Bondage and Positional Asphyxia

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Breathing takes work. More specifically, breathing takes muscular effort. In a healthy person, inhalation takes active effort and exhalation is passive. (By contrast, people having an asthma attack must often work to exhale as well as to inhale, which is one of the reasons why an asthma attack can be a serious medical emergency.)

Positional asphyxia occurs when a person’s body is put into a position where the amount of work they have to do to breathe adequately is greater than the amount of work their respiratory muscles can sustain indefinitely. In a worst-case scenario, their respiratory muscles fatigue to where they can no longer function adequately and the person dies of respiratory muscle failure.

This can occur in an almost infinite number of ways. For example, a person whose torso is suspended upside down is at risk for developing positional asphyxia because in this position the weight of their intestines on their diaphragm can hinder its ability to move and the chest is often pulled into the “exhale” position thus requiring them to expend muscular effort to exhale as well as to inhale. A person whose torso is in this position usually cannot survive for more than a few hours.

I have a case report in which a person tried to climb over a fence, slipped, and ended up hanging upside down and nobody could hear his cries for help. The authorities estimated he survived for about six hours before succumbing to positional asphyxia.

How quickly positional asphyxia can become life-threatening varies widely. In many cases, it takes hours for positional asphyxia to become life-threatening. In other cases, such as when somebody is working underneath a car and the car falls onto their chest and thus severely limits their chest’s ability to move, positional asphyxia can become life-threatening within minutes.

In the real world, excessive alcohol usage is often associated with positional asphyxia fatalities. The drunken person passes out and lands in a position where the amount of work it takes for them to breathe is greater than what their body can sustain. For example, I have a case report in which a man came home drunk and felt the need to throw up. He therefore knelt by his bathtub with his head hanging over into the tub and passed out. This position hindered his ability to breathe, and he died. The forensic pathology literature describes many similar incidents.

There is at least some risk of positional asphyxia developing in a hogtied person, and many police in-custody deaths have been attributed to the police hogtying a suspect. We should note that in many such deaths, the deceased was heavyset and significantly under the influence of alcohol and/or drugs. (A “hogtie” can be briefly described as a tie in which the hands are tied behind the back and the ankles are then tied together and drawn back towards the hands; there are many variants of the hogtie.)

Most particularly, however, was that the police placed the hogtied suspect into the face-down position and kept them in that position for a considerable period (often placed, unsupervised, face-down in the back seat of a patrol car for transportation to jail). Given that such a position could limit the suspect’s ability to breathe, this makes sense. Substantial relief can be provided by the hogtied person rolling onto/being rolled onto their side or, depending on how they are tied, onto their back. This generally allows for much freer motion of the chest wall and thus often restores adequate respiration and greatly mitigates, if not eliminates, the risk of positional asphyxia. (It’s become standard police procedure in many departments that while a person may be placed face-down while being handcuffed, they are then to be rolled onto their side or sat up once the handcuffs have been applied – thus resulting in their being face-down for only a fairly short time.)

An important thing to know about positional asphyxia is that it almost always takes many, many minutes, or even hours, to become life-threatening. Further, the person at risk will develop a gradually increasing level of respiratory distress.

Let me also note that this risk does not always appear and, in my experience, rarely appears at all in a consensually hogtied person. I have known many bottoms who happily spent hours in a face-down hogtie without developing respiratory problems.

When I teach about bondage, I typically teach that there are three types of monitoring:

1) Tightly monitored bondage — in which the top is within about 20 feet or so of the bottom and has them in sight. Some forms of bondage are reasonably safe only in a tightly monitored situation. For example, in my opinion a gagged bottom should always be tightly monitored. (It is reasonably safe to leave such a bottom alone for very brief periods. One of the ways that I teach this is by telling my students, “Never let a gagged bottom out of your sight for longer than it takes you to pee.”)

2) Loosely monitored bondage — which is how one might monitor a sleeping infant left in one’s care. The top can hear the bottom if they yell for help and visually checks in on the bottom every 15 minutes or so even if no call for help occurred. For example, in my opinion a bottom who has been bound spread-eagled to a bed but not gagged would be reasonably safe if they were loosely monitored — as in their top was in the next room. (In medical institutions, someone usually checks restrained patients every 15 minutes.)

3) Unmonitored bondage — in which nobody can hear the bottom if they yell for help and/or cannot respond in time to render aid. In my opinion, certain types of bondage are reasonably safe in an unmonitored situation, but only if the bottom can get themselves outside unassisted in one minute or less if there is an emergency such as a fire or earthquake. (Other conditions apply.)

A hogtied bottom should always be monitored. Depending on how they are tied, they might require either tight monitoring or loose monitoring, but they should always be monitored. A hogtied, unmonitored bottom is not in a reasonably safe situation.

Given that, as stated above, positional asphyxia usually takes a very significant amount of time to become life-threatening, and that the hogtied bottom will be developing an increased sense of respiratory distress, if they are monitored, be it tightly or loosely, then they should be able to communicate this distress to their top and their top should be able to either re-position or re-tie them in such a way that the respiratory distress is relieved long before it becomes life-threatening.

In reasonably safe BDSM, positional asphyxia deaths are 100% preventable. They are preventable by appropriate monitoring and appropriate intervention.

Appropriate monitoring is the solvent for thousands of bondage-related problems.

Best regards to all,

Jay

Multi-state court-qualified BDSM expert witness.

Author of the following books (among others):

“SM 101: A Realistic Introduction”

“Jay Wiseman’s Erotic Bondage Handbook”

“The Toybag Guide to Basic Rope Bondage”

Producer of the following videos (among others):

“Jay Wiseman Teaches Basic Rope Bondage”

“Jay Wiseman Teaches Tight, Immobilizing Bondage”
“Arm Harnesses for Every Body”

“Jay Wiseman Teaches Erotic Bondage for Beginners”