It was a bit of a shock to hear a 14-year-old schoolgirl announce casually to everyone in the class that she was “into kink”. We were in front of 20 other young people in a talk about the potential risks around internet porn. That was already three years ago. ‘Breath play’ or ‘air play’ is potentially lethal. The porn industry and its pundits have rebranded non-fatal strangulation as “play” so it sounds safe and fun. It isn’t. You just need to consent and it’s all ok. It’s not. Police have informed us that sexual strangulation is one of the fastest growing areas of crime today. New research indicates a wide range of injuries that can be sustained by this activity. For instance according to lead researcher, Dr Helen Bichard, “Sexual strangulation is the second most common cause of stroke in women under 42.” It is clear that pornography use is a contributory factor in making such sexual behaviour seem normal and even attractive.

Part of its attraction is the belief that by restricting the airways, a person can experience a bigger sexual high. According to a Sunday Times porn survey in 2019 on how internet pornography is changing sexual attitudes, twice as many young women as young men in Gen Z rated BDSM and rough sex as their favourite genres of porn. It’s found all over the web as well in most social media apps. However the real hidden damage is not from restricting oxygen because people can survive for a few minutes without oxygen. The real terror is from blocking the jugular vein that allows deoxygenated blood from the brain to return to the body. When the vein is restricted the blood builds up in the brain and can cause a stroke. A person can pass out in as little as 4 seconds with pressure on the jugular vein. Sometimes the stroke happens hours, days or weeks after the event making it harder to link to the sexual strangulation event. Often too the victim can’t even remember what happened as the acute stress affects the brain’s memory system.

Sadly, in cases like Grace Millane, “breath play” can go too far. Grace was a British backpacker in New Zealand. A young guy she’d just met online fatally strangled her in a sexual assault. Grace is far from the exception. It’s the cool, edgy sexual sport for youth today. Worth knowing that the young man convicted of her murder had told Tinder dates that he liked strangulation.

What are people really consenting to when they are ignorant of the health and legal consequences? See our research about the health and legal policy considerations governments need to heed to tackle this growing risk to women and girls.


New medical research on sexual strangulation

In an excellent article by Louise Perry in Standpoint Magazine, we learn about new research by Dr Helen Bichard. Dr Bichard is a clinician at the North Wales Brain Injury Service. She talks about “a range of injuries caused by non-fatal strangulation that can include cardiac arrest, stroke, miscarriage, incontinence, speech disorders, seizures, paralysis, and other forms of long-term brain injury.” Dr Bichard goes on to say that “the injuries caused by non-fatal strangulation may not be visible to the naked eye, or may only become evident hours or days after the attack, meaning that they are far less obvious than injuries like wounds or broken bones, and so may be missed during a police investigation.” The study also reports, “Psychological outcomes included PTSD, depression, suicidality, and dissociation. Cognitive and behavioural sequelae were described less frequently, but included memory loss, increased aggression, compliance, and lack of help-seeking. However, no studies used formal neuropsychological assessment: the majority were medical case studies, or based on self-report.”

It takes less pressure to cause brain injury than it takes to open a can of Coke.  See this excellent article for more details. It is not possible to either give or withdraw consent if someone starts to choke you right away- and many do. This makes it illegal and highly dangerous to health.


breath play strangulation
Main structures vulnerable in strangulation (Bichard et al., 2020)



Yet sexology researchers say it’s “exciting”.

Sadly many researchers are not truly independent. Some are close to the porn industry, receive funding, don’t always report a conflict of interest and downplay the effects of porn’s impact. Too often their research is reported without careful scrutiny by busy journalists who are not trained in science nor aware of the games being played. This is leading to huge gaps in the public’s awareness and need for information with which to make informed choices about their behaviour.


Here is an excerpt from this sexology paper:

“Young people may benefit from learning how to talk about and negotiate consent related to choking and also how to mitigate health risks if they choose to engage in choking. Considering that people may enjoy one type of choking but not another, and that ligature strangulation has been found to be riskier than using hands (though either can be fatal) (De Boos, 2019; Zilkens et al., 2016), it may be important for sexuality educators to teach explicit ways of communicating about choking. Doing so may help people to understand the diverse ways people engage in choking and consider what they are, or are not, willing to try. Sexual health educators would be wise to discuss safe words as well as safe gestures, given that people who are being choked may be unable to speak and thus unable to effectively use words to end choking that they want to end.”

Too many sexologists are treating choking/sexual strangulation as a healthy extension to sexual exploration without appreciating both the health and legal risks involved in the issue around consent. 

Here is what one neurosurgeon said in response to this research:

” If the authors don’t unequivocally warn about the danger of any pressure to the front of the neck in their discussion, it would be irresponsible of them at best, particularly as they are associated with departments of public health and health sciences.

First, any pressure on the carotid arteries risks carotid dissection, the most common cause of stroke in young people.  Even seemingly insignificant pressure can tear the intima of the artery.  In neurosurgery we routinely retract the artery during exposure of the anterior cervical spine, and we are always gentle in considering iatrogenic dissection.  There is no safe way to ‘grade’ when consensual pressure is ‘safe,’ particularly by sexually excited males.

Second, risk of dissection aside,  depriving the brain of oxygen in any degree, for any period, risks watershed ischemic events, and is never safe.  Erotic asphyxiation is hypoxia, and thus is always harmful and dangerous. There is no safe way to grade hypoxia.

Third, the carotid bodies are blood pressure sensors located in at the bifurcation of the carotid arteries into the internal and external carotids.

Physicians purposely perform carotid massage by gently applying pressure on the carotid bodies for certain diagnostic purposes.  This is the only indication for anyone putting any pressure of any kind on the front of the neck with the fingers.  It is alway performed only by a physician, and only with EKG  and pulse oxygenation monitoring.  This is because carotid body pressure will drop the blood pressure and pulse and sometimes cause the heart to quit beating in vulnerable patients.  The carotid bodies are located  in the mid to upper cervical spine, precisely where choking occurs.

In summary, there is never a safe way to put pressure on anyone’s neck, and any professional not specifying this in writing about this should be challenged.

It is ludicrous to suppose that a sexually aroused, porn trained male [or female] will be able to safely grade the degree of compression he [/she] is exerting on the carotid arteries and carotid body. His focus at that moment is certainly not on the well being of the human being he is assaulting.  This type of assault cannot ever be described as consensual, as there is no way to realistically give informed consent.”


Men strangling women

Strangulation is overwhelmingly perpetrated by men against women, but many lesbians and bisexual partners engage in it too. It is increasingly common in domestic violence cases. New Zealand introduced a criminal offence of Non-Fatal Sexual Strangulation in 2018. From January to June in 2019 over 700 charges were reported in New Zealand, around 4 a day.

Harriet Harman MP along with other MPs is trying to ban the ‘rough sex’ murder defence in the Domestic Abuse Bill. Brexit and now Covid-19 have delayed the passage of the Bill through Parliament. Some are calling it the “50 Shades of Grey” defence to murder during sex. Harmann called back in April 2020 “to stop this injustice” of the sex game defence which means that a man who admits to causing injuries that kill a woman “literally gets away with murder”.



We have to be aware of how culture can distort sexual behaviour, especially among the young. Glamourising consensual violence with sexual partners, 50 Shades of grey-style, without a counterbalanced view of the real risks involved, is a dangerous road to tread. Sexually adventurous, free speech activists are promoting lessons in schools about consent to BDSM. What they don’t mention are the real medical facts about the harms such as we see above nor the extremely difficult legal issues around consent when the “he said, she said” approach leaves juries in rape, sexual assault or homicide cases at a loss to know the truth. Until we take an honest medical and legal approach to this issue, many more young people will be injured for life or worse.


Mary Sharpe places the issue of sexual strangulation into the wider context of Problematic Pornography Use in this video…

 NB: BBC Woman’s Hour tackled this subject on 25th January 2023. It starts at 42.09. They talk about restriction of airways, but the real risk for strokes is the restriction of blood from the brain which can cause problems within 4 seconds of constriction by choking or sexual strangulation.