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

Hungry for Sex? How We Conceptualize Sex, Matters

Without even realizing it, most of us use metaphors to narrate our sex lives. From “loving the chase” to “getting to third base," sex metaphors are everywhere. Metaphors enable us to represent abstract concepts concretely (Lakoff & Johnson, 1980). According to Conceptual Metaphor Theory, metaphorically framing a concept in a certain way guides one’s thoughts, attitudes, and subsequent behaviour (Lakoff & Johnson, 1980). Likewise, the metaphors we use for sex and sex-related topics tend to be subtle but powerfully pervasive in how they shape how we think, perceive, and act (Lakoff & Johnson, 1980). While there is an abundance of metaphors out there to describe sex, I want to note that the literature that is currently available seems to focus exclusively on the binary genders/sexes and heterosexually-identified individuals, lacking an appropriate appreciation for sexually and gender diverse individuals. With that said, it is no question that the current literature suggests that metaphors can be extremely influential; however, the question remains as to whether sex metaphors are harmful or healthy.

Sex Metaphors are Pervasive, but are They Harmful?

Many of the metaphors used to describe sex can be damaging. They tend to reflect male dominance and often portray women as objects that can be acted upon by men (Borisoff & Hahn, 1993; Weatherall & Walton, 1999; Fernandez, 2008). Weatherall and Walton (1999) suggest that conceptualizing sexual desire and activity as hunger and food can support the objectification of women and perpetuate sexist attitudes. For example, associating a woman with a sweet cookie may reduce her to an object's powerless status (Fernandez, 2008). On the other hand, one may talk about their sex life as a game, where seduction is viewed as making the right moves, flirting may be seen as chasing someone, initiating sexual activity as getting past first base, and sexual skill may be conceptualized as the number of points earned (Borisoff & Hahn, 1993; Weatherall & Walton, 1999). Unfortunately, conceptualizing sex as a game is no better than the food metaphor, as it also harbours negative implications; it reinforces competitive values as it implies a winner and a loser (Thornburg, 1995; Weatherall & Walton, 1999). Likewise, the game metaphor emphasizes that partners are opponents, which may sacrifice connection, intimacy, and mutual satisfaction. Moreover, from chasing someone to getting beyond third base, the game metaphor associates itself with the traditional sexual script’s rigid, outdated, and heteronormative expected sequence of sexual behaviours (Simon & Gagnon, 1986; Borisoff & Hahn, 1993; Thornburg, 1995). Additionally, it is important to note that both the game metaphor and its ramifications extend to how we talk about sexual orientation (Weatherall & Walton, 1999). It could be damaging to discuss sexual orientation as team membership as it creates a sense of “us” versus "them" (Weatherall & Walton, 1999). For example, saying that an individual with a same-sex orientation is “playing for the other team” highlights a point of difference and labels them as an opponent (Weatherall & Walton, 1999).

Lastly, adverse consequences can occur from conceptualizing an orgasm as the end of a journey or the finale of a sexual encounter (Fernandez, 2008; Lavie-Ajayi & Joffe, 2009). Specifically, one might say that they are finished once they reach orgasm, suggesting that orgasm is the goal of sex. However, by conceptualizing orgasm in this way, it has actually been shown to induce feelings of failure, dysfunction, and self-blame among women (Lavie-Ajayi & Joffe, 2009).

Ultimately, many of the current metaphors that we use to conceptualize sex and sex- related topics are outdated and harmful. But does this mean we should completely stop using them in our everyday language?

The Importance of Sex Metaphors

When communicating with a sexual partner, instead of asking them to touch your testicles, it seems to be more socially acceptable to ask them to touch your nuts. Why is that so? Conceptual metaphors can provide a means of communication for sexually taboo topics. The restrictions from sociocultural norms influence which sex-related topics can be spoken about in a socially acceptable manner. In fact, the taboo of sex is pervasive in several cultures, so for many, sex is not easy to discuss openly (Crespo-Fernández, 2015).

While the metaphors of sexual desire and activity as hunger and food can be damaging, as discussed earlier, they can also be liberating in certain contexts. To demonstrate, Allan and Burridge (2006) illuminate various food-related euphemisms for tabooed genitals and specific sexual activities. They describe that penises are often depicted as meat, testicles as nuts, and penile masturbation as beating one’s meat (Allan & Burridge, 2006). Similarly, someone with a clitoris may talk about masturbation as flicking their bean and their first time having sex as popping their cherry (Allan & Burridge, 2006). While not ideal conceptual representations, euphemistic metaphors– such as these examples– give way to a socially acceptable language to talk about the tabooed topics surrounding sex and sexuality.

Furthermore, sex metaphors could also help expand the language we have for non- consensual and unwanted sex, as there seems to be inadequate language available (Thomas, Stelzl, & Lafrance, 2017). To elaborate, in a study by Thomas, Stelzl, and Lafrance (2017), women struggled to convey their troubling sexual experiences due to a lack of available language. Perhaps the presentation of metaphors would have provided a more comfortable way for the participants to describe some of their unwanted sexual experiences. However, it is important to note that our contemporary Western culture lacks an auspicious vocabulary of sex metaphors (Thornburg, 1995). Thus, we must develop new appropriate and healthy metaphors to conceptualize sex and sex-related topics to enhance our language surrounding sex. For instance, human sexuality educator Al Vernacchio’s (2012) revolutionary thought of conceptualizing sex as pizza is an excellent example of a healthy sex metaphor that can result in more positive outcomes. In his TED talk, Vernacchio describes that viewing sex as pizza can establish a mutually satisfying experience for all partners involved (Vernacchio, 2012). Like ordering pizza, sex requires effective communication and the goal of mutual pleasure. Additionally, in line with Conceptual Metaphor Theory, a seemingly subtle metaphor can powerfully influence one’s attitudes and behaviour; thus, we must develop and adopt a healthier repertoire of sex metaphors (Lakoff & Johnson, 1980).

Conclusion

In summary, the current metaphors that we are using to describe sex can have harmful consequences. However, sex metaphors are essential as they provide a language for discussing sex-related taboos (Allan & Burridge, 2006). In addition, as presented by Al Vernacchio (2012), there are healthier alternative metaphors that we could use to describe sex. The next time you hear your friend say that he “can’t stop drooling over her” or that “she looks good enough to eat," you may find yourself questioning how healthy it is to describe sexual desire as food.

Alternatively, perhaps you may use the food metaphor to help you talk about the importance of clitoral stimulation when you masturbate by alluding to “flicking your bean." Ultimately, sex- related metaphors are not inherently good or bad. Instead, we should focus on adopting healthier metaphors to conceptualize sex and sexuality.

Maddy Prosserman, Psychology Student (BAH) 2022, Queen’s University

References

Allan, K., & Burridge, K. (2006). Forbidden Words: Taboo and the Censoring of Language. Cambridge University Press.

Borisoff, D., & Hahn, D. F. (1993). Thinking with the body: Sexual metaphors. Communication Quarterly, 41(3), 253-260.

Crespo-Fernández, E. (2015). Sex in language: euphemistic and dysphemistic metaphors in internet forums. Bloomsbury Publishing.

Fernandez (2008). Sex-Related Euphemism and Dysphemism: An Analysis in Terms of Conceptual Metaphor Theory. Journal of the Spanish Association of Anglo-American Studies, 30(2), 95-110.

Lakoff, G., & Johnson, M. (2008). Metaphors we live by. University of Chicago press. Lavie-Ajayi, M., & Joffe, H. (2009). Social Representations of Female Orgasm. Journal of Health Psychology, 14(1), 98-107.

Simon, W., & Gagnon, J. H. (1986). Sexual scripts: Permanence and change. Archives of sexual behavior, 15(2), 97-120.

Thomas, E. J., Stelzl, M., & Lafrance, M. N. (2017). Faking to finish: Women’s accounts of feigning sexual pleasure to end unwanted sex. Sexualities, 20(3), 281-301.

Thornburg, E. G. (1995). Metaphors matter: How images of battle, sports, and sex shape the adversary system. Wisconsin Women's Law Journal, 10(2), 225-282.] 

Vernacchio, A. (2012). Sex needs a new metaphor [Video file]. Retrieved from https://www.ted.com/talks/al_vernacchio_sex_needs_a_new_metaphor_here_s_one/

Weatherall, A., & Walton, M. (1999). The metaphorical construction of sexual experience in a speech community of New Zealand university students. British Journal of Social Psychology, 38, 479-498.