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This is the Advisor's report on Hypoxyphilia, as it is currently called in DSM-IV, submitted at the request of the DSM-5 Paraphilias Subworkgroup of the Sexual and Gender Identity Disorders Workgroup. The background literature is reviewed together with information from the author's recent and as yet unpublished research derived from an internet survey of more than 100 living practitioners of this paraphilic activity. It is recommended that the term "asphyiophilia," already used in the literature, is preferable as there is little to indicate that the effects of oxygen deprivation per se are the primary motive for the behavior; rather, it is sexual arousal to restriction of breathing. It is properly regarded as a severe and potentially dangerous manifestation of Sexual Masochism which can result in physical harm or death and therefore should be identified as such, perhaps as a specifier. However, there is no good reason to identify it as a separate paraphilia though it should be named in the DSM-5 text as it is a well-recognized and unusual mode of death. Less severe forms of Sexual Masochism which do not threaten life or otherwise cause serious physical harm should not be regarded as mental disorders.

Psychopathic personality disorder and sexual sadism share several common characteristics, such as emotional detachment from the suffering of others or the preparedness to inflict pain or injuries. Based on a sample of 100 male forensic patients (all of them sex offenders, half of them sadistic), the concept of psychopathy and sexual sadism as a unified construct was tested empirically. Pooling indicator variables for psychopathic and sexually sadistic disorders showed that a two-factorial solution yielded a better fit than a single-factor model. The two factors identified psychopathy and sexual sadism as separate latent variables. More specifically, the data were compatible with a path model in which affective deficits and behavioral disinhibition of the psychopathy domain are precursors to sexually sadistic conduct.

As asphyxial episodes during autoerotic activity are rarely reported in women, a review of eight fatal cases and one near-fatal case was conducted to delineate more clearly the characteristics of this syndrome in women. Six cases involved characteristic fatal autoerotic asphyxial activity. The remaining two fatal cases were atypical in that the apparatus that was used for sexual purposes was not intended to cause asphyxia in one case and did not directly cause asphyxial death in the second case. The final case was not fatal. Significantly, the majority of women did not use unusual clothing, props, or devices to augment their activity, for example, five were completely naked and only one was found with elaborate clothing and extra ligatures. Six of the fatal cases had objective evidence of sexual activity, three had used neck padding to prevent chafing, and eight had failed self-rescue mechanisms. Of note, the initial impression in four cases (44%) was homicide (two), attempted suicide (one), and accidental death during sexual activity with a partner (one). These results support the assertion that the manifestations of female autoerotic asphyxial activity reported to date may be initially misleading to investigators. Our purpose in presenting these findings, therefore, is to increase awareness of the more subtle features of this syndrome in women in an attempt to reduce the potential for underdiagnosis or confusion with nonaccidental death in future cases.

At first sight the phenomena discussed in this paper may seem to have little in common. Yet on close scrutiny it becomes apparent that there is an interesting degree of overlap. Although sexual assaults in general clearly involve multiple causes or factors, social and cultural as well as individual, many sexual aggressors do show psychological or biologic abnormalities which require careful evaluation. Continued empiric study of the variables discussed in this paper is therefore important. The clinical as well as laboratory study of paraphilias with dangerous tendencies to themselves or others is also essential for a better understanding of the causes and relationships between these disorders.

Autoerotic asphyxia is the practice of self-inducing cerebral anoxia, usually by hanging, strangulation, or suffocation, during masturbation. This study investigated the relationships between: asphyxiators' ages; two paraphilias commonly accompanying autoerotic asphyxia, bondage and transvestism; and various other types of simultaneous sexual behaviour. Subjects were two concurrent series totalling 117 males aged 10-56 who died accidentally during autoerotic asphyxial activities. Data concerning sexual paraphernalia at the scene of death or among the deceased's effects were extracted from coronors' files using standardised protocols. Anal self-stimulation with dildos, etc., and self-observation with mirrors or cameras were correlated with transvestism. Older asphyxiators were more likely to have been simultaneously engaged in bondage or transvestism, suggesting elaboration of the masturbatory ritual over time. The greatest degree of transvestism was associated with intermediate rather than high levels of bondage, suggesting that response competition from bondage may limit asphyxiators' involvement in a third paraphilia like transvestism.

Autoerotic asphyxia is an increasingly recognised syndrome in which accidental death occurs during solitary sexual activity due to failure of an apparatus that was designed to produce hypoxic augmentation of the victim's sexual response. Evidence of repetitive, secretive behaviour utilizing ropes and ligatures characterizes cases involving either males or females. Here the similarity in reported cases ends with males tending to utilize a far greater range of elaborate devices and props, often designed to cause real or simulated pain with pornographic material and evidence of cross-dressing and fetishism. Females, on the other hand, have usually been found naked with only a single ligature and no unusual or bizarre equipment. To further clarify the similarities and differences between typical cases involving males and females and to assist in the diagnosis of less obvious cases, the literature is reviewed and characteristic findings in both sexes compared and contrasted.

This article reviews the types of sexual anomaly that are especially likely to result in the physical harm or even death of the affected individual. Detailed descriptions based on the literature and the author's clinical material are given. Despite widespread awareness of masochistic behavior, our knowledge of its causation and the most effective method of treatment are still incomplete.