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Guide/III. Safety

Breathing and strangulation

Squeezing a neck has no safe version. This page explains what happens in the body, what the data say, and what you can do instead.

8 min read · 22 sources · checked in October 2026

Oil painting: a raised hand, palm open, signalling stop
In this chapter
  1. What happens in the body
  2. What the data say
  3. Why “I’m in control” is not enough
  4. What you can do instead
  5. If it has happened
  6. When it is not a game
  7. Going further

This page contains no technique, neither “gentle” nor “less risky”. That is not an oversight. Debby Herbenick, a public health researcher at Indiana University, has been studying strangulation during sex for several years. According to a report on one of her talks, her main message fits into one sentence: there is no safe way to strangle someone1.

A word on vocabulary. The English word choking is often used, although it first of all refers to suffocation caused by an object stuck in the throat. What is at issue here is pressure on the neck: strangulation, even when consensual.

What happens in the body

The neck packs into a few centimetres what supplies the brain: the carotid arteries on the sides, the jugular veins that carry blood back to the heart, the windpipe at the front. Pressure can close the veins (blood comes in but can no longer leave), close the arteries (it no longer comes in) and obstruct the passage of air2. The brain runs short of oxygen very quickly. In experiments from the 1940s cited by an Australian medical journal, loss of consciousness occurred on average at around 6.8 seconds, between 4 and 10 seconds depending on the person, and convulsions could appear at around 14 seconds2.

On the side of the neck there is also the carotid sinus, a pressure sensor that helps regulate the heart rate. Compressing it can trigger a reflex that abruptly slows the heart; its exact role in certain deaths is still debated in forensic medicine3.

What can result:

  • loss of consciousness, which in itself already signals at least a mild brain injury, according to a systematic review4;
  • brain damage caused by a lack of oxygen, seizures, speech or movement disorders24;
  • arterial dissection, that is, a tear in the wall of a carotid or vertebral artery, which can cause a stroke later on. The first two weeks carry the highest risk, but strokes have been described several months after a strangulation2, and British forensic medicine guidelines consider the vascular risk to last up to twelve months5;
  • a heart rhythm disturbance triggered by reflex3;
  • death61.

What the data say

Study What it shows Its limitations
Bichard et al., 2022, review of 30 studies4 Arterial dissections, strokes, loss of consciousness, seizures, motor and speech disorders, but also post-traumatic stress and depression Mostly clinical cases and self-reports, in contexts of intimate partner or sexual violence
Herbenick et al., 2022, 4,254 randomly selected students on a US campus7 Among people strangled during sex: 43% felt they could no longer breathe, 38% could no longer speak, around 15% noticed bruises on their neck, 3% lost consciousness Self-reported, a single campus
Huibregtse et al., 2025, 32 female students8 Blood levels of S100B, a marker of neurological injury, higher in the 15 students who had been strangled recently and frequently than in the 17 who had not Cross-sectional study: an association, not proof of cause; small sample
Sweeney et al., 2026, 29 women, randomised crossover trial9 After consensual sex with strangulation, a rise in NfL, a marker of damage to axons, and in an inflammatory marker; no rise after sex without strangulation Small sample, blood taken within 24 hours: long-term effects remain unknown
Sharman et al., 2024, 4,702 Australians aged 18 to 3510 57% had been strangled during sex at least once, 51% had strangled someone at least once Self-reported, a single country

These figures describe a practice that has become commonplace well beyond BDSM. In the Australian survey, most respondents did not know that strangulation, even when consensual, can cause serious injury, and the most frequently cited source of information was pornography (61%), ahead of film, friends and social media11. In the US survey, the first experience occurred on average at around the age of 19, and more than four people in five also associated it with pleasurable sensations7. That is what makes the practice appealing. It does not make it any less risky.

Why “I’m in control” is not enough

The reasoning is tempting: I know how much pressure to use, I keep watch, I stop at the slightest sign. It runs up against several facts.

The margin is measured in seconds. Between “I’m fine” and loss of consciousness, there is no time for an exchange. And a person who is starting to lose consciousness can also lose the ability to withdraw consent, in words as well as in gestures1. In the US survey, more than one person in three said they could no longer speak7. A safeword assumes someone who is able to give it.

Pressure cannot be seen. Around half of people who are strangled have no visible injury to the neck5. No mark does not mean no damage.

The damage can come later. A dissection can show up days or weeks afterwards, when the scene is long past2.

“Only pressing on the sides” is not a precaution. That is precisely where the carotids and the carotid sinus are. Herbenick points out that any restriction of blood flow to the brain is dangerous, however long it lasts1.

Finally, no amount of experience lets you see what is happening inside an artery.

What you can do instead

If what draws you is surrender, vulnerability, being held, other gestures carry that same imagery. They are not safe versions of strangulation. They are different games, with their own risks (see Safety), that work with the same imagery without touching what supplies blood to the brain.

  • A hand resting without any pressure, as a symbol. Negotiate it as a fixed gesture: it does not squeeze, does not slide, does not move upwards. Laid flat on the upper chest rather than on the neck, it removes any ambiguity. If the urge to press comes up, it is no longer the same game, and it needs to be discussed again with a cool head.
  • Wrists held down, above the head or behind the back.
  • Eye contact, held steadily, that you are not allowed to break.
  • Words: naming what is happening, announcing, giving orders.
  • A blindfold, which takes away sight without touching the air supply.
  • Restraint that leaves the neck and chest free: being held in someone’s arms, ankles tied, the other person’s weight on the legs rather than on the torso.

If a partner squeezes your neck without this having been negotiated, that is not a game that got out of hand. It is a limit that has been crossed.

If it has happened

Consensual or not, a strangulation warrants keeping watch over the following days. See a doctor if any of these signs appear, the same day or later512:

  • severe or unusual headaches;
  • vision problems: flashing lights, tunnel vision, a sudden change in eyesight;
  • difficulty speaking or finding words;
  • a hoarse or changed voice;
  • difficulty or pain when swallowing;
  • confusion, memory gaps, dizziness;
  • difficulty breathing.

The numbers: 144 in Switzerland13, 15 or 112 in France14, 112 in Belgium15, 911 in Quebec16. Do not stay alone during the two or three days that follow: the Victorian Institute of Forensic Medicine, in Australia, describes the first 24 to 72 hours as a high-risk period for delayed complications12, and the Tasmanian Department of Health gives the same advice17.

At the emergency department or at the doctor’s, say the word: strangulation. The British guidelines note that patients rarely say it spontaneously, tending instead to talk of having been “grabbed” or of breath play (breathing games), and that an absence of marks should not prevent examinations5. You do not have to explain the context. Say what happened to your neck, for how long, and whether you lost consciousness.

When it is not a game

Non-consensual strangulation is one of the most serious markers of intimate partner violence. In a study carried out in eleven US cities among women who had experienced intimate partner violence, having previously been strangled by their partner was associated with a roughly sevenfold higher likelihood of later being killed by him18. Abuse in a BDSM setting is still abuse, and a scene does not make an act that was not negotiated acceptable.

If this concerns you, or someone close to you:

  • Switzerland: victim support on 142, free and anonymous, which is not an emergency number; in case of danger, police on 11719;
  • France: 3919 (Violences Femmes Info), police on 1720;
  • Belgium: Écoute violences conjugales on 0800 30 03021; in case of danger, police on 10115;
  • Quebec: SOS violence conjugale on 1 800 363-9010, day and night22; in case of danger, 91116.

Other helplines and services are presented in Resources.

Going further

  • Safety: the general principles, other practices and when to call the emergency services.
  • Consent: negotiating, withdrawing consent, recognising a limit that has been crossed.
  • Resources: helplines, victim support and services familiar with BDSM practices, by country.
  • Portrait: setting out your limits, including those concerning the neck, before you need them.

Sources

  1. Backal, N., 2024. Sex and strangulation: Dr. Debby Herbenick speaks at RSVP Center event. Student Life (Washington University in St. Louis). link ↑↑↑↑

  2. Victoire, A., De Boos, J. and Lynch, J. M., 2022. ‘I thought I was about to die’: Management of non-fatal strangulation in general practice. Australian Journal of General Practice, 51(11). link ↑↑↑↑↑

  3. Suárez-Peñaranda, J. M., Cordeiro, C., Rodríguez-Calvo, M., Vieira, D. N. and Muñoz-Barús, J. I., 2013. Cardiac inhibitory reflex as a cause/mechanism of death. Journal of Forensic Sciences, 58(6), 1644-1647. link ↑↑

  4. Bichard, H., Byrne, C., Saville, C. and Coetzer, R., 2022. The neuropsychological outcomes of non-fatal strangulation in domestic and sexual violence: A systematic review. Neuropsychological Rehabilitation, 32(6), 1164-1192. link ↑↑↑

  5. Institute for Addressing Strangulation and Faculty of Forensic & Legal Medicine, 2025. Guidelines for clinical management of non-fatal strangulation in acute and emergency care services, July 2025 version. IFAS. link ↑↑↑↑↑

  6. Sauvageau, A. and Racette, S., 2006. Autoerotic deaths in the literature from 1954 to 2004: a review. Journal of Forensic Sciences, 51(1), 140-146. link ↑↑

  7. Herbenick, D., Fu, T.-C., Eastman-Mueller, H., Thomas, S., Svetina Valdivia, D., Rosenberg, M., Guerra-Reyes, L., Wright, P. J., Kawata, K. and Feiner, J. R., 2022. Frequency, Method, Intensity, and Health Sequelae of Sexual Choking Among U.S. Undergraduate and Graduate Students. Archives of Sexual Behavior, 51(6), 3121-3139. link ↑↑↑

  8. Huibregtse, M. E., Alexander, I. L., Fu, T.-C., Klemsz, L. M., Rosenberg, M., Fortenberry, J. D., Herbenick, D. and Kawata, K., 2025. Association of blood biomarkers for neural injury with recent, frequent exposure to partnered sexual strangulation in young adult women. Journal of Sexual Medicine, 22(5), 961-970. link ↑

  9. Sweeney, S. H., Recht, G. O., Lima-Cooper, G., Datta, D., Buddenbaum, C. V., Day, H., Buehler, B., Huibregtse, M. E., Herbenick, D. and Kawata, K., 2026. Acute blood biomarker responses to consensual sexual choking/strangulation in young adult women: a randomized crossover study. Frontiers in Global Women’s Health, 6, 1717361. link ↑

  10. Sharman, L. S., Fitzgerald, R. and Douglas, H., 2024. Prevalence of Sexual Strangulation/Choking Among Australian 18-35 Year-Olds. Archives of Sexual Behavior. link ↑

  11. University of Melbourne, 2024. Study finds strangling during sex common, but understanding is low. Newsroom, University of Melbourne. link ↑

  12. Victorian Institute of Forensic Medicine, 2026. Non-Fatal Strangulation Discharge Advice. VIFM. link ↑↑↑

  13. Confédération suisse et cantons, n.d. Urgences et dangers. ch.ch. link ↑

  14. Direction de l’information légale et administrative, 2024. Le 0 800 112 112 : un numéro qui vous rappelle en cas d’urgence. Service-Public.fr. link ↑

  15. SPF Intérieur, n.d. Il y a toujours quelqu’un pour vous aider en cas de besoin. 112.be. link ↑↑

  16. Gouvernement du Québec, n.d. Quand et comment utiliser le 911 au Québec. Québec.ca. link ↑↑

  17. Department of Health Tasmania, n.d. Non-fatal strangulation. Tasmanian Government. link ↑

  18. Glass, N., Laughon, K., Campbell, J., Block, C. R., Hanson, G., Sharps, P. W. and Taliaferro, E., 2008. Non-fatal strangulation is an important risk factor for homicide of women. Journal of Emergency Medicine, 35(3), 329-335. link ↑

  19. Aide aux victimes en Suisse, 2026. Aide aux victimes en Suisse, numéro 142. aide-aux-victimes.ch. link ↑

  20. Gouvernement français, n.d. Arrêtons les violences. arretonslesviolences.gouv.fr. link ↑

  21. Écoute violences conjugales, n.d. Écoute violences conjugales, 0800 30 030. ecouteviolencesconjugales.be. link ↑

  22. SOS violence conjugale, n.d. SOS violence conjugale. sosviolenceconjugale.ca. link ↑