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Surrogate Work: Hands-On Therapy

Howard was a 34-year-old virgin suffering from bipolar disorder and severe ADD. When we began our sessions, Howard had little sense of his own agency. He had a job, but he still lived with his parents, who dispensed his medications and micromanaged most aspects of his life. They (and he) didn't think he could survive any other way. After six months of weekly two-hour sessions with me and weekly sessions with his therapist, Howard took charge of his own medications, got his own apartment, and started dating.

But Howard didn't see me, initially, to help him move out of his parents' house. His therapist referred him to me to help him develop the social and sexual skills he needed to have satisfying relationships. While many of my clients are, like Howard, virgins over 30, most are high functioning in almost every aspect of their lives except sex. Rick, 45, is a graphic designer with severe performance anxiety. Nora, 51, is a corporate lawyer who has never reached orgasm and wants to learn how.

I'm a "surrogate partner"—a hands-on sex educator. I began practicing this form of therapy in late 1999, after I took an intensive training with IPSA, the International Professional Surrogates Association, centered in Southern California. When I took the training, I had just completed my Ph.D. and had taught for seven years at the college level. Feeling burnt out after writing my dissertation, I wanted a more body-oriented vocation that would offer an antidote to my cerebral career. After I finished the training, IPSA president Vena Blanchard and Linda Poelzl, a surrogate practicing in San Francisco, mentored me as I began taking referrals from therapists in the Bay Area—one of the few places in the nation where a number of therapists work with surrogates. I now see clients in New York City and in the Baltimore-Washington metropolitan area.

Though I have never practiced surrogate partner therapy full-time, I've witnessed its effectiveness and found it deeply rewarding. Howard saw me for six months, but in many cases, 12 to 20 hours of surrogate partner therapy can dramatically change a person's life. As a surrogate, I work closely with licensed psychologists, psychiatrists, and sex therapists who refer me clients. Most clients see me for 90-minute to two-hour sessions each week. The work generally progresses slowly. Many of my clients have little experience with loving touch. They have a hard time relaxing and being physically comfortable with another person. During the first several sessions, we keep our clothes on and do a lot of talking. I take the client's personal history, and we practice some exercises in which we touch each other's hands, arms, shoulders, head, and face. The purpose of these exercises is not to teach technical skill, but to focus on how it feels to touch and be touched by another, and to stay with an experience, even when it starts to feel uncomfortable.

While the course of the therapy depends on the individual client's needs, I generally follow a standard sequence of exercises that I learned in the IPSA training. Between sessions, I consult the therapist to discuss the client's progress and plan the next session, and the client sees his or her therapist to talk about emotional and sexual issues that come up during our work. As the therapy advances, the client and I take off our clothes and do more exercises—now touching each other sensually over our entire bodies, but still without focusing on the genitals. When the client is comfortable with this, I teach him or her safer sex practices, then we move on to genital touch. With some clients, I engage in genital-to-genital contact, if both the therapist and I think this is needed to help the client resolve his or her issues.

The History of Surrogacy: Masters and Johnson

The sex researchers William H. Masters and Virginia E. Johnson developed surrogate therapy while they were designing and testing a program for treating sexual dysfunctions. In the late 1950s, Masters and Johnson embarked on an 11-year study involving 510 married couples, 54 single men, and 3 single women. The couples did hands-on exercises to treat sexual problems affecting one or both partners, the single women did the same exercises with partners of their choice, and the researchers recruited 54 carefully screened women volunteers to work as surrogate partners with the single men. Masters and Johnson presented their treatment program and its results in Human Sexual Inadequacy (1970). By today's standards, the study seems quite limited and flawed.1 For instance, it overlooked the psychological aspects of sex problems and concentrated solely on four physically manifest genital dysfunctions: in men, erectile dysfunction and difficulty controlling or delaying ejaculation; in women, anorgasmia and vaginismus (contraction of the vaginal muscles making penetration difficult or painful). Today people seek sex therapy and surrogate therapy for a much broader range of issues, such as performance anxiety, lack of experience, low desire, history of emotional, sexual or physical abuse, delayed ejaculation, lubrication problems, disabilities and psychiatric conditions that interfere with one's sex life. While sex therapy has grown much more sophisticated in the last 40 years, Masters and Johnson were clearly pioneers. Before 1970, sexual dysfunctions had been treated through psychotherapy or psychoanalysis with very low success rates. Masters and Johnson developed a two-week treatment program that was 80% effective over a five-year period. The success rate for the single men who worked with surrogates was 75% over five years—nearly as high as the overall success rate. As the renowned gynecologist Alan F. Guttmacher wrote in his New York Times review of Human Sexual Inadequacy, "Such a rate would be extraordinary for any chronic disorder; it is phenomenal in the treatment of inadequate sexual functioning, which in the hands of other therapists has been notoriously resistant to correction."2 Thus, in 1970, Masters and Johnson transformed the clinical landscape. The field of sex therapy was born. Yet while Masters and Johnson had a 75% success rate with surrogate therapy, they stopped using surrogates in 1970 when a man who claimed his wife was working as a surrogate sued the two researchers. Masters and Johnson regretted giving up surrogate therapy, because it was unquestionably their most effective treatment for single men. In 1974, Masters told Time Magazine that since his clinic stopped working with surrogates, "The success statistics with single impotent males have completely reversed." Without surrogates, Masters admitted, "we now have a failure rate of 70% to 75%."3

After Masters and Johnson, some therapists continued to work with surrogates, but overall the new field of sex therapy abandoned this promising treatment in hopes of gaining respectability. Surrogate therapy was one of the most controversial aspects of Masters and Johnson's work. Then and today, many people conflate it with prostitution.

Surrogate, Prostitute... What's the Difference?

While I'm a strong proponent of justice for sex workers of all ilks, I also think it's important to distinguish surrogate partner therapy from prostitution and other types of adult entertainment. Most prostitutes provide recreation, companionship, and often, immediate gratification. As one client said:

I used to hire hookers to get me off. They didn't care if I came too fast. In fact, they preferred it, so I didn't have to be embarrassed when I came in two seconds. A good prostitute gives a guy what he wants and makes him feel like a king.

Surrogates, by contrast, spend most of their sessions teaching social skills and non-genital touch. They also help clients learn to delay gratification. Some clients get frustrated because the therapy seems to be progressing slowly, but as Meredith, a woman client, points out, "Sometimes slower is faster. Sometimes you get where you need to go by going slowly." Raymond J. Noonan, Ph.D., who conducted the only in-depth study of surrogates in 1983 wrote:

Almost one half of the surrogate's time (48.5%) is spent in experiential exercises involving the body non-sexually, with the majority of that time spent in teaching the client basically how to feel—how to be aware of what is coming in through the senses. [Link].4

Noonan also found that the surrogates spent 34% of their session time talking with the client—giving sexual information and support—and 4.5% teaching social skills in public settings. The surrogates devoted only 13% of session-time to sexual activities, such as oral sex and penetration—and only in the later sessions. Although Noonan gathered his data more than 25 years ago, many surrogates practicing today report similar allocations of their time.

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Lisa Carr
April 3rd, 2009
Lisa Carr has practiced surrogate partner therapy for 10 years. She was trained by the International Professional Surrogates Association (IPSA) and currently works in New York City and the Baltimore-...