Stephen J. Hucker, MB, BS, FRCP(C), FRCPsych
  Consultant Psychiatrist,
  Professor, Division of Forensic Psychiatry, University of Toronto

       Forensic Psychiatry. ca

Hypoxyphilia/Auto-erotic Asphyxia

What is Hypoxyphilia?

Hypoxyphilia is a paraphilia which is a sub-category of sexual masochism. Also known by terms such as asphyxiophilia, autoerotic or sexual asphyxia, this potentially lethal sexual practice refers to sexual arousal that is produced while reducing the oxygen supply to the brain.

Official Criteria

The DSM-IV (TR) criterion for diagnosing the condition in living practitioners are the same as those for sexual masochism: The behaviour that results from intense and recurring fantasies or sexual urges over at least six months must be causing significant clinical stress and/or impairment (social, occupational, other).

Hypoxyphilia has been known to medical science for nearly a hundred years, and to others perhaps since antiquity, but most of what we know about it has come from the study of cases in which a mishap has occurred and the individual has died as a result of, or during, the practice. Living practitioners tend not to present clinically or to make their behaviours widely known and hence detailed insight into the paraphilia is not widely available in the literature.

This author has conducted some extensive research in this area and in addition to the knowledge gleaned retrospectively, has a small case study of 15 living practitioners Individuals such as these are of prime importance because they contribute a considerable amount to our understanding of the phenomenon since they provide the only direct knowledge we have of the subjective accounts of the experience of hypoxia and the motivations for inducing it in this fashion


Although it is not unheard of for it to be practiced with partners,practitioners of hypoxyphilia usually engage in the behaviour as a solitary act. They use a variety of techniques to produce the hypoxia. Among the more common are self-hanging, strangulation, choking, suffocation and techniques to restrict breathing movements. Self-hanging is the most common method observed among fatal cases.

Although often a rope or other ligature is the method whereby hypoxia is induced, other ligatures and bindings may also be present that are not involved in the asphyxiating process but were obviously important to the deceased. Sometimes these bindings may be very elaborate indeed. Many forensic texts describe a typical case as involving complex elements including elaborate asphyxiating devices. However, in the author's own series of 171 fatal cases, most were relatively uncomplicated and not all of the more bizarre features are necessarily present.

Suffocation or reduction of the oxygen in the inspired air may be achieved with plastic bags, masks or more complicated apparatus involving some other kind of head covering. Sometimes anesthetics, other gases or volatile chemicals will be included or, on occasion used alone, and administered by this or some other means.

It should be emphasized that this practice is intended to induce sexual pleasure but practitioners are usually aware of the risk element that is inherent in the act should they lose consciousness. Because of that , the individual is usually careful to use some kind of safety mechanism intended to prevent accidental death in the event of unconsciousness.

There is no evidence that hypoxyphilia is a form of disguised suicide. In most cases hypoxyphilic deaths are a complete surprise to family and friends as the deceased was typically in a good mood and giving every indication that they were looking forward to the future.


Estimates of prevalence are based more on mortality rates from hypoxyphilia/AEA than on living cases and are almost certainly under-representative of the practice. {For example, this author has 15 living cases in a relatively contained geographical area.]

Fatalities resulting from AEA practices occur with a frequency of about one per million of the population per year in North America though it is important to note that this figure is based on studies of cases that have been recognized as AEA or Hypoxyphilia.

Demographical Detail:

Nearly all the reported cases of hypoxyphilia have been males and most are under forty years old at the time of death. Disturbingly, however, the practice can begin with puberty for some practitioners.

Characteristics/Predominate Features:

There are no overt or easily identifiable signs of either pre-disposition to this behavior or the existence of the paraphilia. Practitioners may be involved in otherwise healthy relationships, sexual and otherwise, and be committed partners and spouses.

The activity is usually solitary and the individual usually chooses a private or secluded place. When carried out in the home, the activity is usually confined to an out-of-the-way place (eg. basement) at a time when the home is vacated by other family members.

Those who have studied hypoxyphilic fatality scenes have noted several distinguishing features. Some are clearly essential but others are not always present or the evidence may be ambiguous.

First and foremost, it should always be possible to determine how the individual would have intended to control the degree of hypoxia and to escape from the situation. The intention is to survive the ritual not die from it, as might appear at first glance. When death occurs it is almost always due to the failure of a strategy intended to ensure recovery. Many authorities have insisted that a “fail-safe” device is invariably found but in my experience the strategy may often have been simply reliance on subjective judgment, as by releasing hold on a ligature or pulling off a plastic bag, presumably when a feeling of giddiness supervenes.

Second, there must be evidence of sexual activity. Often the body may be found either nude, partially nude, or with the penis projecting through an open fly, perhaps with the hand touching the genitals as if frozen in the act of masturbation. Ejaculation may have occurred though the latter can occur in other types of death and is not a conclusive sign. Cross-dressing in female clothing is a feature in about a quarter of the cases.

An indication of the importance of sexual fantasy to the hypoxyphile is that various forms of pornography and other sexual paraphernalia are often found at the scene or among the deceased’s personal possessions. Sometimes a mirror will have been placed strategically near the body to allow the subject to view himself as he performs his ritual or a camera may have been set up so that the person may photograph or videotape himself. Others will create an entire environment that relates to some special fantasy and may involve, for example, the creation of a torture chamber or other obviously sadomasochistic theme.

Often the elaborate nature of the equipment used in these cases make it clear that the behavior has been carried out many times before, or there may be other evidence of repetition, such as grooved beams from which ropes have been suspended. Some authorities have regarded this as an essential feature of the syndrome but, as they are not always present in otherwise obvious cases, this is disputable.

Although none of the author's living patients reported using hypoxyphilia on a daily basis many did so very frequently and had performed the act numerous times in the past without fatal mishap. They are, however, typically cognizant of the risk involved.

As with fatal cases, the living patients report a wide range of concurrent paraphilias including other forms of masochism, sadism, transvestic fetishism and fetishism. Many perform their ritual in the nude and a number of them cross-dress for the activity. A wide range of sexual paraphernalia are used including mirrors, self-photography, bondage, hoods, blindfolds, enemas, electrical stimulation and beating of self or by a partner. Some individuals view pornography during their activities. The most common method reported used to induce hypoxia is some form of suffocation but several methods are often used in combination.

In the experience of the author, living practitioners of hypoxyphilia tend to be articulate and willing to discuss their thoughts, fantasies and motivations in great detail. Surprisingly, perhaps, half of them describe sadistic fantasies. They report that their activities are part of a more elaborate, usually masochistic, fantasy in which they are forced into painful, uncomfortable or humiliating situations. Some individuals have cross gender fantasies and some clearly describe being sexually aroused by being in physical danger and of struggling against physical restraints.

Hypoxyphilia/AEA Death vs Suicide:

As suggested above, the number of fatalities attributed to hypoxyphilia are suspectly under- representative. In numerable cases, determination of cause of death has been attributed to suicide (or, in some cases, homicide by persons unknown). Unfortunately, misclassification of these fatalities continues to occur even though the phenomenon has become much more widely known.

This can be attributed to a number of things but the most common two are unfamiliarity with this mode of death itself on the part of the investigating officers and the well-meaning interference in the death scene by loved ones who remove embarrassing items, such as sexually explicit materials, that would otherwise make classification more straightforward.


There is no relationship between hypoxyphilia and mental or personality disorder but there is clearly an association with other paraphilias, which have a tendency to cluster in other circumstances as well. Living patients confirm the presence of wide range of concurrent paraphilias including other forms of masochism, sadism, transvestic fetishism and fetishism. More typically masochistic behaviours are frequently noted among the hypoxyphilic fatalities.

There appears to be an intriguing association with mood disorders which are being seen with some frequency in a number of paraphilias, including those that are not illegal. For example, in complete contrast to the fatal cases, all living hypoxyphilic patients that the author has interviewed were suffering from or had suffered from concurrent mood and anxiety disorders. Approximately 60 percent of them had made suicide attempts in the past. While the high frequency of mood disorder might be dismissed simply as the reason why these patients presented to a psychiatrist, a number were referred because of the hypoxyphilic behavior itself and out of concern they were endangering their lives.

As well, the “thrill seeking” characteristics of many men with other common sexually compulsive behaviors has often been observed. Some authors who have studied living AEA cases have been struck by the “death orientation” and have suggested, on psychodynamic grounds, that hypoxyphilia is a “suicidal syndrome.” However, as noted above, most authorities now regard hypoxyphilic fatalities as presumptive accidents and one might consider them more akin to the unintended deaths of those who hang-glide, sky-dive, climb mountains or engage in other hazardous pursuits.

Treatment Options:

This leads to the obvious consideration of treatment options for hypoxyphilia. Here my experience has been that, as with other paraphilias, few are really motivated to give up their means of sexual gratification. For the few that can be engaged, the combination of cognitive behavior therapy and medication would be recommended. With such a strong association between hypoxyphilia and mood disorder, an SSRI antidepressant will have a dual benefit of helping to relieve depression and reducing sexual impulsivity. I myself have also used anti-androgens and, in one case, castration, all with good outcomes followed up, in one or two cases, over many years.

Further Reading:

Hucker, S.J. “Asphyxiophilia: Recommendations for DSM-5” (accepted for publication) Archives of Sexual Behaviour.

Hucker, S.J . (2004) “Hypoxyphilia”. Invited lead article. The Forum, xvi, 4, 2-4.

Byard, R., Hucker, S. J., & Hazelwood, R. (1993). Characteristic features of fatal and non-fatal autoerotic asphyxial episodes in women. American Journal of Forensic Medicine and Pathology, 14(1), 70-73.

Blanchard, R. & Hucker, S. J. (1991). Age, transvestism, bondage and concurrent paraphilias in 117 fatal cases of autoerotic asphyxia. British Journal of Psychiatry, 159, 371-377.

Byard, R., Hucker, S. J., & Hazelwood, R. (1990). A comparison of typical death scene features in cases of fatal male and female autoerotic asphyxia. Forensic Science International, 48, 113-121.

Hucker, S. J., & Stermac, L. (1992). The evaluation and treatment of sexual violence, necrophilia and asphyxiophilia. Psychiatric Clinics of North America.15/3, 703-719

Hucker, S.J., & Blanchard, R. (1992). Death scene characteristics in 118 fatal cases of autoerotic asphyxia compared with suicidal asphyxia. Behavioural Sciences and the Law, 10, 509-523.

Hazelwood, R.R., Dietz, P.E., & Burgess, A. W. Autoerotic Fatalities. (1983). Lexington Books.

Other Resources:

Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Martin Kafka, MD, Psychiatric Times (on-line)

© Stephen Hucker, MB,BS, FRCP(C), FRCPsych 2003 - 2011
This material is provided for personal use only. Any other use is strictly forbidden without the express written permission of the author


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