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The Ethics of Sex Therapy

Psychiatrists and other therapists are obligated by medical ethics not to have sex with their patients, but "surrogate partners" are supposed to -- and that simple but loaded dichotomy goes to the heart of the little understood yet much maligned therapeutic practice of sex surrogacy.

Thirty years after the groundbreaking sex researchers Masters and Johnson suggested that engaging patients physically rather than just verbally could have therapeutic benefits, sex surrogacy remains a murky field at best, eliciting reactions ranging from vague titillation to moral condemnation. Surrogates I contacted for this column were reluctant to speak on the record, giving reasons such as getting burned by moralizing journalists in the past, or fear of jeopardizing the reputations of referring therapists. Other surrogates prefer to remain under the radar rather than risk running afoul of various state prostitution laws, which prohibit the exchange of money for sexual activities. Stories circulate of New York prostitutes who advertised themselves as surrogates, succeeding thereby in little more than ruining a healing profession's reputation.

In fact, surrogates spend less than 13 percent of their session time actually engaging in sexual activities with patients, according to a study ( submitted by Raymond Noonan as his master's thesis in 1984, which remains, to this day, the definitive research on surrogacy. That just shows how little serious attention the subject has received. (My searches of a dozen online medical journals turned up absolutely nothing.) By contrast, 34 percent of surrogates' time is spent talking -- providing sex information and emotional support -- and about 49 percent in touching and other non-sexual bodywork.

"The clear distinction between surrogate therapy and prostitution ... has become even more clear," wrote Noonan, who's now a professor and the author of several well-regarded books on sexuality. "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."

That's an important point. No respectable surrogate will take on a patient without the active and ongoing participation of the patient's therapist, who provides the clinical information necessary for the surrogate to work effectively, and can offer better therapy by learning from the surrogate in return. The therapist can also provide a reality check if the patient and/or surrogate get too emotionally attached. This triad arrangement is essential for successful treatment. But unlike therapy, surrogate work is for a limited, specified time period.

Should you try sex surrogacy? Maybe. For many patients, it's the way to break a vicious circle: They have problems that need to be solved in a relationship, but can't get into a relationship until they've solved the problems. Premature ejaculation and erection difficulties are common difficulties, but so are dating and communication skills, fear of intimacy, shame and anxiety, oral sex techniques (the lack thereof), low-level desire, and plain old inexperience.

Patients are predominantly men and surrogates women, but male surrogates report great success with female patients too. There's disagreement on why the imbalance. For example, some say women need more intimacy (than men) to open up sexually and so are less likely to seek out sex with a stranger -- yet intimacy isn't always the issue; sometimes it's a physical problem. A handful of surrogates work with gays and lesbians.

The International Professional Surrogates Association ( provides referrals to surrogates, but about 90 percent of known surrogates work in California, mostly the San Francisco Bay Area. To keep the profession honest, since surrogates are not licensed or regulated by any government body, IPSA also provides training for surrogates and publishes a code of ethics.

Surrogates are responsible for birth control, and usually will require from you -- and provide -- proof of a negative HIV test. A surrogate should both ask and give.

Not surprisingly, AIDS seems to have cast a shadow of fear over the profession since Noonan's study, but Dr. Stephen Conley, executive director of the American Association of Sex Educators, Counselors and Therapists (, told me he gets "a lot of calls" from people seeking surrogate partners, especially from parts of the country where their services aren't available; they have to travel to New York or California. He's also noticed increased interest among AASECT members. "They've realized it's not prostitution. But there's still no consensus around the issue."

Sex surrogacy isn't for everyone, but it seems that trying to resolve serious sexual dysfunctions just by talking them over is like learning to drive a car by reading about the history of automobiles. You have to practice.

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