Sex therapists talk with their patients to help them confront their sexual problems and improve their sex lives. But some patients need more than talk therapy. They need practice in the bedroom, and have no spouse or partner to turn to.
For these patients, some sex therapists turn to surrogate partners — people who help patients with intimacy issues using a hands-on approach. This can include having sex with the patient.
Although use of surrogate partners is rare among patients of both genders, they are increasingly being used by women whose physical or mental health problems prevent them from enjoying a healthy sex life, experts say. In the past, such therapy was employed almost exclusively by men.
"More and more women are now claiming their birth right to either have an orgasm, or healthy relationship or have sexual satisfaction," said Shai Rotem, a surrogate partner who is based in Los Angeles but practices internationally.
In his 14 years as a surrogate partner, Rotem has worked with women who have a condition called vaginismus, which makes sex painful, women in their 40s or 50s who are virgins and women who have experienced sexual trauma.
The practice is controversial, and most sex therapists don’t work with surrogate partners. Some question its legality, although no laws specifically prohibit surrogate partners, according to the International Professional Surrogates Association (IPSA). And the therapy comes with baggage, including the risk of the patient becoming attached to his or her surrogate partner.
But many experts say surrogate partner therapy has its place in sex therapy, and can be useful to the right patients.
Use by women
Surrogate partner therapy got its start in the 1970s and went through a boom period before dwindling in more recent years. At its peak, the IPSA had 200 to 300 members in the United States, but now has about 50, said Vena Blanchard, president of the IPSA.
Recently, there's been a rise in the number of requests to the IPSA from women patients, accompanied by an increase in certified male surrogate partners. Currently, about 35 to 40 percent of IPSA surrogates are male, Blanchard told MyHealthNewsDaily.
"There's been a steady increase in women taking ownership of their sexuality," Blanchard said. They don't just want sex therapy to please their partner. "They want to make their own lives better for themselves," Blanchard said.
The trend seems to be international. When the Tel Aviv Sex Therapy Clinic was founded in Israel in 1989, none of the patients were female. Now about 40 percent of referred cases are women, said Ronit Aloni, who heads the clinic.
What surrogate partners do
Surrogate partners work with their patients to build their communication skills and self-confidence, and help them become more comfortable with physical and emotional intimacy. Rotem said sessions are well-planned and less anxiety-provoking for patients than real-world sexual encounters, where anything can happen. "[This] is way safer than meeting strange men in a bar," he said.
Rotem begins with exercises in eye contact and hand-holding. Intercourse, when it happens, will be much later in the course of therapy. Every patient is different, but most of Rotem's patients require intercourse as part of their treatment, he said. Treatments usually last between three to six months, meeting for a total of 30 to 35 hours, Rotem said.
Rotem believes he has helped patients. One success was a woman in her mid-40s who had been emotionally abused by her father as a child, was afraid of men and had never had sex with a man, Rotem said. She recently contacted Rotem to say she had been dating a man for three months and was vacationing with him in Hawaii. Another patient with a similar case contacted Rotem to say she was getting married.
"They're not only sexually satisfied and sexually fulfilled, they have full-on relationships, they're loved," Rotem said.
There's also some scientific evidence that surrogate partner therapy works for those with physical health problems. A 2007 study looked at the treatment of patients with painful vaginismus — 16 patients had surrogate partners and 16 patients were in relationships. At the end, all of those who had surrogate partners saw their condition relieved, while 75 percent of those in relationships did. Of those in relationships, 19 percent ended therapy because the couple decided to separate.
Rotem said a surrogate partner is always emotionally supportive of the patient, while this may not be the case in a real-life relationship.
Praise and criticism
Some sex therapists believe surrogate partners to be illegal in their state. Sari Cooper, a couples psychotherapist and sex therapist in New York City, said she doesn't refer patients to surrogate partners because no distinction has been made between surrogate partners and prostitution, in terms of the law.
Cooper said even if she could refer patients to surrogate partners, in most situations, she would not. Often times, particularly with men who are late virgins, it's more important to address underlying social issues than simply "cure" a patient of his virginity, she said.
"Even if you went to a surrogate and you were able to have sexual encounter or intercourse with her, it's not necessarily going to help you in developing a relationship with somebody. Because that person is being paid to do what they're doing," Cooper said.
In addition, "I think there's strong potential for a client to attach themselves to the sex surrogate, and fall in love with them and not be able to move on," Cooper said.
Rotem said becoming emotionally attached to someone is part of the therapy, and the patient is always aware the relationship is temporary.
If the patient becomes attached, "That is great, it's awesome because the client never allowed herself to open her heart and fall in love with someone before," Rotem said. "Being able to fall in love is a skill, it's something we learn." Rotem said. "No one can take this skill from [the patient]."
Another problem for sex therapists is making sure surrogate partners are trained and certified to practice. Cooper said she would not know how to verify the background of a surrogate partner. The IPSA works with sex therapists to refer them to certified surrogate partners, Blanchard said.
Nowadays, medications such as Viagra exist to help men with some of the issues surrogate partners used to address, Cooper said. This may be one reason for the general decline in the use of surrogate partners.
But Lonnie Barbach, a clinical psychologist and sex therapist in San Francisco, said surrogate partners have a place in sex therapy. "A good surrogate is almost like a co-therapist," Barbach said. However, she has never worked with a surrogate partner herself. "I've been successful with the approaches that I use," Barbach said. "It's just not one form of therapy I utilize."
Pass it on: Surrogate partner therapy is rarely used in sex therapy, but more evidence shows it can be beneficial for some women.
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Rachael is a Live Science contributor, and was a former channel editor and senior writer for Live Science between 2010 and 2022. She has a master's degree in journalism from New York University's Science, Health and Environmental Reporting Program. She also holds a B.S. in molecular biology and an M.S. in biology from the University of California, San Diego. Her work has appeared in Scienceline, The Washington Post and Scientific American.