Minimising the Risk

Introduction and Background Sexual choking / strangulation encompasses a range of practices where pressure is applied to the neck to restrict air or blood flow during a sexual encounter. While choking is most commonly associated with the application of hands around a person’s neck, other limbs or ligatures, such as the forearm or rope, may also be used (Herbenick et al., Frequency 3122; Herbenick et al., Prevalence 1059). This article will predominantly use the term “choking” or “sexual choking” to match teen vernacular and public discourse. These terms, however, may be used interchangeably with other more context-specific terms used in the literature such as “breath play”, “strangulation”, “erotic asphyxiation”, and “sexual asphyxia” (Cardoso 1070; Vilhjálmsdóttir and Forberg 4). Recent studies exploring the prevalence of sexual choking (Sharman et al., Prevalence 1; Herbenick et al,. Prevalence 1068; Vilhjálmsdóttir and Forberg 24) indicate that sexual strangulation is a relatively common practice among young adults, including trans or gender-marginalised populations. In a recent Australian study, researchers found that 57% of participants (aged 18–35 years) reported being sexually strangled (from a sample of 4,702 adult Australians; Sharman et al., Prevalence 1). A US-based study of undergraduate and graduate students also found that choking during sexual encounters was consensual 92.1% of the time (Herbenick et al., Frequency 3130), indicating that choking can be a favoured and consensual activity between sexual partners. However, it is widely acknowledged and agreed upon that there is no adaptation of the practice that is entirely free from risk (Cardoso 1069; Schori et al 291); engaging in any form of the act can have harmful and potentially lethal consequences. The authors acknowledge that the devastating effects of sexual violence (including family and intimate partner violence (IPV) and sexual assault), which strangulation and non-fatal strangulation (NFS) form a part of, are a serious and significant issue (Bennett 167; White et al., 2); however, this article seeks to explore sexual choking practices within consensual contexts, given the rising prevalence of these behaviours. Pornography is often noted as the primary reason for the popularisation of sexual choking throughout modern discourse and existing research (Herbenick et al., Frequency 3135; Sharman et al., Prevalence 1). However, erotic asphyxiation and sexual hanging depictions are documented centuries earlier through renaissance paintings and prehistoric art such as Mayan relics (Tarr 57). In their study of 4,702 Australian adult participants (aged 18–35), Sharman and colleagues found that pornography was the most common way individuals reported first hearing about choking as a sexual activity (34.8%), whereas others discovered the concept via discussions with friends (11.5%; Prevalence 6). Other studies have identified shifts in sexual repertoire, such as choking, that may have been influenced by pornography (Herbenick et al., Diverse 624). However, much of public discourse is focussed on pornography’s influence without causal links. Nominal data taken from the Australian Research Council Project Adolescents’ Perceptions of Harm from Accessing Online Sexual Content which investigated teens' (aged 11–17 years) perceptions of pornography is explored in this article. Teens suggested that young people often mimic acts, such as sexual choking, that are depicted in pornography, and criticised pornography for not displaying safety parameters normally used in the BDSM/kink community. Some teens speculated that sexual choking may be a relatively common occurrence between young people. These teens suggest that there is a need for more accessible education and resources about risky sexual behaviours. This article explores teens’ perspectives of sexual choking through a sexological and public health lens and suggests that a broader harm reduction approach may result in better outcomes than an abstinence-only approach. This article may assist to inform public policy, public health strategies, and educational approaches. ‘Breath Play’ in BDSM/Kink The acronym BDSM stands for ‘bondage and discipline, dominance and submission, sadism and masochism’, can refer to a range of meanings and experiences, and often involves consensual power exchange, restraint, or intense sensations (Carlström 404; Lawrence and Love-Crowell 67; Schori et al. 293; Sprott 2). Breath play is an activity some may explore within BDSM/kink, and can include an array of activities that restrict airways or play with breath for sexual arousal (Sharman et al., Strangulation 1; Tomassilli et al., 439). BDSM has become popularised in recent years and is often misrepresented in the media, leading to pathologisation and misunderstanding of the practice (Ortmann and Sprott 34; Shahbaz and Chirinos 21). The BDSM/kink community prioritises safety as part of a “controlled set of practices governed by clear and identifiable cultural standards of behaviour” (Bennett 173). These practices require mutual consent to specific acts and refer to frameworks such as Safe, Sane, and Consensual (SSC), Risk-Aware Consensual Kink (RACK), and “safe words” (Bennet 164; Gewirtz-Meydan 584; Holt 928; Schori et al. 293), where safety is paramount. However, some of the most common injuries within the BDSM/kink community relate to breath play (a.k.a. “choking”; Sprott et al. 1723), including death (Schori et al. 295), and while informed BDSM practitioners are able to practice breath play in more aware and mindful ways, risk can never be fully eliminated (Holt 920; Schori et al. 291). Exploration through kink has been linked to healing and transformation of trauma, contributing to the development of a notion of healthy sexuality (Cascalheira et al. 373; Sprott 2). This exploration may provide a way to confront shame and explore desires and fantasies in a controlled, safe environment, which is compatible with a healthy, normal life (Lawrence and Love-Crowell 69; Gewirtz-Meydan, et al. 584; Sprott 4). Studies warn that in spite of concerns around the growing prevalence of sexual strangulation and choking, stigmatisation of kink-related activities is not conducive to improvements in public health for minority populations (Sharman et al. Prevalence 12; Herbernick et al., Frequency 3135). Shaming those who wish to engage in breath play and sexual choking (kink-shaming) is not advised, particularly given that this article explores that some teens may wish to engage in alternate sexual practices, potentially irrespective of the popularisation of such acts. Teen Perspectives A total of 49 interviews were carried out with 30 Australian teens aged 11–17 years; 30 were carried out in 2021–2022, with a further 19 interviews undertaken with the same teens at least one year later (2023). This research focussed on teen perspectives of pornography, and participants were predominantly recruited through social media. Permission was first sought via a parent who also agreed to an interview, as per the project’s ethics approval, and both parents and teens were given a small gift to thank them for their time. While discussing the impact of pornography, some teens instigated discussions around what they referred to as “choking”. Sexual choking was not the focus of the pornography study, and while the findings discussed were incidental, the organic discussions provide nominal insights into teens’ perspectives of sexual choking behaviours. One big danger with pornography is people start watching it and then they’ll start on the soft porn, and they’ll go from this into the next and that’s how they end up at BDSM. They’ll go to a partner and the partner’s also been watching it, but one of them doesn’t know about ‘aftercare’ and how to go and take care of the partner, or any of that sort of stuff, and while it starts well and they’ll have a hoot of a time, they don’t know proper limits, so they don’t know. For instance, if it’s choking, how to actually choke, because if you do it wrong, it’s not good. (Miles, 16) Miles illustrates a level of digital sexual literacy and awareness by utilising terms such as “aftercare”, a kink-specific terminology, which involves the checking-in and care of a sexual partner following a sexual encounter or “scene” (Fuentes 3). Miles used podcasts and social media to supplement his sexual knowledge, as he felt schools were not providing sufficient information, as is evident in other studies (Cardoso and Scarcelli 8). While most information sourcing for adults in BDSM and alternative sexual practices is done via self-directed means or social groups (Sprott, et al. 49), further availability of resources in non-formal environments could be useful to teens too. “Third-person media effects” may be evident in Miles’s reflection here, where individuals can perceive media to have a stronger influence on others than themselves (Perloff 357). Miles illustrates these effects while trying to make sense of his and his peers’ experiences. Miles speculates that pornography may inform young people’s sexual scripts, but often lack associated safety information that would normally accompany acts within the kink community. He believed the omission of safety information and relevant frameworks is where the harm lies. Similarly, Warren (17) stated: like if they’re watching hardcore stuff and they’re choking a girl, the girl might actually be getting suffocated by not doing it right, they could hurt the girl, like, a false idea of what it actually is. Warren recognised how the adoption of particular sexual scripts could be harmful when they occur without information to assist individuals to practise in safer ways. Given pornography has been explored as an influence for changes in sexual scripts and potentially contributes to popularising acts such as choking (Wright et al. 1100), these changes could be balanced with more available resources and education. In answer to whether resources could be of assistance, Warren answered: if there was a kink or something and they wanted to learn how to do that properly, it’d be good to have a video that they could actually learn. That’d be good. Teens recognised a gap, where more explicit educational resources could assist teens practicing risky behaviours, whether influenced by pornography or not, to engage in ways that can potentially reduce harm. The danger of teens potentially mimicking acts without being educated or informed about safety parameters, was further explored by Miles (16): in my cohort, sexual choking is seen as something that’s a bit risky, but a bit cool, and the girls are into it – but don’t really know how, so there’s a lot of lines that are crossed because they don’t know how to set them up or while there might be safe words, they might not actually know how to implement them and have only seen porn where the safety borderlines are set beforehand, all you see is the porn. Miles reflected that safety practices such as “safe words”, or prior discussions of consent are seldom depicted in mainstream pornography. “Safe words” are a previously agreed-upon word or gesture which communicates to a partner the need to immediately cease a sexual activity (Weiss 78). Although borrowed from BDSM/kink, these frameworks could be considered as part of mainstream communication and harm-minimisation strategies (Herbernick et al., Frequency 3134) and could also be adopted as part of wider sexuality education skill development. It must also be considered that teens may perceive choking to be a risky, “cool” sexual practice and thus may feel peer pressured to engage. Indeed, existing research (Sharman et al. Strangulation) posits that “wanting” to engage in choking behaviours may reflect social conditioning (11), much like other sexual behaviours. Seraphina (12) shared that most young people she knew had seen pornography: “even girls watch that stuff pornography as well, like, with girls doing it, like, pretty much everyone has watched it or has come across it”. She implies that pornography viewing is widespread among teens, where some teens may be inspired by acts depicted in porn. Given choking was perceived as “cool” or “risky”, some teens may perceive expectation and/or pressure to engage in sexual choking, whereas some teens may genuinely desire to engage in these acts. These findings suggest that teens could benefit from education which encourages them to introspect and reflect upon whether they genuinely wish to engage in sexual acts or whether they feel socially pressured to do so. Most teens claimed that they were able to discern that porn is a fantasy and not very representative of reality; “you probably have to also keep in mind if you are looking at that sort of stuff, that it’s staged or fake or whatever and that that’s not realistic necessarily” (Heath, 14). Despite this, some young people believed their peers had a tendency to mimic what they had seen online: yes, it can be harmful for a load of people mainly because some dumb men might see a video and try to do it pornographic acts to a woman. (David, 11) A lot of people copy what they see online in general anyway, especially with the TikTok trends and everything so I reckon that people would copy things online. But I think it’s still pretty bad, I'm not sure why you’d want to copy things like that acts in pornography, I mean sometimes I can understand TikTok trends but I think that’s on a different level and it’s just pretty bad. (Lauren, 13) These findings are supported by existing research (Rothman et al. 743; Smith 71), which found that young people often imitate what they see in pornography. Teens believe their peers can be quite impressionable, particularly in the digital age, and may be primed to copying behaviours online. Arguably, media literacy, including pornography literacy, could assist in encouraging teens to be aware of risk and to be more critical of the content they consume. Given the prevalence of choking behaviours among young people, educational programs and relevant messaging could consider discussing alternate sexual practices and how to engage in safer ways (Herbernick et al., Frequency 3133; Wright et al. 1105), particularly given that the predominant message that young people receive is to abstain, yet behaviours persist. Harm Reduction While it is widely acknowledged that there is no “risk-free” way to engage in choking behaviours (Cardoso 1069; Schori et al. 291), there is a need to acknowledge that there are some that will continue to practice or experiment with these behaviours. In the same way that a “zero tolerance” attitude around illicit substances and other sexual practices impedes help-seeking behaviours, acts as a barrier to education and information, and drives these behaviours underground, so too will an abstinence-only approach to sexual choking. Many authors have written about the dangers and ineffectiveness of abstinence-only sex education programs (particularly in the United States; Heals; LeClair; Santelli Abstinence; Santelli Abstinence-Only; and others), but there is also a significant amount of literature available relating to sex work, HIV/AIDS, chem-sex, and other high-risk sexual behaviours highlighting that “abolition is not effective in reducing those harms and indeed may, in fact, exacerbate them” (Dea 340). Harm reduction is an important yet controversial strategy that provides an “alternative to the moral/criminal” approaches in public health (Dea 302–4). While abstinence is the ideal goal, harm reduction seeks to reduce the harm associated with stigmatised behaviours through a larger, nested approach that allow experts and governments to acknowledge that these behaviours occur within society, without supporting the risky behaviour (Hickle 302; Wellbourne-Wood 407). This approach takes a morally neutral stance which shifts the emphasis to health and human rights, and acknowledges that social approaches are a more suitable and more effective approach (Denis-Lalonde 321; Hawk et al. 4; Hickle 302; Keane 228; Steenholdt and Colquhoun 12). Harm reduction incorporates a range of strategies, including education, information provision, prevention, care guides, and first aid training, along with policy, legislative, and punitive measures (Dea 305; Denis-Lalonde 318; Hawk 2). To reduce harm to individuals who may engage in sexually risky behaviours, experts must navigate barriers such as stigma, marginalisation, or lack of awareness (Sansone et al. 3). The criminalisation of sex work, for instance, can result in increased risk and harms, as sex workers may be afraid to seek help when they are in danger (Dea 305). Harm reduction interventions, on the other hand, link vulnerable and marginalised individuals with experts capable of providing necessary assistance, information, and education (Hickle 302). The criminalisation of risky sexual behaviours alone places clinicians, sexual health practitioners, and those seeking help, assistance, or information, in a problematic position (Piatkowski et al. 62). When faced with an individual seeking assistance, the practitioner must decide whether to aid in the minimisation of potential harms or follow legally sanctioned procedures (referral to domestic family violence services or police referral; Victoire 875). On the other hand, individuals face challenges in seeking help and support due to the stigma and fear associated with the illegal nature of these health behaviours (Piatkowski et al. 62; Stangl et al. 1). As Treloar states: “it’s really hard to step up and identify with living with a stigmatised condition or identity or practice. For someone who’s prohibited criminalised on top of that, the fear of repercussions is even greater” (Treloar in Australian Academy of Science). Stigma, discrimination, and marginalisation of individuals who engage in alternative sexual practices, by both medical professionals and others, is widespread (Bezreh et al.; Hansen-Brown et al.; and others). In order to seek help, an individual needs to feel confident that they will not face criminal sanctions from the police, nor will they be subject to stigma or marginalisation from society (Sansone et al. 7). Conclusion There is little published evidence on how teens perceive sexual choking and strangulation practices. This article offers nominal insight into teens' perspectives of choking depicted in pornography, and speculates on the prevalence of the practice among their peers. Like adults, teens indicated that many young people (of all genders) share an inclination to partake in alternative sexual practices such as “choking”. Participants also recognised that their peers were uneducated in terms of “safer” alternative practices, often learning BDSM/kink-inspired acts from pornography. However, young people felt that pornography could be misleading, given that safety parameters normally implemented in the kink scene were not often displayed on screen, leaving room for potentially dangerous consequences. Some teens suggested that resources and educational information could assist them to navigate these practices in safer ways. More adolescent-focussed research with a greater sample size is needed, with research questions more specifically aligned with the prevalence of sexual strangulation and teens’ interpretation of these risky sexual behaviours, particularly given the limitations of this study sample. The authors note that this article neither advocates nor condones these behaviours. 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