Introduction: Non-natural deaths associated with sexual activity may occur either with or without the involvement of other persons.

Aim: The present study provides an overview of cases of non-natural death related to sexual activities as well as recommendations of how to handle these cases and to identify potentially dangerous pleasure-enhancing techniques.

Methods: This medicolegal, postmortem, retrospective, and prospective study is based on data of autopsies performed at the Institute of Legal Medicine at University Hospital, Goethe University, Frankfurt, Germany.

Main outcome measure: Identification of circumstances, sexual practices, and gender distribution of cases of non-natural death in this context.

Results: Between 1993 and 2017 (25 years), 16,437 medicolegal autopsies were performed, of which 74 cases (43 males, 31 females) of non-natural death were found to relate to sexual activities (0.45%). One female and 21 males had died in the course of autoerotic practices (group I, n = 22). Nine males and 14 females had performed sexual practices with mutual consent (group II, n = 23), and 13 males and 16 females without mutual consent (group III, n = 29). The average age in group I was 45.4 years; in group II, 40.6 years; and in group III, 39.2 years. Most of the deceased were found in their own apartments. Forms of stimulation included vaginal, anal, and oral intercourse; insertion of foreign bodies; use of chemical substances; and tools for respiratory depression/hypoxia. Three cases of death occurred during sexual activities involving bondage and discipline, sadism, and masochism (BDSM). Death due to strangulation was the main cause in group I, whereas intoxications were predominant in group II. Sharp force (eg, knife) was mainly responsible for death in group III. Anogenital injuries were documented in all groups in approximately equal percentages.

Clinical implications: The cases presented show a high variety of circumstances in which non-natural death connected to sexual activity may occur.

Strengths & limitations: This study presents a large postmortem collection of non-natural death cases with associated sexual activity. As the main limiting factor, it must be stated that mutual consent for a sexual practice or consumption of substances was presumed based on the information provided and a lack of evidence against this assumption.

Conclusion: In cases of death associated with sexual activity, medical staff should perform thorough unbiased examinations and documentations. Strangulation and the consumption of stimulants should be classified as life-threatening, pleasure-enhancing techniques. Patients and young people should be informed about these risks. Bunzel L, Koelzer SC, Zedler B, et al. Non-Natural Death Associated with Sexual Activity: Results of a 25-Year Medicolegal Postmortem Study. J Sex Med 2019;16:1547-1556.