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Surrogate Work: Hands-On Therapy

The Core of Surrogate Partner Therapy: Sensate Focus

While the course of surrogate partner therapy is very individualized, most surrogates start by taking the client's history then introduce the client to some basic relaxation and touch exercises. In one of the first exercises I teach the client, we sit silently facing each other, close our eyes, and hold hands. As we take turns caressing each other's hands, we try to keep our minds focused on the sensations. The point is to notice when one's mind wanders and bring it gently back to the sense of touch. The technique is known as "sensate focus." Like many surrogates, I usually devote at least four sessions to non-genital sensate focus exercises, before moving on to genital touch. Sensate focus has two purposes. First, it helps the client learn to enjoy sensual touch without the need for immediate gratification or orgasm and expands his or her awareness and appreciation of subtle sensations. Surrogate partner therapy aims to enrich the client's world sensually and emotionally as well as erotically, and sensate focus can enlarge one's understanding of sex, so it involves the whole body rather than just the genitals.

Sensate focus also teaches the client how to reduce anxiety during sex. If the client can notice when his or her mind wanders and bring it back to sensations while we're touching hands and other less erotically-charged body parts, this will help the client stay focused on sensations during sex. For instance, a man with performance anxiety may find that his mind spins in circles when he begins having sex: Am I going to lose my erection? When am I going to come? Will I come too soon? As a result, he gets lost in anxiety and loses his erection or comes much sooner than he wants. In most cases, this client can overcome his problem by learning—through sensate focus—to notice when his mind starts to spin and bring it back to his sensations and what he feels in the here and now.

I've used performance anxiety as an example, because this is one of the most common issues surrogates treat. Yet, surrogate partner therapy can help with many problems rooted in fear and anxiety. Meredith, 48, suffered seizures in early childhood that left her with a deep-seated dread of her own body. When she reached adulthood, the sensations and excitation of sexual arousal brought up the same terror. She feared that if she allowed herself to feel, even a little bit, she'd get overwhelmed. Fifteen years of psychotherapy helped Meredith understand what caused her anxiety, but she still couldn't break through the terror:

In talk therapy, I could bring my emotions into the session, but when it comes to sex, what do you do? I needed someone who would be with me and support me while I allowed the horror to emerge, so I could learn to tolerate this stuff, let go of my fears and get to the good feelings.

Sexual Problems and the Effectiveness of Surrogate Partner Therapy

The prevalence of sexual problems in the United States is woefully under-researched, but studies indicate that sexual dysfunction is a significant public health issue affecting millions of Americans, and that few people seek treatment. In 1999, the Journal of the American Medical Association reported that among 18- to 59-year-old U.S. adults who had been sexually active in the last year, 43% of women and 31% of the men said they'd experienced sexual dysfunctions, but only 20% of the women and 10% of the men had sought medical advice.5 On February 26, 2009, the International Journal of Impotence Research published a study of 40- to 80-year-old U.S. adults: men most commonly reported early ejaculation (26.2%) and erectile difficulties (22.5%), while the women most often reported lack of sexual interest (33.2%) and lubrication difficulties (21.5%). Only 25% of those with problems had sought help.6

Given the high incidence of sexual problems, it's a shame that surrogate partner therapy isn't more widely known and accepted. As I mentioned above, Noonan's work is the only in-depth study specifically focused on surrogates. But the lack of research on surrogate partner therapy does not mean it's ineffective. Many alternative health treatments are under-studied for political or economic reasons. In the case of surrogacy, the dearth of scholarly interest is rooted in our culture's deep-seated biases against sex work and sex for pleasure rather than procreation. Due to the conflation of surrogacy with prostitution, most therapists who work with surrogates prefer not to speak about it publicly. But those who do vouch for its effectiveness. In The New Male Sexuality, Bernie Zilbergeld, a clinical psychologist I worked with until his death in 2002, called surrogate partner therapy "the most effective" treatment for single men "who have any sex problem."

Other therapists I know who do this kind of work agree with me in thinking it is the most effective therapy for men without regular sex partners. It has been almost 100 percent effective with male virgins of all ages. Usually these men have failed with several women and been so humiliated that they refuse to try again until they feel their problem is resolved.
Some people make the assumption that while surrogate work will help the client function with the surrogate, it won't carry over to other partners. Fortunately, this assumption is incorrect.... In the many cases I've worked with, the ability to function as well with a real-life partner as with a surrogate is over 90 percent.7

As an expert in male heterosexuality, Zilbergeld was primarily concerned with effective treatments for men. Most clients who seek surrogate partner therapy are, in fact, heterosexual men, and most practicing surrogates are women. But many women and gay men have benefited immensely from this form of therapy, and there are surrogates of all genders and sexual orientations for clients of all genders and sexual orientations.8 Most surrogates are open to working with all kinds of people—whoever they are and wherever they may be in their lives.

If you seek surrogate partner therapy: What to expect

Health insurance does not cover surrogate partner therapy. Expect to pay at least as much per hour as you would pay a therapist in your area. Budget at least $2,500 for the entire treatment.

Since surrogate partner therapy isn't available in most parts of the world, you might have to travel. Most surrogates offer intensive sessions, and they may be able to recommend lodging in their area.

Most people have never heard of surrogate partner therapy. If you ask your therapist to refer you to a surrogate, he or she may have no clue what you're talking about. Refer your therapist to IPSA, the International Professional Surrogates Association for more information.

While you're in surrogate partner therapy, it's crucial that you be able to talk to a licensed or certified therapist about your work with the surrogate. If you aren't currently seeing a therapist, or if your therapist isn't open to surrogate partner therapy, ask the surrogate to recommend a therapist. (Members of IPSA only call themselves "surrogate partners" when they are working with a licensed or certified therapist. Some surrogates also practice sexological bodywork or other therapeutic modalities that don't involve a therapist's supervision.)

When you contact the surrogate, expect to answer questions or fill out an application describing your issues and why you are seeking surrogate partner therapy at this time. The surrogate may be too busy to answer email and phone calls from people who are simply curious. Show that you're serious about seeking treatment.

Be prepared to discuss your medical history and any medications, vitamins, herbs, or supplements you're taking. Some health conditions, drugs, and even supplements can affect sexual functioning and desire. Before you see a surrogate, consult your doctor to see if your problem might be physiological. If Zoloft is preventing you from reaching orgasm, a surrogate might not be able to solve the problem, though he or she can probably help you enjoy sex more despite the side effects of your SSRI.

Be ready to practice safer sex—using latex or polyurethane barriers for any genital contact. If you're unfamiliar with safer sex, the surrogate can help you.


  • For surrogate partner therapy in New York City or the Baltimore-Washington metropolitan area, contact Lisa Carr at surrogatecare at gmail dot com or go to her website.
  • For surrogate partner therapy in San Francisco, visit Linda Poelzl's website.
  • For surrogate partner therapy in Los Angeles, surrogate partner training, and referrals to surrogates nationwide, visit IPSA, the International Professional Surrogates Association.


1 Masters and Johnson called sex a "natural function"—disregarding how people are socially acculturated to behave sexually. They also assumed that heterosexuality was "natural" and designed a program to convert gay men to heterosexuality. While their methodology and results have been widely—and rightly—criticized, it is plain that their program for heterosexuals was groundbreaking and more effective than any previous therapy for sex problems.

2 Alan F. Guttmacher, M.D. "Human Sexual Inadequacy for the Non-Layman," Review of Human Sexual Inadequacy by William H. Masters and Virginia E. Johnson in the New York Times, July 12, 1970, accessed on March 2, 2009 [Link]

3 "Trick or Treatment?" in Time Magazine, June 17, 1974, accessed on March 2, 2009. [Link] See also Janice M. Irvine, Disorders of Desire: Sexuality and Gender in Modern American Sexology, Revised Second Edition. Temple University Press, 2005, p. 89.

4 Raymond J. Noonan, Ph.D. "Sex Surrogates: A Clarification of Their Functions." Doctoral Dissertation, New York University, 1984. [Link]

5 The 1999 study was the first population-based assessment of sexual problems in the U.S. since the Kinsey Reports. It was based on the 1992 National Health and Social Life Survey (NHSLS) of 1,410 men and 1,749 women ages 18 to 59. E.O. Laumann, A. Paik, R.C. Rosen, "Sexual Dysfunction in the United States, Prevalence and Predictors," in Journal of the American Medical Association 1999, 281:537–544 [PubMed]; Harin Padma-Nathan, "Prevalence of Sexual Dysfunction, Efficacy of Therapy," in Rev Urol. 1999 Fall; 1(4): 203–204. Accessed on March 2, 2009. [Link]

6 E.O. Laumann, D.B. Glasser, R.C. Neves, E.D. Moreira, Jr. "A population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America," in International Journal of Impotence Research 2009. This study was based on a telephone survey of 742 men and 749 women conducted in 2001 and 2002. The study was published online (in advance of its print publication) on February 26, 2009 and accessed on March 2, 2009. [Link]

7 Bernie Zilbergeld, Ph.D. The New Male Sexuality: The Truth About Men, Sex, and Pleasure, Revised Edition. Bantum Books, 1999, pp. 341, 343-4.

8 I say "all genders" because transgender people can also benefit from this form of therapy. For instance, a person who is just starting to live as a member of a gender other than their sex assigned at birth, might want to have their first sexual interactions with someone with whom they can feel comfortable, and many surrogates are generally open-minded and well-educated in transgender issues. Post-op transsexuals who are in the process of getting used to their genitals after surgery can also benefit from surrogate partner therapy.

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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-...