Clinical characteristics of acute sexual strangulation/choking: a randomized cross-over study

Sexual strangulation, widely referred to as "choking," has become a prevalent sexual practice among young adults, disproportionately affecting females. Despite this high prevalence, little is known about its acute neurobehavioral effects.

To evaluate the short-term impact of sexual strangulation on physical, psychological, and oculomotor functioning, and to explore participants' subjective experiences and perceptions of study participation.

This randomized crossover study included 31 young adult females (18-30 years) who had engaged in both choking-involved and non-choking partnered sex in the past month. Participants completed 3 visits: baseline, post-choking sex, and post-non-choking sex. Mental health assessments (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, Perceived Stress Scale) and near point of convergence (NPC) testing were administered at each visit. Mixed-effects regression models assessed outcome changes across conditions. Additionally, participants completed a post-study experience survey to express their thoughts and feelings regarding study participation.

Primary outcomes were NPC distance (in centimeters) and mental health scores. Secondary outcomes included symptom self-reports following sexual choking and participants' feedback on study acceptability.

NPC distance increased significantly following both choking and non-choking sex, with a greater increase post-choking (19.9% vs 8.1%, P = .007). Depression scores declined significantly only following non-choking sex (P = .038), whereas perceived stress levels decreased after both types of sex (Ps < 0.05). Anxiety scores declined only after choking-involved sex (P = .048). Notably, approximately one-third of participants reported neurological symptoms, such as head rush and blurred vision, following choking-involved sex. Most participants rated the study as acceptable and appropriate.

Sexual strangulation/choking may acutely disrupt oculomotor control and attenuate typical mood-related benefits of sex. These findings support the need to assess strangulation/choking-involved sex distinctly from other sexual behaviors in clinical and research settings.

This is the first randomized crossover study to examine the acute effects of sexual strangulation/choking. Strengths include a within-subject design, assessment acutely after exposure, and multimodal assessment. Limitations include a small sample size, short follow-up, and reliance on self-report data.

Sexual strangulation/choking may acutely impair NPC more than non-choking sex, attenuate the typical mood-enhancing effects of sexual activity (depression), and produce unique affective outcomes (anxiety reduction). As this practice becomes increasingly mainstream, further research is urgently needed to inform health education, clinical screening, and public health responses.