Fatal hazards of a dangerous sexual practice: Self-strangulation as part of an erotic ritual is not uncommon, writes Celia Hall, Medical Editor

STEPHEN MILLIGAN appears to have been performing a very well documented sexual practice that went classically wrong, according to doctors and psychologists.

Auto-erotic asphyxiation - also known as 'scarfing' - aims to increase sensation at orgasm. One psychologist said yesterday that sex involving ligature is 'said to be among the most powerful orgasmic experiences a man can have'.

It is also extremely dangerous and doctors warned that anyone indulging in it should seek sexual counselling immediately.

An American psychologist, Michael Apter, says in his book The Psychology of Excitement that it is the 'most dangerous sex game in the world'.

The man who is half-strangling himself while masturbating risks losing consciousness simply by going too far. He can hang himself if he has set up a noose and is increasing pressure on his neck by standing on a chair and bending his knees; he dies when he unintentionally kicks the chair out of reach.

Auto-erotic asphyxiation is performed by men and women - although more by men - and it is not associated with homosexuality.

Data is limited because it is almost always an activity carried out alone and in secret. The absence of a suicide note and the presence of a noose or ligature and other bindings are characteristic. Padding around the neck is often used to avoid leaving a mark.

When it does go badly wrong the most explicit details are sometimes withheld at an inquest to spare the feelings of relatives. A suicide or open verdict is recorded.

A forensic pathologist estimated that out of 100 suspicious deaths in a year, 1 to 2 per cent were caused by auto-asphyxiation.

'It is a well-known phenomenon. There is good evidence that they have done this repeatedly from grooves on a rafter where the rope has been hung, a drawer dedicated to paraphernalia.

'And because they do it repeatedly suggests that they do derive some benefit from it. We find various methods of depriving the brain of oxygen - masks, paper bags, ligatures.' Bondage, tying themselves up loosely, using mirrors, female clothes or make-up were often involved. There was usually some element of control, systems with ropes that enabled a man to increase pressure on the neck gradually.

There is some debate over why semi-asphyxiation increases orgasmic sensations; the extent to which fear is part of the process and whether oxygen deprivation increases the potency of an erection. Using 'aids' to increase sexual sensation is common, from looking at photographs, to using alcohol, drugs - including amyl nitrate - dressing up and bondage. Amyl nitrate dilates blood vessels and is used as a heart drug. It enhances the flow of oxygenated blood and is held to increase a sense of well-being and abandon.

Dr Philip Cauthery, who specialises in psychosexual problems, said there was a whole range of activities used by men and women to obtain a maximum quality orgasm. 'Auto- erotic asphyxiation is not an everyday occurrence but I have known several cases, one or two deaths and a number of descriptions of it, from taking a person's sexual history.

'It is all about overcoming cultural inhibitions to masturbation. There is still widespread anxiety and guilt about masturbating, often at subconscious levels. These are means of trying to reduce the inhibitions that spoil the quality of an orgasm.'

Semi-asphyxiation - oxygen starvation - induces a dreamlike state. 'Other people may choose to take drugs or alcohol to overcome their inhibition.

'This comes down to culturally induced guilt about sex and it is an absolute tragedy that a man who by all accounts was decent and talented should lose his life in this way,' Dr Cauthery added.

Dr Apter believes that the sensations of light-headedness associated with a restricted oxygen supply are enhanced by danger. Increasing the state of arousal in response to fear and danger are an important part of the practice. The addition of wearing women's clothes or underclothes has often been practised by the cross-dresser as a sexual 'extra' for years.

Tina Baker, principal clinical psychologist at Jersey General Hospital, said: 'The desire for sexual enhancement and pleasure takes over. But it is simply a way of releasing tension and a lot of women can be very understanding about it.'

The Dangerous Edge, the Psychology of Excitement; by Michael Apter, The Free Press; Maxwell Macmillan, Canada; 1992.