Breath Control Play — A long and technical outline of practices and risks

In preparation for being on a breath control play panel at a local BDSM club, I organized this outline, and thought I would post it as well.

This writing represents ONLY my own thoughts and accumulation of research (my resources are varied and include everything from medical articles to Wikipedia to anatomy texts to my general nursing knowledge/experience) and not those of any of the other panelists or the SF Citadel. It is not in any way intended as an endorsement of breath control play of any kind (which is risky, dontchaknow). It’s really long and technical. As people have requested it, I’ve slowly added some citations- I did not originally include these because, as noted above, I originally wrote it up just to organize my own thoughts and didn’t really anticipate that you kinky people would actually read it! 😉

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Breath control play

“Breath control play” as practiced in BDSM is a broad and often misunderstood term, and physiologic effects are often not as they appear. Many common forms of “breath control” do not involve breathing at all, but rather focus on restricting blood flow to the brain. A common thread, however, is decreased oxygen levels in the brain, causing altered levels of consciousness. Different forms of “breath control” have different risks (and, perhaps, different rewards), so it’s important to differentiate between types.

There are three major subsets that can be considered under the umbrella of breath control play: choking, smothering, and strangulation. These are not “clean” divisions (definitions of these words aren’t clear either), and some types of play involve multiple modalities. But before we get into those specifics, let’s take a moment to discuss an indirect physiological effect: stimulation of baroreceptors.

Baroreceptors
• Blood pressure is normally regulated within a narrow range, which is important to maintain adequate blood flow to the organs. This is accomplished using information collected by pressure sensors, or baroreceptors. The most important baroreceptors are in the carotid sinus (in the neck) and the aortic arch (in the chest).
• These baroreceptors send information to sympathetic and parasympathetic (vagal) neurons in the brain, which regulate autonomic control of the heart and blood vessels.
• If the baroreceptors sense that pressure is low, the body reacts by increasing heart rate and constricting blood vessels (especially in arms/legs, to “save” blood for vital organs).
• If the baroreceptors sense that pressure is high, the body reacts by decreasing heart rate and dilating/relaxing blood vessels.
• Things that can stimulate baroreceptors, making the body think “holy fucking shit, pressure is high, better decrease heart rate and dilate blood vessels” include coughing, bearing down (such as when shitting), vomiting, being squeezed tightly around the chest, cold water to the face (sometimes called the “diving reflex”), and pressure on the neck.
o This is used for treatment/diagnosis of SVT (abnormally fast heart rate)- to slow the heart, medical professionals will ask the patient to cough or bear down (called the Valsalva Maneuver) or use carotid sinus massage (CSM) (these are both also referred to as “vagal maneuvers”).
– The medical procedure for CSM involves applying pressure for 5-10 seconds over the carotid pulse just below the angle of the jaw.
– This is done on ONLY ONE SIDE AT A TIME- “Simultaneous bilateral CSM is absolutely contraindicated, because cerebral circulation may be severely compromised.” -Roberts: Clinical Procedures in Emergency Medicine
– Other contraindications commonly listed include recent stroke or TIAs, recent heart attack or significant cardiac history, digoxin toxicity, and carotid bruit. Smokers and diabetics may be at increased risk.
– Some literature recommends against routine use of CSM due to risk of complications, which can include dislodging plaques or clots from the wall of the carotid artery, potentially causing a stroke. Other (rare) reported complications of carotid massage include cardiac arrest, initiation of “bad” heart rhythms such as atrial fibrillation and ventricular tachycardia, and carotid sinus syncope (blacking out). “Given that the rare potential adverse effects are catastrophic, most physicians do not routinely perform carotid massage.” -Tintinalli’s Emergency Medicine
– “With all vagal maneuvers, monitoring, IV access, atropine, lidocaine, and defibrillation should be available during the procedure.” – Roberts: Clinical Procedures in Emergency Medicine

Choking
• Choking means “to have severe difficulty breathing because of a constricted or obstructed throat or a lack of air.” Choking results in asphyxia, which is defined as “lack of oxygen in the blood due to restricted respiration.”
• Choking can be caused by a foreign body in the airway, respiratory diseases that restrict the airway, drowning, compression of the trachea, suffocation, severe allergic reactions, etc.
• For kinky purposes, choke holds that compress the trachea, such as the arm bar choke, are an uncommon variation on breath control.
o The trachea is cartilage and difficult to compress. Forensic pathology literature states: “The amount of pressure on the neck that can bring about loss of consciousness is remarkably low. It is said that five or six pounds of pressure per square inch suffice to occlude the carotid arteries and jugular veins. Thirty-two pounds are required to block the airway.” -Spitz and Fisher’s Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation, page 790.
o This pressure may damage the larynx and fracture the hyoid or other neck bones. “Older individuals may have an alkylosed hyoid bond or an ossified thyroid cartilage, which renders them more brittle and susceptible to fracture.” – Emergency Medicine Reports, Volume 31, Number 17
o Airway compression leads to frightening sensations of air hunger, and in martial arts, a fighter will often submit to such a hold.
o In some martial arts competitions (such as judo), chokes that are intended to target the airway are not allowed due to the considerable risk involved.
o Other mechanisms include those listed under “smothering” below.

Smothering
• Smothering means “to suffocate or stifle by cutting off or being cut off from the air.” This is technically a sub-set of choking (the mechanism is to obstruct air intake).
• In kink, this may be done with a pillow, plastic bag, by blocking the air intake tube of a gas mask or other devise, using hand(s) to obstruct the mouth/nose, etc, and may be partial or complete.
• Certainly the chance of direct damage to the airway is less with smothering vs. a choke hold, and it is “safer” in this way.
• The most obvious effect of smothering (and choking) is to decrease oxygen intake.
o Most people can hold their own breath for about a minute.
o The world record for stationary breath holding is 11 minutes and 35 seconds.
o Under normal circumstances, the human body can be without oxygen for about 3 minutes before cell death occurs. HOWEVER there can be other effects before then!
o Decreased oxygen levels can cause the heart to produce abnormal beats, called PVCs. In rare cases, a PVC hitting at a certain time in the cardiac cycle can cause cardiac arrest.
• Both choke holds and smothering can stimulate baroreceptors on the aorta. Gasping/struggling for breath increases pressure in the chest in a manner similar to the Valsalva Maneuver.
• Another physiologic effect of smothering is increasing carbon dioxide levels in the blood, which leads to a condition called “respiratory acidosis.” This may happen faster in smokers. This can initially cause headaches and drowsiness, in extreme cases leading to unconsciousness and even seizures. In healthy people, acidosis should quickly self-correct once the cause is removed.

Strangulation
• Strangulation is often used as a synonym for choking, but it has a second meaning that is more useful for our purposes: “constriction of a body part to cut off the flow of blood or other fluid.”
• In Judo, “blood chokes” are referred to as “strangleholds” or “strangles.” They may also be called “sleeper holds” or “lateral vascular neck restraints” (LVNR). These holds seek to compress the blood vessels without compressing the airway. They are widely considered to be safer than choke holds, though if the subject struggles, a “blood choke” can quickly become an “air choke.”
• There are three main sub-types of strangulation:
o Hanging- suspension from a line around the neck.
o Ligature strangulation, aka garroting- similar to hanging, but without suspension.
– For the same amount of pressure, decreasing surface area or increasing force increases “effectiveness” and, intuitively and also per forensic pathology literature, increases risk. Consider strangulation with a clothesline vs. a belt.
o Manual strangulation, using the hands or other body part- for example with LVNR.
– Studies on LVNR suggest that subjects with bigger necks and higher BMI tend to go unconscious quicker than smaller subjects.
– “When properly applied, the typical subject loses consciousness within 5-11 seconds, followed by a full recovery with no lasting medical complications.” -Journal of Applied Physiology, “Mechanism of loss of consciousness during vascular neck restraint.”
• Physiologically, several things happen when someone is strangled:
o Carotid artery occlusion: the carotid arteries supply about 70-80% of blood volume to the brain. The remaining 20-30% comes from the vertebral arteries (which are unaffected by this hold). Blocking the carotid arteries results in decreased flow of oxygenated blood to the brain. “The most important mechanism in loss of consciousness [in LVNR holds] was decreased cerebral blood flow caused by carotid artery compression.” -Journal of Applied Physiology, “Mechanism of loss of consciousness during vascular neck restraint.”
o Carotid sinus stimulation (similar to carotid sinus massage), causing decreased heart rate, decreased blood pressure, and decreased flow of oxygenated blood to the brain.
o Jugular vein occlusion, causing blood to “back up” in the brain (this is what cases someone’s face to go red) and interfering with the ability of fresh, oxygenated blood to flow into the brain. Some experts in forensic pathology believe this is the primary mechanism that causes death in most ligature strangulations. “Occlusion of venous outflow from the brain produces stagnant hypoxia… For manual strangulation… venous obstruction is a significant factor that produces loss of consciousness.” -Emergency Medicine Reports, Volume 31, Number 17
o Depending on the force used, there will be some compression of the trachea, but restriction of air flow this way is not considered a major mechanism in most strangulations (even hangings). “Direct injury to the trachea is rare with strangulation.” -Emergency Medicine Reports, Volume 31, Number 17
• While the strangle holds used in martial arts situations have a relatively stellar safety record, note that these holds are most often released well before unconsciousness through a tapout, or released immediately after the person becomes unconscious. If pressure was continued, forensic literature suggests death would occur in 2-3 minutes.

Some other notes and parallels:
• Carbon dioxide levels going up (NOT oxygen levels going down) is what drives the need to breath (in most cases). This is why you can hold your breath longer after hyperventilating (which “blows off” carbon dioxide, but does not increase oxygen stores in the body significantly).
• Another risk of breath play (especially anytime someone is taken to the point of blacking out) is aspiration, which is what happens when someone vomits and the vomit ends up in their airway/lungs.
o This risk is increased with use of drugs or alcohol.
o To somewhat decrease risk, the bottom should be sober (a good suggestion for a lot of reasons) and not have a full stomach (have a small meal at least an hour before play starts).
o Note the tongue can also block the airway- someone who is unconscious should be placed on their side in the “recovery position.”
• LEARN CPR! It’s a good idea for oh so many reasons.
• It is critical for the top to be prepared for the bottom to (potentially) become unconscious, and to ensure that this would not cause other dangers (trauma from a fall, damage from going limp in restraints, the top injuring themselves holding a bottom who is suddenly dead weight, etc.)
• If there is suspicion of damage to the neck (pain, swelling, large bruises, difficulty breathing) after breath play, the bottom should go to the ER if symptoms are mild, or call 911 if they are severe. Local swelling could quickly get worse, resulting in airway and/or blood vessel occlusion (potentially leading to death).
• The choking game, aka the fainting game
o A study by the U.S. Centers for Disease Control and Prevention (CDC) indicated that since 1995 at least 82 youths age 6 to 19 have died in the US as a result of the game.
o This game sometimes uses variations on strangulation, with hands or a ligature.
o The more common variation of the game is for the youth to hyperventilate until feeling symptoms of decreased carbon dioxide levels (such as tingling in extremities/lips and dizziness), followed by holding their breath. This itself is enough to cause loss of consciousness, and is a mechanism for many diving deaths (when divers suddenly black out under water).
o This breath hold may be “assisted” by bearing down (approximating the Valsalva Maneuver), or by having another youth “bear-hug” them around the chest.
o In some cases, hyperventilation itself (without a breath hold) can cause a black out-carbon dioxide acts as an acid in the blood, and when too much is “blown off” blood becomes abnormally alkaline- alkalosis interferes with oxygen utilization by the brain.
• Autoerotic asphyxiation (asphyxiophilia, autoerotic asphyxia, hypoxyphilia)
o Estimates of the mortality rate of autoerotic asphyxia range from 250 to 1000 deaths per year in the United States. These estimates are difficult as families may “sanitize” scenes, leading these deaths to be falsely classified as suicides.
o Deaths often occur when this type of play is done alone- loss of consciousness as a result of partial asphyxia leads to loss of control over the means of strangulation, which leads to continued asphyxia and death. People often rig elaborate “escape mechanisms”- which have a pesky tendency to fail.
o There have been numerous high-profile deaths from autoerotic asphyxiation. One anecdote from Wikipedia: A Baptist reverend died from “accidental mechanical asphyxia”; he was “found hogtied, wearing two complete wet suits, including a face mask, diving gloves and slippers, rubberized underwear, and a head mask.”
• Positional asphyxia (postural asphyxia)
o Inability to breath adequately caused by position, most commonly (but not exclusively) a prone (face down) position, especially hog ties.
o Factors that appear to increase risk include high BMI (obesity), use of drugs such as cocaine, history of respiratory and/or cardiac problems, struggling, and putting weight on the restrained person.
o This is sometimes cited as a cause of deaths in custody, but remains controversial.

Final disclaimer: I do not endorse breath control play! Any type of breath control play is risky, and unpredictably so. You could die. Please don’t sue me. Got that?

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