Michael has received sex therapy at the top of a mountain. He's also had counseling outside his Silicon Valley apartment and in the parking lot of a nearby airport. In each of these locations and many others, he speaks from the privacy of his car. There, he feels he can be more frank with sexologist Gloria Brame than he could inside a therapist's office.
According to Michael, the unconventional character of the sessions has been the critical factor in helping him face his problems. (Because of the personal nature of his therapy, Michael agreed to be interviewed for this story only on the condition that his full name not be published.) Inside his car, the 27-year-old said, he has confronted his desire to seek out sadomasochistic relationships, something he couldn't put into words a year ago. Then, the end of a relationship left him worried about his needs and his ability to meet them. Anxious for reassurance and guidance from someone knowledgeable about kink culture, he picked Brame after stumbling onto an online reference to one of her books on the subject. He said Brame (dubbed "the Dr. Albert Einstein of kinky sex" by one sex educator) has helped him address some of his body image issues as well.
He's even lost some weight. But Brame wouldn't know that firsthand. Although she's been his therapist for 10 months, and they talk once a week, the two have never met. She lives three time zones away, outside Athens, Ga., and conducts sessions with Michael by phone and e-mail.
"I think there was something about not knowing the person, not seeing the person, not blushing in front of the person, that made it easier to talk initially," Michael said. "Even over the phone, my first conversations with her, we talked about things that made me sweat."
For Michael and others who are uncomfortable discussing sexual issues face-to-face, distance sex therapy, as it's known, is providing a new option. Its practitioners include credentialed sex therapists who counsel clients by phone, e-mail or in Internet chat rooms, where they address deeply personal issues without ever meeting. In doing so, they've set off a debate about the ethics, legality and effectiveness of such practice.
"If therapy works, there's some processes and mechanisms that occur in the session that make it work," said William O'Donohue, professor of psychology at the University of Nevada at Reno, whose articles on sex therapy have been published in the journal Clinical Psychology Review. Such mechanisms, he said, can include homework exercises or communication training as well as good rapport and empathy from the therapist. But he said, "What we don't know is, are the processes and mechanisms still working in e-mails and . . . in telephone contact?"
Distance sex therapy has been growing over the last five years, according to Barnaby Barratt, president of the American Association of Sex Educators, Counselors and Therapists (AASECT), a Richmond-based professional organization that certifies various health and social service professionals who specialize in sexuality-related education and treatment.
Barratt bases that opinion on what's he's observed on the Internet and what he's heard from clients and fellow sex therapists; he and other experts say there is no official count of how many therapists offer the service, nor has the treatment method been well studied. Professional groups, including AASECT, have only recently begun efforts to better understand the trend and draft guidelines for practitioners.
But some sex therapists are skeptical. Deborah Fox, a Washington-based clinical social worker and AASECT-certified sex therapist, said a phone conversation or e-mail exchange can't resolve deep-seated problems.
She came to that conclusion after she began offering an online service in 1995, and found that the e-mails she received came in two forms: problems that could be resolved quickly with suggestions and information, and serious issues that required in-depth therapy. Without a personal meeting, she said, she was unwilling to address the latter.
"You can't do therapy over the Web," she said. " . . . It would be very foolhardy to do that. I think the only thing you can do is offer some discreet information, some concrete information." While she retains a professional Web site, www.mindspring.com/~ debfox, she said she does not promote it, rarely gains clients through it, and has raised the price of an online consultation to discourage people from contacting her online.
Few states issue a sex therapy license per se, so most who specialize in this field are licensed in something else -- commonly, psychology or social work -- and then seek certification from professional organizations. Some have also attended one of the few graduate schools that offer degrees in human sexuality, such as at Widener University in Philadelphia. Most offer therapy in an office setting, incorporating sex therapy as part of broader psychotherapy sessions or using it to address specific sexual dysfunctions or perversions. Those issues can range from orgasm difficulties to sexual conflicts in a relationship to specific fetishes.
The Therapist Is In
Many sex therapists who offer distance therapy have an office practice as well, and typically set up a Web site to advertise their services. Some of these sites give contact information for the therapist, while others have online forms they ask prospective clients to complete. Clients find these sites through search engines or online catalogs of sex therapists, such as the one at sexualtherapy.com. Some patients pay a therapist for a one-time e-mail exchange, while others pay for weekly sessions, which are conducted in their medium of choice and can be held regularly for months or years.
At e-sextherapy.com, Florida-based sex therapist Earl Ledford has a cartoon traffic light that turns green when he's online and available for a live chat. For his single or ongoing consultations, he charges from $7.50 for an initial e-mail to $50 for a 50-minute phone, chat or video session via webcam. His hourly in-person fees can be twice that.
A clinical social worker, Ledford said he likes using the Internet to reach clients he knows won't ever walk through his door. Ledford said he's reported remarkable changes in the patients he's worked with by phone and e-mail, and believes they're often more prepared to help themselves than the patients who come into his office. He said many of the patients who seek out a therapist online have already researched their problems, and just need an extra push to overcome them.
"Look at the process of change," he said. "There's millions of people who change behavior or solve a problem without talking to anybody about it. . . I see myself as a facilitator of that with people. If you look at it and accept that, you can accept that someone online, that [patients] don't see, can be a facilitator for that process of change."
Other therapists widely affirm the value of online information in addressing some people's problems -- by providing answers to questions, for example, about erectile dysfunction and orgasm. But the relaying of such information, many contend, is entirely different from a clinical healing process.
Distance sex therapy has also raised legal questions.
Some groups, including AASECT, are wrangling over whether such therapy sometimes violates state-issued counseling licenses, according to Barratt. Can a sex therapist licensed as a psychologist in Virginia, for example, legally provide therapy by phone to a person in Oregon, where the therapist is not licensed?
Ronald Coleman, who practices Internet law in New York, said almost every licensed profession has dealt with similar questions, which arose long before the Internet -- or remote sex therapy -- came into being. What if, he said, a client goes on vacation out of state, and then calls to talk with his therapist? Or suppose the therapist travels with the client to another state? Since sex therapists are not even offered licenses by most states, he said, the legality of distance sex therapy is "murky as hell."
However, Coleman said, license jurisdictions are rarely called into question unless a therapist is charged with some form of abuse, or a local professional guild launches an investigation. " . . . What you have is a regime that is in place to punish people after the fact but that for all practical purposes does very little in almost any profession," he said. He said he's unaware of any cases that stemmed from a distance therapy relationship.
Privacy is also a concern. As with any Internet-based exchange, there is always the risk that personal information will appear in the public domain.
Brame, Michael's therapist, who works often with clients by e-mail, said her clients are less concerned about the threat of broad privacy breaches than about the possibility that a spouse or child would accidentally open a sensitive e-mail. Nonetheless, she said, she always advises clients against using a work-based e-mail account, which can be filtered or monitored.
Barratt complains that online sex therapy provides little accountability, for the therapist or the client. Therapists don't know if a client is following advice. Clients don't know if a purported therapist is qualified. Clients, he said, "don't really know what they're getting. They know somewhere in their minds that the therapist doesn't really know them. This is not really therapy."
But some distance sex therapists say the lack of physical contact sometimes makes therapy easier, because clients are more comfortable in their own environment and therefore more willing to share information.
"Although it may seem that the face-to-face is important, I actually find that people are much freer when they're not distracted," said Brame. She's a sexologist -- an umbrella term used to describe a range of sexuality-related professions, including therapists and educators -- certified by the American College of Sexologists and a doctoral graduate of the Institute for Advanced Study of Human Sexuality, in San Francisco.
"I know that for sex therapy," she said, "the hardest step is going. The hardest step is actually facing somebody and speaking about this stuff, because sex is such a private issue. It's just the most intimate domain."
A Stranger Who Cares?
There are few published studies of distance sex therapy, and no sources interviewed for this story were aware of any randomized, controlled, double-blinded studies -- the gold standard for science. But one unpublished study, conducted nearly two years ago as part of a doctoral dissertation at York University in Toronto, suggests that online therapy of various kinds may help some patients.
Stephen Biggs, a PhD candidate in clinical psychology, surveyed 44 people who said they had received therapy strictly over the Internet. Among these respondents, 16 percent said their therapy involved sexual issues; ages varied and women outnumbered men. Eighty percent (35) said they found the therapy experience somewhat or very positive, but all said they would use online therapy again and "reported that the therapist was empathic," he said.
"It's sort of funny," said Biggs, "but people get this feeling of being cared for from this person they've never met."
Biggs acknowledged, however, that since the study was based on patient surveys and not observations, there was no way of knowing whether the clients actually benefited.
Until more studies are done, there's no way to know if distance sex therapy is effective, said O'Donohue. In the meantime, he said, sex therapists shouldn't charge for distance services.
Ultimately, he said, there should be a federal regulatory group to oversee distance sex therapy. That way, the agency could monitor the transition from office to online the way the Food and Drug Administration makes sure drugs for one ailment aren't blindly sold for another. "Just because a pill works for one type of problem," he said, "someone can't put it in liquid form and sell it for another problem."
And yet, none of these concerns have fazed Michael, Brame's client in California. He said he knows distance sex therapy isn't taken as seriously as traditional sex therapy, but he believes a therapist-client relationship can thrive as long as the two parties understand each other. That, he said, has nothing to do with whether they're sitting in the same office.
He said he's had his share of therapists who didn't understand him or his desires, and he had grown frustrated after terminating therapy with several California therapists. At this point, he said, he's happy to have found someone he can connect with -- even if she's thousands of miles away.
What he hopes to get out of the therapy, he said, is the ability "at some point [to have] a normal relationship with someone that has kink aspects as well as a general respect for another person, and just having the kinky stuff being a normal part of my life." But to get to that point, he said, he has to "come to terms with who I am and other people accepting who I am." He feels he's made progress, and so, he said, does Brame.
"I guess the real thing is, if you talk to an intelligent person who gets inside your head in the right way, who has interesting ways of looking at the world, and you're open to them," he said, "then I find that more important than someone standing there with a tape measure measuring my waist every three weeks."
Jason Feifer is a freelance writer in Massachusetts.
Web sites tout sex therapy services for Earl Ledford (left) and Gloria Brame (right).