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Women in their early 20s risk becoming a generation with higher stroke risk at a younger age because of the “epidemic” of sexual strangulation, also known as the consensual practice of “choking”, forensic and research experts warn.
Dr Amelia McLean, of the Victorian Institute of Forensic Medicine, said the increase in the number of patients who had been sexually strangled is so striking that clinicians are worried normalisation of it will leave a generation with increased risk of brain injury.
After a 16-year-old Sydney girl died in August following what police believe was strangulation during consensual sex, the federal government floated banning choking pornography – the main source of the popularisation of reducing oxygen to the brain to heighten sexual sensation.
But McLean has also been alarmed by TikTok and YouTube tutorials outside of pornography that offer advice on how to slow blood supply in the neck’s main vessels “safely”.
“There are some TikTok clips, also on YouTube, including one that has gone viral which basically is a young woman explaining how to strangle yourself or someone else ‘safely’. She points to the carotid arteries and how to compress them to cut off blood supply to the brain … to be someone’s ‘hand necklace’,” said McLean, who works in VIFM’s clinical forensic medical unit.
That the comments under the YouTube version were mostly positive reflects a lack of knowledge that even minor pressure could cause damage, including small tears to the lining of blood vessels, known as arterial dissection, that may trigger catastrophic events, immediately or later, McLean said.
Sexual strangulation is now so common a feature of sexual assault – some cases of which begin as consensual encounters – that some young patients she examines believe the choking element is unremarkable, she said.
“We examine patients after sexual assault, and we have noticed it seems to be quite generational. If I see someone in their mid-30s, it’s uncommon to hear there’s been strangulation, but when it’s someone in their early to mid-20s or younger, it’s very, very common,” McLean said.
“To the extent where we will not be aware strangulation has taken place, and when we do ask them they say, ‘Oh, yeah, of course that happened’ – as opposed to it being unusual, they don’t seem particularly alarmed about that part of it.”
McLean and non-fatal strangulation research experts such as University of Melbourne Professor Heather Douglas say it is essential that young people are informed about the serious and cumulative harms to brain function risked by even mild blood-flow restriction, but in a way that does not alienate them.
Harm can include hypoxic and anoxic brain injury – causing brain cells to die – cognitive defects such as amnesia, short-term memory gaps, disorientation, and heavily impaired decision-making or executive function, incontinence, cardiac arrest and miscarriage.
Choking can also cause convulsions, seizures and death. The teenager who died in Sydney’s northern beaches is reported to have experienced seizures before losing consciousness.
Frequent exposure to sexual strangulation also correlates with higher rates of mood disorders including depression, anxiety, loneliness and emotional distress.
Douglas last year studied the understanding of risk among young people – the primary demographic using sexual strangulation outside longstanding niche-sex communities – and concluded one reason strangulation has become so accepted is because understanding of the danger is low.
She previously studied the use of sexual strangulation among 4702 people aged 18-35 and found 57 per cent had been strangled at least once and 51 per cent had strangled someone at least once. Young women (61 per cent) were more likely than young men (43 per cent) to report ever having been strangled by a partner, and young men (59 per cent) were more likely to have done it to a partner than young women (40 per cent).
Douglas said clinicians such as McLean are right to be alarmed: “Yes, you might have a generation at risk of stroke, or a generation who might have mild-to-severe brain injury as a result of this behaviour.
“But the prohibition narrative can be something young people don’t respond to, when older adults are saying, ‘never do this’.”
Consent for sexual activities was often assumed to be carried over from one event to the next, with no ongoing negotiation, placing those being strangled regularly at higher risk of longer-term cognitive issues, she said.
“There is really clear evidence coming out of the US comparing young women who have never been strangled with those strangled three or four times in the previous month – and there are clear changes to how the brain looks, the time it takes to problem-solve, and clear changes to the memories [of those strangled],” said Douglas, a longtime violence-against-women academic.
These studies demonstrated that as well as increasing stroke risk, the practice may cause “a generation of young women who might have mild-to-severe brain injury as a result of this”.
In New South Wales, women’s health services have recently reported a huge surge in the number of people concerned they have an acquired brain injury after being strangled, including during sex.
The practice is considered so mainstream that a wide range of heavy pet-style slip chains for women’s necks remain on sale on popular mainstream shopping platforms such as Etsy, and articles promoting erotic asphyxiation as an advanced kink appear in publications, including Women’s Health.
Dr Neil Goldie, service director for emergency medicine at Monash Health, compared the cumulative effects of non-fatal strangulation with the incremental harm caused by multiple concussions.
“A bit like with concussions in football players, people may not notice it at the time, but 10 to 15 years down the track, there might be significant sequelae [chronic conditions or complications resulting from a prior trauma],” he said.
“It can have catastrophic effects of death, or repeated minor hypoxic brain injury causing cognitive decline or memory losses that wouldn’t necessarily be picked up at the time and may become evident later. It’s going to be really hard to measure.”
McLean says an influencer-driven campaign to promote accurate knowledge about potential brain damage from disruption of oxygen during consensual sex, even when it does not leave visible marks, is needed urgently, and the VIFM is considering launching its own.
Non-fatal strangulation is also common in family violence attacks, and research has shown it is a strong indicator of potential escalation of violence and homicide. Police laid 1000 charges in the first year after laws criminalising it as a standalone family violence offence came into force in Victoria in late 2024.
The prevalence of choking in domestic violence situations is probably underreported, as the Australian Institute of Health and Welfare states only about 8 per cent of sexual assault incidents are reported.
Dr Amy Webster, manager of policy, advocacy and research at Sexual Assault Services Victoria, described sexual strangulation as “a manufactured sexual act that has become a lot more common as it’s been promoted and normalised by porn, social media and the manosphere”.
“It’s presented as common and pleasurable, and many people think they should be consenting to it, or consent isn’t needed, or that sexual strangulation can be done safely: but we know that’s not true,” she said.
The practice had changed the way sexual-assault crisis care is provided, making it more complicated, Webster said. The sector had noticed a significant increase in sexual strangulation in stranger assaults, casual encounters and family violence incidents in the last five years.
Jennifer Fielding, unit manager Women’s Emergency at the Royal Women’s Hospital, agreed with McLean that women who have experienced sexual strangulation as part of assault or family violence often do not think to mention it because it is considered so routine.
“Because they see it as normal, they don’t like to place blame when it happens, there’s that minimisation, their outlook on it is different,” she said. “The scary thing is that because of this normalisation, they may not recognise they are at risk until it’s too late.”
And her colleague Amanda Morris, senior program manager of family violence, agreed that as multidisciplinary professionals strive at the hospital to raise awareness and reduce harm from sexual strangulation, messaging about serious danger must be balanced so that women feel comfortable disclosing it.
“We need high-quality, trauma-informed messaging regardless of where [women] are – on social media, in medical [systems], seeing it on the news – so they can choose to seek help,” she said.
If you or someone you know needs help, contact 1800 RESPECT (1800 737 732) or the National Sexual Abuse and Redress Support Service on 1800 211 028.
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Wendy Tuohy is a senior writer focusing on social issues and those impacting women and girls.Connect via X or email.From our partners
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