Forensic aspects of 40 accidental autoerotic deaths in Northern Germany

Between 1983 and 2003, 40 accidental autoerotic fatalities have been investigated. in the Institute of Legal Medicine in Hamburg. Only 50% (n = 20) were autopsied (13 legal autopsies, 6 for scientific purposes and 1 for an insurance company). All the victims were males, aged between 13 and 79 years (among them five children and adolescents, the deceased mainly between 20 and 40 years). The paraphiliacs utilized a great range of devices and props as fetishism, sexual aids or pain-stimulating agents, like intimate feminine garments, ropes, chains, bondages, locks, pornographic magazines, condoms, rubber items, and chemical anaesthetics. The cause of death was strangulation in 20 cases (17× hanging, 3× ligature strangulation), 11× suffocation (8× under plastic bags, 3× with face-masks, 2× thoracic compression, 1× positional asphyxia, and 1× cocaine intoxication). Five cases without autopsy remained unclear because of missing morphological and toxicological findings; it could not be differentiated between asphyxiation/intoxication/natural disease, although the scene characteristics seemed to be typical for autoerotic deaths. It is emphasized that the findings at the scene, the morphological and toxicological examination of the dead body (full autopsy as prerequisite) by experienced investigators and the personal history of the deceased have to be evaluated very carefully and intensely to reconstruct the accidental fatal autoerotic course accurately and undoubtedly (to exclude the possibility of sexual homicide, neglected killing, or suicide).     

Atypical autoerotic death: part II

Autoerotic fatalities encompass a wide array of means and mechanisms used to attain sexual gratification. The most commonly encountered autoerotic practice, specifically, autoerotic asphyxia, denotes death resulting from failure of a release mechanism of the apparatus designed to attain cerebral hypoxia for heightened arousal. Historically, the majority of victims of autoerotic death are Caucasian males under the age of 30. While autoerotic death is most often associated with a constrictive cervical ligature tied to either other parts of the victim's body or to an inanimate object such as a door, several other methods have been reported. These modalities include ligature around the thorax or abdomen, plastic bags covering the face, electrical current, inhalation of a toxic gas or chemicals, or partial or total submersion, known as aquaerotic asphyxiation. This study highlights 11 cases of atypical autoerotic death, including asphyxia with a plastic bag, electrocution, and inhalation of butane and nitrous oxide (N2O). Whereas the manner of death in the majority of autoerotic death cases is deemed accidental, we present and analyze unique and equivocal cases representing 4 different manners of death: accident, natural, suicide, and homicide. The 11 victims were all Caucasian and between the ages of 17 and 55. Ten decedents were males, 1 female. A comprehensive investigation incorporating a thorough scene analysis, gathering of the victim's history, and complete postmortem examination is necessary to elucidate both the cause and manner of death in these atypical cases.     

Causes and circumstances of fatal falls downstairs

Reports of 9156 autopsies performed at the Centre of Legal Medicine of the J.W. Goethe-University Frankfurt over a period of 10 years were reviewed for fatal accidents of falls downstairs, age, gender, drinking behaviour and alcohol influence, the locality and the time of the accident. Among 43 cases (0.47% of all autopsies) were 31 males (72.1%, average age 63.9 years) and 12 women (27.9%, average age 65.8 years). Twenty-nine accidents (67.4%) occurred at home, in six cases (14.0%) in a public building or area. Twenty-three victims (53.5%) were under the influence of alcohol (average blood alcohol concentrations (BAC): 2.56 per thousand), in 19 persons autopsy revealed severe internal disease which may explain the cause of the fall (severe coronary artery disease, myocardial hypertrophy, myocardial infarction, apoplexy, brain tumour). This study indicates that a fatal fall downstairs without an underlying severe disease or alcohol influence is a rare phenomenon.     

Autoerotic asphyxia: part I

Fatal autoerotic asphyxia refers to death during solitary sexual activity with self-induced asphyxiation meant to be brief and reversible. However, an unexpected fatality results from a failure of a release mechanism apparatus. The large majority of victims of autoerotic death are Caucasian males between the second and fourth decade. While autoerotic death may encompass a myriad of other means of achieving sexual gratification, which includes asphyxia by plastic bag or inhalation of noxious chemicals, the most common method is by ligature about the neck. This study presents a 9-year retrospective review of deaths due to autoerotic asphyxia, specifically ligature asphyxia, in Kentucky between 1993 and 2001. Of the sixteen victims, all were Caucasian males between the ages of 14 and 59 years, with a mean age of 38.3 years. Cross-dressing was a feature in 4 cases. A thorough review of the decedent's background, meticulous scene investigation, and complete postmortem examination may shed light on the mechanism and psychosocial predisposition associated with autoerotic asphyxia.     

519例他杀刺创的回顾性研究

本文对５１９例他杀刺创致死的案例进行了回顾性研究．结果显示死者的年龄在１６至３０岁较为突出；１—２处刺创的死者与多于１０处者在杀人动机、现场位置、罪犯与死者关系、致死手段以及血液乙醇检出率等方面存在差异；死于急性失血性休克的５１３例中，４６７例（９０％）检见左心室内膜下出血斑．     

Hyperthermia deaths in Finland in 1970-86

All cases in which hyperthermia had been determined as the basic cause of death during the period 1970-86 were collected from the records of the Central Statistical Office of Finland. Of the total of 230 cases, 228 were included in the present study; the two remaining victims died abroad, and no autopsy was performed in Finland. Most of the hyperthermia deaths occurred while the decedent was taking a sauna bath; most decedents were men aged 42-62 years. An increase in the total number of hyperthermia deaths, and of male victims, was noted from the beginning of the 1970s onward; the number of female victims remained at a relatively steady level throughout, with the exception of a slight rise in 1986. Acute alcohol consumption was detected in most of the victims; in some cases there was also a reference to chronic alcoholism or recent long-term heavy drinking. The findings suggest that in addition to the acute hazardous effect of ethanol on thermoregulatory mechanisms, the long-term consumption of alcohol may have promoted fatal hyperthermia in these subjects.     

Alcohol in a series of medico-legally autopsied deaths in northern Norway 1973-1992

It is well established that use of alcohol increases the risk of fatal injuries. The presence of blood alcohol in autopsied deaths is regularly encountered in medico-legal practices. The aim of this study was to investigate the prevalence and concentration of alcohol in 1539 medico-legal autopsies in two counties in northern Norway in the period 1973-1992, and the reporting of acute alcohol influence among these deaths to the official cause-of-death statistics. Blood alcohol concentration (BAC) >/=0.5 per thousand (50 mg/100 ml) was found in 47.6% (n=456) of violent deaths tested, and in 93% (n=426) of these the BAC was >/=1.0 per thousand. In 17.4% (n=55) of tested natural deaths the BAC was >/=0.5 per thousand. Acute alcohol-influenced violent deaths were under-reported to the cause-of-death statistics. Deaths by motor vehicle traffic accidents did not differ from other violent deaths in this respect. The under-reporting among violent deaths was 41% in cases with BAC >/=0. 5 per thousand and 37% where the BAC was >/=1.0 per thousand during the whole period. It is concluded that post-mortem BAC >/=0.5 per thousand, should be regarded as a possible contributory cause in all violent deaths, and reported accordingly.     

Multiple homicides--forensic and criminologic aspects

The interpretation of medicolegal findings in homicide is an important tool of case profiling (so-called "operative case analysis"). In 17 cases of "multiple homicides" involving 22 offenders (21 males, 1 female; mean age 33 years) and 45 victims (21 males, 24 females; mean age 35 years; 41 fatalities, 4 survivors), the autopsy reports and the prosecution authorities' files were retrospectively analysed with regard to individual characteristics of perpetrators and victims, circumstances, and mode of commitment in order to comprehensively characterise relevant forensic and criminologic aspects. 31 victims were found to belong to the close social environment of the perpetrator, and 32 killings were committed in the victim's, perpetrator's or the joint flat. The main motives included greed (n = 7), personal conflicts (n = 5) and concealing of a crime (n = 9). The relevant injuries were attributable to gunshot wounds (n = 13), sharp force (n = 11), blunt force (n = 3), ligature strangulation (n = 3), smothering (n = 6), fire/carbon monoxide (n = 2) and combined impacts (n = 7). In 12 victims, defense injuries were found. The blood alcohol concentration exceeded 1.5 g/l in 5 victims. In 5 offenders, a psychiatric impairment of juridical responsibility was assessed (and 20 German criminal code, n = 1, psychosis; and 21 German criminal code, n = 4; acute alcohol intoxication). As far as data were available, 16 crimes were judged as murder, 12 as manslaughter and one as physical injury with fatal outcome.     

3例致命伤后行为能力分析探讨

法医在命案现场勘查中,正确分析致命伤后行为能力至关重要,这对重构现场、准确分析解释现场疑点、判断案件性质等有重要意义,同时也是法医工作中的难点和热点问题。人体受到致命伤后不一定立即死亡,其是否具有行为能力及行为能力的大小受多种因素影响,因此分析致命伤后行为能力要结合现场和案情谨慎考虑推断。通过3例案例对致命伤后行为能力进行分析探讨,得出一些关于致命伤后行为能力的思考和观点,以供同行参考。     

Morphology and phenomenology of death by kicking (II)

In the years from 1982 to 1995, 20,504 autopsy cases were examined at the Departments of Forensic Medicine in Hamburg and Greifswald. In 103 cases death was caused by kicking. In the Greifswald area, the occurrence of kicking as the cause of death could be demonstrated in 68 cases (30% of all homicides), which is in contrast to the observations in Hamburg, were kicking amounted to only 2.5% of the homicides. Most of the victims (average age 44 years) were under the influence of alcohol (mean blood alcohol concentration 1.75/1000), and most were on social support. The victims often showed other signs of blunt trauma such as blows with the fist and strangulation. In a few cases, cutting and stabbing wounds were also found. In the majority of cases death was due to severe haemorrhages and aspiration of blood in addition to the direct effects of the head injuries. The crimes were committed by one person in 46 cases, two in 20 and three in 4 cases. The perpetrators (average age 27.6 years) were always younger than the victims. Case reports show that fatal kicking was mostly triggered by relatively trivial arguments. None of the incidents were preplanned by the perpetrators. In contrast to an expected higher incidence of kicking deaths in the urban area of Hamburg, these crimes occurred ten times more frequently in the rural area of Greifswald.     

Autoerotic asphyxiation in a female

Autoerotic asphyxiation is an unusual but increasingly more frequently occurring phenomenon, with >1000 fatalities in the United States per year. Understanding of this manner of death is likewise increasing, as noted by the growing number of cases reported in the literature. However, this form of accidental death is much less frequently seen in females (male:female ratio >50:1), and there is correspondingly less literature on female victims of autoerotic asphyxiation. The authors present the case of a 31-year-old woman who died of an autoerotic ligature strangulation and review the current literature on the subject. The forensic examiner must be able to discern this syndrome from similar forms of accidental and suicidal death, and from homicidal hanging/strangulation.     

Fatal poisoning with alcohol and drugs in the Greater Amman County

A study of fatal poisoning due to alcohol and drugs was carried out, to examine the mortality resulting from alcohol and drugs in the Greater Amman County, Jordan. A retrospective review of all autopsy records and certified deaths issued by the Department of Forensic Medicine at Jordan University Hospital in the greater Amman county was undertaken. During the 18 years (1978-1996) 6109 postmortem cases were performed in our department. A total of 60 cases were identified and analyzed according to age, race, sex, manner of death of the victims along with blood alcohol concentration, the drug detected at autopsies, the scene circumstances, and the geographic location of the accident and death.     

Autoerotic fatalities in Greater Dusseldorf

Autoerotic fatalities in the Greater Dusseldorf area correspond to the relevant medicolegal literature. Our results included exclusively young to middle-aged, usually single men who were found dead in their city apartments. Clothing and devices used showed a great variety. Women's or fetish clothing and complex shackling or hanging devices were disproportionately frequent. In most cases, death occurred due to hanging or ligature strangulation. There was no increased incidence of underlying psychiatric disorders. In most of the deceased no or at least no remarkable alcohol intoxication was found. Occasionally, it may be difficult to reliably differentiate autoerotic accidents, accidents occurring in connection with practices of bondage & discipline, dominance & submission (BDSM) from natural death, suicide or homicide.     

Death from thermal effects and burns

One hundred and fifteen unselected autopsy cases of death from thermal effects and/or fire between 1990 and 1999 were analyzed with regard to time of death, signs of vitality at the scene of the fire, the manner and cause of death, and the extent of soft tissue loss. The cases represented approximately 6% of all autopsy cases at the Institute of Legal Medicine responsible for a catchment area with approximately 700,000 inhabitants. In 23 victims suffering burn injuries, death occurred during initial medical care or clinical treatment. The causes of death were primary respiratory arrest due to smoke poisoning or delayed shock caused by thermal injuries to the skin. Death occurred at the scene of the fatal event in 85 cases: eight cases exhibited no thermal effects; the cause of death in one of these cases was polytrauma incurred in a leap from a height; in seven cases there was poisoning due to smoke inhalation. The remaining 77 cases were characterized by signs of intensive thermal and/or fire effects. Clear signs of vitality (carboxyhemoglobin (COHb) in blood, inhalation and/or swallowing of soot) were found in 84.7% of the victims dying at the site of the fatal event. Of the 13 victims showing no signs of vitality at the scene, a cause of death could be determined in only seven cases; death in the other six cases remains unexplained. Quantification of the soft tissue loss revealed a possible correlation with the temperature and time course of heat exposure.     

Forensic case profiling aspects on multiple homicides from the Cologne-Bonn metropolitan area 1985-2000

The medicolegal and subsequent criminologic interpretation of forensic and pathological findings in cases of homicide makes up an important tool of case profiling. In a retrospective study of 26 cases of "multiple homicides" involving 31 perpetrators (30 males, 1 female, mean age 33.5 years) and 73 victims (33 males, 40 females, mean age 36 years, 68 fatalities, 5 survivors), autopsy reports and prosecution authorities' files were investigated with regard to individual characteristics of victims and offenders, circumstances as well as mode of commitment. The major aim of this study was to comprehensively elucidate and characterise relevant forensic and criminologic features, which may gain importance for forensic case profiling. Forty-six victims were found in the close social environment of the perpetrator and 45 homicides were committed either in the victim's, the perpetrator's or the shared domicile. The main motives included concealment of a crime (n=13), personal conflicts/domestic arguments (n=7) and greed (n=12). The relevant injuries with regard to the cause of death were attributable to sharp force (n=13), blunt force (n=7), gunshot wounds (n=24), ligature strangulation (n=3), smothering (n=5), fire/carbon monoxide (n=4) and combined impacts (n=11). In 15 cases, so called defence injuries were found. In 5 victims a post-mortem blood alcohol concentration >1.5 g/l was determined. In six perpetrators, a severe psychiatric impairment of juridical responsibility was ascertained (Section 20 German criminal code, n=2, psychosis; Section 21 German criminal code, n=4, acute alcohol intoxication). As far as conviction data were available, 27 crimes were juridically assessed as murder, 12 as manslaughter and one as bodily harm with fatal consequences.     

Fatal traffic injuries among children and adolescents in three cities (capital Budapest, Vilnius, and Tallinn)

Motor vehicle accidental injuries are a frequent cause of death among young children and adolescents. The goal of this study was to compare patterns of injury between three capitals (Budapest, Vilnius, and Tallinn). Information on 190 fatal traffic accidents (69 pedestrians, 14 bicyclists, and 107 motor vehicle occupants) between 2002 and 2006 was collected from databases of medico-legal autopsies. The role of victims in accidents, the location of injuries, cause of death, survival period, and blood alcohol levels were evaluated. One-hundred and forty-one (74%) victims had a passive role in traffic as pedestrians, passengers in cars, or public transport. In victims who died at the scene, the rate of head injury was higher than in cases who received medical treatment (odds ratio = 2.58, CI = 1.2-5.55, p = 0.0127). These results underline the importance of postmortem studies to examine the pathomechanism of fatal traffic accidental injuries and to provide information for the prevention of road traffic accidents against children and adolescents.     

Suicide by jumping from high-rise hotels. Fulton County, Georgia, 1967-1986

During a 20-year period from 1967 through 1986, 19 suicidal jumps from high-rise hotels (HRHs) accounted for 24% of all fatal jumping episodes and 1% of all suicides in Fulton County, Georgia, U.S.A. The rate of suicidal jumps from HRHs did not increase during the study period. The number of fatal jumps per hotel-year correlated with the height of the interior hotel atrium. The mean age for all victims was 34 years, and 63% of victims were white males. The majority of victims were local residents who were alone when they jumped and were not registered hotel guests. Registered guests tended to jump from the floor on which their room was located whereas nonregistered individuals tended to jump from the upper-most floors in the hotel. Of 19 HRH jumps, 13 occurred from the inside. Suicide notes were found in 37% of cases. HRH jumps were least common between 6 p.m. and midnight, all decedents were dressed in street clothing, only one was heard to have screamed, and all but one were dead on the scene. Alcohol and drug involvement was minimal. We hope that this information will be useful to those who investigate such deaths and to those who study the behavioral manifestations of suicide.     

Youth alcohol use and dating abuse victimization and perpetration: a test of the relationships at the daily level in a sample of pediatric emergency department patients who use alcohol

Objective: This study retrospectively examined the daily-level associations between youth alcohol use and dating abuse (DA) victimization and perpetration for a 6-month period. Method: Timeline Followback (TLFB) interview data were collected from 397 urban emergency department patients, ages 17 to 21 years. Patients were eligible if they reported past month alcohol use and past year dating. Generalized estimating equation (GEE) analyses estimated the likelihood of DA on a given day as a function of alcohol use or heavy use (≥4 drinks per day for women, ≥5 drinks per day for men), as compared with nonuse. Results: Approximately 52% of men and 61% of women participants reported experiencing DA victimization ≥1 times during the past 6 months, and 45% of men and 55% of women reported perpetrating DA ≥1 times. For both men and women, DA perpetration was more likely on a drinking day as opposed to a nondrinking day (ORs = 1.70 and ORs = 1.69, respectively). DA victimization was also more likely on a drinking day as opposed to a nondrinking day for both men and women (ORs = 1.23 and ORs = 1.34, respectively). DA perpetration and DA victimization were both more likely on heavy drinking days as opposed to nondrinking days (2.04 and 2.03 for men's and women's perpetration, respectively, and 1.41 and 1.43 for men's and women's victimization, respectively). Conclusions: This study found that alcohol use was associated with increased risk for same day DA perpetration and victimization, for both male and female youth. We conclude that for youth who use alcohol, alcohol use is a potential risk factor for DA victimization and perpetration.     

Autoerotic deaths: a 25-year retrospective epidemiological study

It is written in almost all articles on autoerotic deaths that these fatalities account for about 500 to 1000 deaths per year in the United States and Canada. However, contrary to the general belief, this incidence rate was not obtained through a study, but it is an estimation based on 30-year unpublished data from Canada and England. In the present retrospective study from 1985 to 2009, 38 cases of autoerotic deaths were identified in the province of Alberta (Canada). This number corresponds to an incidence of 0.56 autoerotic deaths per million inhabitants per year. The vast majority of these deaths are related to typical, predominantly asphyxial methods, such as hanging. The bodies were most commonly found in basements, bedrooms, and bathrooms. There is no clear evidence of a preferential time of day for these deaths, but there appear to be slightly more autoerotic deaths during summer. The incidence of autoerotic deaths is higher in big cities compared with rural areas. The previously published estimate of 500 to 1000 'autoerotic deaths per year should not be used for Canada. An incidence of 0.2 to 0.5 cases per million inhabitants per year is a better estimate of the incidence of autoerotic deaths. The incidence in United States should be reassessed using epidemiological studies.     

Could Intra‐alveolar Hemosiderin Deposition in Adults be Used as a Marker for Previous Asphyxial Episodes in Cases of Autoerotic Death?

Intra-alveolar hemorrhage and hemosiderin have been cited as possible markers of recent and remote asphyxial events. Little study has been undertaken of the potential significance of intra-alveolar hemosiderin in adults as a potential marker of previous sublethal asphyxial episodes. Ten cases of lethal sexual asphyxia (an entity known to be associated with repetitive sublethal asphyxial episodes) and 20 randomly selected, age- and sex-matched controls had sections of lung stained for hemosiderin. Subsequently, intra-alveolar, iron-containing macrophages were counted. All cases were men (ages 15-50 years; mean 31.8). No significant increase in hemosiderin was found in victims of sexual asphyxia, indicating that asphyxial episodes in sublethal sexual asphyxial activities may not be sufficiently intense or prolonged to cause intra-alveolar hemorrhage or that intra-alveolar hemorrhage in adults is a relatively nonspecific finding. These results do not support intra-alveolar hemosiderin deposition as a marker for previous sublethal asphyxial events in autoerotic asphyxia.