Surrogate Partner Therapy: Why Aren’t We Doing It?

As diverse sexual experiences continue to appear in mainstream society, and sexual expression becomes an encouraged practice, the modern field of sex therapy must be evaluated. Rooted in the work of Masters and Johnson, sex therapy applies a behavioural model consisting of psychoeducation, improving communication, and breaking down and refocusing on sensations as opposed to performance (Rosenbaum et al., 2014). However, an important component of this therapeutic approach is a cooperative partnership. As such, surrogate partner therapy (SPT) was suggested by Masters and Johnson for individuals who were not in a relationship. The role of the surrogate is to implement the therapist’s instruction with the client, and to create an atmosphere in which the client can practice various skills with the goal of increasing sexual comfort and confidence (Rosenbaum et al., 2014). Therefore, the surrogate is to act as a mentor under the supervision of a therapist (Freckelton, 2013). Interestingly, while many components of the Masters and Johnson model have remained consistent over time, the practice of SPT is highly controversial today. To be honest, the legalities are highly complex and although not “illegal” per se (like sex work), it is not really legal…

Below, I explore arguments for and against the practice and SPT, ultimately making the case that, upon careful implementation, this practice should be reintroduced into the mainstream practice of sex therapy.

SPT is commonly misunderstood and mistaken as a sex work. Indeed, sex work involves engaging in sexual activity for a reward, commonly monetary compensation, and this aspect overlaps quite significantly with SPT, in which the surrogate engages in sexual activity with a client and is paid for such services (Freckelton, 2013). However, one must understand the complexities of the role of the surrogate and the range of services provided in addition to sexual activity in order to appreciate the therapeutic nature of this work. In fact, it has been found that 87% of the time spent in SPT sessions consist of nonsexual activities (Rosenbaum et al., 2014). These activities include training in communication, relaxation, and social skills. Moreover, having specific guidelines in place to reduce overlap between sex work and SPT has also proven effective. This includes acting in accordance with goals outlined by the therapist, rather than the demands of the client, and arranging services and monetary compensation through the sex therapy clinic rather than between the SPT and client (Rosenbaum et al., 2014). Evidently, a more complete understanding of SPT makes it clear that there are important distinctions between the work of surrogates and prostitutes.

Concern also arises over the lack of governing bodies for sex surrogates, compared to many sex therapists who are regulated and required to meet strict ethical guidelines. As Freckelton (2013) explains, most surrogates do not have professional or ethical guidelines to follow. Moreover, they do not possess psychological training. However, with proper guidelines and training, one would argue that this critique has no standing. Such is the case in the sex clinic of Dr. Ronit Aloni, a sex therapist in Tel Aviv (Rosenbaum et al., 2014). Dr. Aloni utilizes SPT for some clients, and these surrogates are thoroughly screened and trained in accordance with the International Professional Surrogates Association (IPSA). IPSA has published goals and training recommendations as well as a code of ethics for sex surrogates. Dr. Brian Hicks, an Australian psychologist, has also found success with SPT when strict guidelines are followed and the surrogates are properly trained (Freckelton, 2013). Undoubtedly, SPT can be implemented in a regulated and ethical manner if guidelines are followed and surrogates are adequately trained and supervised.

Lastly, one may question the nature of the surrogate-client relationship and whether this can mirror a true partnership, as well as the lasting effects on both the surrogate and client. Even Masters and Johnson acknowledged the stresses that such a relationship can put on those involved (Apfelbaum, 1977). In contrast to a relationship established outside of therapy, a surrogate-client relationship may lack affection and attachment (Freckelton, 2013). Moreover, Apfelbaum (1977) acknowledged the pressure on the surrogate to create a low stress environment while putting their own needs aside, both during sessions as well as at the termination of the program. However, the emotional hardships of such a relationship can be mitigated by providing the client and surrogate emotional support once the program is complete. In fact, Rosenbaum et al. (2014) argue that “separation is part of life, and learning to deal with it effectively is considered to be a positive learning experience” (p. 326).

Moreover, the opportunity to create a relationship, rather than working within a pre-existing one, may actually result in several advantages. For instance, Lavee (1991) argues that various cultural belief systems influence what is considered appropriate in a relationship and sexual activity. While some of these beliefs may be in contrast to those of traditional sexual scripts, creating a relationship in which a client feels that their cultural values and boundaries are being respected can be beneficial. These dominant beliefs also affect who has the opportunity to engage in meaningful relationships and sexual activities. Exclusion is often faced by those with sexual dysfunctions and individuals with disabilities due to misconceptions that they are ‘abnormal’ or ‘asexual’ (Freckelton, 2013; Rosenbaum et al., 2014). SPT would therefore create an opportunity for these individuals to learn and practice engaging in relationships and sexual activities that may not otherwise exist. Further, a client-surrogate relationship can circumvent complex dynamics that may exist between romantic partners, thus allowing for a greater focus on the physical nature of the sexual dysfunction and implementation of good communication skills in future relationships (Rosenbaum et al., 2014). In fact, a study done in Dr. Aloni’s clinic revealed higher success rates of treatment for vaginismus among women working with surrogates, compared to those being treated with their own partners, as well as earlier completion of therapy (Rosenbaum et al., 2014). Masters and Johnson advocated for the importance of undergoing sex therapy as a couple and doing so in a client-surrogate partnership may not only accomplish this need when a partner is not available, but may actually be superior to working within an existing romantic relationship.

Evidently, SPT is a viable addition to mainstream sex therapy. There is a clear distinction between the work of sex workers and that of sex surrogates, an existing association which can govern such work to ensure professional and ethical standards, and the ability to mitigate any issues that may arise as a result of the nature of the client-surrogate relationship. Moreover, SPT provides an avenue for un-partnered clients to learn and practice the skills of sex therapy. Perhaps the reason for society’s hesitancy towards SPT reflects the dominant cultural ideology and traditional sexual scripts that have permeated Western society (Lavee, 1991). Therefore, we must challenge our existing beliefs and look to others who have had clear success with such programs, such as Drs. Aloni and Hickman. Modelling SPT programs after these will allow for proper implementation and success of SPT, only advancing the work of modern sex therapy.

Julia Friedman, B.A.H. Psychology, 2022

References

Apfelbaum, B. (1977). The myth of the surrogate. The Journal of Sex Research, 13(4), 238-249.

Freckelton, I. (2013). Sexual surrogate partner therapy: Legal and ethical issues. Psychiatry, Psychology & Law, 20(5), 643–659. https://doi-org.proxy.queensu.ca/ 10.1080/13218719.2013.831725

Lavee, Y. (1991). Western and non-Western human sexuality: Implications for clinical practice. Journal of Sex & Marital Therapy, 17(3), 2013-213, DOI: 10.1080/00926239108404344

Rosenbaum, T., Aloni, R. and Heruti, R. (2014). Ethical considerations in surrogate‐assisted sex therapy. The Journal of Sexual Medicine, 11, 321-329. https://doi-org.proxy.queensu.ca/10.1111/jsm.12402