Pathology (1994), 26, pp.

276-280

AUTOEROTIC DEATHS: FOUR CASES

C L I V E TREVOR COOKE, G E R A R D A N D R E W C A D D E N AND
KARIN ANN MARGOLIUS

Forensic Pathology, State Health Laboratory Services, Queen Elizabeth H Medical Centre,
Nedlands, Western Australia

Summary The body was dressed in female clothing, including panties, a bras-
siere, camisole, suspenderbelt and black stockings, and was partly seated
We describe the circumstances and post mortem medical on a chair (Fig. 1). Suspension was from a roof rafter, with a petticoat
findings of 4 unusual fatalities where death occurred during extendingfrom the neck of the deceased to a wire which was tied around
autoerotic practice. Three cases occurred in young to middle- the rafter. The left leg was also suspended from the rafter, by a separate
aged men - - hanging, electrocution and inhalation of a zucchini. ligatureof further femaleclothing. The penis and scrotum were exposed,
The manner of death in each was accidental. The fourth case with a belt and 6 elasticized bands tied around the scrotum. Alongside
was an elderly man who died of ischemic heart disease, the body were ladies' underwear, hair wigs and 2 pornographic maga-
zines, one depicting sexual activity.
apparently whilst masturbating with a vacuum cleaner and a hair
The autopsy showed the body of a middle-agedman of normal build.
dryer.
The facial skin was suffused. There were numerous petechiae, around
and on the eyes. A ligature mark encircled the neck. The penis was
Key words:Autoeroticdeaths, electrocution,asphyxia,inhaledforeignbody.
engorged and semi-erect.
Accepted 15 February, 1994 Internal examination showed mild pulmonary congestion but no
further abnormality. There was no injury to the neck tissues. There
were no epicardial or visceral pleural petechiae.
INTRODUCTION Toxicological study showed a blood alcohol level of 0.131 g%;
S u d d e n death occurring d u r i n g autoerotic sexual activity common drugs were not detected.
is a well recognized p h e n o m e n o n . It appears that the most Further enquiry revealed that the deceased was born the youngest
of 3 children, and had suffered from enuresis until his early teens. He
c o m m o n type o f a u t o e r o t i c d e a t h is a s p h y x i a t i o n due to
had been married for '18 yrs: The year prior to his death his wife had
neck c o m p r e s s i o n c o n s e q u e n t to h a n g i n g , with m a n y found female clothing and pornographic magazines amongst his
reports defining this condition.t-19 Other case reports a n d belongings, which she had disposed of by burning. The basement of
series have d r a w n a t t e n t i o n to m o r e u n u s u a l a u t o e r o t i c the house where his body was found was freely accessible from the
deaths, sometimes referred to as " a t y p i c a l " because outside. Although the house was owned by the local church and used
a s p h y x i a t i o n is n o t a feature. 2 These include deaths due as a child care centre during the day, the basement was apparently a
to electrocution, 21-23 a b d o m i n a l c o m p r e s s i o n , z4 i n h a l a - well-known evening haunt of the local homosexual community.
t i o n oof v o l a t i l e a g e n t s , 2'2s'26 w r a p p i n g , s'27-a
submersion, al self-catheterization,32 a n d the use o f power
hydraulics. 33 C o m m o n to all o f those o f course, is the
use of artificial m e a n s to heighten sexual arousal, with
a fatal result. T h e r e are also rare reports of deaths of a
n a t u r a l cause, u s u a l l y ischemic heart disease, d u r i n g
a u t o e r o t i c sexual activity. 6'34 Little has b e e n p u b l i s h e d
a b o u t a u t o e r o t i c deaths i n A u s t r a l a s i a . a'21
I n W e s t e r n A u s t r a l i a d u r i n g the 8 yr period 1985-92
there were 7 deaths which were recognized to be related
to a u t o e r o t i c practice. As each o f the deaths was u n -
expected, a report was m a d e to the Coroner. I n each case,
post m o r t e m medical e x a m i n a t i o n was u n d e r t a k e n by a
forensic p r a c t i t i o n e r o f this office. O f the 8 cases, 4 were
a c c i d e n t a l h a n g i n g s , o n e o f which is herein described as
representative. A d d i t i o n a l l y , there were 3 n o n - h a n g i n g
deaths which will each be described - - one due to electro-
c u t i o n , a n o t h e r due to c h o k i n g following i n h a l a t i o n o f
a zucchini, a n d the third o f ischemic heart disease.

CASE REPORTS
Case t: Hanging
The body of a 48 yr-old man was found suspended by the neck in the Fig. 1 Accidental asphyxiation due to hanging. There is a cross-
cellar of a suburban house. He had been last seen alive5 days previously. dressing of the male victim.

Figs. 2a and 2b Patterned, superficial electric burn marks on the skin of the abdomen (2a: magnification 0.5) and penis (2b: magnification x 1.5).
Case 2: Electrocution
The body of a 32 yr old man was found lying supine on the bed in his
quarters, in a country mining town. He had been last seen alive 3 days
previously, when he had been drinking in the bar.
The body was naked, showing changes of decomposition. A braided
flexible electric cord extended from a wall-mounted electric plug
(switched " o n " ) to the left side of the chest. The cord had been taken
from an electrical appliance; the appliance plug had been removed from
the cord, bare wires being thus exposed. Attached to one of the live
wires of the electric cord was a 45 cm long metal neck chain, extending
down the left side of the abdomen to a single loop wrapped around
Fig. 3 Posterior view of tongue, larynx and trachea, showing
impacting of' zucchini.
AUTOEROTIC DEATHS: FOUR CASES 277
the base of the penis. The negative wire of the electric cord was in contact
with the chest of the deceased; the earth wire was tucked into the
rubber/fabric shroud of the cord. At the site of contact with the negative
wire on the chest was an electric burn to the skin extending into
subcutaneous fat. A further, patterned, superficial electric burn mark
extended down the left side of the abdomen and around the base of
the penis, the pattern corresponding to that of the neck chain (Figs.
2a and 2b).
Autopsy examination showed changes of decomposition, but was
otherwise unremarkable. Identification was established by fingerprint
comparison.
Toxicological study demonstrated the presence of alcohol in the blood
(0.229 g%) and bile (0.205 g%). It is unlikely that all of this is explained
by post mortem generation due to decomposition.
The electrical apparatus was assessed by professional inspectors. The
metal chain had an electrical resistance of about 100 megohms, greater
when the chain was slack but less when straightened and taut; skin
contact with either the bared wires or more proximal part of the chain
was expected to be particularly dangerous.
Further enquiry revealed the man to be separated from his wife; he
lived in single-mens quarters of a mining company. He had recently
travelled overseas where it is believed he learnt of the autoerotic use
of electricity. The electric voltage overseas was less than half that of
the mining town (110 V as compared with 240 V throughout Australia).
Case 3: Choking
Early one afternoon a middle-aged couple were disturbed by frantic
knocking at the front door of their home. At the door was their neigh-
bout, a 29 yr old man, holding his abdomen and trying unsuccessfully
to talk. The man collapsed to the ground, and died despite attempts
at resuscitation.
The autopsy showed a young man of normal build. The body was
dressed only in trousers, with the waist button unfastened. Removal
of the trousers showed the penis to be semi-erect; around the base of
the penis was a rubber band. On the lower abdomen and in the groin
was dried, white coloured material, subsequently identified as semen.
There were no petechiae on the facial skin or on the eyes.
Internal examination showed a zucchini impacted in the larynx and
oropharynx, totally occluding the airway (Fig. 3). The laryngeal mucosa
showed minor, fresh bruising but was otherwise unremarkable. General
internal examination revealed occasional petechiae on the visceral pleura
of both lungs, but no further evident abnormality'. There were no
epicardial petechiae.
Toxicological study did not identify alcohol or common drugs.
Further enquiry revealed that the deceased had been married for 2
yrs at the time of his death. He was casually employed but, unlike his
wife, was not working on that day. The couple grew zucchinis in their
backyard garden.
278 COOKEet aL
Fig. 4 Scene photograph showing the body of an elderly man,
adjacent to a vacuum cleaner.
Case 4: Ischemic heart disease
The naked body of this 77 yr old widower was found in the bathroom
of his home (Fig. 4). Adjacent to the body, and switched on and
working, were a vacuum cleaner and a hair dryer. A pair of men's under-
pants was impacted in the hose of the vacuum cleaner.
Autopsy examination showed the body of an elderly man o f normal
build. There was no evident injury; in particular there were no apparent
marks of electrical injury.
Internal examination showed enlargement of the heart with exten-
sive ischemic fibrous scarring of the thickened left ventricular
myocardium. Extensive calcified coronary arteriosclerosis was present,
with no thrombosis. There was no significant valvular disease. The lungs
were mildly congested and there was benign hypertensive nephrosclerosis.
Toxicological analysis was unremarkable.
The vacuum cleaner and hair dryer, together with the electric circuitry
of the house, were assessed by an electrical inspector and cleared of
malfunction.
The cause of death was therefore believed to be combined arterio-
sclerotic and hypertensive heart disease. The scene examination suggested
the likelihood that the electrical appliances were being used
autoerotically.
DISCUSSION
Autoerotic deaths are typically unwitnessed, the death
usually occurring in a discrete or isolated setting,
reflecting the secretive nature of this type of sexual
Pathology (1994), 26, July
activity. Correct definition of the nature of the death rests
largely on adequate examination of the scene. Typical
features include: a degree of undressing, commonly with
exposure of the genitalia; cross-dressing or evidence of
female clothing fetishism; pornographic literature; the
presence of a mirror; penile engorgement or semen consis-
tent with recent ejaculation; and some form of
bondage. L4'6 When the body is discovered by a family
member, an attempt to hide the true nature of the death
may be made. as Correct identification of the nature of
the death is essential, not least because of possible life
insurance consequences if the manner of death is
mistakenly held as suicide rather than accident. 4
A recently published monograph described 157
autoerotic fatalities, a7 Of these, 132 (84%) died by
asphyxiation - - that is, mechanical interference with
respiration or cerebral oxygenation - - making this the
most common mechanism of death. In 105 cases the
asphyxia was induced by self-suspension; other methods
included self-strangulation, plastic bag suffocation, chest
compression and body inversion. Indeed, the majority
of other publications on fatal autoeroticism are of similar
asphyxial deaths, focusing particularly on hanging. There
are, however, isolated case reports of more unusual
asphyxiation techniques, including use of an abdominal
ligature, 24 wrapping s'27-3 and inhalation of irrespirable
g a s 20,25, 26
Of the 7 autoerotic fatalities in Western Australia
during the 8 yrs 1985-92 there were 4 autoerotic hanging
deaths, representing approximately 1.5070 of the total
banging fatalities. The selected case is representative of
the standard features of these deaths, although somewhat
older than most; that is, a man suspended by the neck
in a discrete location, showing cross dressing, and an
"escape" mechanism to the ligature which, if properly
activated, enables rapid release of the rope. The ligature
is typically padded to prevent marking of the skin of the
neck.
As the body is usually incompletely suspended,
commonly in the sitting position, there is little or no
injury to the neck tissues. As with most hanging fatali-
ties the mechanism of death is believed to be carotid artery
obstruction resulting in cerebral hypoxia. It would appear
that, at the moment of orgasm, the fine line between a
state of transient cerebral hypoxia and unconsciousness
may occasionally be crossed; once unconscious, the
individual is naturally helpless and, unless assisted by
others, succumbs to fatal cerebral hypoxia.
In the third case we describe, death resulted from
choking on a foreign body (zucchini) in the upper airway.
We have found no similar autoerotic death in the forensic
medical literature, although one case in a series of 43 cases
died from airway obstruction due to a gag in the mouth. 4
In this latter case the gag was apparently being used for
the purposes of asphyxiation to heighten sexual response.
In our case it appears more likely that the deceased was
using the foreign body to simulate fellatio.
A separate group of "atypical" autoerotic deaths are
those of electrocution, where electricity is used for sexual
stimulation.2a-23 These 3 reports include 2 men who had
electrical wiring taped to the nipples and extending into
the rectum, 2a a passive homosexual with electrical circuitry

connected to the scrotum and ano-rectal region, 22 and
a man electrocuted by a "live" table lamp, possibly being
used to warm the genital area. 23 In one case 22 it may have
been that the deceased was electrocuted whilst attempting
to rectify a problem in the autoerotic electrical circuitry.
The electrical device is often connected to a voltage
regulator, to enable deliberate variation of current flow
and hence the degree of stimulation. In our case (Case
2) the amount of current flow could be changed by
making contact with various parts of the neck chain, with
lesser stimulation from the more distal parts of the chain.
The majority of deaths occur when the electrical gadg-
etry malfunctions, or when there is accidental contact
with a more active part of the circuit. It is probable that
the relative thinness of the skin of the genitalia, and
indeed mucosal surfaces, may enable fatality at relatively
low voltages.
Sudden deaths due to a natural disease process, such
as heart disease, are not well described in association with
autoeroticism; there are 2 case reports, both in men who
at autopsy showed significant arteriosclerotic cardio-
vascular disease. One was the case of a 61 yr old man
who died whilst bound with chain restraints; a vibrator
was nearby. 6 The second case was of a 57 yr old man
whose body was found naked alongside a running
vacuum cleaner; the testicles, thighs and buttocks were
tightly bound with pantyhose. 34 Such deaths are prob-
ably less frequent than suddent natural death associated
with heterosexual or homosexual activity, particularly if
with a novel partner. 35
Although the first description of autoerotic asphyxial
deaths appeared in the American literature in the 1950s,
the use of asphyxia as a means of enhancing sexual gratifi-
cation was apparently previously well-known. As
examples, neck compression with heterosexual activity
was known to generations of Eskimos, and the Marquis
de Sade described the induction of erotic sensations by
self-suspension in his book "Justine", published in 1791
(see 1).
There is little information available on how knowledge
of the techniques is first learnt by participants. It would
appear, however, that descriptions occasionally appear
in sex manuals, pornographic literature, detective maga-
zines and the news media; fatalities have occurred
following television broadcasts on autoeroticism. 36"a7
The psychopathology of potentially life-threatening
autoerotic behaviour is not well understood. The gener-
ally held view is that constriction of the neck heightens
sensation, and hence the pleasure of orgasm, as a con-
sequence of cerebral hypoxia and hypercapnia. However,
alternative proposals have been expressed. In 1972,
Edmondson suggested that autoerotic hanging reflected
guilt about masturbation, the suspension being a form
of self punishment, as In that same year Resnik 1 suggested
these hangings were a result of either castration anxiety
(constriction of the neck symbolizing penile amputation)
or oral conflict (the activity simulating infantile feeding,
rebirth or maternal reunion). He considered the act of
masturbation as confirming the presence of the penis,
thereby denying the amputation. Alternatively, it has been
suggested that autoerotic activity may be a reflection of
the erotically arousing effect of danger and .risk,
AUTOEROTIC DEATHS: FOUR CASES 279
the thrill-seeking being associated with arousal and exhila-
ration. 39 Others have suggested an association between
autoerotic behaviour and strict, punitive parenting,
leading to the suggestion that an association between
cruelty and sexuality is formed, the former manifested
as sadomasochism with self-directed pain and humilia-
tion. 12 Alternatively, is there eroticization of helplessness
and risk-taking, victory and a sense of success resulting
from survival? 14As indicated by Sheenan and Garfinke112
"male and female, punishing conscience and guilty
sinner, sadist and masochist, pain and pleasure, victim
and voyeur all seem to converge in a single act".
ACKNOWLEDGEMENTS Thanks are offered to Mr D. A.
McCann, Perth City Coroner, and Professor J. M. N.
Hilton. Mrs Lorraine Kinsey kindly typed the manuscript.
Address for correspondence: C.T.C., Chief Forensic Pathologist, Forensic
Pathology, State Health Laboratory Services, QEII Medical Centre,
Nedlands, WA 6009.
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