The Medical Realities of

Breath Control Play

Copyright © 1997 by Jay Wiseman, author of SM 101: A Realistic Introduction.

All rights reserved. ~ (posted here with permission of the author)

 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 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-threating 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 <carbonic anhydrase> 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 to

 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-outlfow-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 (California

 Highway Patrol) 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 http://www.greenerypress.com/ or write to me at

P.O. Box 1261, Berkeley, CA 94701.

Regards,
Jay Wiseman