This transcript has been edited for clarity.
Dr. Rachel S. Rubin: Hello. I’m Dr. Rachel Rubin, a urologist and sexual medicine specialist in the Washington, DC area. Welcome to another episode of Sex is important.
I have an interesting topic for you, quite shocking in fact. Some of you may have read an article earlier this year in The New York Times Frenchabout the alarming increase in cases of choking or strangulation among young people during sexual intercourse. I recently spoke with Dr. Debby Herbenick about this disturbing and violent trend. Dr. Herbenick is a renowned sexuality researcher and professor at the Indiana University School of Public Health. Welcome, Dr. Herbenick. Can you tell us about your research into this new trend?
Debby Herbenick, Ph.D.: This is one of the most important pieces of research that I’ve done. I’ve been studying sexual behaviors and trends for about 14 years in nationally representative studies. Over time, we’ve seen a trend toward increasing prevalence of rough sex.
There has always been a great deal of sexual diversity in the world throughout history. But the major trend that we have focused on in recent years and that is important for all physicians to be aware of is this rapid increase – in fact, a very significant increase – in what people call “sexual choking,” even though it is a form of strangulation. This increase is particularly seen in adolescents and young adults.
We conducted nationally representative surveys in the United States as well as representative surveys of college campuses. We found that consistently across four representative campus surveys, 64% of women report ever having been choked during sexual intercourse, and about 1 in 3 women (ages 18 to 24) nationwide report being choked during their last sexual activity with another person. This is called choking, but because it typically involves a hand (sometimes two hands or a forearm or an object, such as a belt or cord tied around the neck), it is technically strangulation, since it involves external pressure on the neck to restrict or stop the flow of air or blood.
Insist on: These numbers are staggering, aren’t they? Everyone listening to us today is caring for someone who has been strangled for sexual pleasure. What does that mean from a safety standpoint? And as physicians who care for these patients with migraines and other health issues, what does the research show?
Herbenick: We see people reporting recurring headaches and ringing in the ears. There are things that we have only touched on. Those of us who work in this field believe that anyone who comes in with an unexplained stroke (for example, someone under 50) should consider imaging to see if they have a dissection. We hear of people who, when asked if they have had pressure on their neck, say they have. So we have to think about neurological symptoms. We know that quite a few of them have that.
People who engage in these practices should be informed of the health risks, but we find that most are not. They may have heard that in rare cases, people with high blood pressure can die, but most have never heard of what happens in between. So they don’t necessarily make the connection between their hoarse voice, their recurring headaches, or their sensitivity to light and a feeling of choking. We need to pay attention to neurological symptoms.
Most of the doctors I talk to at conferences say they feel like they can help in this conversation by giving preventative advice and letting their patients know that they may have heard about this trend, and a lot of people are talking about the health implications, and I want to share some information with you – not shamefully or judgmentally, but providing some information so that (patients) actually get some medical facts about this that could save their lives.
Insist on: I see a huge gap in my medical training. I was taught to say, “Hey, do you smoke, do you drink, do you do drugs? Do you have sex? With men, women, or both?” And that’s it. And then maybe use birth control and not get STDs, thinking about herpes, syphilis, gonorrhea, and chlamydia. We weren’t really taught how to talk to patients about the type of sex they’re having, or how to talk to them in an open but also risk-aware way and explain that the concept of safe sex goes beyond wearing a condom and using birth control.
This idea of rough sex and how to talk to teens about it – maybe our pediatricians should be talking about it. Where do we start to address these topics and how detailed should we be?
Herbenick: We’ve found that some young people are already being asked about some of the effects that might be happening to their bodies. Their health care provider might notice bruises or marks on their body from other types of rough sex like hitting and spanking. So that might be a starting point. Choking is much more common than slapping, so if you see marks on the body, that’s also a good time to ask them about other practices, especially high-risk ones like choking or strangulation. That gives them information and even says, “Look, I’m not here to shame you or judge you. I just want you to have some information about this,” and also gives them an opportunity to ask questions.
We found that almost no one talks to their nurse or doctor, even if they have symptoms after being choked or strangled during sex. Only 1% of women with symptoms related to choking, 7% of men, and far fewer trans and non-binary youth say they talk to a nurse or doctor, mainly because they say it doesn’t seem like a serious problem. The symptoms quickly subsided. Sometimes they are afraid of being shamed for their sexual behavior, which is why they say they don’t tell anyone.
You have to give them some kind of open and anticipatory direction moving forward. Not everyone is comfortable asking directly if a patient is engaging in this kind of behavior, but at least by letting people know that you’ve heard of this behavior and providing medical information, you can take a step forward in creating these conversations.
Insist on: Can you tell us where this research is at in terms of next steps? What other avenues are you exploring? And what excites you?
Herbenick: I’m very excited about the work that I did with one of my collaborators and colleagues, Dr. Keisuke Kawata, a few years ago. He’s a neuroscientist. We were looking at the potential cumulative effects on the brain. We’re continuing some of that research now. We’re also doing more targeted studies on other health outcomes and hoping to figure out how to test different educational messages and get people to get more evidence-based information about that and then see if that’s effective in terms of prevention.
Insist on: It seems like a public health campaign is really needed to raise awareness about the health consequences of these activities. We ask people this question quite often. In my clinic, I try to be open-minded: Tell me what sex is like. What does it look like and what do you want it to look like? Because I see a lot of people who have problems, but if they don’t tell me about it, I don’t necessarily tell them about it. Until I heard your talk and I thought: Oh my god, I’m not even asking the right questions.Are you hopeful that there will be more public health messages disseminated?
Herbenick: I am. A few years ago, when choking play among children and adolescents became commonplace, the Centers for Disease Control and Prevention (CDC) put out reports about it and warnings to parents. And the prevalence is much higher than ever. So I would love to see organizations like the CDC and medical groups step up and educate their members and make statements. This is really impacting a huge generation of girls and women, because when it happens during sex between women and men, choking is predominantly happening in girls and women. It’s also common in people who are sexual minorities. But we’re talking about this whole generation of young women and what’s happening to their bodies and their brain health. We really need to engage in this conversation.
Insist on: Very few of us are doctors who are trained in sexual medicine and very few of us feel comfortable and confident talking about sexual health issues. But people are getting hurt. They are experiencing real consequences from these behaviors because of our lack of education, knowledge, and even discussion about it. So thank you for doing this research because if you hadn’t, we wouldn’t have discovered that 64% of people engage in these types of activities. It’s not uncommon.