Sexual choking poses serious health risks despite being perceived as safe by young people

When touching someone’s throat, it can only take the pressure of a handshake to cause serious injury, unconsciousness or death. These injuries, which include brain damage and stroke, are often internal and invisible, showing up days or even months after the initial incident occurred. Experts say many who participate in sexual choking are not aware of the risks.

Choking or sexual strangulation is common among young people, says Prof Heather Douglas of the Melbourne Law School. In a 2024 survey of 4,702 Australians aged between 18 and 35, she and her research team found that 57% reported ever having experienced sexual strangulation; 51% reported ever having strangled a partner and 43.9% reported participating in both.

A police investigation into the death of a 16-year-old girl in Sydney, who is believed to have become unconscious as a result of asphyxiation during sexual intercourse, has brought the practice to national attention again this week.

Douglas says their survey found gender differences in prevalence rates. Young women were more likely to report having been strangled (61%) and young men were more likely to report strangling a partner (59%). Among trans and gender-diverse young people the rates were even higher, with 78% reporting ever having been strangled and 74% reporting ever having strangled someone else. Many had positive perceptions of the act – believing it was safe and led to more enjoyable sex. “I don’t think that a lot of young people know how dangerous it is,” Douglas says.

There have been similar findings globally. Dr Debby Herbenick is the world’s leading researcher on sexual choking.

When Herbenick conducted her first nationally representative survey asking about sexual choking in the United States a decade ago, “the data came back and I was just floored,” she says. Only a small percentage of adults in midlife and beyond reported being choked, but for those aged 18-39, “more than a third of them had reported being choked during sex”.

The issue “felt really urgent”, says Herbenick, who is director of Indiana University’s Center for Sexual Health Promotion. When she spoke to her students about it, “they were like, ‘Oh no, it’s OK. We’re all doing the same thing.’

“I think what bothered me about it, and worried me, was I felt like they weren’t making informed choices. They were making choices, but they weren’t informed.”

Choking, or strangulation?

In Australia, when choking results in serious harm, the laws are straightforward. Every state and territory has specific assault laws around strangulation. “Injuries or a strangulation that causes death or really serious harm can’t be consented to,” Douglas says.

But the fact that many young people believe choking is low-risk and enjoyable is a vexed public health issue.

When Women’s Health New South Wales was funded to improve workforce capacity to respond to strangulation, they ran headlong into this problem. Jackie McMillan, a senior project officer, says: “When we started that work, we realised that we couldn’t do that without also talking about sexual choking.”

Physically, strangulation and sexual choking carry the same risks, but “they’re slightly different conversations,” McMillan says.

“If people are calling what they’re doing ‘sexual choking’, it’s because they’re making a distinction between what they see as a consensual sexual practice about freedom of sexual expression, and something that is violence. And if you start in with a language of violence, you often lose those people … They’re not interested in what you have to say. They turn off because they think that what you’re talking about is not what they’re doing.”

Herbenick agrees. “Our research here is very clear that we need to be using the word ‘choking’,” she says. “If people think about what they’re doing as choking, and you call it strangulation, they think, ‘oh, well, I’m not strangling or being strangled. I’m doing choking and choking is safe’.”

When Herbenick has asked young people to describe how they choke in detail, overwhelmingly they describe applying pressure to the neck, and list symptoms like dizziness, seeing stars and shortness of breath. “And so certainly anyone in those buckets has some evidence of doing what we would call strangulation,” she says.

Herbenick’s research includes a partnership with neuroscientists, testing for brain changes in women who have been choked. While there is a large body of evidence about the neurological effects of strangulation in domestic violence contexts, because the subjective experience of choking can be so different, “in some ways I felt like we had to start from scratch,” she says.

For instance, in domestic violence contexts, there is strong evidence that repeat strangulation has more pronounced neurological effects. “But when you look at those multiple versus single strangulation studies, multiple is often like two or three or four times, right? But then if you look at sexual choking, people are often choked, in our studies, an average of 25 times – but sometimes 50 or 100 or 200 or 500 times, because it’s become such a common thing that people do.”

Observations of women who frequently participate in choking and recently participated in choking both suggested it can cause brain injury.

But data on effective public health messaging is still nascent.

Herbenick’s team tried educational messages around the health implications of sexual choking, the importance of receiving specific consent for choking, and messages about the potential legal consequences if an injury occurs. While they found “all three message types were very well received by young adults”, for women, “only the health and consent messages were especially effective” in changing their intentions around choking.

For men to change their intentions, “they needed to know about potential legal consequences in the event of injury or death,” Herbenick says. “It was tough to see, because of course we would like to think that knowing that something could be harmful for somebody’s health would be enough to make a lot of people change their behaviour.” That finding persisted regardless of whether men were choking or being choked.

All the experts who spoke to the Guardian agreed that widespread and robust sexual education that engages specifically with choking is a vital first step in preventing catastrophic health outcomes.

But school systems are not prepared to engage in this level of sexual education, and young people’s information environment, especially on social media, is flooded with misinformation.

“There are some sex educators … who claim that there are safe ways to choke. And there’s just a lot of regular people out there making TikTok videos claiming there are safe ways to choke,” says Herbenick.

“Pornography is one piece of it,” she adds. “Social media is one piece of it. Anyone whose kids are reading fan fiction or … dark romance novels is almost certainly coming across choking.”

On social media, it is often referred to lightheartedly as a “hand necklace” or through memes like “Choke me daddy”.

Non-judgmental sex education

There are no circumstances under which exerting pressure on the soft tissue of someone’s neck is safe; and when drugs or alcohol are involved, the practice becomes even riskier. But this information is not easy to find. McMillan created a website, It Left No Marks, to help combat this void. “We had to build it because it wasn’t there,” she says.

Wellington-based criminology academic Dr Samantha Keene says the tragic death of UK woman Grace Millane in New Zealand in 2020 “put conversations about rough sex and sexual choking or sexual strangulation on the public agenda”. But lately, she says, it has fallen off the radar.

“We know that sexual choking and sexual strangulation is eroticised in a whole range of media … yet we aren’t addressing that in sexual and relationships education.”

“What we know works is having an evidence-based approach,” she says. That means “meeting people where they are” in a non-judgmental way, by giving them access to information that outlines the range of risks associated with this form of sexual practice.

Meeting young people where they are is not a comfortable conversation, Herbenick says. “A lot of parents are thinking, ‘How am I living in a world where I’m supposed to be talking about strangulation during sex, with my … 13-year-old, 15-year-old?’

“I don’t know, but I can tell you that in our studies, when we ask college students how old they were when they first learned about choking, on average the age is 15. Which means that about half of them are learning about it younger than 15.”

McMillan says it takes “endorsement” to deliver this kind of education.

“That’s endorsement from parents. That’s endorsement from the school. That’s endorsement from the principals. We can’t leave teachers out there alone to discuss websites that they can’t even go to without there being a panic,” she says.

“How can we get teachers to talk about pornography if they can’t even visit the sites that the kids are on? We’ve created an impossible situation.”

International research has found that many of the young people who engaged in choking felt some degree of pressure from their partner, or their wider social environment, to do so. “So there’s questions around whether that is true consent, if we say it’s truly free and voluntary,” Douglas says.

Beyond understanding the consequences physically and legally, “what we need to do is make sure that people are skilled up with the things they need to redirect sexual activities to something else they might find pleasurable,” McMillan says.

“And also that particularly young women know sex is meant to be pleasurable. So if you’re not having fun, don’t do that bit.”