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An examination of autoerotic asphyxiation in a community sample.

Autoerotic asphyxiation (AEA) is a sexual interest that involves heightening sexual arousal by deliberately self-inducing a reduced supply of oxygen to the brain. Most of the literature on AEA is comprised of case studies and research based on people who have died from the practice. The present study explored information about AEA practices and the degree of overlap between AEA and other paraphilias in community participants. Participants (n = 395) were recruited through different online platforms to complete an anonymous survey and 165 were classified as having AEA by reporting mild to strong sexual arousal in AEA. These individuals reported that their interest emerged in late adolescence, and many reported that they discovered AEA via the internet. Regarding safety precautions people take during their AEA practice, 19% of participants reported that they did not use safety precautions. Most people (> 80%) were not distressed by their AEA interest. Additionally, significant relationships were found between AEA interest and many paraphilic interests with masochism being the only paraphilia associated with AEA when considering other paraphilic interests. These results suggest that most individuals engage in less risky manifestations of AEA than what is reported in the clinical literature and that AEA is appropriately conceptualized as a subtype of masochism. The results underscore the importance of gathering information about alternative sexual practices in community samples.

KEY WORDS: Asphyxiophilia, autoerotic asphyxiation, masochism, paraphilias

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There is significant variation in paraphilic interests with some paraphilias associated with significant harm to self if acted upon. Autoerotic asphyxiation (AEA) is a paraphilia that can result in significant harm to self, as it involves heightening sexual arousal by deliberately self-inducing a reduced supply of oxygen to the brain (e.g., Martz, 2003). The Diagnostic and Statistical Manual of Mental Disorders--Fifth Edition (DSM-5; American Psychiatric Association, 2013) classifies AEA as a subtype of masochism. (1) It is referred to as a form of asphyxiophilia, a term that captures those who engage in partnered and/or solo asphyxiophilia. In the present study, AEA is operationalized as those engaging in solo asphyxiophilia. Due to the absence of a partner, AEA is arguably riskier than partnered asphyxiophilia and is a potentially fatal practice, accounting for an estimated 500-1000 deaths per year in the United States (Sauvageau & Racette, 2006).

AEA Case Studies

The literature on paraphilias has largely been conducted with forensic or clinical samples. Most research on AEA involves case studies that have taken one of two approaches. The first approach consists of mental health professionals reporting on case studies of clients they have seen in their practice (e.g., Cesnik & Coleman, 1989; Eber & Wetli, 1985; Johnstone & Huws, 1997). These case studies suggest a high degree of overlap between AEA and other paraphilic interests, as well as mental health problems, such as depression (e.g., Cesnik & Coleman, 1989; Eber & Wetli, 1985; Johnstone & Huws, 1997). The second type of case study consists of researchers extracting information from coroners' files of individuals who have died from AEA (e.g., Behrendt, Buhl, & Seidl, 2002; Solarino, Leonardi, Grattagliano, Tattoli, & Di Vella, 2011; Vennemann & Pollak, 2006). In a large-scale review, Sauvageau and Racette (2006) reviewed 408 AEA deaths reported in the literature from 1954 to 2004. In reviewing these reports, they found that individuals who died from AEA were predominantly Caucasian males, aged 9 to 77 years old, and most induced asphyxiation themselves by hanging, ligature, plastic bag suffocation, or with chemical substances.

AEA and Paraphilic Interests

A clear finding from a review of the literature on AEA is that there is significant overlap between AEA and other paraphilic interests (Behrendt et al, 2002; Cooper, 1996). This is consistent with research suggesting that paraphilic interests tend to cluster; however, clustering is not random as certain paraphilias are more likely to co-occur (e.g., Abel, Becker, Cunningham-Rathner, & Mittelman, 1988; Bouchard, Dawson, & Lalumiere, 2017; Dawson, Bannerman, & Lalumiere, 2016; Langstrom & Seto, 2006). The paraphilia that has been argued to overlap most strongly with AEA is masochism, which is consistent with its classification in the DSM-5. In the only quantitative study (currently unpublished), 71 percent of participants with AEA viewed themselves to be masochistic (Hucker, 2011). The high degree of overlap between AEA and masochism is consistent with case studies (e.g., Martz, 2003; Tattoli, Solarino, Tsokos, Buschmann, & Oesterhelweg, 2017) and a study that examined 117 AEA deaths reviewed based on coroners' files (Blanchard & Hucker, 1991). The literature on AEA and masochism has led Hucker (2011) to argue that AEA is not sufficiently distinct from masochism. A related question that has not been sufficiently examined is the degree of overlap between AEA and partnered asphyxiophilia.

Additionally, previous research suggests overlap between AEA and transvestic fetishism (sexual interest in cross-dressing). Blanchard and Hucker (1991) examined autopsy reports from those who had died from AEA. They subsequently created a bondage (masochism) and transvestic fetishism scale based on information contained in the coroners' reports. They found that there was evidence of bondage and transvestic fetishism in the death scenes of those who died from AEA. Further, older individuals were more likely to engage in bondage or transvestic fetishism, suggesting that AEA practices might become more elaborate over time. Lastly, a curvilinear relationship between bondage and transvestic fetishism was observed. At moderate levels of bondage, there was increased evidence of transvestic fetishism; however, at both low and high levels of bondage, there was decreased evidence of transvestic fetishism. This was interpreted to suggest that strong paraphilic interest might inhibit other paraphilic interests from developing because of response competition, whereas moderate interest might result in the clustering of paraphilic interests.

Present Study

The present study represents the first large-scale community study of those with AEA. This is an important addition to the literature, as previous studies are weighted towards case studies and AEA deaths, which may not generalize to community participants who are not distressed or impaired by their AEA practice. The objective of the present study was twofold. Our first objective was to provide descriptive information about those who engage in AEA, such as the sex distribution, age of onset of AEA, safety precautions that are taken, how people discovered their interest in AEA, and their level of distress. The second objective was to examine the degree of overlap between AEA and different paraphilic interests. First, we hypothesized that there would be a positive association between AEA and masochism along with partnered asphyxiophilia. We also conducted exploratory analyses to examine the degree of overlap between AEA and other paraphilic interests. Second, we hypothesized that there would be a positive association between autoerotic asphyxiation and transvestic fetishism. Thirdly, we hypothesized that there would be a curvilinear relationship between masochism and transvestic fetishism in those with AEA.

METHOD

Participants

An online community sample of adults were recruited to participate in an anonymous online survey of AEA. In total 395 adults were included, as we excluded individuals who withdrew from the study by not completing the survey (n = 169) and those who did not spend an adequate amount of time on the survey by spending less than ten minutes completing the survey (n = 8). Although 395 participants were included in the present study, some participants elected to not answer certain questions and were excluded from a subset of analyses resulting in variation in sample size depending on the analysis. Participant descriptive information for the sample is contained in Table 1. Participants ranged in age from 18 to 61, but the sample was weighted towards young adults (M = 25.9, SD = 8.5). Most in our sample were female, Caucasian, and predominately heterosexual (identified as heterosexual or mostly heterosexual).

Measures

AEA Questionnaire. A questionnaire was developed to enquire about interest in AEA, due to the absence of established questionnaire on AEA (see Appendix A). These questions were developed by the first and third author after reviewing the literature on AEA. AEA was operationalized for participants at the start of the questionnaire as experiencing sexual arousal through deliberate oxygen deprivation by means of hanging, ligature, or suffocation of oneself during masturbation. It was further specified that the term autoerotic asphyxiation means that a person does the act to themselves.

After reading the definition of AEA, participants were first asked questions about sexual arousal in AEA using the same seven-point scale from the Paraphilia Scale (see below) with responses ranging from very repulsive (1) to very arousing (7). They also reported on lifetime AEA behaviour using the same type of five-point scale used in the Paraphilia Scale: 1 (never) to 5 (once a week or more on average). To learn more about their AEA practice, participants were asked several follow-up questions, but only if they endorsed interest or engagement in AEA. They were asked how old they were when their interest and engagement in AEA first emerged, how they first learned about AEA, and if they remembered how their first encounter with AEA occurred. They were asked about their level of comfort with AEA on a five-point scale ranging from extremely comfortable (1) to extremely uncomfortable (5), as well as interest in seeking treatment for AEA. Lastly, they were asked to check off all the safety precautions they utilized when engaging in AEA. For the questions that enquired about how participants learned about AEA and the safety precautions, we included an open-ended response option if participants selected "other." For those respondents who provided text-based responses, we manually grouped responses by theme to examine their frequency.

Paraphilia Scale (Seto, Lalumiere, Harris, & Chivers, 2012). The paraphilia scale consists of 40 items describing different paraphilias. Participants completed the scale for sexual interest by rating their level of arousal to each paraphilia on a seven-point scale ranging from very repulsive (1) to very arousing (7). Although there is limited data on reliability and validity, this scale has been utilized as a self-report measure in several other studies of paraphilic interests (e.g., Bouchard et al., 2017; Seto et al., 2012).

A mean paraphilia score was calculated for each participant by calculating the mean of the items that enquired about paraphilias. Two items were excluded that asked about sexual arousal to men and women, since these items do not assess paraphilias. We calculated the mean score in two ways: by considering the mean paraphilia score with the masochism items included and considering the mean paraphilia score with masochism items excluded. We used this approach because it is possible that any relationship between AEA and the mean score might be inflated by the inclusion of items asking about masochism.

In addition to the mean scores, we created paraphilia subscale mean scores for the various paraphilias following the approach utilized by Dawson et al. (2016). This resulted in several subscale scores: voyeurism, exhibitionism, scatologia, fetishism, transvestic festishism, frotteurism, sadism, masochism, biastophilia, urophilia, scatophilia, hebephilia, pedophilia, and zoophilia. For the analyses, hebephilia and pedophilia subscales were merged to form a pedohebephilia subscale score based on research suggesting that that individuals with sexual interest in prepubescent and pubescent children share many similarities (Stephens, 2015). Additionally, we examined the single-item question on the paraphilia scale that enquires about partnered asyphyxiophilia (i.e., you are having your breathing restricted during sexual activity), given our interest in examining the overlap between partnered asphyxiophilia and AEA. Higher scores were suggestive of a greater degree of arousal to that paraphilic interest.

Procedure

Participants were recruited by advertising the survey on Reddit and Twitter. The online survey was hosted on Qualtrics. An anonymous survey format was utilized since individuals are more likely to self-disclose paraphilic interests when they are completely anonymous (Griffiths, 2012; Joyal & Carpentier, 2016). Given the lack of literature in the area, we believe that an online survey holds merit as an important first step in improving our understanding of AEA in community participants.

To recruit the sample on Reddit, we posted the survey in general survey/sex-related subreddits, in addition to sub-reddits that were specific to kink and Bondage, Dominance, and Sadomasochism (BDSM). First, we made several general postings in the subreddits such as "r/SampleSize" and "r/sex" where the survey was advertised as a study on "sexuality" or "sexual interests and behaviours." We then posted the survey in the same two subreddits, in addition to various other subreddits (i.e., "r/BDSMAdvice", "r/SexAddiction, "r/bdsm", "r/Masochism", "r/paraphilia", "r/sexadvice", "r/slaa", "r/hyper-sexuality", and "r/BDSMgonewild"), specifically recruiting for an "anonymous survey on autoerotic asphyxiation (18+)." As we were unable to locate discussion groups or online communities specific to AEA, we decided that the best way to recruit our sample was to post in groups dedicated to paraphilias, BDSM, and hypersexuality and clarify that we were seeking participants who were interested/engaging in AEA. We utilized a similar recruitment approach using Twitter. The third author first posted on Twitter recruiting participants to participate in a study on sexual interests and behaviour and posted a second tweet specifically recruiting those interested in AEA.

Participants who saw our recruitment advertisements were directed to an informed consent form. After reviewing the informed consent, participants were asked to answer three questions about the informed consent page to ensure that they had adequately reviewed it. If they provided consent and answered these questions correctly, they completed the survey which took approximately 30 minutes. Participants answered questions about their AEA practice, sexual interest, mental health difficulties, alcohol and drug use, sexual sensation seeking and adverse childhood experiences. For the present study, we used a subset of the collected data to address the research questions that guided our study. The study was approved by the university research ethics board.

Data Analysis

To address the first objective to provide descriptive information about AEA, those who endorsed mild to strong arousal in AEA (n = 165, 41.8%) were classified as having AEA. Therefore, AEA was operationalized based on sexual arousal. Table 1 provides descriptive information for those with and without AEA. For those who endorsed AEA, frequency data on AEA practices are provided. We also considered the full breakdown of AEA interest and behaviour for the entire sample and conducted supplementary analyses to examine differences in AEA interest or behaviour by biological sex.

To examine the degree of overlap between AEA and other paraphilic interests, we utilized the full sample (n = 395) and considered the intercorrelations between the AEA sexual interest score, the paraphilia mean score (with and without the masochism subscale), and the paraphilia subscale mean scores. We also considered the correlation between AEA and the partnered asphyxiophilia item. For these analyses we conducted supplementary analyses to examine sex differences. Prior to examining the intercorrelations, we examined the normality of all variables of interest. Most variables had skewness and kurtosis values less than 2 and 7, respectively and Pearson correlations were used for these intercorrelations. For the scatophilia, pedohebephilia, and zoophilia, spearman correlations were utilized because these subscales produced skewness and kurtosis values that suggested issues with normality.

We next entered paraphilia subscale scores that were significant at the bivariate level into a multiple regression analysis to see what predictors would remain significant when considering other sexual interests. We were unable to examine the regressions separately by sex, due to the low number of men in the sample. Lastly, we restricted our analyses to those with AEA (n = 165) and examined whether there was a curvilinear relationship between masochism and transvestic fetishism by utilizing a two-stage hierarchical polynomial regression (the linear masochism variable was entered on the first step and the quadratic masochism variable on the second step). For the regression analyses, we did not violate the test assumptions (e.g., collinearity).

RESULTS

For the total sample (n = 395), the average response for sexual interest in AEA was 3.88 (SD = 2.12). Many reported that they found AEA very repulsive (22.1%; n = 87), somewhat repulsive (11.5%; n = 45), mildly repulsive (8.1%; n = 32), and 16.3% (n = 64) were indifferent. On the other end of the spectrum, 12.5% (n = 49) found AEA mildly arousing, 17.6% (n = 69) found it somewhat arousing, and 12% (n = 47) found it very arousing. Two participants did not respond to the question. When considering biological sex, the average response for AEA interest was 3.98 (SD = 2.08) for females and 3.64 (SD = 2.14) for males. An independent samples t-test indicated that there was not a significant difference in AEA interest scores based on biological sex, t(390) = 1.52, p = .130, d = 0.16.

When examining lifetime AEA behaviour, the average response was 1.92 (SD = 1.22). Most participants had never engaged in AEA (54.1%; n = 213), 19.8% (n = 78) had engaged in AEA once or twice, 11.9% (n = 47) had engaged in AEA once a year or more on average, 9.9% (n = 39) engaged in AEA once a month or more, and 4.3% (n = 17) engaged in AEA once a week or more. An independent sample t-test indicated that there was a significant difference in the AEA behaviour score with females engaging in AEA (M = 2.00, SD = 1.27) more often than males (M = 1.74, SD = 1.04), f(329.60) = 2.11, p = .035, d = 0.22.

In terms of overall paraphilic interests, the average score on the paraphilia scale was 3.33 (SD = 0.78) with the masochism subscale included and 3.03 (SD = 0.79) without the masochism subscale included. The average score for the paraphilia subscales and the percentage of individuals who endorse mild to strong interest for the different paraphilias are reported in Table 2. We also provide the breakdown of paraphilic interests by biological sex.

Descriptive Information about AEA

Participants who endorsed AEA were asked a series of questions to obtain descriptive information about AEA practice (see Table 3). On average, participants were in late adolescence when they first developed the interest or engaged in AEA for the first time. Most participants indicated that they learned about AEA through the internet, followed by through a partner/friend, pornography, and television. Participants were asked about their comfort with their interest in or AEA behaviour. The average response for this question was 2.64 (SD = 1.33) and only 18.6% reported they were uncomfortable. Further, almost all participants indicated that they did not have any interest in pursuing treatment for AEA. We also asked about safety mechanisms that participants employed during AEA. Most participants indicated that they had a partner relieve them of the asphyxiation or that they did not use safety precautions, while just under 15% of participants said that they used their hand or held their breath. A smaller number of participants indicated that they used slip-knots, hanging from shorter structures, or a belt or collar as safety precautions. The results are also broken down by biological sex in Table 3 so that interested readers can examine the different responses for females and males.

AEA and Other Paraphilic Interests

As expected, there was a significant positive correlation between AEA and the paraphilia mean score r (393) = .49, p < .001, even when the masochism subscale was excluded from the paraphilia mean score, r (393) = .38, p < .001. The results were the same for females (paraphilia mean score .50, p < .001 and paraphilia mean score without the masochism subscale .40, p < .001) and males (paraphilia mean score .52, p < .001 and paraphilia mean score without the masochism subscale .43, p < .001).

As expected, there were significant positive relationships between AEA, masochism, and transvestic fetishism (see Table 4). There was also a significant association between AEA and partnered asphyxiophilia r (393) = .64, p < .001. Significant relationships were found between AEA and all other paraphilias except for scatophilia. Nonetheless, with the exception of masochism and partnered asphyxiophilia, the magnitude of the effects was small.

A multiple regression analysis with AEA interest as the outcome and predictors representing the paraphilia mean subscale scores that were significant at the bivariate level was significant F (12, 350) = 16.83, p < .001. In total, 37% of the variance in AEA was accounted for by other paraphilias. When examining the beta coefficients, only masochism was significantly associated with AEA when all other sexual interests were considered (see Table 5).

Lastly, we restricted the analyses to the subset of our sample classified as having AEA (n = 165) to examine if there was a curvilinear relationship between masochism and transvestic fetishism. Both step one F (1, 161) = 1.15, p = .284, [R.sup.2] = .01 and step two F (2, 160) = 0.63, p = .537, [R.sup.2] change = .001 were not significant and explained very little variance. The results suggest that there was not a linear or quadratic relationship between masochism and transvestic fetishism within the context of AEA.

DISCUSSION

Understanding AEA as a Sexual Practice

Given the focus in previous AEA literature on highly select samples, our first objective was to better understand AEA practices in a community sample. Interestingly, those with AEA were predominately female (68%) and there was no difference in the intensity of sexual interest in AEA between females and males; however, women engaged in more frequent AEA behaviour compared with men. These findings are in contrast with the literature from case studies and AEA death scenes where samples were predominately male (e.g., Sauvageau & Racette, 2006). The high number of women in our sample is also in contrast to the wider body of research on paraphilias that suggest men are more likely to have paraphilic interests than women (e.g., Abel et al., 1988; Dawson et al., 2016; Langstrom & Seto, 2006).

We believe there are two possibilities for these findings. First, there was significant overlap in our sample between AEA and masochism and previous research has suggested that sex differences in paraphilic interest may not be as large for masochism (e.g., Bouchard et al., 2017; Dawson et al., 2016; Joyal & Carpentier, 2016). We unfortunately did not have the ability to conduct supplementary analyses to examine whether those with AEA only were more likely to be men because of the small sample with AEA only (1%).

Another possibility is that men may be more likely to have a severe manifestation of AEA resulting in fatalities or significant impairment compared with women. This appears to be somewhat supported in the present study, given that none of the women were interested in seeking treatment, but approximately 4% of men expressed an interest in treatment. Further, it appears that men may have been more likely to endorse using potentially lethal means to induce asphyxia (e.g., 11% of women endorsed that they hang from a shorter structured compared to 15% of men). Nonetheless, it was clear from our study that most individuals who engaged in AEA were comfortable with the practice and would arguably differ from clinical samples or individuals who have died from the practice.

Our results suggested that just under half of our sample reported learning about AEA through television or the internet and a review of an open-ended question suggested that several participants first learned about AEA through news stories about people who died from the practice. This is a concerning finding as it suggests that individuals may be introduced to AEA through media stories that are skewed towards more severe cases. One potential implication is that media coverage of AEA should avoid sensationalized reporting of AEA cases, particularly when reporting on those who have died from the practice. This is consistent with a much older recommendation from a case study of a man who died from AEA after viewing a television show about AEA. The authors argued that the media might be an unsuitable format to discuss AEA because of the potential risk of imitation (O'Halloran & Lovell, 1988).

Our concerns about media depictions of AEA are similar to concerns about media coverage of suicide and its impact on suicidal behaviour. For example, reporting how individuals died by suicide in media coverage is correlated with suicidal behaviour (e.g., Niederkrotenthaler et al., 2009, 2010). Further, reporting on celebrity suicides is associated with suicide rates (Niederkrotenthaler et al., 2009). Both findings are important to consider, because sensationalizing AEA deaths might be associated with AEA fatalities or people attempting unsafe AEA practices. Based on what we know about the reporting of suicide, it is possible that emphasizing certain aspects of AEA in media coverage (e.g., safe ways to practice AEA) may help to reduce riskier practices. Future research should examine the association between different types of media reporting and AEA fatalities.

Lastly, from the examination of safety procedures, it was clear that many participants used their hands or held their breath when engaging in AEA, which is at odds with the published literature that reports more extreme methods to induce hypoxia (e.g., hanging, strangulation; Blanchard & Hucker, 1991; Sauvageau & Racette, 2006). This adds further support to our overarching conclusion that there are important differences between community and clinical samples and that community samples are likely engaging in much less riskier manifestations of AEA. Despite these findings, there were individuals in our sample who were distressed and using riskier safety mechanisms (e.g., hanging, using a slip knot) and a substantial number who reported using no safety mechanism at all. Future research should investigate the factors that are associated with riskier manifestations of AEA, including the possible role of biological sex in riskier manifestations of AEA.

AEA and Paraphilic Interests

The second aim of the present study was to examine the degree of overlap between AEA and other paraphilic interests. The most striking finding was the high degree of overlap between AEA and masochism. There was a moderate association between AEA and masochism and virtually everyone (99%) with AEA endorsed masochism. When all other paraphilic interests were considered, masochism had the strongest relationship with AEA based on an examination of the beta weights. Further, there was a strong relationship between AEA and partnered asphyxiophilia. These findings contribute to further justification of AEA's classification as a subtype of masochism in the DSM-5 and is aligned with past case studies and unpublished research on AEA (Hucker, 2011; Martz, 2003; Tattoli et al., 2017).

There was also a significant degree of overlap with AEA and other paraphilic interests at the bivariate level, though the effects were small. Further, the pattern for the bivariate correlations was largely the same with a couple of exceptions (e.g., moderate sized association between AEA and scatologia for women, but a small non-significant association for men). This finding is consistent with the wide body of literature that suggests significant overlap between paraphilic interests (e.g., Abel et al., 1988; Langstrom & Seto, 2006). Nonetheless, the association reported in the past literature between AEA and transvestic fetishism (e.g., Blanchard & Hucker, 1991; Byard, Kostakis, Pigou, & Gilbert, 2000; Johnstone & Huws, 1997) was only supported at the bivariate level.

The curvilinear relationship between masochism and transvestic fetishism in the context of AEA deaths (Blanchard & Hucker, 1991) was not found in the present study. Our finding may not be inconsistent with the results from Blanchard and Hucker (1991) as they inferred sexual interest from behaviour described in coroners' reports, whereas we asked participants directly about interest in transvestic fetishism. Further, there are likely key differences between community samples and those who have died from the practice. Lastly, as Blanchard and Hucker (1991) report, the practice often becomes more elaborate over time and our sample was younger on average, so paraphilic practices may not have been as elaborate in the sample.

It is important to note in that we are not suggesting that all manifestations of AEA are disordered. In fact, in the most recent revisions of the ICD, sexual masochism has been completely removed from the diagnostic manual (Krueger et al., 2017). In line with this, the DSM-5 (American Psychiatric Association, 2013) differentiates paraphilic interests and paraphilic disorders. Given that many people in our sample who endorsed AEA reported that they were comfortable with their interest and were not engaging in dangerous manifestations of the practice, it is likely that most of our sample could be viewed as having a paraphilia, though we cannot definitively conclude this from self-report data. The present findings underscore the importance of recruiting broad community samples to understand the way individuals practice alternative sexualities, as it may shed light on how people can incorporate these interests into their sex life in a healthy manner. This could be useful information for people who seek out clinical services because of distress or impairment related to AEA.

Limitations

The present study is not without its limitations. First, we used an anonymous online survey to collect self-report cross-sectional data and lacked additional information that could be gathered from an interview or file information to supplement our findings. Despite this limitation, online anonymous surveys increase disclosure of sensitive information and are particularly useful for research on sexual interests and behaviours that are taboo (Griffiths, 2012; Joyal & Carpentier, 2016).

Further, there were individuals in our sample who reported having a partner relieve them of the asphyxiation when engaging in AEA. It would have been helpful to have further information about the partner's role to ensure that the partner was not also inducing the asphyxiation, which would be more consistent with partnered asphyxiophilia. Nonetheless, we clearly operationalized AEA for participants and question about the role of the partner specify that the partner relieves them of the asphyxiation. The partnered asphyxiophilia item explicitly references sexual activity but does not necessarily specify that this behaviour is dyadic. It is possible that individuals with AEA may have interpreted sexual activity to include occasions where they have engaged in AEA. Unfortunately, we were unable to clarify responses to these items due to the method of data collection and future research should clarify the role of partners in AEA practices.

Another limitation is that the high co-occurrence of AEA and masochism may be driven by our recruitment method since we were unable to seek out AEA specific groups and recruited many participants through BDSM groups. Further, many in our sample participated in BDSM forums and may have been more connected to the kink community. It is possible that these findings would not generalize to people who engage in AEA and are isolated from communities that practice AEA or other alternative sexual practices. Additionally, isolation might be a risk factor for riskier manifestations of AEA.

Future Research Directions

The present study highlights the need for additional research on AEA utilizing community samples. Future research should aim to recruit broader representative samples by considering ways to recruit participants with AEA who could be followed prospectively using a mixed-method design. Utilizing interview-based data collection would allow for more in-depth information that could provide a more thorough understanding of AEA.

Future research should also examine the practice of AEA for those who have fully integrated it into their sexual life and are not distressed by their practice. Given that AEA can be a fatal practice, it would also be helpful to understand differences between those who engage in riskier manifestations of the practice compared with those who have incorporated it into their sex lives in a healthy manner and those who may be distressed or impaired. Additionally, future research should examine the mechanisms by which AEA is connected to sexual pleasure and the positive features of the practice.

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APPENDIX A

AEA Questionnaire

Autoerotic asphyxiation is defined as the experience of sexual arousal through deliberate oxygen deprivation by means of hanging, ligature, or suffocation of oneself during masturbation. The term autoerotic asphyxiation means a person does the act to themselves. Please answer the question below.

1. How sexually arousing or repulsive do you find the thought of deliberately cutting off your oxygen supply by means of hanging, ligature, or suffocation of oneself during solitary sexual activity (e.g., masturbation)?

[] Very Repulsive

[] Somewhat Repulsive

[] Mildly Repulsive

[] Indifferent

[] Mildly Arousing

[] Somewhat Arousing

[] Very Arousing

[] Prefer Not to Answer

2. How many times in your life have you deliberately cut off your oxygen supply by hanging, ligature, or suffocation during solitary sexual activity?

[] Never

[] Once or twice

[] Once a year or more on average

[] Once a month or more on average

[] Once a week or more on average

[] Prefer not to answer

For the next 4 questions, if the question does not apply to you, please select "N/A" or write "N/A" in the box provided.

3. At what age did your interest in autoerotic asphyxiation start? If you do not know the exact age, please provide an estimate. If this question is not applicable to you, please write n/a.

4. At what age did you first engage in autoerotic asphyxiation? If you do not know the exact age, please provide an estimate. If this question is not applicable to you, please write n/a.

5. Can you remember how you first learned about autoerotic asphyxiation?

[] Partner/Friend

[] Pornography

[] Television

[] Internet

[] Other. Please specify. --

[] This question is not applicable to me

[] Prefer not to answer

6. If you engaged in autoerotic asphyxiation before, can you remember when your first encounter with it came about? For example, did you actively seek and plan for the experience, did it happen in the moment, or something else? Please briefly explain.

If this question is not applicable to you, please write n/a.

7. What (if any) safety precautions do you take when engaging in autoerotic asphyxiation? Please select all that apply.

[] Tie a 'slip-knot' in strangulation tool (e.g., in rope)

[] Hang from something shorter than myself so I can stand up and relieve the strangulation

[] I have a partner relieve me of my strangulation/suffocation method

[] Other. Please specify: --

[] I do not take any kinds of safety precautions

[] This question is n/a to me

[] Prefer not to answer

8. How comfortable are you with your autoerotic asphyxiation interest/behaviour?

[] Extremely comfortable

[] Somewhat comfortable

[] Neither comfortable nor uncomfortable

[] Somewhat uncomfortable

[] Extremely uncomfortable

[] This question is n/a to me

[] Prefer not to answer

9. Are you interested in pursuing treatment for your autoerotic asphyxiation interest/behaviour?

[] Yes

[] Maybe

[] No

[] This question is n/a to me

[] Prefer not to answer

10. If treatment was available, what you would like the treatment to focus on?

If this question is not applicable to you, please write n/a.

Emily Baxendale [1], Kailey Roche [1], and Skye Stephens [1]

[1] Department of Psychology, Saint Mary's University, Halifax, NS

(1) A paraphilic disorder is only diagnosed if the individual reported significant distress and/or impairment, otherwise the individual is said to have a paraphilia, but not a paraphilic disorder (American Psychiatric Association, 2013).

Correspondence concerning this article should be addressed to Skye Stephens, 923 Robie Street, Halifax, NS BH3 3C3, Canada. Telephone: 902-420-5083. E-mail: skye.stephens@smu.ca
Table 1. Descriptive Information for the Total Sample (n = 395)

                                    Total Sample      AEA (n = 165)
                                      (n = 395)

Age                                26.0 (SD = 8.5)   26.2 (SD = 8.9)

Sex at          Male                    35.0%             32.7%
Birth           Female                  65.0%             67.3%

Gender          Woman                   58.6%             60.0%
Identity        Man                     33.0%             27.3%
                Trans Woman              1.0%              2.4%
                Trans Man                1.5%              0.6%
                Gender fluid             4.1%              7.9%
                Other                    1.8%              1.8%

Ethnicity       African American         1.0%              1.3%
                Asian                    2.6%              1.3%
                Caucasian               86.5%             85.6%
                East Indian              0.5%              1.3%
                First Nations            1.8%              3.1%
                Other                    7.5%              7.5%

Sexual          Straight                35.8%             28.0%
Orientation     Mostly Straight         25.9%             21.3%
                Bisexual                28.9%             39.6%
                Mostly Gay               1.8%              1.2%
                Gay                      3.0%              3.0%
                Asexual                  1.0%               --
                Other                    3.6%              6.7%

Relationship    Single                  26.2%             21.8%
Status          Dating                  12.0%             15.2%
                Committed               30.8%             27.9%
                  Relationship
                Common Law               7.9%              9.1%
                Engaged                  4.8%              4.2%
                Married                 14.2%             13.9%
                Divorced                 0.5%              1.2%
                Other                    3.6%              6.7%

                                   No AEA (n = 228)

Age                                25.8 (SD = 8.3)

Sex at          Male                    36.6%
Birth           Female                  63.4%

Gender          Woman                   57.7%
Identity        Man                     37.0%
                Trans Woman               --
                Trans Man                2.2%
                Gender fluid             1.3%
                Other                    1.8%

Ethnicity       African American         0.9%
                Asian                    3.6%
                Caucasian               87.1%
                East Indian               --
                First Nations            0.9%
                Other                    7.6%

Sexual          Straight                41.2%
Orientation     Mostly Straight         29.4%
                Bisexual                21.1%
                Mostly Gay               2.2%
                Gay                      3.1%
                Asexual                  1.8%
                Other                    1.3%

Relationship    Single                  29.6%
Status          Dating                   9.7%
                Committed               32.3%
                  Relationship
                Common Law               7.1%
                Engaged                  5.3%
                Married                 14.6%
                Divorced                  --
                Other                    1.3%

Note. Participants were classified as having AEA if they expressed
mild to strong sexual arousal in AEA. Those who reported
indifference or disgust were classified in the non-AEA group.

Table 2. Descriptive Information on Paraphilic Interests
for the Sample (n = 395)

                           Total Samples           Females
                             (n = 395)             (n = 256)

Paraphilia               Mean (SD)      %       Mean (SD)      %

Voyeurism               3.70 (2.03)   44.1%    3.27 (1.95)   35.5%
Exhibitionism           1.87 (1.35)    5.7%    1.73 (1.25)    3.5%
Scatologia              1.80 (1.31)    4.8%    1.82 (1.40)    6.6%
Fetishism               3.90 (0.85)   53.4%    3.70 (0.81)   47.7%
Transvestic Fetishism   3.93 (1.49)   46.0%    3.88 (1.37)   41.2%
Frotteurism             2.45 (1.74)   18.0%    2.32 (1.70)   16.0%
Sadism                  4.21 (1.37)   84.4%    3.97 (1.32)   82.4%
Masochism               4.94 (1.44)   93.4%    5.24 (1.28)   95.7%
Biastophilia            2.96 (1.87)   41.0%    2.53 (1.68)   29.9%
Urophilia               2.56 (1.69)   26.6%    2.39 (1.61)   22.7%
Scatophilia             1.21 (0.71)    3.0%    1.14 (0.54)    2.0%
Pedohebephilia          1.27 (0.73)    8.7%    1.20 (0.62)    5.1%
Zoophilia               1.51 (1.28)    7.8%    1.56 (1.37)    9.0%

                          Males (n = 138)

Paraphilia               Mean (SD)      %

Voyeurism               4.53 (1.93)   60.1%
Exhibitionism           2.10 (1.48)    9.4%
Scatologia              1.75 (1.14)    1.4%
Fetishism               4.27 (0.79)   64.5%
Transvestic Fetishism   4.00 (1.70)   54.8%
Frotteurism             2.67 (1.80)   21.0%
Sadism                  4.64 (1.37)   88.2%
Masochism               4.37 (1.56)   89.1%
Biastophilia            3.77 (1.93)   61.6%
Urophilia               2.87 (1.80)   34.1%
Scatophilia             1.34 (0.94)    5.1%
Pedohebephilia          1.41 (0.89)   15.3%
Zoophilia               1.43 (1.00)    5.8%

Note. The average scores are based on the continuous paraphilia
subscale scores with scores ranging from 1 (very repulsive) to 7
(very arousing). For the % variables we dichotomized the responses
so that the paraphilia was judged as present if participants average
responses were suggestive of mild to strong sexual arousal in that
domain.

Table 3. Descriptive Information about AEA Practices (n = 165)

                                     Total      Females    Males
                                     Sample     with AEA   with AEA
                                     with AEA   % (a)      % (a)
                                     % (a)

Age Interest                         17.15      17.02      17.45
Started (b)                          (4.74)     (4.18)     (5.90)

Age Behaviour                        18.15      18.13      18.19
Started (b)                          (4.47)     (4.39)     (4.69)

Where they       Partner/Friend      25.0%      29.4%      16.0%
learned about    Pornography         16.4%       9.8%      30.0%
AEA              Television          11.2%      10.8%      12.0%
                 Internet            30.3%      33.3%      24.0%
                 Other               17.1%      16.7%      18.0%
                 Noticed by Chance    4.2%       3.6%       5.6%
                 Sexual Encounter     1.2%       0.9%       1.9%
                 Self                 3.6%       3.6%       3.7%
                   Experimentation
                 News Stories         0.6%         0%       1.9%
                 Books                1.8%       2.7%         0%
                 Parent               0.6%         0%       1.9%
                 Cannot Remember      1.2%       0.9%       1.9%

Comfort with     Extremely           22.4%      21.0%      25.5%
AEA Interest/      Comfortable
Behaviour        Somewhat            34.0%      33.3%      35.3%
                   Comfortable
                 Neither             25.0%      24.8%      25.5%
                   Comfortable
                   nor
                   Uncomfortable
                 Somewhat            16.0%      19.0%       9.8%
                   Uncomfortable
                 Extremely            2.6%       1.9%       3.9%
                   Uncomfortable

Interest in      Yes                  1.3%         0%       4.2%
Treatment        No                  94.0%      95.1%      91.7%
for AEA          Maybe                4.6%       4.9%       4.2%

Safety           Slip-Knot           11.5%       9.9%      14.8%
Procedures       Hanging from        12.7%      10.8%      16.7%
Used               Short Structure
                 Partner Relieves    20.0%      21.6%      16.7%
                   Them
                 None                18.8%      18.9%      18.5%
                 Other               24.2%      24.3%      24.1%
                 Hold Breath          3.6%       2.7%       5.6%
                 Hand                10.3%      14.4%       1.9%
                 Belt/Collar          3.0%       1.8%       5.6%
                 Pillow               1.2%       1.8%         0%
                 Safer Materials      2.4%       0.9%       5.6%

Note. Analyses were restricted to those who were classified as
having AEA based on reporting mild to strong sexual arousal to AEA.
Some participants who reported AEA did not provide responses to
these questions so sample sizes varied depending on the question.
For the questions that asked about how was AEA was learned an
"other" category was provided for respondents to provide an
open-ended response and the responses that follow other are based
on our review of the dominant themes in these responses. The
question about safety precautions used a checklist format so
respondents could provide multiple answers. The responses that
follow other for safety precautions are based on our review of the
dominant themes in open-ended responses.

(a) Unless otherwise indicated.

(b) Mean (SD).

Table 4. Bivariate Correlations Between AEA and Other Paraphilias

Paraphilia                Total Sample    Females      Males
                           (n = 392)     (n = 255)   (n = 138)

Voyeurism                    .10 *         .14 *        .13
Exhibitionism                .18 **       .19 **       .21*
Scatologia                   24 ***       .31 ***       .12
Fetishism                   .18 ***       .17 **      .28 **
Transvestism Fetishism      .19 ***       .19 **       22 **
Frotteurism                 .18 ***       .19 **       .20 *
Sadism                       27 ***       .30 ***     .30 ***
Masochism                   .58 ***       .59 ***     .61 ***
Biastophilia                 22 ***       .24 ***     .27 **
Urophilia                    22 ***       .23 ***     .22 **
Scatophilia                   .09           .08         .13
Pedohebephilia               .12 *          .10        .20 *
Zoophilia                    .16 **         .10       .24 **

Note. Intercorrelations were examined between the continuous AEA
sexual interest score and each paraphilia subscale scores for the
total sample. Pearson correlations are reported for all but
sctaophilia, pedohebephilia, and zoophilia. For these three
paraphilia mean subscale scores, spearman correlations were used
due to the skewness and kurtosis values. Some participants did not
provide responses to questions about other paraphilic interests and
were excluded from the analyses.

* p <. .05 ** p < .01 *** p < .001

Table 5. Multiple Regression Analysis predicting AEA from other
paraphilias (n = 395)

Paraphilia         b     SEb     P         t          95% CI

Voyeurism         .07    .06    .07       1.18      [-.05, .18]
Exhibitionism     .06    .09    .04       0.76      [-.10, .23]
Scatologia        .06    .08    .04       0.72      [-10, .22]
Fetishism         .01    .12    .004      0.08      [-.23, .25]
Transvestic       .09    .07    .07       1.39      [-.04, .22]
  Fetishism
Frotteurism       .03    .07    .02       0.43      [-.11, .17]
Sadism            .10    .09    .06       1.09      [-.08, .27]
Masochism#        .78#   .07#   .53#   11.35 ***#   [.64, .91]#
Biastophilia      -.01   .07    -.01     -0.18      [-.15, .13]
Urophilia         .08    .06    .06       1.25      [-.04, .20]
Pedohebephilia    .04    .15    .01       0.27      [- 25, .33]
Zoophilia         -.02   .08    -.01     -0.20      [-.17, .14]

Note. All of the paraphilia subscale that demonstrated a
significant bivariate association with AEA were entered
into a multiple regression analysis with continuous AEA
sexual interest variable as the outcome variable. The
paraphilia mean subscale scores were the predictors.
Significant predictors are in boldface.

*** p < .001

Note: Significant predictors are in #.
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Author:Baxendale, Emily; Roche, Kailey; Stephens, Skye
Publication:The Canadian Journal of Human Sexuality
Date:Dec 1, 2019
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