Sex Surrogates: A Clarification of Their Functions

Research and Advocacy

Sex Surrogates: A Clarification of Their FunctionsSexualities in Perspective

Raymond J. Noonan, Ph.D.
SexQuest/The Sex Institute, NYC
© 1984, 1995-2002 Raymond J. Noonan, Ph.D.

Preface to the World Wide Web Version (Millennium Edition):

This research was conducted during 1983 for my culminating project for my master’s degree at New York University, which was granted in February 1984. It has been cited often in the years since that time and remains the definitive research on the subject of what sex surrogates actually do in their therapeutic activities with clients in sex therapy.

As we enter the 21st Century, sex therapy utilizing the services of surrogates continues to be popular, largely because it is a very effective therapeutic modality. Still, too, does the public continue to have a fascination with surrogates and what they do, despite a temporary decline in the number of surrogates and therapists who worked with them in the early 1990s because of some of the reasons noted below. Despite these facts, little in-depth research has been conducted since I wrote the paper that has either corroborated or updated my findings or expanded on them, looking for changes in their practices. Because of the many requests for my study that I have received over the years and the continuing interest in my work in this area, I have decided to publish the original document in World Wide Web format for the benefit of everyone who has either a research or personal interest in sex surrogate therapy.

Nevertheless, because it was done in the early 1980s, it is essentially a snapshot of the practices of surrogates almost twenty years ago. Surrogate therapy has probably changed somewhat over the past two decades for several reasons. These changes need to be documented and incorporated into our collective knowledge about normative sexuality and how to address the various problems we have created or maintained around it.

Since 1983, the impact of AIDS has become a deep concern of both surrogates and therapists, as well as of the general public. That impact was not yet felt when I collected my data in 1983. Exactly how it has affected the work of surrogates remains to be studied. Certainly in the years immediately following my study when AIDS was mistakenly believed to be a strictly sexually transmitted disease, many surrogates, who in retrospect were not particularly at risk for HIV infection, stopped practicing or modified their practice as surrogates out of fear. Many therapists also stopped referring clients to surrogates out of fear of legal liability. As the reality of HIV infection has become better known (despite politically motivated efforts on all sides to enforce many misconceptions), surrogates—who are mostly female working with heterosexual males—are continuing to help clients function better sexually while promoting responsible sexual behavior at all levels. Little or no research exists, as far as I know, that has investigated how gay male surrogates, who worked mostly with gay male clients in the 1980s, have changed their practice.

Since the 1980s, also, women have become more aware of how surrogates might help them effectively deal with various sexual dysfunctions. Often female clients will ask their therapists, or seek out therapists who are open to the possibility, to find a male surrogate with whom they might work. Largely because of the sexual double standard that continues to operate in many, if not most, therapists, however, most clients of surrogates continue to be male. The degree to which women have begun to work with surrogates to solve their sexual problems, or who consider it a viable option, are questions that require additional research. In addition, the differences that may exist in the design of the therapy program itself and how a female client might work with a surrogate, as compared to how males work with surrogates, is a research topic that remains open. To my knowledge, heterosexual male surrogates remain the rarest of sex surrogates, as in the early 1980s.

The most troubling aspect of research on sex surrogates to me is something I alluded to in my paper below that I think has become more serious. Yet, it’s just an impression that has yet to be verified by any research. I suspect that there are many more surrogates working out there, independently trained by varying standards by the therapists with whom they may be working, who are both isolated from other surrogates and from researchers. This leaves them unaware of the most recent knowledge and advances in the field, because rarely are therapists trained in working with surrogates. It also deprives us of the knowledge gained from experience that these “hidden” surrogates may have learned. SexQuest/The Sex Institute in New York City tries to be available to help maintain contact among those actively participating in this profession.

I invite the reader’s participation in the discussion through comments or questions via e-mail. If you know of additional sources of information, books, or articles not mentioned or cited in this article, I would also appreciate knowing about them. Eventually, I plan to continue this research (when I recover from getting my doctorate). Surrogates interested in becoming a part of the Surrogates Network of the Eastern Surrogates Association (ESA) and the International Professional Surrogates Association (IPSA) are also invited to contact me at SexQuest/The Sex Institute at the link above. If, after reading this article, you think you might be interested in working with a therapist who works with surrogates, contact IPSA, whose link you will find later in this article.

— Raymond J. Noonan, Ph.D.
December 2, 1995/January 1, 2000

ABSTRACT

Sex surrogate therapy, while becoming a growing practice since its introduction as a highly effective therapeutic modality by Masters and Johnson, remains today an area of controversy with complex legal, moral, ethical, professional, and clinical implications. Misconceptions about who the sex surrogates are and what they do are shared by both the public and professional community alike, with the greatest confusion still seeming to exist about the role of the surrogate with that of the prostitute. What are the functions of a sex surrogate and in what perspective can we put them to give us a better understanding of surrogate therapy in relation to sexological theory?

The author surveyed 54 sex surrogates who were part of a surrogates’ networking mailing list representing about 65-70% of all known legitimate trained surrogates, the 54 respondents representing about 36% of all known surrogates [in 1983-84].* In addition to demographic data, the instrument asked respondents to estimate the percentage of time they spent in each of seven activities with clients.

The data gathered seemed to support strongly the author’s hypothesis that sex surrogates provide more than sexual service for their clients, spending almost 90% of their professional time doing nonsexual activities. In addition, the surrogate functions as educator, counselor, and co-therapist. Clearly, the sex surrogate functions far beyond the realm of the prostitute. Implications for the field are explored.

Introduction:

Sex surrogate therapy has become a growing practice since it was introduced as a highly effective therapeutic modality for single men by Masters and Johnson (1970). It remains today an area of controversy within the sexual sciences, with complex legal, moral, ethical, professional, and clinical implications. While the use of professional sex surrogates is ethically permissible as part of the sex therapist’s armamentarium according to the American Association of Sex Educators, Counselors, and Therapists (1978), adequate research has yet to be generated to settle the debate over its effectiveness and appropriateness. In addition, misconceptions about who the sex surrogates are and what they do are shared by both the public and professionals alike, resulting in flourishing misinformation and innuendo.

Of primary importance within this framework is a confusion between the roles of sex surrogates and those of prostitutes which exists because sex surrogate therapy has the potential for intimate sexual interaction and the surrogate is paid for her or his work. In addition, some authors have commented on the effect of media accounts of sex surrogates which have tended to focus on the bizarre, the sensational, and even the untrue (Braun, 1975; Lily, 1977; Roberts, 1981). What then do sex surrogates actually do in the course of treating a patient or client?

In approaching that question, the author hypothesized that sex surrogates provide more than sexual service to the clients with whom they work, that sex surrogates are more than what Roberts (1981) calls “an elitist type of prostitute . . . the most common misconception.” The distinctions commonly noted between the two usually rely on the intent of the sexual interaction: the prostitute’s intent being immediate gratification localized on genital pleasure; the surrogate’s intent being long-term therapeutic re-education and re-orientation of inadequate capabilities of functioning or relating sexually (Brown, 1981; Jacobs, et al., 1975; Roberts, 1981). Masters and Johnson (1970) say, “. . . so much more is needed and demanded from a substitute partner than effectiveness of purely physical sexual performance that to use prostitutes would have been at best clinically unsuccessful and at worst psychologically disastrous.”

IPSA, the International Professional Surrogates Association (n.d.), writes, “A surrogate is a member of the three-way therapeutic team (supervising therapist, client, surrogate) who acts as partner to a dysfunctional client in the therapy program and participates in experiential exercises involving sensual and sexual touching, as well as social and sexual skills training.” Others have described, either briefly or in part, typical surrogate sessions, including Allen (1978), Apfelbaum (1977), Brown (1981), Masters and Johnson (1970), Roberts (1981), Symonds (1973), Williams (1978), and Wolfe (1978). Jacobs, et al. (1975) give us a brief overview: “The usual therapeutic approach is slow and thorough. . . . Exercises are graduated and concentrate on body awareness, relaxation and sensual/sexual experiences that are primarily non-genital.” Where appropriate, the surrogate also teaches “vital social skills and traditional courtship patterns which finally include sexual interaction.” What none of these writers give us is a perspective of the relative amount of time or importance that each aspect of the surrogate therapy session or program places on the entire process. Such a perspective would give us a clearer understanding of the true functions of a sex surrogate, enabling us at some future time to place the whole and the parts of surrogate therapy into a useful theoretical perspective relative to clinical sexology as well as to normative sexual functioning.

The present study, the author believes, brings us closer to such a goal by first elucidating general categories of surrogate transactions with a client, and then statistically tabulating average percentages of time that fifty-four surrogate respondents spend with a typical client in each of these items. The limitations of this study are that the respondents consist of surrogates who voluntarily filled out and returned a questionnaire requesting information about their functions as surrogates as well as demographic information (see Appendix A) who were drawn from a surrogates’ networking mailing list that represents about 65-70% of all known legitimate trained surrogates (Sullivan, personal communication, January 10, 1984). As such, the fifty-four surrogate respondents who participated in this study represent about 36% of the 150 estimated known surrogates which is estimated to be approximately one half of all surrogates [in 1983-84]. It might be assumed that the results of this study would not be generalizable to surrogates who have not been trained using currently known methodologies. As Roberts (1981) noted, “Since the writings of Masters and Johnson gave no detailed outline of methodology in the use of surrogate partners, nor made a clear differentiation between couple therapy and surrogate therapy, therapists who subsequently used surrogate partners had to develop their own methodology.” Presumably surrogates trained outside of IPSA’s standards for a well trained professional surrogate might have an idiosyncratic methodology based on her or his own experience or the particular therapist(s) with which the surrogate is associated. An additional problem noted by Jacobs, et al. (1975) was that “the current sub rosa status of surrogates makes gathering data . . . an impossibility,” a problem which virtually assures that certain segments of the surrogate population will be kept isolated from current professional trends and developments. Nevertheless, the data does give us an indication of the current state of accepted professional practice.

Methodology:

The research participants were drawn from a mailing list compiled by Maureen Sullivan, a past president of IPSA, and others associated with Surrogate Networking, an independent informal network designed to keep surrogates in touch with each other. It is a confidential list available only to those listed in it, and contained, at the time of the mailing for the present study, ninety-seven names. A questionnaire (Appendix A), cover letter (Appendix B), self-addressed stamped envelope, and self-addressed numerically encoded return postcard were mailed to each person on the list. Out of these, 54 completed questionnaires were returned, 3 letters were returned addressee unknown or moved, and 4 questionnaires were returned unanswered for various reasons. Subtracting the 7 blank questionnaires from the 97 sent, there was a 60% response rate (54/90), a somewhat higher response rate than was expected because of unconfirmed reports of the reticence of many surrogates to take the time to participate in studies. All 54 of the finished questionnaires were included in the statistical analysis of the data.

The items used for the present paper included the demographic information and the first question of the section asking about the respondents’ activities as surrogates. That question said, “Please estimate the percentage of professional time you spend in each of the following activities with a typical client.” The choices, along with the average results, are listed in Table 1. A few respondents had difficulty proportioning the figures to add up to 100%; they did however have their own proportional relationships to each other which were retained when the figures were converted to a 100% baseline.

Table 1. Average Percentage of Time Spent by a Surrogate in Each Activity with a Client (N = 54).

Results:

The demographics were as follows:

43 female, 11 males.
Average age: 39 (ranging from 25 to 61: mode = 37; std. dev. = 7.714).
Religion: 8 Catholic; 6 Jewish; 16 Protestant; 17 other; 7 blank.
Religiosity: 14 are currently practicing their religion; 25 are currently not practicing it; 15 didn’t answer.
Race: 53 White; 1 Oriental.
Marital status: 11 single; 13 married; 2 separated; 14 divorced; 1 widowed; 9 non-married couple living together; 4 other.
Average number of children: 1.4 (ranging from 0 to 4; mode = 0 (n = 20); std. dev. = 1.367).
Highest level of formal education: average level achieved: Bachelor’s degree plus some advanced study (ranging up to 6 doctorates: mode: some college (n = 17)).
State of residency: 39 California (72.2%); 10 New York, New Jersey, Washington, DC, Virginia; 3 Wisconsin, Arizona, Washington; 2 Hawaii, Australia.
Years practicing as a surrogate: average: 4.26 years (ranging from 2 months to 10-1/2 years: mode = 4 years).
Approximate number of clients seen per year: average: 27.23).
Sexual orientation: 17 exclusively heterosexual; 23 primarily heterosexual; 8 bisexual; 3 primarily homosexual; 2 exclusively homosexual; 1 blank (75% prim/excl heterosexual; 15% bisexual; 9% prim/excl homosexual).
Contraceptive normally used: 8 condom; 4 pills; 2 i.u.d.; 10 diaphragm; 3 foams or suppositories; 31 self sterilized: 2 partner sterilized; 2 rhythm or natural family planning (adds up to more than 54 because some surrogates use different methods regularly).

The following percentages were estimated to be the amount of time spent on each activity:

16.41% talking with client, giving sexual information (range = 0-30%; mode = 10%; std. dev. = 7.150);
17.69% talking with client, giving reassurance and support (range = 5-40%; mode = 10%; std. dev. = 7.469);
1.31% observing client in social situations, such as potential singles meeting places (range = 0-10%; mode = 0%; std. dev. = 2.276);
32.10% touching activities, teaching sensuality and body awareness techniques, e.g., massage (range = 12-70%; mode = 25%; std. dev. = 14.274);
16.39% experiential activities, non-sensual, non-sexual, such as body image exercises, sexological exam, and relaxation exercises and techniques (range = 0-39%; mode = 10%; std. dev. = 8.670);
12.96% sexual activities, intercourse, cunnilingus, fellatio, teaching sexual techniques (range = 0-50%; mode = 5%; std. dev. = 10.377);
4.39% social activities, such as going out to dinner with client as part of therapy (range = 0-20%; mode = 5%; std. dev. = 4.644).

Discussion:

The data gathered by this study seem to support strongly the hypothesis that sex surrogates provide more than sexual service for the clients with whom they work. The data suggests that they provide sex education, sex counseling, social skills education, coping skills counseling, emotional support, sensuality and relaxation education and coaching, and self-awareness education, in addition to functioning as a sexual intimate. Indeed, the survey indicates that a majority of time is spent outside of the sexual realm, suggesting further that surrogate therapy employs a more holistic methodological approach than previous writings, both in the professional and lay presses, would seem to allow. In addition, the author would suggest that the surrogate seems to provide more than just adjunctive service skills for the therapist, sometimes both functions overlapping, particularly in the areas involved with talking, where the surrogate spends approximately 34% of her or his time giving sexual information and reassurance and support. Also, depending on the therapist’s therapeutic model, some overlap may occur in the experiential, non-sensual, non-sexual area, though here probably to a lesser degree.

Perhaps most significant is the average amount of time that the surrogate typically spends in non-sexual touch. (This, of course, refers to specifically non-genital, non-erotic touch, since it can be argued, as this author would tend to support, that everything we do incorporates something of our sexuality, and therefore nothing we do is strictly non-sexual.) 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. Combining the two averages, we find that the surrogate typically spends the clear bulk of her or his time (82.5%) enhancing the cognitive, emotional, and sensual worlds of the client. And then only after that does the 13% of the erotic time come into focus, bringing our time accounting total to 95.5%. The remaining 4.5% focuses on social skills in public settings, clearly the least important aspect of what the surrogate deals with. Does this suggest that the superficial socializing skills most of us have been bored with since we were children have been effectively taught? This author would hazard an affirmative; it’s the private world at the core of personalities and relationships that we shy away from in Western culture.

Finally, a profile emerges of the average sex surrogate: she is a white female, late 30s-early 40s, and not very religious. She is one way or another single with 1.4 children. She is college educated and lives in California, has been practicing as a surrogate for 4 years, 3 months, seeing 27 clients per year. Finally, she is a heterosexual who does not need to concern herself or her partner with chemical or mechanical methods of contraception because she has been sterilized.

Again the limitations of this study are that the results may not be able to be generalized to the estimated 50% of all surrogates who function outside of the “official” professional surrogates’ network, since they may be isolated from a current awareness of new developments in the field and since they are unlikely to contribute anything to the body of knowledge about the field as long as they remain isolated from other surrogates. In addition, we may not be able to generalize our findings to those surrogates who chose not to read or complete and return the questionnaire. Nevertheless, this study has been able to offer some clarification of current professional surrogates’ functions and tell us a little more about who they are. It hopes to broaden our understanding of its vast complexities.

Summary and Implications:

This study attempted to explore the functions of today’s sex surrogate and offer some positive or negative evidence of whether or not to support the hypothesis that sex surrogates provide more than sexual service to the clients with whom they work. The problem was not one of discovering their functions; sufficient general information exists in the literature and the author’s working with surrogates provided justifiable bases on which to construct an instrument. What was needed was an ordering of priorities, as it were—a way to judge the relative merits of each of the suspected components of the sex surrogate therapy program. Time was decided to be the suggestive element: the more time that was spent on each item, the more important it was presumed to be. Using this framework, the author has demonstrated that almost 90% of the surrogate’s time is spent in non-sexual activities: 48.5% in experiential, non-erotic exercises: 34% in talking, giving sex information and emotional support and reassurance; and 5% focusing on social skills in public settings. Only 13% of the surrogate’s professional time is spent engaging in sexual activities. The clear distinction between surrogate therapy and prostitution as noted in the literature has become even more clear. Indeed, the study even suggests the possibility of a new hypothesis: that sex surrogate therapy may offer therapists—and the consumer public—a more holistic methodological approach to the treatment of sexual dysfunctions when used with other standard therapeutic modalities.

Another implication of this research is worth noting here: If we are reasonably certain that sex surrogates will have to perform functions that are akin to those of the therapist, or that overlap with those of the therapist, it might suggest to us the need to emphasize adequate training and supervision of some sort for sex surrogates, to help them to more fully establish themselves as serious, responsible, and professional sexual health workers who are fully a part of the therapeutic spectrum. In addition, we all must continue to press for more research to give us more answers to myriad questions about surrogate therapy.

References:

Allen, N. (1978, June). Sex therapy and the single woman. Forum, 44-48.
American Association of Sex Educators, Counselors, and Therapists. (1978, March, revised). AASECT code of ethics. Washington, DC: AASECT.
Apfelbaum, B. (1977). The myth of the surrogate. Journal of Sex Research, 13(4): 238-249.
Braun, S. (Ed.). (1975). Catalog of sexual consciousness. New York: Grove Press, pp. 135-137.
Brown, D. A. (1981). An interview with a sex surrogate. In D. A. Brown & C. Chary (Eds.), Sexuality in America (pp. 301-317). Ann Arbor: Greenfield Books.
International Professional Surrogates Association. (n.d.). General information about IPSA and surrogates. Los Angeles: IPSA.
Jacobs, M., Thompson, L. A., & Truxaw, P. (1975). The use of sexual surrogates in counseling. The Counseling Psychologist, 5(1): 73-77.
Lily, T. (1977, March). Sexual surrogate: Notes of a therapist. SIECUS Report, 12-13.
Masters, W. H., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown, pp. 146-156.
Roberts, B. (1981). Surrogate partners and their use in sex therapy. In D. A. Brown & C. Chary (Eds.), Sexuality in America (pp. 283-300). Ann Arbor: Greenfield Books.
Symonds, C. (1973, September). Sex surrogates. Penthouse Forum. Quoted in S. Braun (Ed.), (1975), Catalog of sexual consciousness (p. 137). New York: Grove Press.
Williams, M. H. (1978). Individual sex therapy. In J. LoPiccolo & L. LoPiccolo (Eds.), Handbook of sex therapy (pp. 477-483). New York: Plenum Press.
Wolfe, L. (1978). The question of surrogates in sex therapy. In J. LoPiccolo & L. LoPiccolo (Eds.), Handbook of sex therapy (pp. 491-497). New York: Plenum Press.

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