowment. They are destroyed all the time by ageing, alcohol and other drugs, blows to the head and so on. It might be rational to decide to 'spend' some of our generous but finite supply on activities we enjoy, but spend carefully.
Like anything else in SM, sensible play requires a calculation of risks against pleasures, and the minimising of whatever risks you can. For example, some BC enthusiasts report that a second attempt at causing unconsciousness during a session requires a much longer period of oxygen deprivation, which increases the danger time for neurones, and is also not so satisfying. Rationing the amount of this sort of play to special occasions with substantial gaps in between might be advisable both in terms of brain conservation and pleasure! (DD)
N.B. Although we are able to do without a considerable proportion of our brain cells, there are some extremely sensitive areas of the brain for which minimal loss can result in noticeable problems.
In laboratory experiments on rodents, a two minute interruption of the oxygen supply did not cause neurological failure; only after anoxaemia was induced several times in regular intervals of one hour was there an indication of permanent brain damage. (cited from Wise)
The normal ph-level of blood lies between 7.35 and 7.45; anything above these levels is called alkalosis, and anything below them acidosis. Even mild fluctuations are unhealthy; pH-levels under 6.9 and above 7.8 are not conducive to the continuation of life. The concentration of carbon dioxide in an individual's blood increases if his/her respiration is restricted in any way. pH-levels in his/her blood decrease, a respiratory acidosis will follow. Simultaneously, the concentration of oxygen in his/her body tissue will diminish, bringing about a metabolic acidosis. I don't know whether this should be seen as an additional risk of breath control games. Research still in progress.
Hyperventilation does not count as one of the direct risks of breath control play (it is associated more with the risks of diving). Anyone who feels a tingling sensation in the hands and around the mouth after having had an orgasm probably hyperventilated during sex. The actual physically felt need or stimulus to breathe i.e. the feeling that one's lungs will explode if one does not take a breath immediately is not caused by a lack of oxygen in the blood but by an increase in the amount of its carbon dioxide content. During hyperventilation more carbon dioxide is expelled from the body in proportion to the amount of oxygen it takes in. If one holds one's breath at this moment, the actual stimulus to release and inhale again may under certain circumstances not be activated until after one has actually lost consciousness through lack of oxygen. Exactly this situation has been the cause of numerous diving accidents with many divers simply assuming that they can hold their breath for longer periods after hyperventilating. Whilst they may feel healthy and alert, they can lose consciousness under water suddenly and without any warning. Thus, if one's partner for whatever reason had hyperventilated before having his/her source of oxygen cut off, be prepared for the possibility of his/her falling unconscious even if s/he may still seem relatively alert.
Another important aspect to be aware of is that of alkalosis (see Fluctuations in Blood pH-levels in this instance we are dealing though with the opposite of the mechanism described) which can be brought on by hyperventilating. Some people value the sensations which it generates and leave it at that. These range from dizziness, a mildly clouded awareness and a tingling in the face and in the extremities. In extreme cases, cramps and blackouts can also result. Although an alkalosis is not exactly healthy, it is hardly conceivable that one could endanger one's life through deliberate and willful hyperventilation. As soon as one stops hyperventilating, the body quickly regains its normal balance (to aid recovery one can re-inhale one's own breath from a bag several times in order to supply one's body with carbon dioxide).
In assaults which involve strangulation or during auto-erotic breath control play also, it can occur that the victim/partner vomits. Relevant literature provides details of fatalities which have resulted from vomit which for want of free passage through the mouth or because of the particular position in which the unconscious victim happened to be lying entered the lungs. Had the victims survived, the consequent lung infection could have also probably lead to death. The probability of someone vomiting is considerably raised by:
It can never be ruled out entirely: one should always be prepared for the possibility that a helpless partner for whatever reason could vomit at any moment. It is important to bear this in mind if one is to tie one's partner up elaborately in some awkward position. A partner who vomits must be freed immediately from anything impeding his/her respiration and, if completely incapacitated, should also be brought into a safe position.
If ones partner is submerged for too long, his/her overpowering urge to breathe can result in the inhalation water. The lung can absorb small quantities of clean fresh water within seconds. Larger volumes of water such as is the actual case in drowning cause a variety of complications which, in addition to anoxaemia, can lead to death. The small amount of water which one would be more likely to expect in a BDSM-related accident, will generally not have any serious consequences. However, a physician should definitely be consulted if one experiences during the course of the following two days recurrent headaches, a burning sensation in the chest, breath-related pain, fever, difficulty breathing, or blurred consciousness.
The situation with regard to salt water is quite different: salt water is not absorbed but causes water to flow from the blood stream into the lung an extremely unhealthy occurrence. It is better not to duck anybody in salt water at all.
In rare cases a psychological trigger-moment (sudden fright, fear) can bring about a glottal cramp which will subside, at the latest, once an unconscious state has been reached; in the case of drowning this is, of course, too late, but for our purposes it will suffice.
The inhalation of cold water can furthermore cause an irritation of the vagus which, in connection with the aforementioned Carotid Sinus Syndrome, can have unfavourable consequences for the functions of the heart. Concomitant with the effects of anoxaemia on the heart, cardiac arrest may be the outcome
To avoid inhalation of water, one could consider making use of the phenomenon described in the section concerning Hyperventilation: ones partner could be made to hyperventilate beforehand, suppressing the respiratory reflex (i.e. the physical need/urge to breathe) and thus avoiding the possible inhalation of water. This (highly experimental) advice is primarily intended for those who insist on keeping their partners submerged until they are half dead: everyone else simply stops before there is any danger of any real harm being done.
Victims of actual assaults involving strangulation often suffer various injuries to the larynx, especially fractures of the hyoid bone and the thyroid cartilage, as well as injuries to the thyroid gland. Swelling and bleeding can place pressure of the vocal chords and impede speech. Such injuries are not easily inflicted and should not really occur all too often within the parameters of BDSM. They are not life-threatening as long as no swelling develops in the region of the respiratory tract which could represent an impediment to breathing (this may not become evident until several hours after). Caution is nevertheless advised with regard to the larynx: during activities which involve choking or strangling, the larynx should be treated as gently as possible, if not left out altogether. Should discomfort in the area of the larynx persist after breath control play, a physician must be consulted.
Petechiae: As a result of increased pressure within the head (such as when veins in the neck are obstructed, most typically in strangulation) small vessels can burst, especially in the gums of the mouth, eyelids, and in the conjunctiva. These remain visible for several days and, although not nice to look at, are generally harmless. A picture (WebPath).
Aneurysms: Roughly five percent of the population suffers from aneurysms, ie. bulges in artery walls. If there happens to be such an aneurysm in the brain, the aneurysm may rupture if arterial blood pressure rises. This leads to a series of conspicuous symptoms, in particular a severe headache. Middle aged people are the most susceptible. There is only a twenty to thirty percent chance of fully recovering from a ruptured aneurysm in the brain, the probability of death is the same. Aneurysms in the brain can rupture as a result of sex, physical exertion during sport, coughing, vomiting and straining the sphincter while defecating thus breath control play represents one cause amongst many others.
Injuries resulting from Cramps: Lack of oxygen in the brain can lead to convulsions and spasms which can cause injury. Research in progress.
Asthma: With time asthma sufferers apparently develop heart problems which could well increase any additional risks associated with the functioning of the heart. Research in progress. However, there is the occasional report of asthma sufferers who find that they are personally more able to manage their condition since engaging in breath control play in a sexual context.
"I don't really have asthma as such, but an allergy to house dust which has got considerably better since coming consciously to terms with it through, amongst other things, breath control play. By doing this, I've learnt especially how to get a hold on dangerous states of panic (The "Shit, I can't breathe panic!" syndrome)." (F,32)
Crucifixion: If someone is tied up in such a way that all his/her bodyweight is carried by his/her outstretched arms (as is the case in classical crucifixions), his/her thoracic breathing will be considerably restricted. This can lead to death although only after quite a long period of time has elapsed (in the relevant literature, the actual duration of this process is shrouded in silence). As usual, do not leave tied persons unattended.
Problems arising through Arteriosclerosis: "A properly applied carotid
sleeper hold can also cause death. One would not expect any trauma to the structures of
the neck, however. The compression of the carotid arteries, with resultant decreased
cerebral blood flow, can theoretically precipitate a stroke in an individual with
atherosclerotic disease of the carotid and/or cerebral vasculature. The pressure may cause
dislodgement of atherosclerotic material with a stroke due to an embolus. Blood flow to
the brain is from both the carotid and the vertebral arteries. If the vertebral arteries
have impaired blood flow due to atherosclerosis then occlusion of the carotid arteries may
compromise an already compromised circulation with resultant thrombosis and/or
This particularly concerns smokers, diabetics and older people.
Pneumatic Embolism: "The opinion, often presented in medical text books, that a pneumatic embolism may occur as a result of increased pressure applied during a lethal strangulation, is theoretically conceivable, but practically impossible." (GM86)
"On the basis of evidence available by contrast to various published assertions a pneumatic embolism occurring in the case of someone being hanged is not, or at least hardly ever, to be expected." (BAP83)
If in doubt, it is advisable not to see a Nose-Throat-&-Ear specialist, but to visit the Accident & Emergency Clinic at the nearest hospital the members of staff there are accustomed to seeing the strangest of things and are unlikely to bat an eyelid if told of the circumstances under which the injuries were incurred. As is the case with other injuries occurring within the sphere of BDSM-activities, do not lie to the doctor! Firstly, this can make it difficult to reach the correct diagnosis and, secondly, the doctor, unable to believe your invented story, may end up suspecting domestic violence. Be assured that it is more a relief to the doctor than a cause for grave concern if you simply explain "My partner hurt me inadvertently during SM play". Do not take unnecessary risks simply because you feel that it is too embarrassing to go to hospital. Be aware that the emergency doctor is bound by law to maintain medical confidentiality at all times; anyone who feels really strongly about it can remind him of this. If the medical staff censure or reprove you, bear in mind that doctors generally know just as much about breath control play as the rest of the population which is next to nothing.
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