anomalies.

The magnitude of decompensation should be

assessed and optimized if possible. The aim of
intraoperative management is to gain rapid control of
airway, prevention of aspiration, barotrauma, swings of
blood pressure, myocardial depression, worsening of
pulmonary hypertension and left to right shunt, reversal of
shunt and cardiac failure. Ventilatory management is
directed towards maintaining stable airway pressures,
normoxia and normocarbia. Postoperative management
should constitute adequate analgesia and prevention of
adverse cardio-respiratory events.

of invasive haemodynamic monitoring and ventilatory

support, continued into the postoperative period.

References
1.

Ind J Radiol Imag 2006; 16: 325-27.

2.

Ellis RW, Van Creveld S. A syndrome characterized by ectodermal dysplasia,

polydactyly, chondrodysplasia and congenital morbus. Arch Dis Childhood
1940; 15: 65.

3.

Varela M, Ramos C. Chondroectodermal dysplasia (Ellis-van Creveld

syndrome): a case report. Eur J Orthod 1996; 18: 313-8.

4.

Howard TD, Guttmacher AE, McKinnon W, Sharma M, Mckusick VA, Jobs

EN. Autosomal dominant postaxial polydactyly, nail dystrophy, and dental
abnormalities map to chromosome 4p16, in the region containing the Ellisvan Creveld syndrome locus. Am J Hum Genet 1997; 61: 1405-12.

5.

Mahoney MJ, Hobbins JC. Prenatal diagnosis of chondroectodermal dysplasia

(Ellis-van Creveld syndrome) with fetoscopy and ultrasound. N Engl J Med
1977; 297: 258-60.

6.

Brueton LA, Dillon MJ, Winter RM. Ellis-van Creveld Syndrome, Jeune
syndrome, and renal-hepatic pancreatic dysplasia: separate entities or disease
spectrum? J Med Genet 1990; 27: 252-5.

Conclusion
Our patient showed many of the characteristic
changes described in literature. No case reports regarding
anaesthetic management of these patients have been found.
The principal goal of anaesthetic management in these
patients is to maintain cardiorespiratory stability, with use

Sharma OP, Saraf R, Gupta B. Ellis-Van Creveld's syndrome (a case report).

Case Report
Autoerotic Asphyxia by Hanging
Recep Fedakar1, Okan Akan2, Blent Eren3
Forensic Medicine Department,3, Grkle 16059, Bursa, Turkey, Council of Forensic Medicine of Turkey Bursa Morgue Department, Bursa, Turkey,
Council of Forensic Medicine of Turkey Bursa Morgue Department2, Bursa, Turkey.

Abstract
A case of sexual asphyxial death by hanging is
presented. A 41-year-old man was found dead hanging by a
towrope. A mirror was placed in front of a table, reflecting
him in full height. A photograph of a celebrity mannequin
was found against him. The towrope was arranged for the
compression of the neck, and controlled voluntarily by a
shower apparatus. Autopsy findings revealed an ascending
ligature mark, 2 cm in width on the neck. Although this is a
very ancient behaviour, we are presenting a very rare case
from Turkey. We aim to discuss sexual asphyxiation
phenomenon together with the features of the previous
Turkish cases on the aspect of the forensic viewpoint, as
well as the similarities and differences between different
nations and religious.

Introduction
Autoerotic asphyxiation is well-known phenomenon
described in medical literature, particularly in forensic
medicine reports, known as accidental autoerotic deaths.
This attitude is defined as a non-psychotic mental disorder
where unusual or bizarre imagery acts are necessary for
sexual excitement, such kind of imagery or acts tend to be

462

insistently and involuntarily repetitive.1

Although this is a very ancient behaviour, we are
presenting the fourth case from Turkey. We aim to discuss
sexual asphyxiation phenomenon together with the features
of the three previous Turkish cases on the aspect of the
forensic viewpoint, as well as the similarities and
differences between different nations and religious.

Case Report
A 41-year-old man was found dead hanging by a
towrope at the kitchen of a bank's guesthouse (Figure 1). A
mirror was placed in front of the table, reflecting him in full
height and also there was a broken mirror in the kitchen.
The victim was found by a bank's official driver. When the
driver opened the balcony door of the kitchen, the mirror
which was located leaning against the door was broken. The
curtains of the kitchen were drawn and the door was locked.
His undershirt was bounded as a brassiere over his nipples
and underpants were slipped on his head. The towrope was
arranged for the compression of the neck, and controlled
voluntarily by a shower apparatus (Figure 1). A photograph
of a celebrity mannequin was found against him. His
toenails were polished (Figure 2). The victim's body was
partially supported by the ground. There were two bottles of
J Pak Med Assoc

bone or the thyroid cartilage. Both lungs were congested.

There were no pathological findings in organs, except for
slight atherosclerosis on the aortic wall and slight left
ventricle hypertrophy. Alcohol concentration in the blood
was 0.96 mg/ml. The cause of death was attributed to
asphyxia by hanging. The manner of death was finally
considered to be an accident.

Discussion
Majority of autoerotic asphyxia victims are reported
to be adolescent or young adult males.1-5 Even though the
three previous Turkish cases were young adults,2-4 the
deceased presented in this report was a married middle-aged
male.
Figure 1. A view of the deceased as found hanging by a towrope controlled voluntarily by a
shower apparatus at the kitchen. His undershirt was bounded as a brassiere over his nipples and
underpants was slipped on his head.

The autoerotic death scene usually appears in a

secluded location, where nobody could disturb or watch the
victim,1-5 as was the case in the present report.
One of the important aspect of the psychopathology
of autoerotic asphyxiation is "fetishism". While
masturbating, individuals may fantasize about the fetish
object.5 Women's clothes, and other objects found at the
scene include various types of sexual aids: ropes, chains,
bars, locks, sex magazines, condoms, plastic bags, rubber
items. Individuals may rub, suck, or wear the item or they
may insert in into their body orifices.1-5
Approximately 25% of victims were reported to
wear female clothes [often female underwear]5 in line with
our case and the other three cases in Turkey. This type of
attire presumably provides additional impulse increasing
the level of arousal.1-4

Figure 2. The polished toenails

nail polish and a box of cigarettes on the bed. The deceased

lived apparently a normal social life as an inspector of a
bank, with a wife married for 12 years and two children. He
had been inspecting the branches of the bank and living
alone for three months. His wife could think of no reason
for him to commit suicide. There was no psychiatric
background, no suicide note, and no history of attempted
suicide.

Autopsy Findings
The deceased was 173 cm in height and weighed 85
kg. Postmortem hypostasis was marked on the hands and
feet. His face was markedly congested and facial petechial
haemorrhages were present and also there were many
petechial haemorrhages in the conjunctivae. The tip of his
tongue had been bitten by his teeth. An ascending ligature
mark, 2 cm in width was seen on the neck. There were
bruises of the neck muscles and no fracture of the hyoid

Vol. 58, No. 8, August 2008

As in the present case, about half of the cases were

married, with a normal sex life and their wives were usually
aware of their behaviour.1 In the present case, his wife was
not aware of his unusual sexual activities and the victim was
engaged in normal sexual life similar to the previous
Turkish cases.2-4
The deceased in the present case seemed to want to
create a partial asphyxia during masturbation. However,
unintentional and prolonged compression of the neck
appears to lead to a sudden and unexpected loss of
consciousness, probably because of the failure of the selfrescue mechanism.1 Loss of consciousness due to hypoxia,
sudden cardiac arrest caused by cardiac sinus reflex, vagal
stimulation due to vagal nerve irritation by hanging or rectal
dilatation by foreign body, like the case presented by
Yemisigil et al2 were reported.
It is of great importance to clarify the origin of
autoerotic asphyxiation death, accident, suicide, homicide
from juridical side. In some cases scene reconstruction and
psychological autopsy were effective for the differentiation

463

between accident and suicide. Thus, criteria for the

differential diagnosis of sexual asphyxia from suicide are
very important since the victims may sometimes leave notes
that might resemble suicide attempt, as can be seen in the
case reported by of Sari et al.4

recognized as one of the sexual taboos. Based on the notion

of a religious standard for sexual taboos, the differences in
the incidences of sexual asphyxia between different
communities might indeed be the result of differences of
religious background.

In the laboratory investigation, it was found that our

case was under the influence of alcohol, while in the other
three cases, no drug or alcohol was detected in contrast to
the cases in literature.1,5

The majority of Turkish population is Muslim.

Islamic rules are a major determinant in social life and
personal attitudes, especially in rural areas. The
insufficient.medical information imply that autoerotic
activities are not rare among unmarried young males and
females in our country.9,10 However, these observations rest
on clinical samples and may not reflect patterns of sexual
behaviour in the normal population. Attempts to study
sexual behaviour in the normal population are hindered by
unwillingness on the part of the respondents, because
sexuality is still considered as a taboo topic of discussion by
the larger part of the Turkish society.9,10

From a psychological viewpoint, it has been

suggested that the autoerotic activity results from a
castration or separation anxiety6 or a desire for selfpunishment for sexual behaviour, rather than from a
heightening of sexual pleasure from the self-induced
asphyxia.7
According to the anthropologists, Eskimo children
are known to hang themselves in a sexual game, Yahgans in
South America tied the neck to induce partial strangulation
for exhilaration.6 Although this is a very ancient behaviour
and some reports have estimated that at least 50-1000 such
cases occur each year in United States, or 0.1 cases per
million inhabitants per year in Sweden, 0.5 in Denmark,
0.68 in Alberta, Canada,1 and 0.49 in Hannover region,
Germany5, we are presenting the fourth case in Turkey. The
incidence in Turkey seems to be far lower than that the
countries mentioned above, although the precise incidence
of such deaths in Turkey is unknown. In the present day, the
incidence of sexual asphyxia generally appears to be higher
in Anglo-Saxon/Germanic populations, but lower in
Japanese, Latins and non-Caucasions.8 This discrepancy
may be due to the cultural, ethnic and religious
backgrounds, which influence the sexual behaviour of
individuals.
A large-scale population survey on autoerotic
activity in Turkey does not exist. Studies in student
populations show that for 50 percent, the main sexual
activity was masturbation.9 In another study, 11.5 percent of
female and 87.2 percent of male university students
admitted to having masturbated, while 21 percent of the
females and 26 percent of the males reported that
masturbation was unhealthy.10 Masturbation is commonly
regarded as a kind of sin in Islam, as it is in most other
religions. Although there is no written rule in the Koran that
prohibits masturbation, most people who refrain from
autoerotic activities believe that such behaviour is sinful. In
the Judaism and Christianity culture, masturbation had been

464

Additionally, autoerotic asphyxial death has been

misinterpreted and misdiagnosed for many years because
the social stigma and partly because the police and the
medical profession are unaware of its existence.1
A certain number of cases may be missed, as the
circumstances surrounding the discovery of the victim
might not always be clear; evidence may be destroyed by
family or friends of the victim out of shame. Therefore,
these might be some of the reasons of the rarity of sexual
asphyxiation phenomenon in our country.

References
1.

Ueno Y, Asano M, Nushida H, Nakagawa K, Adachi J, Nagasaki Y. Sexual

asphyxia by hanging- a case report and review of the literature. Legal Med
2003; 5: 175-80.

2.

Yemiscigil A, Karali H, Ege B, Hanci IH, Ertrk S. Autoerotic asphyxia. J

Forensic Med (in Turkish) 1991; 7: 165-68.

3.

Demirel B, Isik AF, Aydin M. An autoerotic asphyxial case: Suffocation with

plastic bag. In: Annual Meeting of Forensic Medicine. Istanbul, 2001.

4.

Sari H, Yavuz S, Asirdizer M. Medicolegal evaluation of a death occurred

during autoerotic activity. J Forensic Med (in Turkish) 2002; 16: 56-62.

5.

Breitmeier D, Mansouri F, Albrecht K, Bhm U, Trger HD, Kleemann WJ.

Accidental autoerotic deaths between 1978 and 1997 Institute of Legal
Medicine, Medical School Hannover. Forensic Sci Int 2003; 137: 41-44.

6.

Resnik HL. Erotised repetitive hangings: a form of self-destructive behavior.

Am J Psychother 1972; 26: 4-21.

7.

Edmondson JS. A case of sexual asphyxia without fatal termination. Br J

Psychiatry 1972; 121: 437-8.

8.

Ikeda N, Harada A, Umetsu K, Suzuki T. A case of fatal suffocation during an

unusual auto-erotic practice. Med Sci Law 1988; 28: 131-4.

9.

ok F, Ersever H, Gray LA. Sexual behavior in a group of university students.

HIV/AIDS Tip Dergisi (in Turkish) 1998; 1: 23-9.

10.

Erkmen H, Dilbaz N, Seber G, Kaptanoglu C, Tekin D. Sexual attitudes of

Turkish university students. J Sex Edu Ther 1990; 16: 251-61.

J Pak Med Assoc