Identifying and Intervening with Patients Who Have Been Choked During Sex

Within the past decade, a growing number of adolescents and young adults have engaged in sexual choking or strangulation (SC/S; Sharman et al., 2025). Although it is normalized among many young people, the practice poses risks to their health and safety. Sexual asphyxiation, or “choking” (the latter being a popularized term), is actually “strangulation” because an outside force (e.g., a hand) obstructs the blood/air flow to the brain, whereas “choking” refers to blocking the windpipe from inside the neck (Sauvageau & Boghossian, 2010). Although SC/S practitioners tend to believe the behavior is harmless, it is, in fact, quite dangerous. No one can be choked safely. Because psychotherapists will increasingly be encountering patients who engage in SC/S, this brief article introduces psychotherapists to SC/S essentials they should know, including its harmfulness and the knowledge and skills needed for effective therapy interventions.

Almost 60% of American college-age women have experienced SC/S in their sexual encounters (Herbenick et al., 2021c). Studies from Australia, the United Kingdom, and Iceland found prevalence rates ranging from 38 to 70% among young adults with high rates among those who identify as transgender or nonbinary (Smailes et al., 2025).

SC/S appears to be a heterogeneous practice (Turkson & Knapp, 2026). Some participants willingly engage in it for personal pleasure while others may be bullied, pressured, or forced into participating (e.g., during sexual assault). SC/S may also occur in consensual rough sex, which could include, among other practices, hair pulling, punching, or slapping (Herbenick & Galper, 2026). However, consensual rough sex could escalate into nonconsensual aggression (Herbenick et al., 2021b). Nonconsensual SC/S, like other forms of unwanted sexual violence, is a sexual assault.

Health Risks Associated With SC/S

The health sequelae of SC/S could range from minor (e.g., hoarse voice, neck bruises) to severe (e.g., headaches, vision changes, strokes, brain injury, or even death; Valera et al., 2022). Participants may become unconscious within seconds, and death can occur in less than two minutes (Family Justice Center Alliance, 2023). The damage from SC/S may not become manifest for days or months later (Valera et al., 2022). The long-term cognitive impact of strangulation is not well understood. However, initial studies suggest that hypoxia (episodes with a lack of oxygen) can increase neuroinflammation and degrade brain health (Sweeney et al., 2026).

Participants in SC/S often do not understand its associated health risks and see the behavior as safe and commonplace (Conte et al., 2025; Herbenick et al., 2021a), as media and peer influences have normalized SC/S (Sharman et al., 2025). For example, Shor and Liu (2026) found that depictions of SC/S in pornography have increased in the last 25 years and are now found in about 15% of all videos. These depictions do a disservice insofar as they present choking and other forms of aggression as enjoyable and safe activities.

In their sexual relations with men, college-aged women are disproportionately the recipients of SC/S, and often report mental health problems, such as anxiety and depression (Herbenick et al., 2021a). However, it is not known whether anxious or depressed women are more likely to engage in this behavior or whether the SC/S behavior increases anxiety or depression.

The Context in Which SC/S Occurs is Important

SC/S can look very different depending on the context, given that the activity may be consensual, non-consensual, or occur as a result of “forced or coerced” consent.

Consensual SC/S

Usually, SC/S occurs as a consensual activity with an exclusive partner (Herbenick et al., 2023). However, consent may not be “informed” in that young people are often unaware of the serious health risks of SC/S. For example, some may not have engaged in SC/S if they had known about the health dangers beforehand. Thus, psychotherapists may educate patients about these risks so they can make informed choices about their behavior. Also, consenting to a partner is not the same as legal consent, as one cannot legally consent to behaviors like SC/S that may cause one serious harm (Ratcliff et al., 2026).

Nonconsensual SC/S

Abuse is common in relationships, particularly for young women and sexual/gender minoritized individuals (The Hotline, 2025), the same groups who have the highest frequency of being sexually choked (Herbenick et al., 2023). Researchers have recognized a potential overlap between abuse and SC/S, such as how a prior history of experiencing domestic/intimate partner violence (DV/IPV) may increase the risk of engaging in SC/S (Herbenick et al., 2025). Therefore, psychotherapists should be especially alert for signs of abuse when SC/S is present. They can assess DV/IPV using established measures, such as the Danger Assessment scale, which includes questions on C/S and loss of consciousness (Messing et al., 2022).

Compliance/Forced Consent

Consent for engaging in SC/S occurs across a continuum. Some people engage in SC/S willingly; others are choked without their consent; and others engage in it to please their partner or to avoid reprisals such as withholding affection or financial support. It is hard to conclude that the latter group consents freely, given that consent occurs under pressure or coercion, reflecting the limited power many women have in their intimate relationships (Herbenick et al., 2023). Those with a history of sexual victimization are more likely than non-victims to engage in consensual or non-consensual rough sex, which may include SC/S. Perhaps the history of victimization makes it more difficult to refuse consent due to fear (Peterson et al., 2026). Thus, psychotherapists may sensitively obtain a sexual history, including sexual victimization, in their intake and clinical interviews.

Withdrawing Consent

Withdrawing consent during SC/S may be difficult or impossible. Those who are being choked/strangled during sex may not be physically able to speak or convey their wishes, or their judgment may be clouded by hypoxia. Also, adolescents or young adults may not have the maturity (development in their prefrontal cortex) to make wise decisions, thus increasing their vulnerability to risk-taking or sensation-seeking behaviors such as engaging in SC/S (National Research Council, 2011). Psychotherapists can inform patients that consent is needed prior to SC/S and that people are often physically incapable of withdrawing consent during the act.

Effectively Evaluating and Treating SC/S Requires Certain Competencies

Psychotherapists, especially those who work with adolescents or young adults, should possess the knowledge and skills to address SC/S. However, SC/S in relationships has only recently become prevalent among young people and, therefore, has only recently been studied (Herbenick et al., 2025). Thus, many psychotherapists may not have the familiarity with, or training to address, this area.  

In addition to the usual elements of effective psychotherapy (e.g., building a strong relationship and providing an individualized approach), psychotherapists can improve their outcomes with patients who are choked during sex in several ways. They can examine their own attitudes toward such sexual behaviors, be alert to the presence of SC/S, and know both how to engage patients on the topic of SC/S and empower them to make decisions that promote patient health, well-being, and equality in relationships. One way is to provide psychoeducation on the dangers of SC/S and what constitutes “informed” consent, such as the need to know the health risks prior to participating in SC/S.

Examine Attitudes and Feelings

Competence includes emotional competence, or the ability to handle one’s emotions when working with patients who engage in SC/S. Psychotherapists may sometimes feel anxiety or anger due to the danger involved in SC/S. Therefore, psychotherapists must examine their attitudes, including the possibility that they will become judgmental, overly pathologize their patients, or that their personal disgust over this behavior may leak into psychotherapy through their nonverbal expressions or word choices. However, the psychotherapist’s role is not to judge. Instead, they can understand the circumstances that led the individual to adopt those behaviors, such as peer pressure, normalization in the media, or the normalization of oppressive beliefs about women and sexual/gender minoritized persons.

Identifying Patients Who Are Choked During Sex

Even before psychotherapy begins, psychotherapists can help to normalize the discussion of the topic by placing brochures on SC/S in the waiting room and including questions about SC/S, or other sexual or relationship issues that the psychologist deems important, on their intake forms and during the initial interview (e.g., when taking a sexual history). Routinely asking these questions signals that this is a common enough experience to explore with all young patients.

Learn How to Engage Patients on This Topic

Many patients who engage in this behavior enjoy it and do not want to stop, or their consent to engage in SC/S may not be informed by its dangers. Therefore, psychotherapists who raise the topic as a clinical issue may be perceived as overly intrusive, prudish, or out of touch. Of course, patients have the right to identify their treatment goals, and respecting patient decision-making means that sometimes patients will make decisions their psychotherapists may deem unwise. Nonetheless, psychotherapists also have an obligation to promote their patients’ well-being and to raise the dangers of SC/S when there is evidence that the patient was being choked (e.g., hoarse voice, neck bruises, loss of consciousness, patient confirmation of being choked during sex). Fortunately, they have options for framing the topic in ways that increase patient engagement.

Link SC/S to Presenting Problem.

The first option is to link the topic to the patient’s presenting problem. If the patient is having heightened anxiety, neurological symptoms, or relationship issues, for example, psychotherapists can explore any link between their symptoms and their sexual practices.

Use a Sliding Scale of Consent to Raise the Topic.

Often, patients who are being choked during sex do not view the behavior as a problem and may not see it as relevant to the reason that they started psychotherapy. The issue of consent arises wherein patients have the ultimate choice as to which topics to address in psychotherapy and which to avoid. Given the potential seriousness of the health risks involved, however, psychotherapists can use a sliding scale of consent (Knapp & Fingerhut, 2024) and introduce new goals for the patient to consider. These may include discussing SC/S and including the choking partner in treatment if the patient is in a safe, otherwise non-abusive relationship (see Turkson & Knapp, 2026). Psychotherapists can increase the likelihood that patients will engage with the topic by listening without judgment and with curiosity about why the patient engages in this behavior; only after patients feel heard should the psychotherapist ask permission to raise concerns about the behavior.

Focus on SC/S Psychoeducation.

Finally, framing the issue as educational may help some patients become more open to discussing it. The psychotherapist could start, for example, with nonjudgmental discussions of the reasons they engage in SC/S, their history of use, the nature of the relationships in which it occurs, the benefits, if any, of engaging in it, and, finally, their perceptions of any drawbacks. Only after patients have a chance to feel heard could psychotherapists ask their patients’ permission to address the health concerns related to this practice.

Empowering Patients

One goal of psychotherapy is to empower patients to make decisions about their own welfare. Because the degree of consent among those who participate in SC/S may vary along a spectrum, empowering patients also varies according to the context in which SC/S occurs. For participants who engage in SC/S without coercion, empowerment may mean providing information about the health risks needed to make an informed decision. If the therapeutic alliance is strong enough, psychotherapists may also help raise their patients’ consciousness by examining the role of power differentials in society, such as how women and gender/sexual minoritized persons are often the targets of DV/IPV (APA, 2018). For others, it may mean addressing cognitive distortions about self-worth, learning relationship skills such as assertiveness, or identifying safe ways to leave an unrewarding relationship. Of course, psychotherapists should screen their patients for DV/IPV. In abusive relationships, seeking an advocate or legal protection may be indicated because leaving a relationship can increase the victim’s risk of serious injury or death (The Hotline, 2025).

Practice Pointers

Because of its prevalence and potential for harm, psychotherapists should learn about SC/S, screen for DV/IPV, and hone the skills needed to strengthen their effectiveness with patients who engage in SC/S by

• re-evaluating their feelings and attitudes about SC/S or the people who practice it,
• learning how to engage patients in allowing a discussion of this topic,
• striving to empower their patients to make informed decisions, free from coercion.