Sexual choking or strangulation can take several forms, including the use of hands or forearms, ligatures such as ropes or belts, hanging, and chokeholds commonly associated with combat or restraint techniques. ⁵ Historically linked to violence, assault, or suicide, choking has increasingly become normalised within sexual encounters, particularly among young people, ⁶ creating growing concern from a public health perspective.

Emerging evidence also points to possible neurological consequences associated with repeated exposure to sexual choking. A 2023 MRI-based study reported atypical patterns of brain activity among women who experienced frequent choking during sex, particularly in regions involved in emotional regulation, motor function, and conscious awareness. These findings raise concerns that repeated episodes of oxygen restriction may have longer-term effects on brain functioning. ⁷

Despite these documented risks, sexual choking is frequently minimised as “just a kink” or framed solely as a matter of sexual preference. Such narratives can obscure the underlying gendered dynamics and potential harms associated with the practice. Importantly, agreeing to sexual activity does not automatically imply consent to strangulation or choking. ⁸ Although both men and women report experiences of being choked during sex, research consistently shows that women are disproportionately affected. ⁹

Research has also identified notable differences in how consent is perceived between those initiating choking and those experiencing it. Individuals performing the act were more likely to report that consent had been clearly communicated, whereas those being choked more commonly stated that explicit consent had not been discussed beforehand. ¹⁰ These findings underline the need for clear, ongoing, and context-specific communication around consent, particularly when behaviours involve significant physical risk.

Over the last decade, sexual choking has become increasingly widespread among young people, ² shaped in part by pornography, social media influences, and changing peer norms around sexual behaviour. Although now more visible in mainstream sexual culture, the practice originally emerged within specific BDSM communities involving bondage, dominance, submission, and sadomasochism. ¹¹

What was once considered a marginal or taboo sexual behaviour has increasingly entered mainstream sexual experiences, particularly among Generation Z. Many young women now report being choked during sex regularly, and in some cases without prior discussion or consent, reflecting how deeply the practice has become normalised within contemporary sexual culture.

Evidence from several countries suggests that sexual choking is becoming a significant international public health concern. In Australia, more than half of adults (57%) aged 18 to 35 reported having experienced choking during sex. ¹⁰ Studies from the United States indicate that many individuals first encountered the practice before the age of 20, ¹² while research from New Zealand points to a similar increase among younger populations. ¹³ Canadian studies have also shown that women under the age of 30 are disproportionately affected. ¹⁴

To date, most clinical and academic research on sexual choking has been concentrated in countries such as the United States, the United Kingdom, Canada, and Australia. However, reports suggest that the behaviour is also becoming more socially visible across parts of the Middle East, North Africa, and South Asia, ¹⁵ despite limited medical research, legal recognition, or policy discussion in these regions. This lack of evidence and institutional attention highlights a major gap in global public health and gender-based violence research.

Mainstream pornography platforms operate globally with minimal regulation, exposing young audiences across different cultural contexts to sexual content that frequently depicts choking without any visible discussion of consent, negotiation, or safety. Adolescents in cities such as Nairobi, New Delhi, or New York may encounter repeated portrayals of choking as routine sexual behaviour, often stripped of any context around risk or mutual agreement. Research suggests that consistent exposure to these depictions can contribute to perceptions that choking is normal, pleasurable, and largely harmless. ⁴

At the same time, social media platforms such as TikTok and Instagram have further amplified the normalisation of choking through short-form content that frames it as desirable, romantic, or sexually exciting. Viral trends and suggestive videos often present choking as a symbol of passion or intimacy, while rejecting such practices may lead individuals to fear being labelled “boring” or sexually inexperienced. Within this evolving digital sexual culture, choking increasingly becomes associated with desirability and sexual status rather than potential harm or violence.

Emerging evidence indicates that social media and pornography are playing a significant role in shaping young adults’ sexual expectations and behaviours. In these environments, participation in practices such as choking can feel socially expected, making refusal more difficult and creating pressure to conform to perceived sexual norms. ¹⁶

Importantly, this process is not simply cultural but also technological. Social media algorithms tend to prioritise provocative and highly engaging content while discouraging nuanced discussions around consent, coercion, trauma, or health consequences. ¹⁴ As a result, the physical and psychological risks associated with choking are often absent from the content young people consume online.

Within this context, understandings of consent can become increasingly unclear. Studies show that a substantial proportion of individuals who experienced choking during sex reported that explicit consent had not been obtained beforehand (one in four people). ¹⁰ Some participants also believed that previous agreement to choking automatically implied ongoing consent in future encounters. Together, social pressure, digital influence, and limited public discussion about risk contribute to environments where assumptions replace active and informed consent.

Legal systems across the world are increasingly struggling to respond to the growing normalisation of sexual choking and the complex questions it raises around consent, injury, and accountability. In 2022, England and Wales criminalised sexual choking under the Domestic Abuse Act 2021. However, fewer than 10 per cent of cases result in prosecution, raising concerns about justice and enforcement. ¹⁷ Australian law says consent is not relevant if choking causes injury or risk to life. The law states that using force can be unlawful even with consent. If harm occurs, consent is unlikely to be accepted as a defence. ¹⁸ Yet despite these legal developments, pornography and digital platforms continue to normalise choking as routine sexual behaviour, often detached from any discussion of risk, coercion, or bodily harm.

In many parts of the Middle East, North Africa, and South Asia, sexual choking remains largely invisible within public health and legal discourse, not necessarily because the behaviour is absent, but because broader restrictions around sexuality discourage open discussion, reporting, and research. At the same time, many young people increasingly view choking as a normal part of intimacy rather than a potentially harmful act linked to violence, coercion, or injury. This growing disconnect between legal recognition, public perception, and sexual practice highlights an urgent need for further research examining how sexual choking is understood, negotiated, experienced, and normalised across different social and cultural contexts.

Although research on sexual choking has expanded considerably in recent years, the existing literature remains fragmented. Studies vary widely in terminology, definitions, study populations, recall periods, and measurement approaches, making comparisons across findings challenging. Much of the current evidence is derived from university-based samples in high-income countries, with limited synthesis of prevalence estimates and associated health outcomes across broader populations. To date, no systematic review has comprehensively examined the prevalence of sexual choking among adults alongside associated physical, mental health, and sexual health outcomes.

Aim of the current systematic review

Guided by a pre-specified study protocol (Appendix 1- Study Protocol), this systematic review aimed to synthesise quantitative evidence on sexual choking among adults aged 18 years and older. Specifically, the review sought to: 1.

systematically identify quantitative studies reporting the prevalence of sexual choking among adults;

This systematic review was conducted to identify and synthesise quantitative evidence on the prevalence of sexual choking among adults aged 18 years and above, including associated physical, mental health, and sexual health outcomes. The review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The study protocol is provided in Appendix 1, the detailed search strategy in Appendix 2, the PRISMA checklist and flow diagram in Appendix 3, the quality appraisal framework in Appendix 4, and the full data extraction framework in Appendix 5.

Studies were eligible for inclusion if they included adults aged 18 years and above, examined sexual choking, strangulation, or closely related neck compression practices occurring during partnered sexual activity, reported quantitative prevalence estimates or sufficient numerical data to calculate prevalence, used quantitative study designs including cross sectional surveys, cohort studies, population based surveys, or epidemiological studies, and were peer reviewed journal articles published in English.

Studies including some participants younger than 18 years were eligible if adult data could not be separated, but the mean sample age was 18 years or above, indicating that the majority of participants were adults.

Studies were excluded if they primarily included participants younger than 18 years, were qualitative studies, mixed methods studies without extractable quantitative prevalence data, editorials, commentaries, reviews, conference abstracts, dissertations, case reports, or studies that did not specifically examine sexual choking within a sexual context or failed to report prevalence estimates or sufficient data for prevalence calculation.

Electronic database searches were conducted in MEDLINE, CINAHL, and APA PsycINFO from database inception to March 2026. No publication year restrictions were applied in order to maximise retrieval of potentially relevant studies. Searches were limited to peer reviewed articles published in the English language.

A comprehensive search strategy was developed to identify quantitative studies examining sexual choking prevalence and associated outcomes among adults. The search strategy combined three key concepts: quantitative and epidemiological study designs, sexual choking and related neck compression practices, and sexual or partnered contexts.

Search terms included controlled vocabulary and free text keywords relating to epidemiological and quantitative study designs, including cohort studies, epidemiologic studies, case-control studies, cross-sectional studies, clinical trial, statistic, questionnaire, survey, quantitative, epidemiology, observational study, surveillance, chi-square, regression, and statistics and numerical data.

These terms were combined with choking-related terminology, including choke, choking, strangulation, asphyxiation, neck compression, breath restriction, choking during sex, strangulation during sex, erotic asphyxiation, and breath play. Additional search terms relating to sexual context included sex, intercourse, intimate, and partner. Boolean operators, truncation symbols, and database specific subject headings were adapted appropriately for each database platform. An initial exploratory search was conducted to identify relevant terminology and indexing terms prior to development of the final advanced search strategy.

The final database search identified 854 records, including MEDLINE (n = 574), CINAHL (n = 172), and APA PsycINFO (n = 108). Supplementary searching was additionally conducted in Google Scholar, where the first 200 records were screened for relevance. To strengthen comprehensiveness and minimise the risk of missing eligible studies, backward and forward citation chasing was undertaken for included studies using citation tracking approaches.

All identified records were exported into EndNote reference management software for screening and duplicate removal. Full database specific search strings are provided in Appendix 2.

All identified records were exported into EndNote reference management software, and duplicate records were removed using the EndNote automated deduplication function alongside manual verification procedures prior to screening. A total of 227 duplicate records were identified and removed.

Following deduplication, titles and abstracts were independently screened by two reviewers against the predefined inclusion and exclusion criteria. Studies considered potentially relevant were retrieved for full text assessment. In total, 41 full text articles were assessed for eligibility.

Thirty studies were excluded following full text review for the following reasons: book chapter or book (n = 1), secondary data analysis (n = 1), review article (n = 1), qualitative study (n = 1), database review article (n = 1), and absence of sexual choking prevalence data or extractable quantitative findings (n = 25).

Eleven studies met the eligibility criteria through database searching. Backward and forward citation chasing of included studies identified two additional eligible studies, resulting in a final sample of 13 included studies for narrative synthesis.

Any disagreements between reviewers during the screening and eligibility assessment process were resolved through discussion and consensus. The study selection process is presented in the PRISMA flow diagram in Appendix 3.

A structured data extraction framework was developed based on the review objectives and existing literature. Extracted information included author and year, study objective, country, study design, setting and population, sample size, age characteristics, gender distribution, terminology and definitions used for sexual choking, prevalence estimates, recall periods, subgroup findings, consent-related findings, physical, neurological, mental health, and sexual health outcomes, contextual and motivational factors, and methodological limitations.

Data extraction was conducted systematically across all included studies to support narrative synthesis and comparison across studies. The full data extraction framework is provided in Appendix 5.

Methodological quality of included studies was assessed using a modified Joanna Briggs Institute (JBI) appraisal approach for prevalence and cross sectional studies. Appraisal criteria included appropriateness of sampling frame, sampling method, adequacy of sample size, description of study participants and setting, validity and reliability of measurement approaches, adequacy of statistical analysis, and management of response rates.

Studies were categorised according to overall methodological quality and risk of bias. Quality appraisal findings are summarised in the relevant results table and detailed in Appendix 4.

Due to substantial heterogeneity across studies in terminology, operational definitions, recall periods, populations, and outcome measures, meta analysis was not considered appropriate. A narrative synthesis approach was therefore undertaken.

Findings were synthesised according to the review objectives, including study characteristics, prevalence estimates, variation by gender, age, and region, physical, neurological, mental health, and sexual health outcomes, and methodological limitations and research gaps.

Additional thematic synthesis was conducted for emergent contextual themes relating to consent practices, pornography exposure, motivations for choking, and broader public health implications. Although consent was not a predefined review objective, consent-related findings emerged consistently across included studies during narrative synthesis and were therefore reported as an additional contextual theme.

The 13 included studies were published between 2020 and 2026 and were conducted primarily in the United States (n = 10), Australia (n = 2) and Italy (n = 1). ^{9 , 10 , 12 , 16 , 19 – 27} Substantial variation was observed in the terminology used to describe sexual choking practices. Terms included “sexual choking,” “sexual strangulation,” “being choked during sex,” “breath play,” and choking within broader “rough sex” behaviours. Definitions and measurement approaches also differed across studies, with some studies focusing specifically on manual neck compression during sex, while others included broader strangulation-related behaviours.

Recall periods varied substantially and included lifetime prevalence, past year prevalence, past month experiences, and event-level measures relating to participants’ most recent sexual encounters. Differences were also observed in outcome measurement approaches, consent-related variables, and assessment of physical, neurological, mental health, and sexual health outcomes. Detailed study characteristics are presented in Appendix-6.

Prevalence estimates varied substantially across the 13 included studies, reflecting differences in study population, recall period, country, and measurement approach. Overall, the highest prevalence estimates were reported in university and young adult samples, while nationally representative adult samples generally reported lower estimates.

Across U.S. university-based studies, lifetime prevalence of being choked during sex ranged from 36.0% to 47.3% among general student samples. ^{20 , 22} One study reported that 42.1% of undergraduate students and 32.1% of graduate students had experienced choking during sex, while 37.1% of undergraduates and 27.6% of graduate students reported choking a partner. ¹² Among autistic university students, 42.5% reported being choked, and 30.8% reported choking a partner. ²¹

Event-level estimates, which captured choking during the most recent sexual event, were lower but still notable. Study reported that 18.3% of university students had been choked and 16.0% had choked a partner at their most recent sexual event. ²⁴ Another U.S. undergraduate study found that women were more likely than men to report being choked during the most recent sexual event, while men were more likely to report choking a partner. ¹⁶

Nationally representative U.S. studies reported lower prevalence than university samples. A study found that 21.4% of women and 11.0% of men had ever been choked during sex, while 19.6% of men and 12.2% of women had choked a partner. ¹⁹ A later nationally representative U.S. study reported that women’s lifetime prevalence of being choked was 15.8%, with 10.9% reporting past-year experience; women’s lifetime prevalence of choking a partner was 9.2%, and past-year prevalence was 6.2% . ²⁷

International studies reported high prevalence, particularly among young adults. In Australia, researchers reported that 56.0% of undergraduate students had been strangled during sex and 51.2% had strangled a partner, with 17.9% and 13.1%, respectively, reporting these behaviours at their last sexual event. ²⁵ In a national sample of sexually active Australians aged 18 to 35 years, 56.9% reported lifetime experience of being choked or strangled, 16.2% reported being choked at their last sexual event, and 50.5% reported lifetime choking or strangling a partner. ¹⁰ In Italy, it was noticed that 13.2% had been choked and 60.0% had choked a partner, although measurement differences should be considered when interpreting these estimates. ²⁶

Across studies, a consistent gendered pattern emerged. Women were more likely to report being choked during sex, while men were more likely to report choking a partner. Several studies also reported higher prevalence among transgender, gender non-conforming, or gender-diverse participants, and among LGBTQ+ or sexual minority groups. Age-related patterns were also consistent, with younger adults reporting a higher prevalence of choking-related behaviours than older adults.

Detailed prevalence findings are summarised in Appendix-7.

Consent practices varied substantially across studies. Although many participants described choking experiences as consensual or wanted, explicit verbal consent was not consistently obtained prior to choking during sexual activity. ^{10 , 22} Several studies reported reliance on nonverbal communication, body language, prior sexual experiences, or assumptions of consent. ^{24 , 26}

A study found that 38.1% of participants relied on body language or nonverbal communication to indicate consent, while 50.2% had not agreed upon safe words or safe gestures beforehand. ²⁴ An Italian study reported that 22.2% of participants had never been asked for consent before being choked during sex. ²⁶ Similarly, evidence revealed that 20.9% of participants reported never being asked prior to being choked. ²⁸

Several studies also identified non-consensual experiences or pressure to engage in choking behaviours. ^{10 , 26} Among autistic university students, approximately one-fifth reported experiences of non-consensual rough sex, including choking. ²¹

Common motivations associated with choking included pleasure, experimentation, intimacy, emotional closeness, adventurousness, curiosity, and perceived partner enjoyment. ^{26 , 28} Pornography was frequently identified as an important source of exposure to choking behaviours. ^{10 , 19}

Detailed findings are summarised in Appendix-8.

Physical and Neurological Outcomes Associated with Sexual Choking

Several studies reported a wide range of physical and neurological symptoms associated with sexual choking. Commonly reported outcomes included breathing difficulties, inability to speak, dizziness, watery eyes, swallowing difficulties, head rush sensations, neck pain, and alterations in consciousness.

One study reported that participants frequently experienced difficulty swallowing (38.9%), watery eyes (37.2%), inability to speak (37.6%), breathing difficulty (43.0%), and head rush sensations (43.8%) during choking experiences. Additional symptoms included dizziness or lightheadedness (15.2%), neck pain (18.5%), neck bruising (14.8%), blurred vision (11.9%), and loss of consciousness (2.6%). Overall, 18.8% of participants reported some form of altered consciousness during choking events. ¹²

Similar findings were identified in another study examining participants’ most recent sexual event, where choking related symptoms included head rush sensations (37.1%), difficulty swallowing (21.4%), inability to speak (21.5%), breathing difficulties (16.9%), gasping for air (18.0%), watery eyes (17.8%), coughing (8.0%), dizziness or lightheadedness (5.1%), neck pain (4.9%), blurred vision (3.9%), and neck swelling (1.3%). Loss of consciousness was reported by 0.4% of participants, while 7.2% reported alterations in consciousness during the event. Although many participants described pleasurable or euphoric sensations, adverse physical symptoms were also frequently reported. ²⁴

Additional studies reported comparable physical outcomes, including breathing difficulties, sore throat, unconsciousness, and bloodshot eyes, with bloodshot eyes reported by 27.7% of participants. ²⁵ Fainting was reported by 0.4% of participants in one Italian study, ²⁶ while another U.S. study found that 2.1% of participants reported passing out during choking experiences. ²⁰

Overall, findings across studies suggest that sexual choking may be associated with a broad spectrum of acute physical and neurological symptoms, although neurological outcomes were inconsistently assessed across studies.

Mental Health and Psychological Outcomes Associated with Sexual Choking

Several studies reported psychological and emotional outcomes associated with sexual choking, although formal mental health assessment measures were used inconsistently across studies.

One U.S. study identified associations between sexual choking experiences and adverse mental health indicators, including overwhelming anxiety, feeling very sad, feeling so depressed that functioning became difficult, and feeling very lonely. ⁹

Another study reported mixed psychological responses to choking experiences. While most participants described pleasurable or euphoric sensations (81.7%), a notable proportion also reported feeling scared during choking encounters (14.3%). ¹² These findings suggest that choking experiences may involve simultaneous pleasure, fear, and emotional distress for some individuals.

Among autistic university students, participants commonly described choking experiences as emotionally distressing, with 60% reporting experiences as upsetting, 30% as scary, and 15% as traumatic. ²¹ Although no formal psychological assessment tools were used, the study highlighted important subjective emotional responses associated with choking-related experiences.

One Australian study additionally reported that educational intervention and exposure to information regarding choking risks contributed to changes in participants’ perceptions and understanding of choking related harms and consent. ²⁵

Overall, the available evidence suggests that sexual choking may be associated with a range of psychological and emotional outcomes, including anxiety, fear, distress, loneliness, and trauma related experiences, although research examining long term mental health consequences remains limited.

Sexual and reproductive health outcomes

Limited evidence examined sexual and reproductive health outcomes associated with choking.

One study found that choking during sex was commonly associated with sexual pleasure, with 41.1% of participants describing choking as “very pleasurable.” ¹² Participants also reported pleasurable and euphoric sensations associated with choking experiences, suggesting that sexual gratification may contribute to continued participation despite awareness of potential risks.

Associations between sexual choking and contraceptive practices were also reported. One U.S. study found lower condom use among participants who had experienced repeated choking during sex. ²³ The same study additionally identified a greater likelihood of implant or intrauterine device (IUD) use among individuals with choking histories, as well as increased likelihood of withdrawal method use among women reporting choking experiences.

An Australian study further reported associations between choking participation and enhanced or more intense orgasm experiences, alongside increased pleasure and excitement linked to strangulation during sex. ²⁵ The study also found that more permissive sexual attitudes were associated with greater participation in choking-related sexual behaviours.

Overall, findings suggest that sexual choking is closely linked with pleasure seeking, sexual experimentation, and changing sexual norms, while also raising potential concerns regarding condom use and sexually risky behaviours.

Detailed findings are summarised in Appendix-9.

Most included studies demonstrated moderate-to-high methodological quality based on JBI appraisal criteria. Common strengths included large sample sizes, detailed reporting of participant characteristics, and use of probability-based or campus-representative sampling methods. However, nearly all studies used cross-sectional designs and self-reported questionnaire data, limiting causal interpretation and increasing susceptibility to recall bias and social desirability bias.

Substantial heterogeneity was identified across studies in terminology, operational definitions, and measurement approaches. Studies variably used terms including “choking,” “strangulation,” and “sexual strangulation.” Recall periods also varied considerably, including lifetime, past-year, past-month, and event-level measures. Few studies used validated instruments or standardised measures of choking severity, duration, frequency, or physical force, limiting direct comparability across studies and reducing feasibility for meta-analysis.

This systematic review synthesised quantitative evidence relating to the prevalence of sexual choking among adults aged 18 years and above and examined associated physical, mental health, and sexual health outcomes. Across the 13 included studies, prevalence estimates varied substantially according to population characteristics, recall periods, and measurement approaches. Nevertheless, the findings consistently demonstrated that sexual choking is increasingly common among younger adults, particularly within university populations and young adult sexual networks. Lifetime prevalence estimates ranged from 11.0% among men to 67.0% among women, with the highest prevalence generally observed among undergraduate and young adult samples.

The review is important because evidence relating to sexual choking has expanded rapidly in recent years, yet the literature remains fragmented across disciplines including public health, sexual health, neuroscience, psychology, and forensic medicine. Existing studies use inconsistent terminology, definitions, and outcome measures, limiting direct comparability and obscuring broader epidemiological patterns. To our knowledge, this is among the first systematic reviews to synthesise quantitative evidence relating specifically to prevalence alongside reported physical, neurological, mental health, and sexual health outcomes.

The findings additionally highlight the growing relevance of sexual choking as a public health issue. Reported outcomes extended beyond transient discomfort and included breathing difficulties, altered consciousness, dizziness, fainting, neck pain, and loss of consciousness. Although many participants described pleasurable or euphoric sensations associated with choking experiences, the frequency of acute physiological symptoms raises important concerns regarding safety and potential longer-term neurological consequences.

The findings of this review suggest that sexual choking has become increasingly embedded within contemporary sexual practices among younger adults. The highest prevalence estimates were consistently reported within university-based and young adult samples, while nationally representative adult studies generally reported lower prevalence. This pattern may reflect broader generational shifts in sexual norms, experimentation, and digitally mediated sexual cultures.

These findings align with sexual script theory, which proposes that sexual behaviours are shaped through broader cultural expectations, peer norms, and social learning processes. ²⁹ Within contemporary digital environments, pornography and social media may contribute to the normalisation of choking by presenting it as pleasurable, adventurous, or routine within partnered sexual encounters. Previous pornography content analyses identified high levels of aggression within mainstream pornography, with women disproportionately represented as recipients of aggressive acts. ^{30 – 32} More recent research additionally identified associations between pornography exposure and sexual choking behaviours among young adults. ⁴

The higher prevalence among younger adults may reflect wider changes in sexual culture rather than isolated experimentation. Choking appears to be moving beyond BDSM or niche sexual contexts and becoming more visible in mainstream heterosexual and casual sexual encounters. This shift may be influenced by pornography, peer norms, and changing expectations around adventurous or rough sex, although more research is needed to understand these influences clearly. ^{32 , 33}

Importantly, evidence from Australia and Italy demonstrated prevalence patterns broadly consistent with U.S. findings, suggesting that choking may represent an increasingly international phenomenon. However, the evidence base remains heavily concentrated within Western high-income countries despite widespread global exposure to online sexual content. Research examining sexual choking within non-Western populations, culturally diverse settings, and low- and middle-income countries remains extremely limited.

A consistent finding across studies was the gendered distribution of choking experiences. Women were substantially more likely to report being choked during sex, whereas men more frequently reported choking a partner. Similar gender asymmetries have also been identified in previous research examining sexual choking and aggression-related sexual behaviours among young adults. ³⁴ The higher prevalence observed among younger adults may reflect broader changes in contemporary sexual norms and increasing acceptance of adventurous or rough sexual practices within casual and partnered sexual encounters. ³⁵

These findings suggest that choking may frequently occur within broader gendered sexual scripts involving dominance, submission, and unequal power dynamics. Within heterosexual encounters, women may more commonly occupy receptive roles, whereas men may more frequently adopt initiating or dominant roles. Within this context, choking may represent an extension of broader sexual expectations surrounding adventurous or rough sexual practices.

The findings additionally raise questions regarding how younger adults interpret risk, intimacy, and sexual desirability within contemporary sexual culture. Previous research has suggested that some young women may feel pressure to participate in certain sexual practices in order to align with perceived sexual expectations or norms within heterosexual relationships. ³⁶ At the same time, several included studies reported elevated prevalence among transgender, gender-diverse, and LGBTQ+ participants, although subgroup evidence remains limited. Future research should therefore more comprehensively examine how choking experiences differ across gender identities, relationship structures, and sexual orientations.

This review identified a broad range of physical and neurological symptoms associated with sexual choking, including breathing difficulties, difficulty swallowing, inability to speak, dizziness, blurred vision, altered consciousness, and loss of consciousness. These findings are clinically important because neck compression may impair oxygenation, airway function, cerebral blood flow, and vascular integrity even when external injury is absent.

Existing forensic and medical literature examining non-fatal strangulation has long recognised that external neck compression may result in hypoxic injury, carotid artery dissection, stroke, acquired brain injury, and delayed neurological complications. ^{37 , 38} Although the contexts of domestic violence strangulation and consensual sexual choking differ substantially, the underlying physiological mechanisms of oxygen restriction and vascular compression remain relevant. The findings of this review therefore support growing concern that repeated choking exposure during sex may involve clinically significant physiological risks.

Emerging neuroimaging research additionally raises concern regarding potential longer-term neurological effects associated with repeated choking exposure. Functional MRI studies identified altered neural activation and functional connectivity patterns among women frequently exposed to choking during sex compared with choking-naïve controls. ^{7 , 39} Biomarker studies have also reported elevated serum S100B concentrations among women exposed to frequent choking, suggesting possible neurological stress or blood-brain barrier disruption. ⁴⁰ Although current evidence remains preliminary and causality cannot be established, these findings highlight the need for greater clinical and neurological investigation.

Importantly, many participants simultaneously described pleasurable or euphoric sensations associated with choking experiences despite reporting adverse physical symptoms. This overlap between pleasure and physiological risk complicates simplistic understandings of choking as either entirely harmful or entirely benign. Nevertheless, the frequency of respiratory symptoms, altered consciousness, and fainting identified across studies supports a precautionary public health interpretation.

Mental health outcomes were examined less consistently than prevalence or physical symptoms, although several important findings emerged. Included studies identified associations between choking experiences and anxiety, depressive symptoms, loneliness, sadness, fear, and psychological distress. Among autistic university students, some participants described choking experiences as upsetting, frightening, or traumatic, despite others describing pleasurable or intimate experiences.

These findings suggest that emotional responses to choking may be highly complex and multidimensional. Previous literature examining aggressive or coercive sexual experiences similarly identified associations with anxiety, emotional dysregulation, depressive symptoms, and trauma-related distress. ⁴¹ However, longitudinal evidence examining the long-term psychological consequences of repeated choking exposure remains extremely limited.

Evidence relating to sexual and reproductive health outcomes was comparatively limited but suggested important behavioural associations. Several studies identified links between choking and sexual pleasure, orgasm enhancement, experimentation, intimacy, and excitement. At the same time, repeated choking exposure was associated with lower condom use and changing contraceptive practices. Similar associations have been identified in broader research examining pornography exposure, sensation-seeking, and sexual risk-taking among young adults. ⁴²

Collectively, these findings suggest that choking may increasingly form part of broader patterns of sexual experimentation and evolving sexual norms among younger adults. However, the coexistence of pleasure, risk, distress, and physiological harm underscores the need for more nuanced public health and clinical responses.

The findings of this review suggest that sexual choking is increasingly situated within broader changes in contemporary sexual culture, particularly among younger adults. The combination of high prevalence estimates and frequently reported physical symptoms raises important public health concerns, especially given the limited awareness surrounding potential neurological and physiological risks. Emerging public health commentary has similarly highlighted concerns regarding the growing normalisation of choking within contemporary sexual culture and the limited awareness of associated harms. ⁴³ Although many participants described choking as pleasurable or consensual, the findings highlight the complexity of balancing sexual autonomy, risk perception, and health education within modern sexual relationships.

The increasing visibility of choking within mainstream sexual discourse may additionally contribute to perceptions that choking is a normal or expected component of sexual intimacy among some young adults. From a public health perspective, greater awareness may therefore be needed regarding the potential risks associated with neck compression during sex, particularly within sexual health education, university wellbeing services, and healthcare settings.

This review identified several important methodological limitations within the existing literature. Most studies used cross-sectional survey designs and self-reported questionnaire data, limiting causal interpretation and increasing susceptibility to recall bias and social desirability bias. Substantial heterogeneity was observed across studies in terminology, operational definitions, and measurement approaches. Studies variably used terms such as “sexual choking,” “strangulation,” and “breath play”, while recall periods ranged from lifetime measures to most recent sexual event reports. Few studies used standardised or validated instruments assessing choking severity, duration, frequency, or physical force. This heterogeneity limited direct comparison between studies and reduced the feasibility for meta-analysis. The evidence base was also geographically narrow. Ten of the 13 included studies originated from the United States, with only limited evidence from Australia and Italy. Very little research examined older adults, disabled populations, culturally diverse groups, or non-Western settings. Although some studies included transgender and gender-diverse participants, subgroup analyses were frequently underpowered. These methodological limitations highlight the need for more standardised and clinically informed research approaches in future studies.

The findings of this review suggest that sexual choking has become sufficiently prevalent among young adults to warrant greater attention within public health, sexual health education, and clinical practice. Sexual health education programmes may need to address choking explicitly within broader discussions of bodily autonomy, communication, risk awareness, and sexual decision-making. Healthcare professionals working within sexual health, emergency medicine, primary care, mental health, and university wellbeing settings may additionally benefit from greater awareness regarding choking-related practices and associated symptoms. Patients experiencing dizziness, fainting, neck pain, breathing difficulty, or psychological distress following sexual encounters may not spontaneously disclose choking experiences unless specifically and sensitively asked. Future research should prioritise longitudinal study designs, clinically informed neurological assessment, standardised measurement approaches, and inclusion of more diverse populations and international settings. Greater attention should also be given to differentiating consensual and non-consensual experiences, contextual relationship factors, frequency of exposure, and long-term health outcomes.

This review has several strengths. It systematically synthesised quantitative evidence relating to sexual choking prevalence and associated physical, neurological, mental health, and sexual health outcomes using predefined review objectives, multiple databases, PRISMA guidance, and methodological quality appraisal procedures. The review additionally incorporated prevalence variation according to gender, age, region, and study design. However, several limitations should also be acknowledged. Only English-language peer-reviewed studies were included, potentially excluding relevant non-English or grey literature evidence. Considerable heterogeneity across studies limited direct comparability and prevented meta-analysis. In addition, most evidence originated from university populations within high-income Western countries, limiting broader generalisability.