Cambodia Youths and Mental Health (reprinted from the Globe Magazine)

In the west there is a cliché that refers to the fact that we can blame our parents for the way we have turned out.  This is especially true when it comes to the negative things:  the way we have adjusted to life, our failed marriages and relationships, financial mistakes, and even health and legal problems. Easier to blame and not be responsible.

But is there some truth to this?  How much are they to blame?  Aren’t they the ones who are suppose to guide us and direct us through those fragile young years of our life as we try to go out on our own and become independent?

What about these twenty-somethings  here in Cambodia who have often drastic differences and gaps between themselves and the multiple generations with whom they live and are influenced, and with whom they can be so far apart in culture, tradition, and even appearance, education and experience?

The young girl who is mocked for wearing sexy clothes, the young boy whose hair is too long, the young adult male who is in love, but must marry the woman who his family has chosen, or the woman who has been divorced and now told that she is “used goods and no man will want [her] again.”

The new generation, the ones who will someday run the country’s businesses and government, are left with few coping mechanisms in this modern world, with little social support, and even sometimes misguided education to adjust and develop in this rapidly changing Kingdom!

When we examine the difference in generations here in Cambodia it is important to consider the history in part.  There is small part of a missing generation due to the history of war and violence in this country, thus leaving a gap between the older generation, one that places its experience and functioning on tradition and culture; and a younger generation in their teens and twenties who are being dominated now by a global superculture that brings a great many influences, education, exposure, change, and different belief systems that conflict with the older methods and beliefs.  New things bring excitement but also challenges and conflict when this new way of being conflicts so strongly with the traditional belief systems of the older generation.  This external and internal conflict are what can lead to feelings of abandonment, lack of social acceptance, decreased self esteem, and often an internalization of strong feelings of guilt for rejecting the traditional culture, and thus their caretakers or parents.

What a struggle it must be for these twenty somethings to be exposed to modern technology, modern thinking about dating, sex and sexuality, education, socialization, and even family systems, but to feel guilty to partake and integrate some of those ways of thinking into their own sense of self and into their social lives.  Change is a powerful thing, but we have to be prepared to make changes and be accepted when those changes are in the end implemented.  For in the end, they impact who we are as individuals

This generational conflict, one that can be so divided and with so little buffer becomes a conflict for each young adult trying to grow up. He or she has no one they can share with, no one they can talk to and no one to go to when they have problems, questions, or are simply confused.  The older generation is not there to guide and the younger does not go to each other for support.

Take the example of a young man from a good family here in Cambodia, moderately wealthy, from divorced parents, and attending good schools but has come to terms that his sexuality is not of the mainstream – that he is gay.  He has struggled to find identity within that realm, to reach out to friends that for many years simply mocked him.

“I go to parties and my father and his friends laugh at me.  My friends don’t understand and think I want to be a girl. Even my teacher at school tells me that being gay is wrong and that gay men have no penis and cannot have sex. I don’t know who I am or what I can do.  I don’t know about my future.”

But more importantly are the strong conflicts within himself and his family, the rejection by his family, the pull of all financial supports for his education and living.  Where does this leave him?  “I feel lonely and have no one to talk to.”  Not only in a place of depression and abandonment, but strong rejection and potentially at risk for a self destructive lifestyle.

This may not differ too much than even a western family and their reaction to the same news that their son is gay, but again, the supports in place are different.  A young adult has access to better education and to an environment in which he can find the social supports necessary to go through this struggle, in the best of cases.  He has been taught to seek out others in a time of need, to talk to others and to share his fears and anxiety.  Instead, the older generation here has taught them to suppress, to save face, and to not open up to friends as that is weakness and will bring shame to himself and his family. This leads to guilt and to an even greater self destruction.  This is worrisome.

Where is this person or any other facing any problems to go?  Another client stated, “I have no one to talk to. My friends can’t understand and don’t want to talk about real things.  I would be laughed at if I went to therapy.”

To open to others is weak and shameful.  So where do they go?  Only inside themselves where they may not be well equipped to handle the pressure of this changing world? Or outwardly destructive where alcohol, violence, self harm, and drugs can easily become a coping means?

Why are we not teaching our kids?  Why are we not letting them understand society, the changes and how these influence us?  Are we afraid it may harm them?  How is this going to impact the future of them and this country?  Denial and lack of sharing/communication are so strong in this country that families hide everything. That is not protecting them from harm, but causing it.

Financial problems, as we know, are one of the largest causes of conflict, divorce, and domestic violence in the west.  What about when families begin to suffer in the new economy.  Do they talk to each other and share their stories? The sharing and knowledge that other people are dealing with the same issues is one of the most powerful means of coping with a problem.  But this is a culture where we are taught never to share, never to speak of problems, and never to open up to new ways of thinking.  Simply, we cannot.

I think of a recent case of a young girl who attempted suicide. She had a bright future and was from a good family, despite some family issues and now recent financial set backs.  She was understanding the pressures and stress that her family was under and her own stress trying to develop and understand a changing Cambodia and social status.  She even made attempts to talk to her friends about her plan, but even then her friends did nothing besides ignore it.

One of her friends at school told said she could not understand why no one helped.  “she told her friends it would be her last day alive, and they just said good bye.” They even went with her when she purchased the overdose she was planning to take.

Did they ask her anything, comfort her, talk to her? She had to save face for herself and for her family as she knew deep inside, although never communicated, that her family was facing a loss of status and that it would be terrible and shameful to her community.  She is now sitting in a coma on life support.  And her family is likely wondering how all of this could have happened. When her family was asked, they just said “when she gets better, we will have a big party to celebrate.”

Suppression.  This is modeled behaviour which is how we tend to learn the best.  This is copied from the older to the younger and reinforced by both generations.  It becomes a social construction and a major handicap to good development.  Supress!  Is this what the new generation is learning even when the problems that face them continue to grow at exponential rates and are far different than the ones that faced the traditional culture?

A strong woman with confidence, education, and determination comes to treatment as she is suffering from a loss of individual identity and feeling as if she is only that of the family system, of a woman, of a Cambodian, but not of herself.  She talks about new experiences she wishes to engage in or explore, new thoughts and ideas, a new sense of power and being outspoken, “but the fear of shaming my mom and the guilt is too much.”

“My mother wants to be close to me but does not understand boundaries.  She wants to know everything about me, but when I try to tell her about things, she tells me that young women should not discuss such things in private or public.  She looks at me with disapproval. I feel guilt, resentment and a burden to her”   –  a 27 year old female patient.


The outcome and potential dangers of this old school education and belief system is potentially devastating for the twenty somethings here.  Trying to cope in a rapidly changing country while being told not to change, to embrace old traditions, myths, and belief systems, without adapting them to this new world leads only to conflict inside.  The mental health risks and therefore social impact are considerable.

And it is not just suicide.  Look around at our society.  Mental Health disorders are on the rise.  Some estimate it to be near 50 percent of the population.  Admittedly this includes PTSD from the war, but there are more pressing and contemporary psychological issues developing in Cambodia and being emphasized by the superculture and exacerbated by lack of resources, education, simple guidance, and coping means.

Look and see how they are coping.  Substance abuse is on the increase, outward violence and self-harming behaviours are becoming more and more common. Marriage issues are on the rise as conflict occurs at home and we have no means of settling disputes beside the old ways of denial, alcohol, adultery, or worse, domestic violence.  Depression and anxiety developed from lifestyle and social or family issues with nowhere to go.  Fears and phobias and adjustment disorders, abandonment, social and developmental issues and even personality disorders.  Who is to blame?

But not is all so grim. As humans we are so capable of adapting, able to come through problems and to grow despite even the worse circumstances.  Cambodia suffers mostly from being exposed to the modern world and rapid exposure makes adaptation very complicated.  This change can lead to similar problems we see in the west as they will manifest in different mental health and physical health conditions.  It is through awareness and education, continued modeling behaviors that lead to acceptance and change, self-awareness and understanding of our own behaviors, and simply taking a chance to share and open up that are critical. Overcoming the fears, guilt, or shame that are associated is hard.

As a client made it clear, “no one understands how [I] feel and no one wants to listen.”


This is not something that is just part of Cambodia and its culture, it is something that is all over the world. My clients here are the same as back home, in some ways, but handicapped in others by this gap.

If we blame someone else for our problems, we don’t have to take responsibility.  But in the end, no matter who we can or want to blame, we are, in fact, the only ones left to deal with them – by ourselves, with our friends, support of our family, or of course a professional.  Assuming these simple resources are available to us and do not lead to further isolation or continue to increase the confusion, lack of trust, deception, and lack of intimacy between these generations. Yes, your children will have something or someone to blame!

As I see more clients with more contemporary issues it relieves me to see them get the help they feel they need, to fight the traditions and belief systems and social norms that they have learned, and to try something new.

But where does it leave the young gay man with a now developing sense of self, but still no acceptance and tolerance by his family or friends – things we need so badly.  Or of the young girl who sits in a coma, who, if she recovers, will be shed with a grand party for living, but what got her to her current place will never be discussed? Or to the countless other people out there who are not even seeking help but hiding it away, just like they have been taught to?



Fantasies, Fetishes and All Things Fun

Fantasies, Fetishes and all things Fun

So you have met this amazing guy and have been hitting it off for months. It has been full of great conversation, exciting adventures and of course great sex in bed.  One night as you make your way to bed, he heads to the bathroom for his nightly routine and comes out dressed in leather, whip in hand and handcuffs for you in the other…hot? Maybe…Or do you run?

People have all sorts of fantasies from simple threesomes; domination and submission;  incorporating certain objects, people, places or animals; diapers; fisting; bondage and pain. The list goes on and I certainly am not going to share my own, but we all have them whether they are vanilla or extreme.  One question always comes up – are they healthy?

The DSM-IV, the “Bible” for us Shrinks, categorizes possible such things within Sexual Dysfunctions to include Paraphilias and other Sexual Disorders and Dysfunctions.  Paraphilias or the ones we are more aware of and often the ones involved in fantasy play including exhibitionism, voyeurism, fetishism, sadism and masochism, and even pedophilia. The second category examines premature ejaculation, erectile disorders, gender identity disorder and others.

But if a pair of leather boots or being urinated on is part of your sexual fantasy world does that mean you should be booking some time on my couch? Not necessarily…

Most fantasies are normal and even healthy as they are a great release of our sexual desires and when played out in a safe fashion can be exciting, adventurous and fun. I mean, who doesn’t like a little role play or being tied up every so often? Incorporating toys or playing doctor (my personal favorite)?

But these can become problematic for some if they start to interfere with your life in some negative ways.  The DSM points out that they are not disorders unless these fantasies, urges, or behaviors occur for a significant period of time and interfere with either satisfactory sexual relations or everyday functioning. There must also be a sense of distress. In other words, the fetish or other behavior must negatively impact you and create a sense of distress in that you feel you are unable to control them.

Fantasies can come about in so many different ways from unresolved issues as a child, from pairing an ordinary stimulus with a sexual experience, or the carrying of a transitional object from infancy into adult sexual development. They can also arise from unusual or traumatic sexual experiences in which they are more likely to create problems and distress in adulthood. In the case of sexual trauma, either a reaction that includes fear of intimacy and inability to participate sexually; or a reaction formation in which the victim plays out sexually in order to “normalize” what has happened to them. Both cases are unhealthy and should be referred to for treatment and support.

Fantasy can also just come about by simple curiosity and wanting to push our limits and try new things. Our minds can be creative and fun for sure and it likes to push itself, so enjoy the ride. Pornography, for example, can often introduce us to such things this way and allow us to experience something vicariously through others before participating ourselves or maybe never doing, but just thinking about it!

We are sexually stimulated very easily and by so many different means, and for some that may make us uncomfortable but many times that is part of our social upbringing that seeps into our psychological self. Think about a straight man watching gay porn. It will still turn him on, but does that mean you can change him? No. Give it up, it will only cause more stress for him and for you!

So if it makes us uncomfortable and causes great impairment, then it needs to be examined and you should seek some advice, support or professional care.  If it is simply something new and different, we like it and it makes us feel good (and is legal, safe and healthy) then carry on doing it! And do it with conviction and vigor!

Sex is fun! Be safe! Be smart! And remember that healthy sexual development is key to overall growth and sense of self, especially in our “gay” world where there are so many extra turns to negotiate and conflicting messages along the way. Be true to yourself and do only what makes you comfortable!

Join me on my couch next week…I will be waiting…

Part II

Alright, so the fetish or paraphilia is causing you problems in developing relationships, being intimate in more “normal” ways, or is causing you other social, professional, or legal issues (pedophilia, exhibitionism, bestiality) in your life. Well then this so called fetish has gone from being fun and playful to being a psychological dysfunction and causing undo distress in your life. Now you need some couch time with the good doctor…

These erotic tendencies can be reshaped through many means so that you can go back to enjoying some good old vanilla sex with your boyfriend or whomever, while also spicing things up but not having to rely on specific behaviors or objects that are causing the distress to yourself or to them or worse, to unwanted recipients. Treatment approaches work around medications, psychoanalysis, hypnosis and cognitive behavioral treatments.

Don’t worry, none of these are too painful and will lead to a better sex life for all, not to mention a whole lot less stress in your life. 

The most common intervention is something called aversive conditioning which is just using a negative association to eliminate the behavior. The fetish developed often by the pairing of an object/situation with pleasure, now that process can be reversed and is sometimes done automatically through legal actions or shame. Other means can be more drastic including watching yourself commit the negative actions, watching more aversive consequences or by pairing other negative stimuli (nasty odors) with the behavior. It is just re teaching your brain in a simple form. We really aren’t as complicated as we might like to think we are.

More positive ways include social skills training, teaching empathy to victims (exhibitionism), or using a plethysmograph (machine attached to your penis to measure erection) to control your levels of stimulation. And even more fun, reconditioning the brain through masturbation techniques by learning how to associate the pleasure of masturbation and climax with more acceptable stimuli through repeated exposure and therapy.

Yes, my job can certainly be more than interesting at times. You know this all sounds so clinical in nature, but really it is built upon reversing so many things that we have learned in how we think and our associated behaviors. Remember, we developed the paraphilia by being turned on by something and then associating that feeling with a certain object or situation and making it so that we feel we MUST be in that situation or with that object to get off. We can unlearn that and often a key is in meeting a good and understanding partner that can help you learn to change those behaviors so that you will get off with him instead! You simply outgrow it. And hey, there is nothing more fun than enjoying good healthy sex with another hot guy!

Don’t think that it all has to be boring. Toys, cuffs, leather, outdoor (but discrete) sex and so many other things are fun and fabulous…unless it victimizes someone else or hurts yourself. Sex should be mixed up and fun and interesting, but a paraphilia often becomes compulsive and unhealthy. And our goal of course  is to keep sex healthy!

Go have fun and try out some masturbatory exercises! Or get someone to help you!

See you next time on the couch…

Gay Men and Body Image

So being a bit of a socialite in the world of Miami Beach, I tend to have a good deal of dinner parties, cocktail events and other various socials at my house. I enjoy these things immensely and tend to cater to all different groups of people from the Arts Community, Philanthropists, my everyday friends, and of course the usual gay boys of SoBe. In my planning, I of course consider which group I am inviting and what I am serving, and the one thing I have learned is that the differences are far and great between them…and this comes down to some simple things: one of which centers around food.

So my gay boys come over and though the alcohol goes down fast, I have basically stopped making food for these events. This is SoBe after all, and body image becomes everything in this community, as it does in most of the gay community across this country and the world. All those hours each day spent in the gym to have these wonderfully chiseled bodies, that I do simply adore myself, have led this community to suffer from many body related issues, eating disorders, that can also lead to other mental health disorders and substance abuse.

Is it normal to have these chiseled abs, defined chests, and bulging biceps? Hell no, although we adore it, the stress on our bodies is severe and often destructive (like dehydration to make those abs pop), but the stress on our mental health, sense of being, and our own identity is at even greater risk here! Gay men tend to have an increased report of eating disorders (and substance abuse) than do heterosexual men. This generally is estimated to be 3 times more but that number is likely a low one due to the fact that few men actually seek treatment for these disorders and few doctors document it as men tend to get away with it more often, whereas docs look for it in younger women.

So why is this the case? Are we, as a group, subjected to things that heterosexual men are not? Many report that it comes back to the pressure on gay men to look good, to have the perfect bodies, and to present themselves a certain way within the community. Even if one is not into having the perfect body, the social pressure to avoid certain foods in public is still there. I see them lingering around the food at a birthday party waiting for the perfect moment to sneak away with a mini cupcake or a nice fried spicy chicken wing, hell even a little low fat hummus on a carrot stick. But alas, even in the “healthy” option, there is a pressure not to be seen eating at a public event. Well, unless of course it is an olive in a martini.

Social pressure and body image has often been deemed as a cause for anorexia and bulimia in women so it would be logical that this would apply to men as well, especially in the gay community where we are bombarded by beautiful men (both in reality and in the media) and this aching desire to look just like them. A fear that we will not get into certain clubs, be able to find the right boyfriend, or simply be rejected for not being an Adonis.

But there is another reason that is far more dooming for us all. Eating disorders, and other body dysmorphia issues, arise even more so because we face pressures that we cannot control or handle and do not have the mechanisms to deal with them. We use them as a means of dealing with the outside world that is full of stress, fears and rejection, because for many there is no other way. The increased levels of bullying; the fears of rejection; being abandoned by family and other supports; lack of tolerance in school and work; decreased levels of satisfaction in personal relationships; and of course desperation to be part of a group that tends to judge more greatly by appearance, only exacerbates it all.

Like all at-risk populations, the gay community faces far greater challenges and threats than the heterosexual one in general, and thus the increase in negative coping mechanisms and, in turn, mental health issues are far greater. We see this with substance abuse as well. We can balance positive accepting relationships, both personally and in community; good health and exercise; having a fantastic AND healthy body, and being happy with ourselves as an individual. Not an easy task for many, but one that must be achieved in order to avoid these self-destructive patterns that can lead to the exact opposite result we are looking for.

So, I am off to bike around the beach for an hour or so to get some sun and exercise, admire those hot bodies, and come back and enjoy guilt free Sunday pizza and wine night at my house with some friends. I may even have an extra slice…I can do a couple extra crunches tomorrow and still enjoy it this evening! 

Gay Men’s Obsession with Straight Men

I’m Gay and in Love with my Straight Friend

A dilemma that we all face at some point in our life and one that has also become a sort of “challenge to conquer” in our little gay worlds. Sure, we all love to think that everyone is gay, and sure we all like to believe that we are the one that can turn that straight boy homo, but this is a simple recipe for disaster…for everyone!

I have heard it all from “I can’t help who it is I fall in love with” to “I am doing him a favor by helping him find the homo inside of him”. I understand the “ego” and bragging rights that comes from sleeping with a straight man, but as with most sexual conquests that ego ride is short lived and can often lead to self doubt, hurt, destroyed relationships, and internal conflicts on behalf of both people involved.

If we are looking for affirmations of our own sexuality this makes no sense either. What aspect of this conquest, as that is all it is, is a positive reflection of an individual, of our sexual self, of our own identity as a healthy gay man? Isn’t it our goal to develop healthy sexual relationships, for both partners, and that provides internal and external reinforcement for who we are?

Sexuality plays a strong role in the gay culture and a strong part of our external reinforcement as a gay person, but as we know it is destructive on many levels from self-efficacy to health ramifications. We act out sexually to fulfill this identity and to feel accepted by peers with the expectation that we will internalize such things and develop into a secure individual who is seeking out positive and healthy relationships with self and others.

Thus comes the conflict of either falling in love with a straight man or simply just wanting to fuck one. It will be impossible in either scenario for this relationship to be healthy. We may be able to get them in bed with us through experimentation, drugs and alcohol, or simply healthy curiosity on their part, but the fallout is going to be drastic. Take their perspective for a minute when they wake up or sober up from the situation. How are they going to respond? Fear? Anger? Self-doubt? At the least, extreme confusion and feelings of being overwhelmed. Think about how hard it was for you to come to terms with being gay at the start…and now this hetero defined individual is plunged into this. Easier when it is a hook up and they walk away, but not so easy when it is a friend who you had a crush on, things went too far, and now you all have to figure out how to deal with it. A recipe for disaster and a recipe for the end of a friendship!

Now for the gay man involved…you guys! I think having a crush on your best friend is cute and fun and sure, a nice fantasy for masturbation or a good wet dream. But to turn that crush into an obsession is destructive to you as a person and within your own identity. We have to have boundaries, both internal and external, in order to develop our sense of self. And our relationships are supposed to add to that and reaffirm it…not mess with it! Wanting what you truly cannot have is only leading you into a direction of personal unhappiness, feeling unfulfilled and feeling like a failure in relations, not to mention potential destructive behaviors.

Lastly, let’s just say that your straight best friend is struggling with their own sexuality and you are the one that “helps them find their way.” What then? You get them in bed, sex is hot, your dreams seem fulfilled and you are happy. But are they? Next comes their issues of being confused, of coming out, of struggling with their sense of self, trying to find their identity, fear, emotional issues, family issues and all the rest of the gamut of “coming out” to self and others. Admirable if you can help support them through it as a lover and friend, but again, likely destructive for both!

Being gay is hard enough even as times change and our identity becomes stronger as we feel more accepted by society, friends and family. It is these things that allow us to be safe and develop in a healthy manner. But we must remember that suicide, stress, alcohol abuse, mental health issues, and other at-risk behaviors are far more prevalent in the homosexual population. Why? Because it is hard enough already…why make this more complicated?