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How deathly is choking during sex?

Updated: Oct 11, 2023

Choking is the main cause of death in BDSM, but less common than it is thought

Man holding the throat of a blindfolded woman.
Shutterstock image ID 1891364068 by LightField Studios

I strongly recommend not to practice choking. This article is part of a series intended to show that choking is unsafe, may cause brain damage, and is potentially lethal.

Deaths by autoerotic asphyxiation

Choking appears in the popular imagination as a deathly activity, largely because of the many celebrities that have died of autoerotic asphyxiation.

However, it is important to distinguish between breath play practiced in solitary and that practiced in couples. In the former, loss of consciousness or control over the body can lead to dead because the person cannot escape the asphyxia, while in the latter the person doing the choking has some control over the process.

But even the number of deaths produced by autoerotic (i.e. solitary) asphyxiation has been exaggerated. It is often mentioned that it causes “500 to 1000 deaths per year in the United States and Canada” (Sauvageau, 2012), but that number is an estimation based on unpublished data.

An epidemiological study based on 38 autoerotic deaths in Alberta, Canada, gave a lower number: 0.56 deaths per million inhabitants per year (Sauvageau, 2012). Multiplying this number by the population of the United States, 333 million, gives us an estimate of 186 deaths per year caused by autoerotic asphyxiation.

The number of autoerotic deaths per million inhabitants per year is similar in other developed countries: 0.3 in Australia, 0.14 in Sweden and 0.5 in Germany.

Choking deaths in BDSM

Another paper (Schori et al., 2022) inquired specifically about deaths involved in BDSM play. Doing a literature search, they identified 17 deaths produced by BDSM activities. Of those, all were caused by asphyxia except one case, in which death was caused by hemorrhage due to inserting an inflatable balloon and other objects in the vagina. One death by asphyxia was caused by blocking the mouth and the nose with tape and fingers. The remaining 15 deaths were by strangulation, 5 with the hand or the forearm and 10 with ligatures (rope, belt, collar or chain).

One of the cases of strangulation was a shibari scene in which two women were hanged with the same rope suspended from the ceiling (Roma et al., 2013). When one of them lost consciousness, her weight hanged the other. The first ended up death and the second, in a coma.

The rate of death was similar across genders: 9 men and 8 women.

In 9 of the cases, both partners were experienced in BDSM. In 2 cases, the top was a professional dominatrix. In 3 cases, the participants had discussed breath play techniques and cardiopulmonary resuscitation (CPR). Therefore, experience and education were not enough to prevent the deaths.


The conclusions are a mixed bag. On the one hand, fatalities caused by BDSM are rare: 15 occurred in the United States from 1986 to 2020, and 3 in Germany from 1993 to 2017. On the other hand, breath play caused a disproportionate number of the deaths in BDSM. It is fair to say that, by far, choking is the most deathly BDSM activity.

But dying is only the worst thing that can happen during breath play. There may be other health consequences, including brain damage. These are much harder to assess. I will discuss that in future articles.


  • Roma P, Pazzelli F, Pompili M, Girardi P, Ferracuti S (2013) Shibari: double hanging during consensual sexual asphyxia. Arch Sex Behav 42:895-900.

  • Sauvageau A (2012) Autoerotic deaths: a 25-year retrospective epidemiological study. Am J Forensic Med Pathol 33:143-146.

  • Schori A, Jackowski C, Schön CA (2022) How safe is BDSM? A literature review on fatal outcome in BDSM play. International Journal of Legal Medicine 136:287-295.

Copyright 2023 Hermes Solenzol.

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