Accidental autoerotic deaths between 1978 – 1997 Institute of Legal Medicine, Medical School Hannover D. Breitmeier a,*, F. Mansouri a, K. Albrecht a, U. Böhm b, H. D. Tröger a, W. J. Kleemann b aInstitute of Legal Medicine, Medical School Hannover, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany bInstitute of Legal Medicine, University of Leipzig, Johannisallee 28, D-04103 Leipzig, Germany Abstract Between 1978 and 1997 the Institute of Legal Medicine of the Hannover Medical School examined 17 fatal autoerotic deaths. The incidence for the Hannover region was 0.49 cases per 1 million inhabitants per year. The victims included 17 men with an average age of 36.8 years; a peak in the age distribution was seen between 20 and 29 years. 12 of the men were found by friends or family in a domestic environment, while other situations in which the victims were found included the victim’s own car, a hotel room, a canal embankment, a public parking lot as well as the holding cell of the youth detention center. The men were of varying socioeconomic status and held a number of different types of jobs or still attended school. 5 of the men were found completely nude, while 5 were only undressed below the waist. 4 men wore women’s clothes and 2 were fully clothed with exposed genitals. Besides women’s clothes, other objects found at the scene included various types of sexual aids, including ropes, chains, metal bars, locks, sex magazines, condoms, plastic bags, rubber items, etc. In four cases blood alcohol levels between 0.1 and 2.5 ‰ (urine alcohol levels between 0.2 and 2.5 ‰) were found. Toxicologic examination revealed chloroform, ketamin, a propane-butane gas mixture in one case each, and in two cases cocaine and morphine. Causes of death included central paralysis after strangulation (7 cases), * Corresponding author: Tel.: 0511 532 4599, Fax: 0511 532 5635, e-mail: [email protected] 1 asphyxiation (4), subarachnoid hemorrhage (2), intoxication (1), hypothermia (1), left heart failure (1), and drowning (1). The history, findings at scene, and autopsy findings and, in individual cases, other investigations are of utmost importance to accurately reconstruct a fatal autoerotic accident. Keywords: autoerotic accident, accidental autoerotic death, cause of death, death scene, psychical and social personality Introduction A portion of autoerotic accidents results in serious injury of varying degree; many of these injuries are not recognized or not reported [1]. Fatal autoerotic accidents that are not specially designated in the cause-of-death statistics, are often found in the forensic literature in the form of case reports. These deaths are also partially labelled as suicides [7- 10] due to the in part unusual circumstances in which the body is found [2-6]. Homicides have also been known to be disguised as an autoerotic accident [11]. However, despite the frequent description of these accidents, little is known about their incidence. The aim of this work was to retrospectively gather epidemiologic data and to describe the characteristics of the circumstances in which the body was found as well as autopsy results for fatal autoerotic accidents in the jurisdiction of the Institute for Legal Medicine at the Hannover Medical School between 1978 and 1997. Materials and Methods All cases of legally-mediated autopsies and viewings of bodies in the Institute for Legal Medicine at the Hannover Medical School as well as the case files of district attorney’s offices were evaluated. This work considers all fatalaties occurring during autoerotic activity as accidental autoerotic deaths (AAD), regardless whether the death is natural or not. 2 Results Between 1978 and 1997 the Institute of Legal Medicine of the Hannover Medical School performed 15,687 forensic examinations (autopsies, viewing of bodies). The analysis of this data revealed seventeen fatal autoerotic deaths. An autopsy was performed in fifteen cases, in two cases the body was only viewed (Case 1-17). Eleven victims died in the Hannover region, six within the jurisdiction of the Institute for Legal Medicine in the areas around Hannover. All victims were males between the ages of 16 and 76 years (Table 1). One of the men was widowed, three were married, and thirteen were single. The cases included five employed men, four were unemployed, two engineers, two repairmen and one retiree, one school-age boy, and one architect. In one case it was not possible to identify the victim’s occupation. Twelve men died in their own or their parents apartments. Other locations in which the victims were found included: car, a jail cell of the juvenile jail, a hotel room, a frozen canal and a parking lot. Ten of the victims were known by friends and family. The other seven victims were found by police, firemen, a jail guard, a colleague at work, a passerby as well as a maid. Four of the victims were wearing women’s clothes when they were found (Table 2). Sexual aids that were found on or around the corpse are listed in Table 3. Traces of sperma was found on the body or clothes of nine victims. Sexually deviant behavior prior to the fatal incident could be identified in 3 of the men. In one case a videotape was found, in which the man had filmed himself during autoerotic activity. In a second case a married man was involved in sexual contact with prostitutes, with whom he undertook unusual techniques; one homosexual man undertook increasingly aggressive sadomasochistic techniques in the time before his death. Friends and family questioned by police indicated they had noticed no clues of any autoerotic activity while the victims were still alive. 3 The influence of alcohol could be shown in 4 of the men. The following blood-alcohol concentrations (BAC) and urine-alcohol concentrations (UAC) could be determined: Case 1 BAC 1.4‰ UAC 1.9‰ Case 4 BAC 1.3‰ UAC 2.5‰ Case 5 BAC 0.1‰ UAC 0.2‰ Case 14 BAC 0.6‰ UAC not measured Toxicologic analysis revealed the following substances: the anesthetic “Ketamin” in the therapeutic range (1-6 µg/ml) was found in Case 16 (2.5 µg/ml), chloroform in Case 11, a propane-butane gas mixture inhaled from a plastic bag was found in Case 17. Cocaine or morphin derivatives were found in two cases (13, 14). Three men (Cases 9, 13, 14) were known to police as consumers of illegal drugs. Seven men (41.2%) died as a result of strangulation, four (23.4%) died secondary to asphyxiation due to rebreathing, and two died of a subarachnoid hemorrhage after ruptur of an aneurysm of a congenital vascular abnormality in the Circle of Willis. Other courses of death included acute left heart failure, intoxication, hypothermia, and drowning. Discussion Since not all regions fell under the jurisdiction of the Institute for Legal Medicine of the Hannover Medical School for the entire study period, the frequency of fatal autoerotic accidents was only calculated for the City and County of Hannover. The eleven cases of autoerotic accidents occurring in this region, for which the average population was 1,127,000 over the 20-year study period, results in an incidence of 0.49 cases/million inhabitants per year. A similar or slightly higher incidence was also calculated for other regions [2-17]. In light of our calculations and those found in the literature, the death rate in Germany attributable to autoerotic accidents is approximately 40 to 80 deaths per year. 4 However, a certain number of cases may be missed, as the circumstances surrounding the discovery of the victim might not always be clear; evidence may even be destroyed by family or friends of the victim out of shame [13, 18]. Unfortunately not every case underwent autopsy. In the literature one report describes a case in which a homicide was framed as an autoerotic accident [11, 19]. Almost all victims were found in a location that was either familiar to them or in which they felt they would not be disturbed or watched. The doors at the scene were often locked. Access to the corpse was often uncomplicated if the victim lived alone. As reported in the literature [12, 18, 24], our study found approximately 30% of the men were not clothed, while approximately 25% were wearing women’s clothes (often underwear) when they were found. This type of attire presumably provides additional erotic energy, thereby increasing the level of arousal. [26]. A total of eight men were under the influence of alcohol, drugs, medications, or other chemical substances in our study. The medication found in Case 16, Ketamin, is used in the field of Emergency Medicine, and creates a state of dissociative anesthesia [27]. Case 17 involved the inhalation of the aliphatic hydrocarbone propane and butane via a plastic bag; these gases can precipitate often fatal arrhythmias through stimulation of the vagus nerve [28]. Recent reports have describe an increased incidence of the abuse of gas inhalation in either pure form or as a mixture [20, 29, 30]. Inhalation of a local anesthetic [31], propane, laughing gas, and tetrachlorethylene [32-34] have been described. Toxicologic analysis revealed cocaine metabolites and morphine derivates in one case. The change in mental status and decreased reaction time associated with these substances could also play a role in the failure of safety mechanisms and the lack of the victims’ ability to save themselves [24]. In six of seven cases such safety mechanisms were in evidence. The men therefore setainly seemed aware of the danger inherent in self-strangulation. States of oxygen deprivation were created not only by strangulation, but also through the introduction of various objects into the oral cavity (socks, rubber balls, etc.) or by enclosing the victim’s 5 head in plastic bags, which in some cases were even fastened closed in some manner. Often you can only speculate about the victims’ prior experience regarding autoerotic fantasies [12]. The presence of sexually explicit magazines and pamphlets detailing, for example, bondage methods, provides evidence that the victim had previous experience with these topics. Strangulation was the most common cause of death in our study. The fact that the strangulation results in a relatively rapid state of hypoxia, which subsequently leads to an increase in sexual excitement and/or a more intensely experienced orgasm, as well as the method’s ease of use, is in our opinion largely responsible for the high incidence of self- inflicted hypoxia in the setting of autoerotic acts. This form of autoeroticism is also known as hypoxiphila, sexual asphyxiation or autoerotic asphyxiation [12, 36, 37]. These behaviors are categorized as masochism or tranvestic fetishism if the victim wears clothes of the opposite sex [38]. Because of the complexity of each individual case, it is often difficult to differentiate whether the case should be considered a homicide, an accident, or a suicide. The evidence gathered during an autopsy can often only be evaluated as a whole when analyzed together with the history. Therefore it is of utmost importance that the circumstances in which the victim was found, evaluation of data gathered at crime scene by an experienced forensic pathologist, and elucidation of the victims’s social situation should be considered together in the evaluation of these types of cases. 6 References [1] K.M. Kirksey, M. Holt-Ashley, K.L. Williamson, R.O. Garza, Autoerotic asphyxia in adolescents, J. Emerg. Nurs. 21 (1995) 81-83 [2] M.A. Rothschild, V. 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