Death during autoerotic asphyxial activity is usually considered accidental due to unanticipated failure of the device that was used to induce hypoxia during sexual arousal. Two cases of hanging are reported in which apparently typical features of autoerotic asphyxial activity were present. As a result of the discovery of a suicide note in one case and the absence of certain characteristic features in the other, the deaths could not be designated accidental. Although the majority of deaths that occur during autoerotic asphyxial episodes are accidental, the possibility of suicide must always be entertained, even in cases that may initially appear typical.