Case ReportsAn Illustrative Case of Suicidal Hanging Versus Accidental Hanging Associated With Autoerotic Activity Necessary Medicolegal Death Investigation and Role of Cognitive BiasZou, Jalynn BS; Bauler, Laura D. PhD; Brown, Theodore T. MDAuthor Information From the Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI. Manuscript received February 13, 2020; accepted April 24, 2020. The authors report no conflict of interest. Reprints: Theodore T. Brown, MD, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Dr, Kalamazoo, MI 49008. E-mail: [email protected]. The American Journal of Forensic Medicine and Pathology: September 2020 - Volume 41 - Issue 3 - p 220-222 doi: 10.1097/PAF.0000000000000576 Buy Metrics Abstract The majority of hanging deaths are relatively straightforward when opining the manner of death, typically determined to be suicide. However, there are rare hanging deaths that require the forensic pathologist to seek additional information. Forensic pathologists commonly consider an accidental manner of death when the hanging death scene includes evidence of solitary sexual activity consistent with autoerotic asphyxia. Here, the authors present a case of an initially apparent suicidal hanging where important death scene details photographed by the medical examiner investigator and history provided by family members during subsequent conversations ultimately helped the forensic pathologist conclude an opinion that the hanging was accidental, likely due to autoerotic activity. The decedent, who hanged himself in the closet of his bedroom, was wearing shorts that were initially believed to be inadvertently torn; however, further investigation revealed his shorts were intentionally modified to expose his genitalia. Additional evidence documented from the death scene photographs and conversations with his mother revealed items and activities consistent with autoerotic behavior. Before opining a manner of death in hanging deaths, forensic pathologists are encouraged to consider details beyond that obtained from the initial death scene investigation and postmortem examination. A thorough medicolegal death investigation should not be viewed as introducing cognitive bias, but rather as necessary information needed to determine the most accurate cause and manner of death. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.