CASE REPORT
Complicated Suicide Versus Autoeroticism?
A Case Involving Multiple Drugs and a Porta-Potty
Evan Matthew Dickerson, MD,* Prentiss Jones, PhD, Dennis Wilkins, Janis Regnier, BS,
and Joseph A. Prahlow, MD,
Abstract: In this report, a unique and bizarre case of complicated
suicide is presented. The decedent was found dead in the basin of a
porta-potty, wearing womens pantyhose, jewelry, and makeup. The ini-
tial investigation was suspect for homicide. Although an autoerotic ac-
cidental death cannot be excluded, the patients medical history and
autopsy results provided evidence for suicide, including several sub-
stances positive in his serum. Tramadol was quantified to be 140 mg/L,
approximately 470 times the therapeutic range. Moreover, formalde-
hyde was also present, presumably absorbed from the contents of the
chemical toilet. An exhaustive search could not reveal similar circum-
stances of suicide in a porta-potty or with the levels of tramadol found
in the decedent.
Key Words: paraphilia, porta-potty, suicide, tramadol, transvestitism
(Am J Forensic Med Pathol 2013;34: 29Y33)
S uicides and accidental deaths can mimic homicide until fur-
ther investigation and pathology are reviewed. In this report,
a unique case of suicide by drug overdose with possible con-
tributing factors of positional asphyxia, hyperthermia, and ex-
posure to the chemical contents of a porta-potty is described.
Moreover, the circumstances surrounding the death are of im-
portance. A search of the media and medical literature failed
to reveal a similar case.
RESULTS
A 36-year-old man was found dead in the waste receptacle
of a porta-potty in a park on a late afternoon of a hot August
day. Police were notified of an abandoned vehicle in the park-
ing lot adjacent to a local park and found the body while in-
vestigating the vehicle. The vehicle was found with the front
windows down. The interior and exterior were covered with
hand-drawn graphic images and writings alluding to the male
genitalia and to homosexual acts. The vehicle contained several
articles of clothing including the decedents wallet, identifica-
tion, cellular phone, receipts, and an open gym bag. The bag
contained personal lubricant among other items. The drivers
seat contained several tubes of lipstick that matched the color
of the writing on the car. Upon searching the park for the
Manuscript received June 4, 2012; accepted September 10, 2012.
From the *School of Medicine, Indiana University, Indianapolis; South Bend
Medical Foundation, South Bend; Portage Police Department, Portage;
and School of Medicine, Indiana UniversityYSouth Bend at the Uni-
versity of Notre Dame, South Bend, IN.
The authors did not receive sources of support or funding for this study.
The authors report no conflicts of interest.
Reprints: Evan Matthew Dickerson, MD, School of Medicine, Indiana
University, 631 N Morton St, Bloomington, IN 47404. E-mail:
evandickerson@gmail.com.
Copyright * 2013 by Lippincott Williams & Wilkins
ISSN: 0195-7910/13/3401Y0029
DOI: 10.1097/PAF.0b013e31827ab5f3
Am J Forensic Med Pathol & Volume 34, Number 1, March 2013
Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
owner, the decedent was found in the tank of the portable toi-
let at the edge of the parking lot. The decedents leather jacket,
vehicle keys, and additional tubes of lipstick were found in-
side the porta-potty.
Scene investigation revealed an obese man lying on his
back slightly rotated on his left side in the fetal position with
only an arm and torso visible through the opened porta-potty
seat (Fig. 1). Upon closer inspection, the decedent was noted
to be shirtless, wearing only womens stockings. The body was
extricated from the basin of the toilet by cutting the top periph-
ery of the tank, allowing for further investigation and autopsy.
At autopsy, the approximately 220-lb (100 kg) decedent
was noted to have early signs of decomposition, including skin
discoloration, slippage, and bloating most prominent in the face
and neck but notably absent posteriorly. His head was mark-
edly flexed with his chin touching his chest (Fig. 2). He was
wearing womens makeup, a pair of nylon leggings, and a left
nylon sock. The body exhibited blue debris and had a chemi-
cal smell. No identifying scars or marks were noted.
The flanks, back, and arms showed confluent linear, cur-
vilinear, and irregular abrasions (Fig. 3). Irregular abrasions
were present on the chest and abdomen. Multiple irregular and
confluent apparent chemical burns overlapped the abrasions
and were primarily present on the flanks, back, and left upper
extremity; the lesions were dry, thickened, and firm.
On internal examination, the abdominal organs showed
signs of decompositional change but few other abnormalities.
The aorta showed minimal areas of atherosclerosis, whereas the
heart showed marked biventricular dilatation. The heart was
of normal weight at 380 g. The lungs were unremarkable with
no evidence of pulmonary edema. The stomach contained ap-
proximately 150 mL of brown fluid, which contained at least
3 capsules exuding a viscous material. A battery-operated vi-
brating device was present within the rectum (Fig. 4). With the
exception of mild hepatic steatosis, the remainder of the internal
examination and the microscopic examination was unremark-
able. There were no external or internal neck injuries identified.
Urine, serum, bile, and vitreous fluid samples were sub-
mitted for toxicologic testing. The urine drug screen was posi-
tive for amphetamine, tramadol, methylphenidate, nicotine,
cotinine, and caffeine. Serum drug testing revealed the presence
of ethanol, formic acid, tramadol, O-desmethyltramadol, meth-
ylphenidate, ritalinic acid, D-amphetamine, and L-amphetamine.
Routine drug testing was not performed on the bile and vitreous
samples; however, both samples were analyzed for tramadol and
amphetamine. Drug concentrations are presented in Table 1.
Subsequent police investigation failed to reveal any evidence
that suggested someone other than the decedent was involved in
this death. Family members denied knowledge of homosexual
tendencies and suicidal ideation. DNA analysis was run on sev-
eral samples collected from the lipstick, swabs of the porta-potty,
and body swabs; the results matched the DNA of the decedent.
Upon investigating the decedents home, numerous prescriptions
and over-the-counter medications were obtained. Included in
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Dickerson et al
FIGURE 1. View showing the decedent through the opening
of the toilet seat with only arm and torso visible.
these was a 240-tablet tramadol HCl 50 mg prescription bottle
containing 213 tablets; it was filled on the night of the dece-
dents death.
Based on the autopsy findings and the historical and in-
vestigative information surrounding the case, the cause of death
was listed as the combined toxic effects of formaldehyde, am-
phetamine, and tramadol with possible contributing factors of
positional asphyxia and hyperthermia. The manner of death was
ruled suicide.
DISCUSSION
Cases of suicide can mimic homicide upon initial investi-
gation.1 Nevertheless, the unique presentation of this case is of
importance. An exhaustive literature/media search was unable
to obtain a similar case with the manner of death reported here.
Cases of individuals getting trapped in the basins of chemical
toilets have been reported in the media,2,3 but none of which
resulted in fatality. Provided the immediate evidenceVthe de-
cedent was found dead in the basin of a chemical toilet; the
vehicle was found abandoned with extensive graffiti/vandalism
present; blunt force trauma was evident about the flank, back,
and abdomenVhomicide must be suspected. Furthermore, it is
possible to conceive that a hate-crime against an individual
who practices alternative sexual lifestyles occurred: the dece-
dent being assaulted, dressed in womens clothing, forced into a
porta-potty, and the vehicle vandalized.
FIGURE 2. Photograph showing decedent in fetal position
with head flexed to chest in the small dimensions of the toilet
basin (after top of seat section has been removed).
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Am J Forensic Med Pathol & Volume 34, Number 1, March 2013
FIGURE 3. Right flank of decedent exhibiting the curvilinear
abrasions. Note the congealed substance on the skin, consistent
with the preservative solution contained within the toilet basin.
The results of police investigation, autopsy, and toxicology
indicated otherwise. The pattern of the flank and other abra-
sions was isolated to the area of central obesity, indicating a
methodic approach to minimize injury when entering the rela-
tively small opening within the toilet seat. No other evidence of
trauma was present at autopsy. At largest thoracic diameter, the
decedent was approximated to be 42 cm, whereas the toilet lid
opening was approximated to be 28 by 38 cm (Fig. 5). Ulti-
mately, the habitus of the man would likely have prevented an
assailant from forcing the body through the opening without
excessive trauma being incurred (or the assailant simply giving-
up because of the difficult task at hand).
It is important to note the bizarre circumstances sur-
rounding the decedents death. Paraphilia is occasionally de-
scribed in the forensic literature and may be evident at scenes of
suicide.4 Paraphilias are a group of sexual disorders character-
ized by sexual arousal in response to objects or situations that
are not part of normal human arousal activity patterns.5 Al-
though the family reported no known history of cross-dressing,
it is likely that the decedent had a history of partaking in prac-
tices of transvestitism because he was found with an anal vi-
brator while wearing womens clothing and makeup, indicating
a level of sexual arousal associated with the act. Moreover, it is
possible that these acts were of a more common practice; the
FIGURE 4. Photograph of device obtained from the decedents
rectum.
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Am J Forensic Med Pathol & Volume 34, Number 1, March 2013 Complicated Suicide Versus Autoeroticism

TABLE 1. Drug Concentrations

Drug Serum Bile Vitreous Urine

Ethanol 50 mg/dL NT NT NT
Formic acid 45 mg/L NT NT NT
Tramadol 140 mg/L 34.2 mg/L 8.2 mg/L 176.7 mg/L
O-Desmethyltramadol 5.8 mg/L NT NT NT
Methylphenidate 0.2 mg/L NT NT Present
Ritalinic acid 2.5 mg/L NT NT NT
D-Amphetamine 10.6 mg/L NT NT NT
L-Amphetamine 2.9 mg/L NT NT NT
Total amphetamine 13.5 mg/L 2.9 mg/L 0.6 mg/L 14.6 mg/L
NT indicates not tested.

decedent perhaps found sexual excitement from contact with
feces thus partaking in coprolagnia.6
Accidental death must be considered given the circum-
stances. The scene suggests that a degree of autoeroticism may
have been involved. The anal vibrator and transvestitism with
the possibility of coprolagnia draws question to the decedents
intention for climbing into the portable toilet. It is possible to
conceive that the decedent purposefully forced himself into the
tight quarters but was then unable to get back out. Moreover, he
could have been overcome by the toxic fumes and lost con-
sciousness. In addition, the ingested medications found in the
decedents serum could have been taken to enhance the eroti-
cism but also could have added to the patient unexpectedly
losing consciousness. All of the previously mentioned scenar-
ios are possible and would suggest that the decedent did not
possess the intention to commit suicide. Ultimately, it is a
manner of death that must not be immediately excluded from
the investigation.
The crime scene and information obtained from the dece-
dents family support suicide as the manner of death. According
to family, the decedent frequently referred to his vehicle as his
baby. It is unlikely the decedent would have defaced his ba-
by if he was planning to return to the vehicle and drive it.
Clearly, there was intent and purpose in the drawings and in
leaving the vehicle in the parking lot. In addition, 4 cigarette
butts were found on the pavement behind the vehicle, all of
which matched the decedents DNA, indicating that there may
have been hesitation while he forged his resolve to enter the
porta-potty.
An interview with a friend revealed that the decedent was
having homosexual thoughts. While at a truck stop, the dece-
dent went into the mens bathroom planning to perform oral sex
on another male. He did not perform the act but did reveal his
thoughts and actions to his friend. Struggling with such ten-
dencies helps to provide an explanation for the vulgarities the
decedent drew on his vehicleVthey were an expression of his
frustration and search for identity. Among other explicit draw-
ings expressing the desire to perform homosexual acts, the text
I am gay was drawn on several locations.
The family reported that the decedent had been battling
with depression and was being treated with medication. The
medications found in his home were paroxetine, trazodone,

FIGURE 5. Views displaying the measurements of the porta-potty basin (left) at 52.1 by 104.1 cm and toilet opening (right) at
28 by 38 cm.

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Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dickerson et al
and tramadol; stolen prescriptions from his father for parox-
etine, gabapentin, and cyclobenzaprine were also present. Of
the 240-tablet tramadol prescription filled on the night of the
decedents death, 27 tramadol were missing and thus were
likely ingested that night. The large quantity consumed fur-
ther supports the intention of the decedent to commit suicide.
In addition, according to family, he was struggling with a
recent breakup with his girlfriend. This life stressor in com-
bination with his sexual identity struggles likely contributed
to his depression, providing greater support for suicide as the
manner of death.
The primary component of many chemical toilets, including
the one in this case, is formaldehyde.7 Formaldehyde is a colorless
gas at room temperature but is commonly used in aqueous solu-
tions such as in disinfectants, preservatives, and fixatives. Form-
aldehyde is a highly reactive chemical known to be oxidized to
formic acid via red blood cells and the liver.8 Exposure to form-
aldehyde results in damage by 2 mechanisms. First, formaldehyde
itself is an irritant that can be absorbed systemically through
multiple routesVingestion, inhalation, or direct contact.9 At au-
topsy, firm (formalin-fixed), chemical burns were noted over
several parts of the body. The skin hardening was essentially due
to the fixing of the tissue and is reported in other cases discussing
formaldehyde exposure.10 Although the mechanism of inhala-
tional injury with formaldehyde is unknown, inhalation of the
vapors can result in asthma and pneumonitis and acute respiratory
distress syndrome.9 None of these was evident at autopsy, but it is
reasonable to presume that there might have been formaldehyde-
initiated respiratory irritability before death. Ingestion, conversely,
results in a combination of liquefaction and coagulation necro-
sis,11,12 neither of which was present in the reported case, therefore
indicating minimal formaldehyde exposure via ingestion.
The primary metabolite of formaldehyde, formic acid,
provides the second mechanism of injury in cases of formal-
dehyde exposure. Formaldehyde is rapidly metabolized, within
90 seconds of absorption into the blood, to formic acid.9 The
possible toxic effects of formic acid include the following
mechanisms: an enzyme inhibitor of multiple metabolic path-
ways, decreased blood pH resulting in metabolic acidosis, and
renal tubular necrosis leading to anuria.9 Normal formic acid
levels range between 0 to 12 mg/L (with an absolute level of
toxicity not being reported).13 The decedents formic acid level
was 45 mg/L, well above the reference range, indicating that
systemic absorption of formaldehyde had occurred. Whether
some of the formic acid production occurred postmortem can-
not be stated with absolute certainty; however, because the re-
mainder of the investigation leads to the conclusion that the
decedent managed to maneuver himself into the toilet basin, it
is reasonable to presume that at least some formaldehyde ex-
posure and toxicity occurred before death.
Amphetamine is a chemical that promotes stimulation of
the sympathetic nervous system. More specifically, amphet-
amine is a sympathomimetic amine that exerts a stimulatory
effect on the sympathetic or thoracolumbar nerves to organs of
the body.14 Structurally, amphetamine resembles the bodys
naturally occurring stimulatory neurotransmitters norepineph-
rine and dopamine. Amphetamine causes increased release of
norepinephrine and also blocks its reuptake by nerve endings
thereby resulting in increased levels of norepinephrine that may
be cardiotoxic.15 Tolerance to amphetamine occurs rapidly, thus
making interpretation of results a challenge. Fatal outcomes
attributed solely to amphetamine have been observed in a wide
range of blood amphetamine concentrations. In a review of 17
fatalities attributed solely to amphetamine, the peripheral blood
concentration ranged from 1.1 to 7.4 mg/L.16 Although it is
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Am J Forensic Med Pathol & Volume 34, Number 1, March 2013
impossible to determine the degree of tolerance to amphetamine
the decedent may have acquired and despite the possibility of
postmortem redistribution, the high concentration of amphet-
amine (13.5 mg/L) reported herein is remarkable.
Tramadol is a synthetic analog of codeine that possesses
opiate-like properties. Tramadol is a mu-opioid receptor agonist
that has a unique dual mechanism of action. It possesses central
opiate receptor agonist activity and also exerts norepinephrine
and serotonin reuptake inhibition in the central nervous sys-
tem.17 Tramadol is typically considered to exhibit a lower ad-
verse effect profile and abuse potential compared with other
opiates.18 The primary metabolite O-desmethyltramadol is 2 to
6 times more potent than the parent drug and reaches peak se-
rum level in 2 to 3 hours, allowing for a delayed onset of ac-
tion.18,19 Common adverse effects reported include nausea,
vomiting, constipation, and somnolence.18,20 Furthermore, in
cases of poisoning, seizures, respiratory failure, pulmonary
edema, coma, and liver failure have occurred.18,20 In a study
that evaluated the role of tramadol and its metabolites in drug-
related deaths and drug impairment, it was suggested that
interactions of tramadol with other drugs might contribute to
fatalities.21 Although fatal intoxication with tramadol is rare,
several cases have been previously reported.18,22 The highest
reported blood tramadol level for cases of tramadol intoxication
alone was reported to be 15.1 mg/L.18 In a separate case of
multiple drug intoxication, the highest reported blood tramadol
level was 38.3 mg/L,23 at least 100 times the therapeutic range
of 0.1 to 0.3 mg/L.18Y20
The decedent reported in this case had a tramadol level of
140 mg/L, which is approximately 470 times the therapeutic
range. In no other case could such a level of tramadol be found
in the literature. It should be noted that the source for sampling
was from the heart and thus was not peripheral; however, tra-
madol does not typically exhibit postmortem redistribution.20,24
Moreover, months after the reference laboratory value was
obtained, the results were verified from a separate tube of blood
and were within 20% of the reference laboratory value.
With no anatomical explanation for death but a sufficient
toxicologic explanation, it would be reasonable to rule this
death as simply being caused by the combined toxic effects of
the several drugs and toxins identified. However, because of the
unique body position and the history of an extremely hot out-
door environmental temperature, it is reasonable to consider
positional asphyxia and hyperthermia as potential contributing
factors in this death. Positional asphyxia occurs when mechan-
ical respiration cannot occur because of contortion or posi-
tioning of the body.25 Environmental hyperthermia occurs when
a bodys temperature-regulating capacity cannot cool the body
sufficiently, the body core temperature elevates, and central
nervous system and cardiac failure ensue.26,27 Neither posi-
tional asphyxia nor hyperthermia can be considered definite
contributing factors in this death; nevertheless, their potential
contribution to death cannot be dismissed.
In a complex suicide, more than 1 mechanism is applied
resulting in death.28 The case presented exhibits multiple factors
contributing to the decedents death; however, the secondary
insult resulting from the constraints of the toilet basin, heat, and
chemical contents of the toilet were possibly unintentional
mechanisms contributing to death. Therefore, the suicide more
likely represents a complicated suicideVthe initial insult
resulting in suicide (the substances ingested) allows for a sec-
ondary insult that was not originally planned as part of the
suicide.28
The current case is of interest to the forensic community
for a variety of reasons. The case emphasizes the importance for
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Am J Forensic Med Pathol & Volume 34, Number 1, March 2013
forensic investigators and police to be aware of unorthodox
practices and paraphilias. The bizarre practices of the decedent
in this case produced a scene that suggested the possibility of a
homicide or an autoerotic demise. Whenever scene investiga-
tion suggests the possibility of a homicide, it is imperative that a
thorough investigation be performed, including the performance
of an autopsy. Careful correlation of autopsy findings and death
scene investigation are essential in determining how a death
may have occurred. Accurate toxicology findings can provide
abundant evidence regarding not only the cause of death but
also the manner of death. In the current case, the history of
depression and the extremely high level of tramadol in combi-
nation with amphetamine provide a tremendous amount of ev-
idence for suicidal overdose.
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