The Psychosexual Needs Amongst Sexual Surrogate Clients

Sexual Surrogacy could be considered a grey area of sex therapy due to its legal, moral, and ethical implications. Not every country sees it as a legal form of therapy, however for all intents and purposes, we will examine surrogacy within the scope of it’s functioning in the United States, where it is legal and is governed by the International Professional Surrogate Association (IPSA). The IPSA explains the preferred term for this form of therapy is surrogate partner therapy to avoid stigma and uphold a level of professionalism for the industry.

There is a considerable lack of research and literature in the arena of surrogate partner therapy (SPT) that explores this unique type of therapy’s specific applications, effectiveness, as well as provides more Intel of the demographic that benefit from this form of therapy. With this said, we will explore the most typical client that is referred to SPT and examine their psychosexual needs, as well as look at a brief overview of SPT with the research and literature that is available.

Brief History/Overview

Masters and Johnson originally introduced this form of therapy in 1970. It grew out of their couple-model of sex therapy, as they developed a collaborative program for treating various forms of sexual dysfunctions to couples from their extensive research that was initiated in 1954.

Partner surrogate therapy is a form of therapy that uses a sex therapist, a surrogate, and a client, creating a triadic therapeutic relationship. Generally, a client will have a few sessions with a sex therapist and if a surrogate is recommended, the therapist will narrow down an appropriate fit for the therapeutic relationship between client and surrogate based on the surrogate’s success rate and their experience with the particular issue at hand. It is important to note that a therapist will only refer a surrogate to a male client that is single and without a regular sexual partner.

A surrogate will work with the client in structured and unstructured experiences, generally in a short term working relationship. As Dr. Marty Klein mentioned, a therapeutic relationship with a surrogate can last anywhere from two sessions to two years. This is to help the client build social and physical self-awareness, as well as learn skills that involve physical and emotional intimacy. The surrogate will also consult with the therapist prior to working with the client, and later again, which helps bring insight to the therapist to further work with the client on their psychosocial issues, as well as further develop their interpersonal awareness. This unique working relationship between surrogate and therapist could be considered greatly helpful to the client, as the therapist is receiving accurate information on what is working and not working for the client. The therapist can then further assist with modalities that range from CBT to ACT. Ironically, studies show that surrogates spend approximately 86% of their professional time doing non-sexual activities with the client.

The use of surrogates has steadily declined in the United States since the 1980’s, which can be hypothesized due to the fear of AIDS at that time, as well as therapist gradually turning to pharmacology to treat sexual dysfunctions in more recent times. It appears that the use of pharmacology is more of a quick fix solution, which doesn’t address the complex issues that manifest within a dysfunction or that surrounds intimacy issues. The IPSA would argue that a surrogate uses a more holistic approach to treatment via relaxation techniques, sensual touching, social skills education, and teaching effective ways to communicate. Some research has shown the usefulness of SPT as a form of therapy for many sexual dysfunctions. This is probably due to the fact that surrogates provide sex education and counselling, emotional support, social skills education, coping strategies, along with sensate focus techniques depending on the dysfunction, along with sensuality training and coaching; sexual intimacy plays a very small roll. In summary, a surrogate is helping to provide many aspects a sex therapist does, but in a more hands on role; which most likely also involves intimacy to some degree.

The Client

The most common client referred to a sexual surrogate is a heterosexual male that presents with a combination of sexual and emotional dysfunctions or inhibitions, which we will focus on for the intent of this essay. Common sexual dysfunctions SPT can be prescribed for include premature ejaculation, primary & secondary impotence, inhibited sexual desires, and changes in ejaculatory functioning. These dysfunctions could have manifested by various means, some but not limited to are: emotional trauma (from various channels like divorce, past sexual abuse, becoming a widower, etc. ), poor sexual self-confidence, intimacy issues, lack of sexual experience, behavioural disabilities, as well as physical disabilities like brain injury survivors, or clients born with debilitating conditions like multiple sclerosis. The IPSA adds that women too can seek the need of a surrogate due to poor body image, difficulties with penetration or orgasms, relationship concerns, etc. It is important to note that surrogacy is not biased on gender and could assists social anxieties and specific sexual dysfunctions to either gender.

In a comprehensive study on the effectiveness of surrogates by Dean Dauw, 501 heterosexual male clients were treated using the assistance of a surrogate. From this sample of men, 95% were highly educated, had obtained at least a 4-year college degree, and were professionally employed. The other important statistic from this study explained that 97% of these clients sought surrogate assisted therapy because conventional therapy was not effective or didn’t work for them. This is an alarming amount of men from the sample size of this particular study, which could indicate that conventional therapy doesn’t always work for certain people. It also points out that the fit of the therapist is an important factor that contributes to the success of a client in helping them overcome their issue. This is also a good indicator that not all clients whom need or seek SPT are disabled, or with a physical disability. The study by Dauw explains that clients with general anxieties, or temporary erectile disorders have needs for experienced learned intimacy, or need to gain sexual confidence; which is just as important as the disabled clients seeing a surrogate for their needs.

Psychosexual Needs

Sex therapy within the scope of working with couples usually follows a model that includes psychoeduction, improving communication between the couple, new learned activities, as well as focusing on sensations rather than performance. The purpose of this model is to recognize the biopsychosocial context of the couple seeking therapy. For clients that do not have a partner, SPT gives them the ability to undergo this form of therapy with a proxy partner so that they can experience the same process. The need to experience this mode of therapy with a proxy partner is imperative for any client that is recommended SPT, regardless of their sexual dysfunction or social anxiety, this could be considered the first need for any client involved in this form of therapy.

Needs with Anxiety

In an interview with Dr. Marty Klein, he explains that SPT is a great form of therapy for clients who are anxious or for clients who are psychosocially undeveloped, whom cannot create relationships for themselves. Examples of these clients would be someone with Asperger’s or autism, people who experienced a great deal of trauma or PTSD, or even clients who are overwhelmed with guilt and shame related to sexuality. Since heterosexual men who present with secondary erectile dysfunction issues and a variant of an emotional dysfunction; premature ejaculations could be considered one of the most common SPT client; in which we will examine their needs. Whilst someone with autism might need more social skill training than a man who is simply presenting with premature ejaculation, there would still be a great deal of anxiety under the surface for both client. These are great examples of a need for comfort. There would need to be a level of comfort in the relationship between client and surrogate, as well as client and therapist, so that the client has the best chance to pursue working through their anxiety.

Unfortunately anxiety can be a psychosocial factor for many sexual dysfunctions. In the example of the clients above, surrogate therapy is particularly helpful at alleviating anxiety and getting the client desensitized. Whether it is teaching a client masturbating practices with interventions like a sensate focus technique, which teaches the client to learn how to slow down, how to control feelings, and learn different sensations; or it’s desensitizing a client slowly into social interactions with women so they can further learn socialization skills that could lead them to non awkward sexual interactions. When a person is not developed socially, SPT will address the psychosocial deficits of the client so that he or she can be relaxed enough to learn how to have a relationship.

Needs Surrounding Shame

Many people have shame and guilt around sexuality, or their body image. As time passes and some sexual experiences and relationships are gained, when shame is involved, these experiences are most likely not satisfying. They could prevent a person from having the potential of a pleasurable experience, or a positive body image or sexual image of oneself. According to Dr. Marty Klein, some people can be so incapacitated by shame or guilt that they have forced themselves to be unable to create a satisfying emotional connection, not to mention a satisfying sexual connection with another person. For these clients, SPT is an excellent modality; it gives them the platform to confront their shame in a safe environment. These clients need to feel encouraged; they need to take the process very slow, so that they can learn to develop a connection, resulting in a satisfying relationship.

A heterosexual man whom experiences premature ejaculation (or other secondary erectile dysfunctions) who is seeking SPT and also seeing a sex positive therapist could have negative thoughts like feeling like a failure and be highly frustrated with his condition, not to mention negative feelings about having to treat the issue at all with a surrogate. Perhaps feelings of shame and negative beliefs of sex have lead to not being able to get an erection or have lead to ejaculating too quickly. Both surrogate and therapist should be mindful of the stigma of shame that is attached to feelings of being a sexual failure. If a client is internalizing shame, it could be possible that they would also be avoiding sexual topics and sexual situations, not to mention have misunderstandings around sexuality. It would be the job of the therapist to psychoeducate as well as reframe these beliefs.

Clients who have zero sexual experience or knowledge could easily face shame associated with having to use a surrogate. Being a mid-life male virgin (who is a common client referred to SPT according to the IPSA) could present with many negative self-beliefs, and potentially have the thought of “not being manly enough”. Shame could lead to many negative and fearful sexual thoughts for the client, hence the therapist and surrogate should both show compassion and work with the client on their belief system around their shame.

Appropriate Behaviour

Clients who have an emotional dysfunction, especially ones whom have experienced emotional trauma (sexual abuse for example), or who have had an accident that physically changed them and their behaviours, would have the need to (re)-learn appropriate sexual behaviour. Holzum’s thesis (5) pointed out a study by Aloni, Keren, and Katz from 2007 that examined a man that had suffered trauma after a physical accident. After the accident, the client started to exhibit problematic behaviours such as trying to touch and caress women without their permission. SPT was introduced to the client to assess his understanding of his behaviour; whilst sensate focus was then used to delay gratification in order to learn when behaviours are offered and granted. (5) A therapist working in conjunction with the surrogate would make sure the client had an increase in body awareness to further prevent inappropriate behaviours, like learning when it is acceptable to masturbate.

Need for Intimacy

Clients that experience sexual dysfunctions, as well as clients that have the need for learning social skills and sexual interactions both will fundamentally share the desire for intimacy on some level. Perhaps intimacy is taken for granted; a positive about SPT is that it provides a substitute partner to someone who potentially would never be able to experience intimacy. SPT provides a client with these experiences; they are carefully monitored and discussed between the therapist and surrogate to ensure the client is meeting their goals.

Whilst there is little research on the topic of dating anxiety with the assistance of sexual surrogates, a case study has been done on the use of surrogates with a 29 year old virgin to assist with talking, touching, and kissing. Talking, touching, and kissing could be considered the very basics of intimacy, the means to form a connection with another person. It could be confusing to a client to learn intimacy in a false intimate relationship, especially if they have no experience dating or no experience with the opposite sex (when assuming heteronormative patients); hence a surrogate is to never assume the role of a potential girlfriend or real date. When assessing surrogacy in a broader sense, Dr. Marty Klein explained that the goal of this therapy is not for the client to simply just have fun; the goal is for the client to grow, to learn new experiences, and to gain insight on the process. This would be an important fundamental for a therapist to explain to a client when working with a surrogate. Virgin clients could be particularly vulnerable and could require a vast amount of psychoeducation around the purpose of the role of the surrogate.

This study found that after fourteen sessions with the therapist, and thirteen sessions with three different surrogates, the client was able to talk, hold hands, and kiss a female; however these skills were more difficult to transfer to a woman that was known to him via his social network. In the end, the therapist terminated contact with the surrogates, and later face-to-face appointments with the client due to resistance and keeping his goal of wanting to be able to talk, touch, and kiss a woman. After several months of keeping in touch with the client via email, and then a follow up appointment, he was then able to confirm his goal was achieved. This paper did conclude that surrogates in relationship therapy can help a client overcome social anxiety as well as teach them the social skills needed to learn basic intimacy. Providing a social connection, not just a sexual one, shows that SPT can introduce clients slowly to forming a human connection.

Conclusion

The number of registered surrogates with the IPSA has steadily declined since the height of this form of therapy was being used and majority of the research currently available on this topic was done. At present, there is an excellent opportunity to continue research and learn more about the effectiveness of surrogates and further investigate the success rates with clients that present with sexual dysfunctions and social naivety. With such little data currently available, it is impossible to state in absolutes whether sexual partner therapy is effective, let alone explore in greater breadth the population of more clients that could benefit from SPT. Clinicians who have worked with surrogate partners have suggested that this form of therapy is effective, yet further research is needed.

Many studies available today (not all) do mention in some capacity the positive effects of surrogate partner therapy. Research conducted has been across a variant range of clients with very different presenting issues, studies range from female clients presenting with vaginismus to male clients with severe brain injuries.

However the IPSA clearly defined the most typical client for surrogate partner therapy was a heterosexual male with a combination of sexual and emotional dysfunctions. Abused men, mid-life male virgins, highly educated professionals, and men who experience inhibited or rapid ejaculation are several prime examples. Perhaps one of the greatest psychosexual needs of these men would be intimacy; forming a human connection. This is imperative to examine for sexual or emotional dysfunctions, as desire and intimacy are the first phase in the human sexual response model (which Helen Kaplan added to Master and Johnsons model). Without desire, intimacy or a human connection, erections would be extremely difficult; and so would be experiencing a positive sexual encounter.

This population of men would also need to alleviate their levels of anxiety around sexual functioning and social connections, not to mention their insecurities surrounding sexuality. A therapist would potentially have to explore desensitizing in either a sexual or emotional context. Or with disabled clients, changing the perception of never being loved to help mend insecurities. These men would need to feel relaxed and comfortable in order to persevere. Negative sexual beliefs around shame and guilt would also be also important to examine as a therapist in order to reframe the clients sexual belief system into a more positive, accepting approach to sexuality.