The shame of truth – death due to accidental autoerotic asphyxia

Introduction

Accidental autoerotic death (AAD) is uncommon in forensic pathology practice. ¹ Defined as accidental death, it occurs as a result of usually solitary, sexual activity when some type of apparatus is used to enhance sexual stimulation which causes unintentional death. AAD is typically caused using different devices and objects intended to increase stimulation and sexual pleasure.^2–7 The most common type is autoerotic asphyxia, which leads to deprivation of oxygen to the central nervous system, rapidly disrupting the central inhibition mechanisms that control sexual function, and results in an increased sexual response.^1,2,8 Most commonly, the hypoxic stage is achieved by self-strangulation, hanging, chest compression, or other methods such as plastic bag asphyxia, inhalation of noxious chemicals, autoerotic drowning, electricity, and sometimes a combination of them.^1,5,7,9–16

A common feature of AAD is the presence of a self-rescue mechanism to ensure survival and get out of a dangerous situation. However, a self-rescue mechanism is not required to diagnose AAD. In autoerotic asphyxia, death usually occurs due to problems with the self-rescue mechanism^2,4,17 which allows the practitioner to release the pressure and voluntarily decrease the grade of hypoxia. If this goes wrong and there is a faster loss of consciousness than expected, the self-rescue mechanism will not work and death results. We present a case of AAD with atypical findings.

Case report

A 37-year-old white male was found dead by his mother in her apartment. He was hanging naked on a Swedish wall with a soft belt (3.5 cm wide) around his neck (Figure 1).

The deceased’s mother last saw him alive at 9 a.m. after he returned from a night spent in a nightclub. His mother went out for groceries, returning an hour later. She rapidly cut the belt, but realized her son was dead, and covered his body with an item of her clothing. She was ashamed of her son's behaviour and repeatedly asked the investigator to state that his death was due to a stroke.

At the scene, the victim was naked, wearing only black socks. The body was found supine on the floor in his mother's bedroom (Figure 2), in front of the Swedish wall, where his mother's clothes were hanging. A female dressing gown covered the body. The legs were flexed at the hip and knee joints and rotated to the right. Seminal dried fluid was observed on the glans penis and the inner aspect of the right thigh. There was a well-developed, unfixed, purple lividity located over the dependent parts of the body, except for the body areas exposed to pressure. The rigidity was well-developed in the facial and neck muscles and partially developed in the upper extremities. The body was still warm. No traumatic injuries were present over the body except for a ligature mark on the neck. There was a laptop and smartphone on the cabinet in front of the wall, protected by a password, making them impossible to access. The cut belt was on the victim’s chest. No information about the actual belt location on the neck was available.

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Figure 1.

Swedish wall.

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Figure 2.

Scene investigation: the body was found naked on the floor, with dried seminal fluid on the inner aspect of the right thigh (circled).

No suicide note, evidence of foul play, drug-use paraphernalia, or prescribed medication was present at the scene. No pre-existing psychiatric or medical conditions or recent trauma were known. The victim’s mother stated that he was happy with his personal and professional life.

An autopsy was ordered by the legal authority. External examination revealed diffuse facial cyanosis and palpebral petechiae. An obvious ligature mark was observed on the neck: on the posterior aspect of the neck there was a 2–2.5 cm in width, brownish-red ligature abrasion extending bilaterally on the lateral aspects of the neck. On the right and left side of the neck, the ligature abrasion became superficial and faint, extending frontward and upward up to the mandibular angle bilaterally. Finally, the right and left ligature marks joined at the chin level, where there were two irregular reddish-brown abrasions (Figure 3a–d). Multiple dot-like abrasions were also observed in the mid-third part of the anterior surface of the neck.

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Figure 3.

(a) Anterior aspect of the neck – bilateral ligature abrasions joining at the chin, with two irregular reddish-brown abrasions. (b) Posterior aspect of the neck – horizontal brownish-red ligature abrasion and (c–d) Lateral aspects of the neck – superficial, faint ligature marks on the right and left of the neck (black arrows).

Autopsy revealed congestion of the internal organs, oedema of the brain and lung, petechial haemorrhages under the pleura of the lungs, and dark red liquid blood. There was no injury to the larynx and hyoid bone.

Toxicological analyses performed on blood samples collected during the autopsy showed positive results for alcohol (170 mg/dl) and cocaine (0.2 mg/ml).

Based on the available evidence, death was found to be due to accidental asphyxia during autoerotic practice.

Discussion

The most common victims of autoerotic death are men, usually under forty.^4,9,18,19 Cases involving women are sporadic, and when they are found naked at the scene, suspicion for potential homicide and sexual abuse is raised.^4,10,19–22

Autoerotic asphyxia (hypoxyphilia) is frequently accompanied by non-lethal paraphilias such as transvestism and bondage, different props and devices for sexual stimulation, pain-stimulating agents, pornographic magazines, ropes, chains, rubber items, and chemical anaesthetics,^{1,3,16,23–26} which will support a finding of accidental death. However, even after thorough investigation, it is still essential to exclude suicide or homicide.^1,9,16,18

Moreover, typically, the family members of the victim are the first to discover the body and will usually be shocked and ashamed and unaware of the behaviour of their relative. Therefore, they may modify the scene before the police arrive to conceal the erotic nature of the death with its associated social stigma and protect their and the deceased's reputations.^9,17,18,23

This case shows several atypical findings of AAD.

Firstly, the body was completely naked. While undressing is common in suicides due to gunshot wounds and stab wounds, it is less common in asphyxia, and the deceased knew that he had only limited time to indulge in autoerotic asphyxia yet had fully undressed. It is open to question whether the risk of being discovered by his mother while he was engaged in his autoerotic practice increased his sexual arousal.

The accidental hanging was atypical. The ligature abrasion produced by the soft belt showed features consistent with a maximum loop pressure on the posterior aspect of the neck and the point of suspension located anteriorly. At chin level, the abrasions coming from the lateral aspects of the neck joined together. Due to scene alteration by the victim’s mother, who cut the belt, it was not possible to identify the belt’s position around the neck at the moment of death; two theories are proposed. The first involves a complete loop of the belt around the neck, with just one end of the belt moving frontward to the chin level and then fixed to the Swedish wall (Figure 4a). The second involves the intersection of the two ends of the belt at chin level and their fixing on the Swedish wall (Figure 4b).

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Figure 4.

Graphical reconstruction of potential asphyxia dynamics. (a) First theory: there was a complete loop of the belt around the neck, with just one end of the belt fixed to the Swedish wall and (b) Second theory: there was a crossing of the two ends of the belt at the chin level and their fixation to the Swedish wall.

In atypical hangings, asphyxia may occur due to head hyperextension with the subsequent forced forward movement of the cervical spine against the larynx and the tongue base, leading to their potential compression. Even though these structures are not compressed, death may result from compression of the carotid arteries and sinuses. It is possible that the atypical location of the suspension point represented a self-rescue mechanism that the victim used to control the grade of neck pressure and provide a safe exit in case of unexpected problems.

Further, the evidence of a slight ligature mark may indicate that the victim placed protective padding (such as a towel, clothes, or other soft materials) between the belt and the skin to prevent bruising and abrasions.^7,9,17,27,28 The multiple dot-like abrasions on the neck's anterior surface may represent the victim's attempt to free himself from the accidental hanging. However, it cannot be excluded that they may have been produced post-mortem while cutting the belt or by potential padding material or another object interposed between the belt and the skin.

The location of the hanging is also uncommon. The belt was fixed to a Swedish wall, a wall with gymnastic bars commonly used for home exercise. It could have given the victim the chance to step easily to each of the different bars to reach the desired level of neck compression to increase his sexual pleasure. However, it may also represent an additional self-rescue mechanism to prevent a fatal outcome.

The failure of the self-rescue mechanism(s) may be explained by an unexpected loss of consciousness due to a combination of alcohol and cocaine intoxication. It could have impaired the deceased's ability to judge the actual level of neck compression that eventually led to death.

In this case, even if plausible, it is not possible to confirm that the victim was using his electronic devices to watch pornography since they were protected by a password. However, such scenarios are common in AAD, and the evidence that the victim was practising autoerotic asphyxia in his mother's bedroom in the presence of such devices supports the hypothesized circumstance. The presence of dried seminal fluid may also suggest this. However, it does not necessarily indicate that masturbation occurred before death, as ejaculation may occur terminally due to neurophysiological reflexes, and semen may be present within the urethra in a variety of lethal conditions.^17,29

Finally, substantial evidence to support accidental sexual asphyxia is the mother's behaviour. She was not refusing to accept that her son was dead, but she was extremely ashamed and humiliated by the way he died. Her major concern was to keep the real cause of death secret because of the stigma. She altered the scene, cutting the belt, and was unwilling to provide information regarding the body and ligature positions at the time of the event.

According to the detailed scene investigation, the behaviour of the deceased's mother, the lack of pre-existing psychiatric conditions and any suicide note, and the autopsy and toxicological findings, the death was found to be accidental autoerotic asphyxia due to hanging.

Determination of the manner of death in AADs can be challenging and has a significant legal, social and economic impact that may affect payments of an insurance policy or wrongly charge a perpetrator with a homicide.^9,17,30 Thus, a multidisciplinary approach is required to reach the right conclusion.

Highlights

Autoerotic deaths are defined as accidental deaths that occur during individual, usually solitary, sexual activity in which some type of apparatus used to enhance sexual stimulation of the deceased causes unintentional death.