Religious matters and spiritual issues frequently abound during the Holiday Season. Therefore, I will discuss an important spiritual issue today. As a pain management specialist, I have long recognized a particular pattern: many patients primarily complain of a symptom, specifically physical pain, but they are unlikely to bring up a deeper underlying issue – how their experience of pain and the subsequent physical impairments have affected their relationships. In other words, they wish their physical pain would go away because of the negative impact pain has on a variety of their relationships and they are also experiencing a great deal of emotional and spiritual pain.

For instance, a patient with chronic (long-term) pain may be chiefly concerned about her inability to participate in the activities and lives of her children. She may not be able to sit for a prolonged period of time (without pain exacerbation and being disruptive) to watch her son play in a soccer game or her daughter practice gymnastics. She may be worried about how her painful condition has interfered with her sex life and is thus concerned her husband will seek sex elsewhere and eventually leave her and their children.

A single male or female patient with chronic pain may be concerned about his/her diminished attractiveness to the opposite gender and thus reduced ability to find and marry his/her conception of a perfect or acceptable mate. An elderly man with chronic pain may feel guilty about his burden on his wife, as she has to help him physically with many acts of daily living. A religious person may be worried he will fall out of favor with his church, mosque, or synagogue, as he cannot withstand the pain aggravation from prolonged positions, and is also concerned he will lose his main social circle of friends.

The numbers of cases I have seen are enormous and I can continue to cite a long list of examples, and thus last time, in lesson 1, this author made the bold claim that life is ultimately about relationships! …and a variety of relationships exist, including with ourselves, a higher power, our environment, and other people. The key to having successful, mutually beneficial relationships with others is to first develop good self-concept by forming an authentic and empowering relationship with our inner selves.

Unfortunately, this is more easily said than done because of constant external influences that bombard and disconnect us from our inner sense of peace and tranquility, and the hustle and bustle, and stress related to the Holiday Season may exacerbate our experience of negative emotions. In addition, some of us may have lacked good parental figures to help us with this difficult spiritual task. Thus, many people focus on external relationships, especially with a romantic/intimate partner, without first developing a strong sense of inner security and self-love.

A key concept is that we cannot give what we have not experienced and possess. Thus, a child raised without love and respect is unlikely to be able to give authentic love and respect to others. And even more, once the unloved child grows up to become an adult, it is difficult for him to develop successful relationships, not just because he is unable to love, but also because he is not able to be receptive of love. This adult is often condemned to a lifetime of failed, poor and unfulfilled relationships, leading to the experience of numerous unhealthy emotions, such as depression, anger, self-hatred, and apathy. A pattern of repeated relationship failures typically represents a symptom of much deeper psychological and emotional disorders, and spiritual disconnection.

It is a sad reality that few pain management specialists are capable of and skilled enough to help patients with chronic pain conditions to deal with their predicament – of how their painful conditions affect, whether perceived or real, a wide variety of relationships. Some pain specialists focus on prescribing mainstream medications, such as opioid pain pills, anti-inflammatory drugs, and anti-depressants. Others focus on performing a variety of procedures, hoping to reduce or eliminate the pain.

Some doctors refer out to complementary or alternative healthcare providers, while some will refer to surgeons to “fix” the pain condition. Other doctors will refer their pain patients to a variety of mental health providers, sometimes with the goal of teaching them pain-coping skills. Unfortunately, despite all these attempts and interventions, many patients are left with chronic pain conditions, and few physicians are skilled enough to help their patients learn to cope with the various problems, including relationship issues, secondary to the patients’ ongoing pain condition.

Lesson #2: Even with kind and caring parents who were capable role models of good communication and life/stress-coping skills, it may not be enough to aid us down the line to cope with the deep and wide range of problems that often confront us in life.

Key Points

1) Inside each and every one of us is our true, authentic spirit. It’s something we were born with; it is ours and ours alone, and it can’t be really taught or learned, but regrettably it can be taken away.

2) We are all born with an authentic spirit, but traumatic life events can derail us off the spiritual path at any point in our lives. A life event may be so traumatic that it exceeds even a well-adjusted individual’s ability to cope, using his normally positive and healthy life and stress coping mechanisms, and he basically “loses” his soul as he becomes derailed off his previous spiritual path.

War is an atrocity, but is a good and common example of spiritual derailment. War provides scientists with many opportunities to study human behavior and coping strategies. Many lessons can be gleamed from the atrocious acts of war, e.g. numerous soldiers who participated in combat during World War I experienced a pattern of symptoms that led to the initial diagnosis of a “new” mental health disorder, termed shell shock or battle fatigue syndrome, which was eventually replaced by another term, PTSD (Post-traumatic stress disorder) in the psychiatric manual DSM III, applied retrospectively for WWII combat soldiers and thereafter.

The point is that even a well-adjusted, spiritual individual may lose his soul at some point from witnessing, experiencing, and/or participating in prolonged and repeated mass killings and maiming during wartime. In other words, a happy, outgoing individual may leave for war, but returns without his soul, and with very observable behavioral and personality changes that reflect his inability, worn down or lack of sufficient ability to cope with his traumatic combat experiences.

3) Definition of a spiritual guide: someone who helps others understand and cope better with the paradoxes and mysteries of life. However, in a paradoxical way, most people perceive him as a mystery because his presence and skills are outside of conventional people’s own life experiences. Most people have never encountered a spiritual guide and thus have difficulty understanding him, and in fact, many persons may not even be able to recognize him for who he is – a spiritual guide, who has deep, profound understanding and mastery of both spiritual issues and a wide range of practical life experiences, and thus has the uncanny capacity to mysteriously guide a derailed person back onto the spiritual path.

4) It is a rather universal phenomenon, whether we realize it or not, for us to lose, one way or another, our authenticity/spirituality at some point in our lives, and then we consciously or unconsciously struggle fanatically to find it again. Some of us are derailed as a young child (and thus do not remember and are usually not consciously aware of our spiritual derailment), while others lose our way as an adult, but it’s important for us to realize and accept that we are not alone in this problem.

5) We’re all tested by the numerous adversities in life, and thus virtually all of us have at times hoped and yearned for, and sought out an authentic spiritual guide to help us during our critical times of need – or at least wished for a spiritual guide to magically come along and help us get back on the right track.

6) Unfortunately, we must beware of the fact that most self-proclaimed spiritual guides, healers, or experts are fraudulent in that they have not resolved their own inner conflicts, past traumatic events, etc., i.e. they have not yet healed themselves, but they go around pretending to be healed and constantly trying to heal others, but are actually interfering in other people’s healing process. And some spiritual guides are plain fraudulent in that they are con-artists, i.e. they consciously and knowingly lack any special training or natural healing talent, but pretend to “heal” others and have the underlying primary motive of monetary gain. Authentic spiritual guides walking the talk are truly rare.

7) It is very easy to use our 5 senses to focus on and experience the “external” world, but most of us do not want to face our inner selves and delve deep into the process of honest introspection. Even when we look inside ourselves, many of us use a variety of techniques/defense mechanisms to deceive ourselves (self-deception) and avoid seeing what we do not like about other people are exactly what’s inside of us (hypocrisy). Thus, some of us may be paradoxically aggressive toward and attack other people with the similar traits that we have and want to keep hidden within. We tend to have strong defense mechanisms to mask our true selves and avoid “facing the music”.

Therefore, authentic and gifted spiritual guides are uncommon. This author is using the term “authentic” to refer to the soul, i.e. an authentic person is walking the spiritual path, whereas unauthentic refers to a broken spirit, darkness, lost soul, or derailment off the spiritual path. An authentic spiritual guide recognizes those who have fallen into darkness due to some sort of disconnect with their inner selves, often after experiencing a traumatic event(s) or perhaps prolonged exposure to physical harm/threats and emotional trauma. An authentic spiritual guide then tries to help the derailed individuals to slay their inner demon(s), in order to come back into the light.

In contrast to unauthentic spiritual healers who are foremost driven by money, egotism, and/or misled by idealism, authentic spiritual guides are selfless and altruistic, giving of themselves without the desire or expectation of receiving anything back in return for their effort, time, and own money that are often required to heal others in the almost impossible-to-see emotional and spiritual planes of life. Authentic spiritual guides are like unrecognized ninjas who slip in and out of people’s lives, hopefully leaving them in a better emotional and spiritual place. And to be frank, health insurance companies do not recognize nor reimburse spiritual guides for their humanitarian/emotional and spiritual health services.

Hope this helps you to recognize genuine authentic spiritual guides and differentiate them from all the other fraudulent spiritual healers, who are quite common, write all sorts of self-help books, create an online presence with websites and through various social media during our current technological explosion, act nice in public, and fail to follow the same advice that they so passionately and avidly give to others, but often copy and try to imitate the authentic spiritual guides.

  One last tip: unauthentic spiritual guides are unlikely to independently recognize an authentic spiritual guide because…to borrow a popular phrase: “It takes one to know one”. Unauthentic spiritual healers imitate authentic spiritual guides not because they recognize them, but rather because they see or sense others honor, respect, and seek out authentic spiritual guides for their effectiveness and success in helping others to reconnect with their inner selves.

Happy Holidays and hope to see you next time.

Tobey Leung, MD 

Thanksgiving Day heralds the onset of the Holiday Season for many Americans. A wide variety of emotions, such as loneliness, sadness, hopelessness, loss, grief, bereavement, dysthymia (chronic baseline of mild depression) to full-blown major depression episode, happiness, joy, contentment, elation, belongingness, love, jealousy, envy, resentment, anger, hatred, disgust, guilt, shame, disappointment, fear, desperation, frustration, and hopefulness, may be magnified during this time of year. Some people may feel distressed and even overwhelmed by their feelings, but do not quite know how to cope with their emotions. They may feel compelled to act on their emotions with “negative” behavior, such as a variety of harmful addictions or acting out by harming others.

Advices are usually given out freely and numerous articles are written, but unfortunately, they are simply too superficial to be helpful to readers who come from a variety of background and experiences, and have different sets of problems. No favorite quotations, phrases, clichés, proverbs, anecdotes, words of wisdom, or wise sayings, regardless of their popularity or how it may provide a person with a temporary sense of solace and “good-feeling”, can adequately address people’s feelings partially because of the vast, complex, and often misunderstood or under-appreciated elements that compose any given individual’s personal situation, psyche and state of mind. In fact, current emotions may be haunting and lingering symptoms of deeper, longstanding, rather serious, and unconscious/subconscious problems from the distant past.

Lesson #1: If we cut to the chase, life is ultimately about relationships! Therefore, when a disconnection from our inner self is present, we tend to fail in various relationships at many levels and thus experience the feeling of numerous negative emotions.

Key Points

1) Life is basically about relationships, but people vary in their communication styles and relationship skills and thus have different levels of success in relationships. Some people never learned about moderation and balance, often because they lacked competent and skilled parents or substitute caretakers/role-models who took the time and taught appropriate life and stress coping skills.

Thus, children grow up with dysfunctional communication styles and coping skills, typically at one or both extreme ends: (1) similar style as the parent(s)/caretaker(s), or (2) adoption of polar style of the caretaker(s) through the process of rebellion. A key point is neither extreme communication style and coping skills are fruitful to the individual and thus to surrounding people and environment in the long run and miss the moderate, balanced, centered, or “middle way”, so often recommended by spiritual authors.

2) A variety of relationships exist in life, and we can place them into 4 major categories:

    a) Relationship with our inner self

    b) Relationship with a “higher power”

    c) Relationship with our environment

    d) Relationship with other people:

• intimate partner(s)
• our parents
• our children
• other family members, such as siblings or extended family
• friends
• boss/authoritative figures
• co-workers
• subordinates
• acquaintances
• strangers

3) Few people in this world have attained a high level of spirituality. However, people use the term “spiritual” in a variety of ways and often assume others have the same definition. For instance, some people use the term spiritual and religious interchangeably, whereas others consider them to be two very separate things. This author defines a spiritual person as someone having found inner peace and tranquility, i.e. finding authenticity within, regardless of whether it was through religion or another path. Thus, a highly spiritual person is secure deep down about oneself, has a pure heart and soul, and possesses the moral virtues of loving-kindness, compassion, fairness, and temperance (not just tolerance of other people and their beliefs).

A spiritual person, after discovering inner peace, is then capable of developing a clear mind, in comparison to many other people who experience constant mental chatter or noise that clouds their perception, interpretation, and understanding of life events, environment, a higher power, and other people. Thus, most people live in various forms and degree of self-deception, whereas a highly spiritual person has overcome the fallacy of self-deception (or perhaps experiences a lesser degree of self-deception), which in turn allows her to deal with others and the environment in a more authentic, honest, and fair way.

4) In contrast to spiritual people, who start by focusing on relationship with oneself and developing a good self-concept before they focus on developing relationships with others, many people with emotional problems go about it backwards: they seek external relationships first, in particular a romantic/intimate partner. The problem with seeking security through external relationships, without developing inner sense of security first, is that one cannot really give what one does not already possesses and has experienced.

For example, one cannot provide authentic security and give true love to another person if one does not possess true love and a good self-concept through a sense of solid security within. One simply cannot give what one does not have. And unfortunately, an unloved and abused child often grows up to become an adult who has difficulty not just in giving love, but also in receiving love.

5) A good test of a person’s spiritual level is how he relates and deals with strangers. Although some of us abuse our own family members, many people love and treat loved ones, primarily own family, with respect, but the matter of fact is that it is relatively easy to respect, love, and care for a spouse or child because they represent extensions of ourselves. However, only a very secure person with inner peace and tranquility possesses a mindset and belief system that allow her to truly treat, respect and love a mere stranger to the same or similar degree as her own family on a consistent basis.

Happy Holidays and see you next time for lesson #2,

Tobey Leung, MD

The basic principle revolves around balance. The most common parental mistakes fit into two major categories: either (1) We ignore or inadequately address the child’s fears, or (2) We tend to over-comfort the child and thus reinforce the child’s fears. The most effective strategy is to find good balance by reassuring the child and adequately addressing her fears, without unintentionally reinforcing the message that something is really out there in the dark to be afraid of.

Here are 7 Practical Tips:

1) Most parents are familiar with their child’s stalling tactics, such as “I’m thirsty” or “I’m hungry”. A parent doesn’t want to fall for the child’s tactics, but it is true that hunger can keep a child up at night. An important tip to remember is that 45 minutes before lights-out is the optimal time for a bedtime snack. Some good snack choices are yogurt with fruit, crackers, and applesauce.

2) Do indeed check the closets to reassure your child that no monster is lurking there, and then talk about how you, as an adult, deal with scary things, such as, “Darling, when I’m afraid, I think about places and things that make me feel safe.”

3) Listen to your child and then discuss the common weird and creepy noises that he hears and be sure you are able to explain what really causes them.

4) Provide positive reinforcement by telling your child how proud you are of him for being brave.

5) Try encouraging your child to draw a picture of the monster, and then discuss what’s real and unreal. For instance, snakes and bears are real, while many fictional characters in books, TV programs, video games, and movies are unreal.

6) Help your child not to watch potentially scary programs before bedtime.

7) Take advantage of your child’s imagination to ward off monsters with a nightlight, a water-filled spray bottle, which can have the label “Monster Spray Away” that she can use to spritz the night creatures away, or a bedside magical wand that can turn monsters into friendly protectors.

Happy Halloween and sweet dreams, without the night frights!!!

Tobey Leung, MD

Click on photo to view video

Enormously huge fighters compete in the world of combat sports. A small percentage of people in the world are born with the genetic predisposition to become large-sized adults, while another small percentage have the genetic predisposition to become small-sized adults. Most people are within a “medium range”. The environment, such as malnutrition, can have dramatic effect on the final size of an individual adult.

How can we tell whether an enormous-sized person was simply born with the genetic predisposition to become an adult along the upper echelon in size, thus a “normal” person at the upper end of a bell-shaped curve versus someone who is “abnormal”, i.e. the individual’s large-size is secondary to pathology. Large fighters abound in the world of mixed martial arts (MMA): with some being “normal” huge and others being “abnormal” large. For example, I hear many MMA fans ask, “How did Hong Man Choi get so big?”

The answer is Hong Man Choi has acromegaly/gigantism, which is almost always due to a pituitary tumor, known as adenoma. Since the pituitary is a central endocrine gland, the people with gigantism also have disturbance of many endocrine functions, e.g. glucose intolerance. Antonio ‘Big Foot’ Silva is another MMA fighter who competed for quite a while before he was treated surgically for his pathology.

How do we know if someone has acromegaly/gigantism or if he is simply a large person along the bell curve, representing a “normal” population of people? One key attribute of acromegaly/gigantism is the afflicted individuals have similar facial features, regardless of race or ethnicity. For example, although Antonio Silva is Brazilian and Hong Man is Korean, their face looks alike. The bone & cartilage changes have very distinct affects on the face/skull, along with enlarged hands/feet.

The characteristic clinical manifestations are the consequence of chronic growth hormone (GH) hypersecretion, which in turn leads to excessive generation of the somatomedins, i.e. the mediators of most of the effects of GH. Overgrowth of bone is the classic feature, but GH excess produces a generalized systemic disorder with deleterious effects on numerous body systems and an increased mortality rate. However, the deaths are rarely due to the space-occupying or destructive effects of the pituitary adenoma per se.

In adults, GH excess leads to acromegaly or the syndrome characterized by local overgrowth of bone, especially the skull and mandible (jaw bone). In childhood and adolescence, the onset of chronic GH excess leads to gigantism. Most people with gigantism develop facial features of acromegaly if GH hypersecretion persists through their teenage years and into adulthood.

Acromegaly is a chronic disabling and disfiguring disorder with increased late morbidity and mortality if left untreated. Spontaneous remissions have been reported, but the usual course is slow progressive development of symptoms and signs. Early manifestations include enlarged hands and feet along with coarsening of facial features. By the time a physician makes the diagnosis, virtually all patients have the classic manifestations, which include thickening of the calvarium, increased size of frontal sinuses, prominence of the supraorbital ridges, enlargement of the nose, and downward and forward protrusion of the jaw bone, which leads to widely spaced teeth. Predominantly soft tissue growth results in enlarged hands/feet. A bulky, sweaty handshake is notorious for the condition.

A wide variety of symptoms and signs may be present: excessive sweating (hyperhidrosis), lethargy/fatigue, numbness/tingling in hand/fingers (due to carpal tunnel compression), painful joints, sensitivity to bright light (photophobia), thyroid goiter, enlarged salivary glands, hypertension, enlarged heart (cardiomegaly), kidney stones, degenerative knee and hip joints, and degenerative spine.

People with acromegaly ought to undergo therapy to halt progression of the disorder and prevent late complications. Therapy is designed to remove or destroy the pituitary tumor, reverse the GH hypersecretion, while maintaining normal anterior and posterior pituitary function. Many patients with acromegaly undergo transsphenoidal selective surgical adenoma removal, especially those with small or medium-sized tumors.  

Did you know that dancers tend to live happier, healthier, and longer lives? A variety of studies have shown that dancing can increase strength, flexibility, balance, coordination, stamina, and memory, while reducing the risk of certain medical conditions, such as dementia and emotional problems. Other benefits of dancing are the socialization aspect and training the nervous system to perform new motor skills.

Dancing can combat stress, depression, and loneliness. There are a variety of dances out there to choose from to fit everyone’s individual situation, personality, and inherent preferences and tastes. For the young or old, dancing – like any other activity – can be addictive, but the benefits outweigh the risks for most people. It contributes to the dancer’s length of life and quality of life – providing her something to live for, giving her something to focus on that she enjoys.

In addition, dancing diminishes social isolation and can help reduce the pain and aches associated with a longer life. An article in the New England Journal of Medicine reported dancing 11 days per month could reduce the chance of developing dementia by over 60%. Perhaps dancing engages the dancer’s mind and thus protects the dancer’s “brain power”.

Carrying your body weight across the dance floor, like any weight-bearing exercise, can build stronger bones and reduce the occurrence of osteoporosis, while toning muscles, including the essential “core muscles” that are required for good posture, vital to being a good dancer and to prevent injury while performing the various common activities of daily living.

The dancing footwork improves cardiovascular and muscle endurance, and dancing can be a fun way to lose weight. For example, a 150-pound person can burn substantial amount of calories while dancing: less with lower tempo dancing styles and more with higher tempo dancing. Swing dancing: 235 calories/hour, ballroom: 265 cal/hr, square dancing: 280 cal/hr, and salsa dancing: 420 cal/hr!!! Some avid dancers have claimed that dancers are better lovers and have healthier sex lives, but that claim has not been confirmed scientifically.

See ya out on the dance floor!!!

Professional/large scale focus on Friday, with 1st time user workshop held at a different site: pier 38. It is suitable to those who are considering a website or blogsite, but have not yet done so. Developers and designers are focused on Saturday, and bloggers and content creators will be focused on Sunday. Tips for better writing, ideas to spruce up your site, and opportunities to connect with other WP users are available. Also, the creators of WP will be in attendance, with Matt Mullenweg giving his annual “state of the word” address on Sunday. Click on the photo to view a brief clip from WordCamp San Francisco 2010.

Click on photo to view video

WordCamp San Francisco last took place in May, 2010 and is scheduled for August 12-14, 2011. What is WordCamp?

a) A gathering of people to make up new words (neologism) to add to the dictionary.

b) A misspelling: actually world camp, where people all around the world gather in San Francisco for a camping trip.

c) Actually a slave camp, where participants are taken secretly to Alcatraz Island for harsh manual labor, but must promise to give their word to never tell.

d) A large camp full of people, to compete in the game of scrabble.

e) A Wordpress (a popular blogger platform) educational conference with programs for publishers, bloggers, and developers.

The first question to answer is: what are the established and known benefits of exercise during pregnancy? Physically active pregnant women tend to experience improved fitness and sense of well-being, less adverse symptoms of pregnancy, and 50% decrease in gestational diabetes and 40% reduction in preeclampsia.

Second, what are the known or well-established risks of exercise during pregnancy? High intensity third trimester exercise leads to low birth weights, while starting a new exercise program in poorly conditioned women results in higher than normal birth weights.

Next, what concerns of exercise during pregnancy have not been borne out scientifically? Maternal hyperthermia (elevated maternal body temperature) has been associated with fetal neural tube defects, and has thus led to the belief that exercise-related hyperthermia may be teratogenic. However, these fears may be unsupported because of the increased blood volume, earlier initiation of sweating, and larger body habitus generally found in pregnant women may collectively dampen the hyperthermic response to exercise during pregnancy.

Fear of fetal hypoxia during maternal exercise has also led to the discouragement of exercise during pregnancy. However, we need to consider the physiologic adaptations to pregnancy, which may relieve that fear. We know that most functional changes occur by 12 weeks of gestation, including increases in plasma volume, red blood cell mass, heart rate (HR), stroke volume (SV), and thus cardiac output (CO = HR x SV). Thus, exercising women experience 40% greater increase in cardiac output and 20% greater increase in blood volume compared to sedentary women.

Uterine blood flow has been shown to decrease during exercise, but the maternal uterus compensates by shunting blood from the myometrium (the smooth muscle layer of the uterus responsible for contractions) to the placenta, and thus increases uteroplacental tissue oxygen extraction. If fetal hypoxia was significant, we would expect to find a compensatory elevation in fetal erythropoietin levels. However, fetal erythropoietin levels tend not to increase in response to sustained strenuous maternal exercise, which contradicts the belief of fetal hypoxia induced by maternal exercise. Also important is that exercise during pregnancy has not been shown to increase the incidence of miscarriages or pre-term labor.

What are the recommendations for exercise in pregnancy based on a current review of the risks, benefits, and physiologic adaptations? First of all, exercise is not recommended in high-risk pregnancies. Contraindications to exercise during gestation include significant heart disease or anemia, cervical incompetence, uterine bleeding, ruptured membranes, fetal distress, more than 1 prior miscarriage or premature labor, and uncontrolled hypertension or renal disease.

For pregnant women who do not have any of the above contraindications, current recommendations include initiation of a new exercise program with short duration (15 minutes) and low intensity (55-65% of maximum heart rate) at a frequency of 3 times per week. Low impact (walking) and non-impact (swimming) are preferred over high impact (jogging) exercises. The duration, frequency, and intensity of exercise can be gradually increased, but the intensity is not recommended to exceed 85% of the mother’s maximum heart rate (MHR), which is roughly estimated by the equation: 220 minus the pregnant woman’s age. For example, the MHR in a pregnant 20-year-old is 220 minus 20 = 200, and thus the intensity should not surpass a heart rate of 170 (200 x .85).

Supine exercise, such as floor exercises lying on the back, is not recommended after the first trimester due to the elevation in myocardial oxygen demand compared to exercises in the standing position, but exercises to strengthen the pelvic floor are recommended. Strengthening exercises are restricted to only light resistance, and proper breathing technique is emphasized for weight lifting (inhalation during the eccentric phase and exhalation during the concentric phase of muscle contraction). In addition, fluid and caloric intake should be monitored carefully because of the additional nutritional requirements of gestation.

Exercises during pregnancy can be categorized as either low-risk (e.g. walking, swimming, low-impact aerobics, light weight lifting) or high-risk (e.g. mountain biking, heavy weight lifting, contact sports, scuba diving below 10 meters, skiing, ice skating). Immediate discontinuation of exercise is recommended if the mother experiences any of the following symptoms: shortness of breath, dizziness, nausea, weakness, pain, generalized edema, uterine contraction, vaginal bleeding, fluid leakage, or diminished fetal activity.

Tobey Leung, M.D., FAAPMR

http://www.TobeyLeung.com

Introduction

As we mentioned in the recent article on domestic human trafficking, sex trafficking is the most common form of modern-day slavery, especially targeting the female gender and children. Unlike the common image of young adult women, voluntarily and consensually prostituting themselves for monetary gain, made popular in movies and television shows of the 1970s and ’80s, the current commercial sex industry involve millions of domestic and international victims who are forced into prostitution and pornography for little if any money.

In addition, the typical American believes the young girls are beaten up and abused in distant lands, such as Eastern Europe, Asia, and Africa, but in reality, human sex trafficking takes place in major U.S. cities and small towns, right smack in the American civilians’ backyards. We explained the essential psychology behind the magnitude of the domestic problem in our last article on human sex trafficking, focusing on how female victims, with 12 to 14 as the average age of entry, are “recruited” and manipulated to stay in the forced sex industry. Our goals in this article are to expand on the scope of the problem in international human sex trafficking, which few people recognize is the fastest-growing business of “organized crime”, and to explain the major commonalities and differences between domestic and international human sex trafficking, with strong focus on the modus operandi of the offenders. 

The Media & General Public

The general public often have a lot of misconceptions on complicated issues, and the media frequently propagate the misconceptions further. The typical audience member has a short attention span and yearns for simple answers. Most people are black and white thinkers, and thus strongly want plain black and white answers. However, perhaps only 10 to 30% of life is relatively black and white, with the majority being gray. Nevertheless, reporters are required to cater to this fact of simplistic journalism; stick with the black and white, and avoid gray zone discussions. Thus, we may hear, “Blacks and Mexican gangs go to war over teen prostitution; film at 10″.

The general public members do not want to hear or read a long and complicated excursion with several explanations and with the impression of uncertainty and lack of closure. The public want to hear neat concise answers, even if they are untrue. The major reason is most people are not deep philosophical thinkers and thus they have relatively unsophisticated explanations, such as “foreigners are evil”, but then they also have a natural tendency to want to hear that they are right. Most people do not want to hear the complicated truth and are unhappy if told their beliefs or they are wrong. 

So why would the media present a misleading picture? The primary reason is the same one that motivates most of us – money! The media are involved in a highly competitive business, and thus the need for survival and to make money motivate them to come up with ingenious ways to stimulate the mass to refer to their newspaper, radio station, television channel, or blogsite for their daily news. In general, journalists are seldom rewarded for accurate, intelligent, thoughtful coverage of a topic; rather they are more often encouraged to develop news of high entertainment value in order to attract a larger membership, audience, or readership.

One must tell the public what they want to hear about and present issues as simplistic as possible, while conforming to the customers’ expectations, beliefs, wishes, biases, and prejudices, hence myths and misconceptions. To do otherwise kills business, and everyone is out of a job. News reporters are not in the business of journalism to educate the public; instead to inform the audience of what they already have preconceptions of. However, audience members want the facts right, but the world is full with facts, and so the journalists are expected to present a few – the most interesting ones. Journalists are given liberty to pick and choose the hot ones to whet the public’s appetite. Many people have racial and ethnic biases and tend to believe criminals are evil. So, journalists play on people’s biased beliefs and portray criminals as evil and depict blacks and Hispanics as especially heinous gangbangers. They even play with the public members’ emotions by spinning an issue into a highly charged and controversial one, such as police racism and celebrity scandals. But, in reality, human traffickers come from all races, ethnicities, and countries.

Domestic vs International Trafficking

The United States faces its own homegrown problem of interstate sex trafficking of the under-aged, as discussed in the last article, but also faces its involvement with international victims, with the U.S. serving as both the starting and ending point of the trafficking. Although domestic trafficking of minors is an escalating problem, the illegal and immoral activity is even a greater international problem of epidemic proportion, with most victims abducted or taken from the former Soviet Union, South and Southeast Asia, Latin America, and other under-developed nations, and then relocated to the consumers who reside in more developed countries, including North America, Asia, Western Europe, and the Middle East.

We can explore the international human trafficking problem with the similar model of illegal drug trafficking, i.e. to follow the supply chain and the demand side of the problem. Sigmund Freud alluded to the potential social problems of collective patients with “sexual neurosis” over a century ago. With the ridiculously huge numbers of people in the world with sexual neurosis who demand having sex with the under-aged, it opened a huge business opportunity for those who are willing to supply sexually neurotic people’s demand of minors for sexual intercourse. The huge demand and the large amount of money that sexually neurotic perpetrators are willing to pay in order to fulfill their pathological appetite enticed many people to organize in growing nationwide (domestic) and international crime networks of human trafficking to supply and meet the tremendous international demand side of the equation, and thus to actively participate in the currently third-largest criminal enterprise in the entire world.

Domestic human sex trafficking involves recruitment of victims from within the U.S., transportation and storage of victims at sites within the U.S., and finally dealing the victims’ sexual services to consumers all within the United States. Meanwhile, international human trafficking can take place with the entire supply chain outside of the United States. For instance, a victim can be abducted from Latin America and transported to Asia for pimping or sold to a sole client residing in Japan, and the victim never crosses or enters the U.S. border. Thus, the above case is often called foreign human trafficking. In other situations of international sex trafficking, the victim originates from the U.S. and is transported to another developed country. Or the victim originates from a foreign nation, but is trafficked into the United States. Therefore, at some point along the supply chain, international trafficking has a domestic component and crosses the U.S. border, either exiting or entering.

Foreign Human Sex Trafficking & Rescue

In contrast to domestic human sex trafficking, battling international sex trafficking requires an understanding of the wide range of foreign local customs and cultural practices, in addition to acknowledgement of the potentially greater vulnerability of corruption within various foreign law enforcement organizations. For instance, in many foreign nations, such as India, which has a long history of the common custom for parents to “arrange” or force their children into early marriage, and in other regions of the world, girls as young as 4 to 7 years old are forced to marry adult men, the issue cannot be successfully approached from a pure regulatory and law enforcement standpoint.

Forced marriages place young girls with many potential setbacks, such as losing their chance for school and education, deprived of their innocence and childhood, where they lose the opportunity to explore, play, and learn, forced into hard physical labor as an enslaved spouse in a mandatory marriage, and exposed to health risks, including contracting HIV and the medical consequences of early pregnancy, which is high risk because of the girl’s immature and thus narrow birth canal, and the high rate of subsequent  bladder fistulas, leading to infections and social embarrassment of urinary leakage, i.e. incontinence.

The motive of the parents who force their child into early marriage may not be entirely selfish and may be actually protective; for instance, in some cultures, such as in Ethiopia, parents may want their girls to marry young out of fear that unwed girls are often abducted and raped, while married girls are considered off-limits by the majority members of that culture, and to keep their girls from experiencing the social stigmatism of being unwed. The problem is quite different in India, where there is widespread child prostitution. Parents may intentionally sell their children to work in brothels, or other family members, friends, and acquaintances may convince, manipulate, or trick the parents into placing their child into the hands of the trusted offender in hope of a better life for the child, but the child is then sold or placed into brothels, where the general living conditions are inhumane. 

In our last article, we discussed the common problems that domestic law enforcement are confronted with, including the pimps’ use of manipulation, through the degradation-abandonment cycle, to control the child/teen prostitute’s actions of staying in a life of enslaved prostitution and of relentlessly protecting the pimps from the police. In comparison to domestic sex trafficking, international sex trafficking presents additional problems for those people who attempt to “rescue” child/teen prostitutes. In many under-developed geographic regions, a former child prostitute who escaped the life of enslaved prostitution grows up to be a young adult and leads the grassroots effort in rescuing other child prostitutes from their predicament.

These young adults, who were lucky enough to escape the degrading life of forced child prostitution, may gather a small band of volunteers who seek out child/teen prostitutes to rescue. However, they are faced with the same vicious degradation-abandonment cycle obstacle that domestic law enforcement have to overcome, and perhaps with the advantage of having lived “inside” enslaved prostitution, the former child prostitute has developed the keen skill or knack of identifying the “right” youths who are mentally prepared to escape, to rescue from the brothels. It can be a very dangerous task for the former child prostitute and her volunteers to pull off and successfully enter and rescue a specific targeted child/teen prostitute without encountering physical or violent resistance from the brothel owners and keepers.

A failed rescue attempt often dooms the targeted child prostitute, who is then relocated from city to city as a ploy to keep the child from being tracked down and rescued. In addition to the risk of targeting the “wrong” child for rescue, in which case, the child will physically resist the rescue attempt and instead try to remain with the brothel owner/manager, the rescuers are faced with the reality of corrupt individual police officers, who tip off the brothel owners/keepers before a raid of the brothel can be carried out successfully. Thus, the former child prostitute with the aid of volunteers may decide to pull off a rescue attempt on their own, without police protection, in order to avoid the issue of corrupted police who warn the brothels beforehand. In addition, despite a successful rescue, the former child prostitute or any of the volunteers in her rescue squad may become targets of violent retaliation, including assassination.

The Supply Chain of International Trafficking

Let’s dwell deeper into the supply chain of international human sex trafficking, using illegal drug trafficking as a model: manufacturers, traffickers, and dealers. The “manufacturers” in international human trafficking for sexual exploitation are often different than in domestic trafficking, in which we explained in the last article are most commonly products of a dysfunctional family or home where the child is abused physically, emotionally, sexually, or often a victim of all three forms of abuse, and thus the child goes from a bad to a worse situation by running away.

The second most common product of domestic prostitution slavery is the thrown-away youth, abandoned to live on the streets and at very high risk of becoming manipulated and trapped by a pimp, through initial recruitment by a “bottom” girl, into forced sexual slavery. In contrast to these domestic manufacturers of human trafficking, the international human sex trafficking manufacturers are the products of primarily being sold to the traffickers for monetary profit. The sellers at the starting point of the international human supply chain can be parents, family members, friends, acquaintances, and professional abductors and con artists.

The typical buyer on the demand side wants an “attractive product”, and thus many scams use modeling agencies or professional model photographers as the front to lure attractive young victims through their doors. The Internet may be the initial point of contact between perpetrator and victim, but eventually there has to be a physical meeting place – the modeling agencies or the modeling photographers’ office. The unwitting victims are lured to sign up for travel to remote exotic or adventurous places, where they are presumably going to meet influential figures in the modeling industry, but are instead led to the handlers or traffickers. In these cases, traffickers generally trick their victims into giving up their identity forms, such as drivers’ licenses, passports, and birth certificates, under the pretense of protecting the victims from losing such valuable means of identification. However, without any form of I.D., the teenagers have a difficult time finding opportunities to support themselves even if they escaped, especially in a foreign land, and thus often return to the trafficker.

The United States can be involved in either the early (manufacturing/recruiting) or the end phase (dealing/selling to particular clients) of the supply line, in addition to the middle phase of transportation and “storage” (trafficking) before the product is finally sold to the buyer. Professional con artists may lure an attractive product through the pretense of a date or getting romantically involved for the sole purpose of putting the product into the hands of the traffickers in exchange for a monetary “finder’s fee”. The con artist may also work for professional abductors and befriend the potential victim, for instance, by gaining her trust with his charms and offering to show her around in the foreign land that she is visiting, with the ultimate intent of setting her up at a pre-set time and place of the kidnappers’ choosing for professional abduction.

In general, traffickers are highly organized, with a hierarchy system like other criminal organizations that can manage competently the “manufacturer” phase, the actual trafficking, and finally placing the product into the consumer’s hand (dealing). Traffickers represent every social, ethnic, and racial group. Some offenders may belong to a small gang, while others are members of large nationwide or international criminal organizations, and some yet have no organized crime affiliation and are self-employed in their own “small business”, functioning alone or with a few helpers along the entire supply chain as the manufacturer/recruiter, transportation and storage, and dealer. It’s also important to note that traffickers do not come only from the male gender and that women also run many established human trafficking rings for sexual exploitation.

The primary motive for organized human sex traffickers is exactly the same as illegal drug traffickers – plain greed, while the primary motive for most consumers on the demand side is pathological sexual neurosis. The product – victims – are typically forced one way or another into the supply chain, followed by trafficking and ending up as enslaved sex providers. The victims’ motives can be quite psychologically complex, unconsciously driven by the degradation/abandonment cycle, and thus trying to satisfy their pimp, madam, brothel owner/manager, or husband is usually a key motive in order for them to survive and maintain the status quo.

Foreign Cultural Customs & The Importance of Temporal Changes: Thailand Example

As mentioned previously, international human trafficking is complicated by differing cultural customs of various countries, nations, or societies, and thus makes it difficult for a foreigner to understand the exact cause and nature of the trafficking problem. In addition, one thing that is sure to be constant is change, and thus as conditions change, the cause and nature of the foreign human trafficking crisis also changes. In turn, the effective solution or remedy may also change with time. Let’s use the human trafficking calamity in Thailand as an example to illustrate the above principles.

Serene rivers, expansive gorges, pristine beaches, luscious landscapes, and beautiful valleys are some of the natural wonders of Thailand that attract over 14 million tourists to visit this southeast Asian country annually. However, human sex trafficking was rampant in Thailand during the 1990s. The Thai government responded to the annual increase in victims by passing the Prevention and Suppression of Trafficking in Women and Children Act in 1997, and thus criminalized trafficking women and children for sexual exploitation with stiff penalties for violations, such as imprisonment ranging from a year to life. Protection of male victims was excluded in the law, but according to the United Nations (UN), a law has been drafted that allows for prosecution of trafficking male victims and has been finalized in 2006, but awaits passage through the Thai legislature.

Meanwhile, human trafficking is currently a $12 billion dollar industry in Thailand. What happened after the passage of the 1997 law was that the number of brothels dropped dramatically, but were replaced by other types of establishments, such as massage parlors, karaoke bars, cocktail lounges, beer bars, and cafes. In essence, people were trying to dodge the law, while the human sex trafficking trade continued as usual. Villagers in the northern region of Thailand were the most common victims of human trafficking. According to the 2001 Second World Congress against Commercial Sexual Exploitation of Children, seventy percent of 800 families in one small Thai region, Mae Sai, had sold a daughter into prostitution. 

Siroj Sorajjakool, PhD, a professor at Loma Linda University, reported that the sex trade in Thailand had become less brutal and forced prostitution less common in the years immediately subsequent to the 1997 law. However, Dr. Sorajjakool noted that economic prostitution was rising, and the issue seemed to move away from forced sex into a form of debt bondage. In general, village girls were customarily more vulnerable to enter the sex trade due to their limited or absence of education, but more of the prostitutes were poor urban girls instead of village girls by 2001.

Dr. Sorajjakool pursued another research project in 2009 and interviewed more than 30 individuals who were working to combat the human trafficking dilemma in Thailand, the country coordinator for the UN Inter-Agency Project on Human Trafficking, various non-government organizations (NGOs), UN bureaus, and officers of the Thai government. He discovered the girls at Chiang Rai, a city located at the northernmost tip of Thailand, were the most vulnerable victims for entering the sex trade in 2009. Dr. Sorajjakool concluded that many of the villagers used to live and was quite content with a very simple life, but as capitalism and a culture of materialism slowly crept into the economically developing northern territory, these same villagers required more possessions than what their current financial resources could provide. At that point, the villagers from the Akha and Hmong tribes in the northern hills of Thailand sold family members, typically young daughters, into the sex trade to support the family’s newly accustomed lifestyle.

Dr. Sorajjakool’s research suggested families initially sold girls into the sex trade due to circumstances surrounding poverty, but as certain parts of Thailand grew economically more than other parts, it was the wealthier villages that were more likely to sell daughters into the sex trade, in order to maintain their current lifestyle or to acquire more materialism, i.e. to help pay for more material possessions. Thus, greed is a major reason why sexual exploitation of young girls continues to take place in Thailand. Therefore, approaching the human sex trafficking problem from an economic standpoint was not the correct solution, at least not in Thailand.

The United States Regulators & Enforcers

The U.S. Congress passed the Trafficking Victims Protection Act (TVPA) in 2000 and created the initial comprehensive federal law to specifically address the issue of human trafficking, with an international focus. The TVPA has a 3-pronged p approach: (1) prevention through international public awareness programs and a State Department-led monitoring and sanctions program, (2) protection through a T Visa and services for foreign national victims, and (3) prosecution through new federal crimes along with severe penalties.

After September, 2001, the U.S. Immigration and Customs Enforcement, known as ICE, was charged with enforcing the TVPA because of the potential threat to homeland security presented by human trafficking. It was predominantly the fear that terrorists could access and follow the same travel routes and use the same methods of human sex traffickers that prompted ICE’s Human Smuggling and Trafficking Unit to identify individuals involved in human trafficking. It’s a pity that a federal agency, such as ICE, may not have be given the lead in enforcing the TVPA if it had not been for the 9/11 terrorist acts.

Another branch of the Department of Justice (DOJ), the FBI, also enforces the TVPA and in conjunction with the DOJ Child Exploitation and Obscenity Section and the National Center for Missing and Exploited Children launched the Innocence Lost National Initiative in June, 2003. These agencies’ combined efforts target the huge growth of domestic child/teen sex trafficking and have successfully rescued almost a thousand victims in 8 years. With an estimated 300,000 domestic minors at risk, rescuing an average of slightly over a hundred children per year can be perceived as barely touching the tip of the iceberg, but then again a thousand domestic children rescued from a life of sexual exploitation, especially given the difficult task of breaking the degradation/abandonment cycle of domestic child/teen prostitutes’ dependency on their pimps/traffickers, is a highly commendable accomplishment.

Both ICE and the FBI, in addition to local, state, and other federal law enforcement agencies, along with national victim-based advocacy groups, have participated in joint task forces that share their respective expertise and resources to combat the ever-growing criminal enterprise of domestic human sex trafficking. In addition, the Human Smuggling Trafficking Center (HSTC) was formed in 2004 and continues to serve as a hub or fusion center for human smuggling and trafficking information, and brings together analysts, investigators, officers, and experts from various agencies, including ICE, FBI, CIA, State Department, and Department of Homeland Security. Also, with DOJ funding, many jurisdictions across the land have developed human trafficking task forces to combat the problem at the very important local level because domestic human sex trafficking can take place anywhere and the battle against sex trafficking usually starts at the local enforcement level. Thus, state and local criminal justice officers must remain alert for signs of trafficking within their jurisdictions and meticulously follow up on the smallest clue or hint of sex trafficking.

What Can Civilians Do To Help Combat Human Sex Trafficking?

What can a civilian do to help counter the huge problem of human trafficking? At some point in every civilian’s life, they have to decide whether they’re going to be part of the problem, part of the solution, or part of the landscape. Without a conscious decision, most people remain part of the landscape by default, while others unknowingly remain part of the problem. Helping to enhance public awareness is a vital process that anyone can do, with some time spent on obtaining information and education on the problem and developing a fearless attitude toward speaking to people on a taboo subject.

Consider seeking assistance from or joining non-governmental organizations (NGOs) involved in battling sex trafficking. You can also familiarize yourself with the numerous websites that semi-overtly advertise for prostitution. Be wary that many of these porn sites showcase children/teens victimized by sex trafficking, but they are presented in ways that portray them as older girls who seem to enjoy sex and work for profit. Nothing is farther from the truth as most of these girls or boys live in captivity, under the worst conditions imaginable, and are typically pale, exhausted, and malnourished. By the way, most vice units are familiar with the common advertisement sites used by sex traffickers.

Other than vice squads on sting operations, patrol officers are often the first responders and thus the initial law enforcement officers to make contact with the child/teen prostitutes and their customers. Thus, enormous effort has been made to educate patrol officers on the signs of a victim of human sex trafficking. Therefore, civilians can also learn these signs, but I do not recommend any untrained civilian, no matter how smart he thinks he is, who he thinks he is, whether he’s the UFC mixed martial arts fighting champion or competition firearms shooting champion, to personally intervene and attempt a rescue; instead he should call local police about the signs of a possible victim of human sex trafficking that he personally witnessed or overheard.

Given that caveat, the signs that civilians can be aware of include criminal gang activity (possible violent and organized sex traffickers), when you overhear repeated acts of domestic violence or verbal disputes (which could represent a trafficker abusing a victim, or a customer having a dispute with a victim over money or the sex act to be performed), frequent foot traffic in and out of a house or facility, especially men, that seems similar to illegal drug dealings, a youth who claims to be older than (s)he appears, a young person without any form of identification, a minor who frequently enters a cheap motel alone or accompanied by a man, and especially if she is observed to be transported and dropped off by an adult man, a youth who seems to have limited knowledge about how to get around in the local community, an individual lacking personal possessions, persons who live on or near work premises, large number of occupants compared to living space, someone hanging out alone apparently because of the lack of or with restricted communication (no cell phone) and transportation, and a facility where you observe different persons are frequently picked up and dropped off (possible victims moved by traffickers). A single sign is just a general indicator, but a combination of multiple signs should increase your suspicion of the presence of human sex trafficking.

Particular locations, such as cheap motels, truck stops, strip clubs, massage parlors, and spas, are havens for child/teen prostitutes forced into sex trafficking. However, many people have apathy or an attitude of indifference to the awful situation of the victims forced into human sex trafficking. Therefore, such a person may see the same teen at a truck stop on numerous occasions and expresses his demeaning judgment or talks down to and yells at the youth. This person, at best, is part of the landscape and perhaps even part of the problem. A more compassionate and empathetic individual would likely suspect something is wrong and the youth is in need of help, not lecturing. However, I once again warn an untrained civilian not to directly intervene, but rather the best choice of action is usually to indirectly intervene by notifying local law enforcement about the signs that were witnessed.

It is a patrol officer who you will most likely speak to once (s)he arrives on the scene. Detectives may conduct a more thorough investigation if they feel it is warranted. After executing a search warrant, photographs are key to a successful prosecution because no words can describe the cramped filthy living quarter a victim is forced to reside in and thus the reminder of an invaluable old saying: A picture is worth a thousand words! If needed or if detectives are stumped, they may refer to federal resources and contact their local U.S. Attorney’s Office, ICE, or FBI field office.

Remember the common methods used by pimps/traffickers to control the victim: manipulating the degradation/abandonment cycle, verbal threats, physical bondage, locked room or brothel, forced drug addiction, physical assault, torture (frequently the convenient cigarette burns), and gang rape. Thus, as a physician, I have the personal opportunity to screen youths for physical signs of abuse, such as cigarette burns, bruises, blunt trauma, multiple bone fractures, but in different phases of healing, brands on the skin or scars that may indicate “ownership”, needle marks along a vein(s), and malnourishment. I also get a little suspicious if a third party strongly insists on interpreting for the youth. However, you may be able to pick up on some of these visible physical signs in non-medical settings, too.

As a criminal profiler, I can quickly scan a youth in a non-medical setting for emotional signs of victimization, such as hyper-vigilance specifically towards an adult companion, over-sensitivity to or obvious fear of displeasing an older escort, over-reliance or dependence on a male adult, and an older companion using degrading remarks alternating with threats of abandonment towards the youth. I have to admit that I can feel angry and sad if I frequently dwell on the fact that millions of international victims (mostly young females) are living at the present moment under horrible situations of modern-day slavery, driven by the sex traffickers’ primary motive of greed, and that suppliers are just trying to keep up with the high demand of sexually neurotic consumers who desire sex with minors. Luckily, I developed the ability at an early age of always finding peace by turning inwards and am soothed by my spiritual beliefs and receive consolation from my belief that I am trying my best, although I am only one person, to do what is morally right and not to give up and continue to try to guide humankind to grow spiritually, albeit one person at a time.

Tobey Leung, MD, FAAPMR

Board Certified Physiatrist

Criminal Profiler

Ninjutsu Grandmaster (10th degree black belt)

http://www.TobeyLeung.com