“In many ways, oxygen is to the human body, and particularly to the heart and brain, what oil is to a car’s engine. Indeed, there’s a medical adage that goes ‘hypoxia (becoming dangerously low on oxygen) not only stops the motor, but also wrecks the engine.” (The Medical Realities of Breath Control Play, Sexuality.org, Jay Wiseman)
In a world where we love tying each other up (yes please) and delivering a good spank physical injury in play is commonplace. For the most part it is light bruises or red marks which disappear in days if not hours. People excited, displaying what their Top gifted them the night before are all over Fetlife or showing the marks off at gatherings.
Once in a while, we see injuries/marks a little more serious. Branding, scarification, bleeding cuts, lacerations, split skin, and very deep bruising involving the muscles come to mind. These are less common but no less welcome and attributed to heavy play.
Part of play for many, some even plan them. Easy to recognize, often talked (or bragged) about, and thousands of resources of information on how to care for them exist. We see the marks, can share them, and others know what to do. Although potentially dangerous, we have a map to work from and take care of them. What about the unseen risks?
There is a sneaky bastard many have not heard of. Something that can happen even during lighter bondage/rope play. It can be hard to recognize, and difficult to react to: Positional Asphyxia.
What is Positional Asphyxia?
Positional Asphyxia occurs when our bottom cannot get enough oxygen because of the position we have put them and the muscles supporting breathing wear out becoming over tired. Between hog ties, ball suspensions, predicament bondage, and other inventive poses we cause mechanical stress on the structures of the chest. Restricting the bottom from breathing normally. Eventually, the muscles supporting breathing give out putting them in a life threating position (hypoxia- the lack of oxygen at the tissue level).
I should clarify, I am not writing about breath play or other kinks which intentionally restrict breathing. Positional Asphyxia is the result of accidental circumstance in situations where we are not planning on breathing, or the lack there of, being part of play.
Positional Asphyxia is more likely to occur when there are additional physical stressors which causes their body to work hard. Wrestling, being thrown around in a CNC scene, physically demanding positions, and physical exercise are a few examples. The use of or stimulants or alcohol also increases the risk. Medical conditions such as heart disease, asthma, bronchitis, etc. can contribute also.
Someone who is physically exhausted and in a compromising position is particularly at risk as they may be unable to tell you they are in trouble. Gravity and their own physical state are working against them.
Recognizing Positional Asphyxia
When we play hard and for long periods of time subspace, fatigue, and lack of focus can make it difficult to see when a bottom may be in trouble. Let’s face it, both partners get tired and a bottom at the end of the physical rope (pun intended) may be lethargic and slow to respond. This combined with a top being tired from play can make us miss what is really going if Positional Asphyxia is an issue.
These things together can make distinguishing between what is normal (in the context of kink) and real trouble a much more difficult task. However, there are some general indicators which can help you see trouble and act quickly.
Symptoms of Hypoxia: (can vary from person to person)
Acute Symptoms- Shortness of breath, rapid breathing, fast heart rate, wheezing, coughing, changes in skin color (particularly the fingertips and inside of the lips)
Severe Symptoms- Inability to communicate, confusion, loss of consciousness, slow heart rate
Other symptoms may include- restlessness, headache, sweating, cold and clammy
Assessment and Response
THIS IS NOT MEDICAL ADVICE- When in doubt seek medical assistance immediately.
Before you run for the hills, as long as you are doing what is needed to check on your bottom you should be able to catch any issues before they become serious. Generally, it takes a long time for Positional Asphyxia induced hypoxia to occur as a result of being bound. However, once it does set in, there is no time to waste.
Hopefully, you know the person you are playing with very well and generally know how they act or react to various play. If they are acting abnormal to what you know of them, are displaying sign/symptoms of hypoxia, or you have a reasonable suspicion they are in medical trouble, seek medical assistance immediately. With that being said, there are some quick things you can do to help you assess their physical state and respond to potential hypoxia.
Assessment: Level of consciousness- are they unresponsive or seem very confused? Are not speaking or responding to questions? Breathing is fast or gasping? Do they have a headache? Heart Rate is very fast or very slow? Are they cyanotic (bluish color inside the lips or fingertips)? Perform a capillary refill test, do they refill in more than 3 seconds? Are they cold and clammy to the touch even though sweating?
If the answers to one or more of these are yes, they are possibly in a hypoxic state. The more yes’s you have the more likely they are in serious trouble.
Response: If you reasonably believe your partner is hypoxic (the result of positional asphyxia) – CALL FOR MEDICAL ASSISTANCE NOW! Do not wait, hem and haw and worry about what people will think. Hypoxia is a life-threatening condition which can cause serious harm to major organs and death in a very short period of time. Sometimes minutes.
Get them out of any bonds and elevate their upper body and legs adjust as necessary however it is easier for them to breathe; continue to talk to them and encourage them to breathe deeply and slowly; keep them awake if at all possible; do not let them smoke, drink, or eat. Stay with them and do these things until medical first responders arrive.
If they lose consciousness and are not breathing and have no pulse, begin and continue CPR until medical first responders arrive.
You are the only one there and have to make a decision quickly. Yes, take a minute to help figure out what is going on, but minutes may be all you have. DO NOT WASTE THEM ON INDECISION!
Prevention
Now that you have dumped a full fecal load in your shorts and have sworn off any kind of bondage understand that there is a lot in the way we interact and play which helps prevent Positional Asphyxia and hypoxia from ever happening. The more we improve on the following skills and aspects, the less likely bad things happen.
Attentive and Present: Stay close to anyone retrained or bound. Not just because of positional asphyxia but there are other ways a restraint can have a negative impact. Have everything you need in the room with you before you begin to play. Including a charged cell phone and safety shears/rescue hook (keys and bolt cutters for hard restraints). Be attentive throughout the whole scene, paying attention to how they are doing and responding.
Communication (verbal and nonverbal): The louder the better. If they are loud, they are breathing and getting oxygen. Constantly be talking and eliciting a reaction from them. Use dirty talk, make them answer questions, whatever. The point is if they are becoming less communicative, we need to assess why. Watch their nonverbals. Are they a wiggler who has stopped wiggling? When you slap their thigh do they normally react? Etc. The longer play continues, the more physically drained you both may get. Make a point of asking how they are doing if you are unsure.
Physical Restraint Setup and Body Position: How and where you apply bonds be it rope, leather, or chain can impact the bottom’s ability to breathe freely. As you are applying the bonds check to make sure they are not so restrictive they will prevent the expansion of the chest. Ties which put additional stress on the chest such as behind the back arm binders or others which put the arms behind in an awkward position cause the muscles in the chest to work harder.
Gravity plays a roll. Head down positions will impact the ability to breathe over time. Weight/pressure placed on the chest such as a hogtie position (their weight is on their chest) make the diaphragm and chest muscles work harder to maintain breathing and wear out faster.
Be Technically Proficient: I cannot stress this enough. Learn and know your craft. Practice, loads of research, classes if possible, and interacting with more experienced players is a must. You both will have a better time and more likely to avoid issues.
Health Assessments (disclosure and annual physicals): Any medical condition which may affect play must be disclosed. This is for both of your safety. Even if the issue is the top’s. Get yourself and your bottom to a doctor once a year, or more often if necessary, for a general physical. We change as we age. It is just a fact of life.
Knowledgeable of Body processes and Physiology: Although I do not consider this a must, it is definitely helpful. Knowing how the body and its processes work can help inform your play and give you an increased margin of safety. Not to mention devious ideas 😉
Hydration: Drink lots of water before, during, and after play. We need water to make sure our bodies are working at their best. Water is critical in the oxygenation and blood circulation processes. If we are dehydrated, we are not going to be able to transfer oxygen efficiently to our muscles and organs.
Well Rested Before Play: Being well rested helps us be our best during play, ensures our muscles are ready for the stress, and we can endure for longer periods without our muscles giving out.
Final Thoughts
Regardless of your kinks or type of player you are, Positional Asphyxia is a risk you need to be aware of and know how to react to. For most players, this is probably something you will never see in your lifetime, hopefully because you have built good habits into your play.
Take the time to really learn and practice your craft, and have fun doing it. My goal through these types of articles is to help you do just that, have fun safely. Almost everything we do is risky, just take the time to find the counterbalances to those risks.
Do not be scared…… be informed!
Special Note and thanks: Great thanks to Dee Wells an amazing ICU Nurse for her expert eyes on this article. I may have stayed in a Holiday Inn last night but she does the serious stuff for a living….besides being kinky. And thank you to Dr. Wishesnottobenamed, wizard of the Emergency Room and Trauma-Fixer Extraordinaire. His insight was invaluable when sorting through what was important to include in this article.
For more information on Positional Asphyxia and Hypoxia and related information check out the links below:
Viewpoints Concerning Erotic Asphyxiation (bdsmcafe.com)
Bondage, Hogties and Positional Asphyxia (devianceanddesire.com)
Jay Wiseman essay on Self Bondage
Positional Asphyxia by Various (selfbound.net)
Article: Positional asphyxia | ESINEM Shibari Classes
Positional asphyxia (slideshare.net)
Hypoxia and Hypoxemia: Symptoms, Treatment, Causes (webmd.com)
How to Check Heart Rate: 5 Methods and What Is Normal (healthline.com)
