Each year, approximately 1.3 million women in the United States will experience various forms of aggression by an intimate partner. The clinical implications of “choke-holds” and lethal outcomes have recently garnered national attention. Nonfatal strangulation (NFS) and blows to the head or face resulting in traumatic brain injury (TBI) represent forms of aggression that create short and long-term sequelae for the victim – including non-adaptive mental health sequelae such as depression, anxiety, and ptsd.
Since the early 2000s, researchers, advocates, and lawmakers have recognized the lethal aspects of Nonfatal Strangulation (NFS) for women experiencing partner-inflicted violence. Once recognized, these research endeavors were the impetus for changing state laws making NFS a felony rather than a misdemeanor assault (e.g., obstruction of breathing). The Training Institute on Strangulation Preventioneducates advocates in a variety of professions and contexts regarding NFS and also provides a nation-wide indication of which states consider this crime a felony. A recent report published by the Government Accountability Office (GAO) and submitted to congressional committees, acknowledges that partner inflicted brain injuries occur from blows to the head and strangulation and public health resources are needed to determine the incidence and prevalence of this issue (United States Government Accountability Office, 2020)
Choking during sex is prevalent among young adults in the United States, with significantly more women than men reporting a history of having been choked (Herbenick et al., 2022). Choking during sex is technically a form of strangulation as it involves using hands or a ligature to apply external pressure to the front and/or sides of the neck to restrict the airways or blood vessels. However, people usually refer to this form of strangulation as “choking”. The 2016 National Survey of Pornography, Relationships, and Sexual Socialization (NSPRSS) —a U.S. nationally representative survey—found that 21% of women ages 18 to 60 had ever been choked during sex. However, choking was most prevalent among younger women, with more than 35% of women ages 18 to 29 having been choked during sex (Herbenick et al., 2020). In contrast, approximately 15% of U.S. men ages 18 to 29 reported having ever been choked. More recently, a 2020 survey of randomly sampled students from a U.S. university found that 58% of women, 26% of men, and 45% of transgender and gender non-binary participants had ever been choked during sex, suggesting that choking may be increasing in prevalence (Herbenick, et al., 2021).
As choking/strangulation during sex is prevalent among young adults in the United States, and studies have examined associations between having ever been choked and participants’ current mental health symptoms (e.g., feeling depressed, anxious, sad, lonely) in the prior 30 days and in the prior year. In one study, participants were 4352 randomly sampled undergraduates who completed a confidential online survey and reported lifetime partnered sexual activity. 33.6% of women and 6.0% of men reported having been choked more than five times. After adjusting for demographic characteristics, having been choked remained significantly associated with all four mental health outcomes, except for overwhelming anxiety among men (Herbenick, et. al., 2021).
Scientific knowledge about the long-term health risks of non-fatal strangulation is largely derived from research on strangulation occurring as part of intimate partner violence (IPV) as well as research on The Choking Game. Also sometimes referred to as the “fainting game,” “space monkey,” or “pass out,” The Choking Game is a non-sexual game in which young people strangle themselves or a peer to produce a head rush or feeling of euphoria; but again, youth call this form of strangulation “choking”. In these contexts, strangulation - especially when done repeatedly or at greater intensities - involves health risks that may be immediate (e.g., loss of consciousness, death) or delayed (e.g., stroke, death). Long-term consequences of non-fatal strangulation include depression, post-traumatic stress disorder, recurrent headaches, tinnitus, and anxiety. Having been choked/strangled multiple times - whether from IPV or the adolescent choking game – is associated with elevated risk of such health sequelae.
Even though choking during sex has become prevalent among U.S. adolescents and young adults, little is known about potential short- and long-term health consequences of being choked during consensual sex aside from scattered media articles and forensic reports of unintentional deaths. From a physiological perspective, choking during sex can occlude the blood vessels and/or airways, depriving the oxygen supply to the brain, which can cause insidious neurologic impairment, especially if it occurs repeatedly. Yet there are also important differences between strangulation types. For example, The Choking Game is often done with the goal of passing out and experiencing a head rush or euphoria, whereas IPV strangulation often occurs as an escalation of threat and violence. Also, IPV strangulation often occurs alongside other forms of violence, such as blunt force trauma to the head.
Additionally, it may be that being choked makes people feel like they have less agency or autonomy over their own bodies. When choking/strangulation is done in ways supported by consent conversations, communication, safe words and safe gestures, aftercare, and other safeguards championed by some members of kink and BDSM communities, being in a submissive role may feel comfortable or even empowering—though, even with such supports, choking and other forms of strangulation may still lead to unintentional deaths. However, popular media articles combined with the limited research on contemporary, mainstream choking/strangulation during sex suggests that most young people are not engaging in choking with these kinds of supports. Thus, it may be that being choked in the mainstream ways it is often enacted—often without clear consent, communication, safe words or gestures, sobriety, or a familiar partner—leads to a diminished sense of sexual and/or reproductive autonomy, and may increase feelings of learned helplessness, thus increasing risk for poorer mental health.
Notably, there may be a physiological mechanism that accounts for the relationship between being choked during sex and mental health symptoms. The interruption of cerebral blood flow combined with hypoxia from respiratory arrest can manifest transient neurologic symptoms, such as headache, dizziness, blurry vision, and disorientation. Chronic and frequent deprivation of oxygen and glucose in the brain can trigger uncontrolled release of glutamate, which can lead to excitotoxicity, calcium overload, and free radical formation within neurons. In other words, frequent choking can significantly hinder neuronal communications; ultimately, it can lead to the development of mental health symptoms. Such relationships between neurologic insults (e.g., TBI, ischemic stroke, non-fatal strangulation in IPV), acute symptom provocation (e.g., headache, dizziness), and emergence of mental illness have been documented.
Biological sex also likely plays a role in influencing resiliency or vulnerability to choking-induced cerebral ischemia. Epidemiological data suggest that females may respond more adversely to concussive injury and ischemic injury with greater injury severity and requiring longer recovery time compared to their male counterparts. While many underlying factors for these sex differences have been proposed and studied, such as anatomical/musculoskeletal differences, sex-hormone levels, and genetic influence, these factors are highly intertwined and difficult to isolate
Finally, it may be that people who are already experiencing sadness, depression, loneliness, and/or anxiety are more likely to seek out and/or be receptive to choking/strangulation as part of partnered sexual experiences. It has been suggested that some subset of people who have experienced trauma may subsequently explore historically non-normative forms of sex to reclaim their own power and heal from such traumas; this has been described through auto-ethnographic scholarship and warrants further attention in subsequent qualitative and empirical research, and specifically in the context of choking.
Resources:
Ending Violence Association of BC (2019 April). Non-Fatal Strangulation. https://endingviolence.org/wp-content/uploads/2019/07/EVA-Notes-Non-Fatal-Strangulation.pdf (includes strangulation signs and symptoms, and “The Five Strangulation Questions).
Herbenick, D., Guerra-Reyes, L, Patterson, C., Rosenstock-Gonzalez, Y.R., Wagner, C., & Zounlome, N. (2022 February). "It was scary, but then it was kind of exciting": Young women's experiences with choking during sex. Archives of Sexual Behavior, 51(2). 1103-1123. Available from: https://link.springer.com/article/10.1007/s10508-021-02049-x
Herbenick, D., Fu, T.C., Patterson, C., & Rosenstock, Y.R. (2021). Prevalence and characteristics of choking/strangulation during sex: Findings from a probability survey of undergraduate students. Journal of American College Health. DOI:10.1080/07448481.2021.1920599
Herbenick, D., Fu, T.S., Wright, P., Paul, B., Gradus, R., Bauer, J., & Jones, R. (2020)
Diverse sexual behaviors and pornography use: Findings from a nationally representative probability survey of Americans aged 18 to 60 years. The Journal of Sexual Medicine, 17(4), 623-633.
Training Institute on Strangulation Prevention (Free online training, resource library, and legislation map). Available from: https://www.strangulationtraininginstitute.com
United States Government Accountability Office (2020 June). Report to Congressional Committees (GAO-20-534 Domestic Violence). Domestic violence: Improved data needed to identify the prevalence of brain injuries among victims. Available from: https://www.gao.gov/assets/gao-20-534.pdf