Sex and death. These two subjects tend to frighten clinicians the most, says therapist Laurie Mintz. And as luck would have it, at the dawn of her clinical career, she encountered both in the same session. It was a day that would change her life, and her professional trajectory, forever.
It was 1985, and Mintz, then a predoctoral intern at the University of California, had spent the last four months working with Brendan, a 21-year-old college senior who used a wheelchair and was terminally ill. In most sessions, they discussed Brendan’s grief around his impending death, a topic they’d both navigated candidly and bravely. But on this day, in this particular session, something new happened.
As he was about to leave, Brendan took a long glance out the window, and sighed. “I’m terrified to admit this,” he told Mintz, his voice quivering, “but I’ve never had sex. I don’t want to die a virgin.”
Mintz was speechless. She’d never had a client bring up sex before. She knew that Brendan wished he had a girlfriend, and they could’ve had sex. But given his condition, Mintz knew a girlfriend probably wasn’t in the cards for him. She knew, too, that seeing a prostitute wouldn’t sit well with him. It was risky and not the kind of experience he wanted. Mintz was stumped. So, after the session, she went to her supervisor for advice. His solution? Find Brendan a surrogate partner.
Mintz had never heard of surrogate partners. But she learned about them soon enough.
At the supervisor’s arrangement, a slender woman in her early 30s arrived at Mintz’s office a few days later from a local organization that claimed to provide intimate—and therapeutic—companionship. The woman took a seat as Mintz explained Brendan’s situation. When it came to intimacy, Mintz told her, Brendan would need someone who wasn’t fazed by his disability and terminal illness. Most of all, he’d need someone who was gentle. The woman reassured Mintz that she could provide that for Brendan. And then, she said, she’d fulfill his dying wish.
Mintz was confident that this woman—this surrogate partner, as she called herself—could help Brendan. “I remember feeling like she was a good person,” she recalls, “someone who would treat my client with the care, respect, and tenderness he needed.” So she arranged for Brendan and the surrogate to meet, and waited.
A few weeks later, Brendan entered Mintz’s office beaming. He told her that he’d met the woman at a nearby hotel, and after several hours of talking, they’d had sex. “I can’t thank you enough,” Brendan said. “Of all the work we’ve done together, this has been the most meaningful.”
A few months later, Brendan passed away.
“I’ll never forget that case as long as I live,” Mintz says. “The fact that I could help this young man get his dying wish in a way that didn’t feel bad or dirty to him was absolutely beautiful.”
Beautiful, yes. But was it ethical? Was it legal?
Where No Therapist Has Gone Before
The International Professional Surrogates Association (IPSA), the country’s most widely recognized organizational body for surrogates, has been training and overseeing them for almost half a century. And since its inception, the organization hasn’t been the subject of a single lawsuit, nor have therapist licensing boards or state or federal government sought to regulate its operations.
But if the work involves, ostensibly, the exchange of sex for money, how has it managed to continue unimpeded?
In 1997, The San Jose Mercury News interviewed Kamala Harris, then a deputy district attorney for the Alameda County DA’s office, who said of sexual surrogacy, “If it’s between consensual adults and referred by licensed therapists and doesn’t involve minors, then it’s not illegal.”
But surrogate partner therapy has stuck around for other reasons too, says Vena Blanchard, a surrogate partner and current president of IPSA. In all cases, she notes, a surrogate partner maintains an open line of communication with the client’s referring therapist, reporting back to them after each weekly appointment, and vice versa. It’s part of what surrogates call a triadic relationship, comprising the client, therapist, and surrogate partner. As a result, surrogate work is deemed clinically informed—even though most surrogate partners aren’t licensed mental health professionals.
Blanchard also says that, despite the headlines and rumors, sexual touch and intercourse is rare in surrogate partner therapy, accounting for only about 15 percent of all interactions. And when it does occur, it’s often after months or even years of slow, careful, methodical work on other aspects of the client’s intimate life.
“Not every client who comes for surrogate partner therapy comes for sexual dysfunction,” Blanchard adds. “Sometimes they have difficulty with emotional intimacy, social interactions, or coming to terms with their sexual orientation or interests.” About half of all IPSA’s clients are midlife virgins with severe social anxiety. Some struggle with erectile dysfunction or achieving orgasm for psychological reasons. And others have suffered trauma or have a physical disability that prevents them from having or enjoying sexual activity. So, like any therapy, Blanchard says, the treatment varies by person.
“Regardless, jumping into sex would be bad for these clients,” she adds. “We know that. We don’t want to do that.”
How did surrogate partner therapy come about? By most accounts, its origin lies in the work of the famous St. Louis–based research team Masters and Johnson, which pioneered studies on human sexuality and sexual disorders for almost four decades beginning in the late 1950s. The team introduced the concept of the surrogate partner, making collaboration with a therapist a cornerstone of the surrogate’s work.
One night, in 1973, Barbara Roberts, a social worker inspired by Masters and Johnson, gathered a handful of colleagues around a kitchen table. They decided they wanted to take the progress made by sex therapists a step further. After all, not all clients who were unhappy with their sex life had partners available to practice the intimacy skills their therapist was teaching them. So, Roberts and her colleagues decided, they’d train people to demonstrate these skills to them. By replicating loving relationships, employing intimate touch—and yes, sometimes even having sex—they’d go where therapists couldn’t. With that, IPSA was born.
Over the decades that followed, through roller coaster periods like the AIDS epidemic and the rise of managed care, surrogate partners came and went. At its peak, in the 1980s, IPSA managed several hundred surrogate partners; today, it manages closer to 100, nearly a quarter of whom practice in California, the largest number of any state.
Throughout its history, IPSA has maintained its progressive stance. Roberts and her team educated clients about anatomy and physiology. They highlighted the importance of women’s sexual pleasure, not just men’s. They focused on body positivity. And perhaps most notably, they reframed sex as an act of deep connection, rather than a goal-oriented or performance-based task with an emphasis on intercourse—what their therapist counterparts referred to as sensate focus. In the process, they believed, they’d show people who were unhappy with their sex life how to approach it in a new way.
To Touch and Be Touched
Mark Shattuck, IPSA’s treasurer and a surrogate partner based in San Francisco, calls surrogate partner therapy “a sandbox for relationship,” a safe space where clients can explore what a healthy romantic relationship looks and feels like. It’s why many sessions take place in a living room or bedroom in the client’s or surrogate’s home, rather than in an office.
In most instances after a referral has been made, the surrogate has been briefed on the client’s presenting problem, and a meeting between the surrogate and client arranged, Shattuck says treatment begins with taking an inventory of the client’s sexual history. The surrogate will often ask the client where they learned about sex, and about their first memories of sex, their parents’ attitudes toward sex, and early or pivotal sexual experiences.
Next, depending on the client’s comfort level—asking for consent is a constant throughout the process, Shattuck says—the client and surrogate will plan the session’s activities together, which often include teaching intimate touch through caressing each other’s body.
“I’ll start by asking, ‘May I caress your hand?’ Shattuck says. “As the active caresser, I caress how I want, and then we switch roles. Unlike massage therapy, you’re touching the way it feels good to you, the toucher.” Next, the pair might proceed with a mutual face or foot caress, or a foot bath—“wonderful, caring acts,” Shattuck says.
Blanchard agrees. “While I’m touching,” she says, “I’m bringing a high level of consciousness and attention into my own hand, feeling the shape and texture and temperature of my client’s hand. Then we switch roles and the client touches my hand, slowing down, relaxing, and really feeling.” Blanchard says she’s had clients cry during this stage, telling her they’ve never experienced touch like this before—or that they had no idea such intentional, caring touch even existed. “It’s meant for connection, not arousal,” she explains. “It’s slow, sensual, nurturing, and tender.”
A large part of surrogate partner therapy is intended to promote body awareness and body positivity. To this end, Shattuck also does what he calls the mirror exercise, where both he and the client disrobe to their level of comfort and take turns standing in front of a full-length mirror, describing their own body from head to toe while the other person listens.
“I might say something like, ‘I’m losing my hair, but I have a great beard,” he says. “Then, ‘My ears are a little small, but that’s okay.’ Next, ‘I have really nice shoulders and good chest because I work out.’ Then, ‘I like my ass. I think it’s nice and round. And my penis is normal and average. It’s worked well for me.’ Then, hopefully, they can do the same thing.”
Blanchard calls this an important step for clients who’ve long been at war with their own body because it doesn’t fit the cultural standard of attractiveness. “Maybe they’re too tall or too short or too skinny or too heavy, and they’ve been bullied because of that,” she says. “With a surrogate, they’re reversing that cultural expectation and healing the injury, feeling these nurturing touches. They’re finally able to relate to their body not as a source of pain, suffering, and humiliation, but as a source of contentment, connection, and pleasure.”
While some might wince at this or wonder about clients’ willingness to engage, Shattuck says that by the time most people come to surrogate partner therapy, they’ve spent years or even decades in talk therapy without the opportunity to test intimacy skills in a safe, controlled environment. “They are ready to do this,” he says. “After years of waiting, they’re ready to move forward with their lives.”
To be clear, advanced stages of the work can involve sexual touch. But both Blanchard and Shattuck stress that there’s absolutely no expectation that sex is involved. When it does come into play, it’s used strictly for therapeutic or teaching purposes. As in therapy, they say, the ultimate goal of surrogate partner work is for clients to develop the intimacy skills they need to function independently with a non-surrogate partner.
Blanchard recalls one of her most memorable clients, a middle-aged sexual abuse survivor who was so touch averse that he could tolerate only a handshake, and would recoil at the sight of couples kissing in public. For the first few months, Blanchard and the man sat eight feet apart, never touching. But as she built trust with him over the next three years, he gradually allowed Blanchard to inch closer and closer until, finally, he let Blanchard touch his hand through a towel. Then, a few sessions later, his bare hand. Much later, he was able to get over the anxiety of taking off Blanchard’s dress—while she wore a slip underneath. “Good,” he said matter-of-factly a few sessions later. “Now that I’m not afraid of touch anymore, I’d like to save more intimate touch for a girlfriend. Now I know how to help her understand me.” That was the end of surrogate partner therapy for him.
Learning to say goodbye, or conscious uncoupling, is the final stage of the work, Shattuck says. “That’s the difference between sex work and what we do,” he explains. “Think of going to a sex worker like going to a nice restaurant, where you have a menu to pick from. If you like the food, you might come back again and again. But surrogate partner therapy is like going to cooking school, where someone has ingredients to show you how to make a great dish. Then they send you off to cook for somebody else.”
A Secret Relationship
Of course, not everyone is so enamored with surrogate partner therapy.
“Many therapists see it as sex work, not surrogacy,” says Joe Kort, sex therapist and codirector of the Modern Sex Therapy Institutes. “They don’t believe there can be ethical ways of doing this. They view it as infidelity, even if a spouse has agreed. They’re suspicious of it.”
In a 2012 interview with Newsweek, the late, renowned sex therapist David Schnarch claimed that “the vast majority of certified sex therapists did not and do not use surrogates because of the potential risks,” citing emotional transference and lawsuits. “Most sex therapists,” he continued, “can effectively treat patients’ sexual dysfunctions and help them develop relationship skills without resorting to surrogacy.”
Psychotherapist and ethics specialist Ofer Zur also takes a critical stance. On the website for the Zur Institute, he writes that while sexual surrogacy was popular in 70s and 80s, “the idea of psychotherapists, marriage and family therapists, social workers, counselors, and mental health professionals referring clients to surrogate partner therapy is highly controversial and very little examined in current times.”
Zur includes a list of important considerations for therapists contemplating surrogate partner therapy, including whether it falls under the standard of care, the ethics of referring a severely psychically disabled client, and certain psychiatric symptoms that may increase risk to the client or legal risk to the therapist. “Therapists may want to contact their malpractice insurance provider to verify if such a referral is covered under their policy,” he adds. If they decide to move forward, he advises having the client sign an informed consent document that outlines the limitations, risks, and benefits. “Documentation is very important,” he writes.
Still, Zur offers a soft endorsement of IPSA. “Make sure that the surrogate is, preferably, IPSA certified,” he adds, “which also means that he/she is committed to complying with IPSA’s Code of Ethics and will collaborate with the referring therapist.”
Although the ethics codes of most major therapist professional organizations recognize the importance of referring to specialists if it’s needed and benefits the client, not a single one has an official specified position on surrogate partner therapy. Blanchard says that the American Association of Sexuality Educators, Counselors, and Therapists used to have a policy for referring clients to IPSA, as did several smaller California-based therapist associations, but that the relationship was terminated at the suggestion of the organizations’ legal teams. “Right now, we have no direct relationship with other groups,” she says, “but there’s no hostility, either.” These relationships wax and wane, adds Shattuck. “It really depends on the political climate and who’s running these organizations at the time.”
But therapist and sexologist Tammy Nelson, who’s had surrogates teach and speak at her Integrative Sex Therapy Institute, says this silence hints at something. Many therapists do support surrogate partner therapy—just not openly.
“The relationship between surrogates and therapists is sort of a secret one,” she explains. “Publicly, many therapists will say, ‘Oh that’s illegal, you should never use a surrogate,’ and then they’ll secretly ask me if I know any surrogates they can refer a client to. Most therapists probably think it’s a good idea, but they don’t want to get into trouble.”
Is surrogate partner therapy sex work? “It’s a gray area,” Nelson says. “Any time you pay someone to touch you sexually, it’s illegal. But there’s been no legal controversy around this because the court system recognizes that this is a therapeutic modality.”
By and large, surrogate partner therapy has considerable support within the sex therapy community, even among those who express trepidation about it.
“When done right with adequate training, I do think surrogate work is clinically informed,” Kort says. “Some therapists may take issue with it, but I think this stems from a lack of sex education and naiveté. When working with trauma survivors, surrogates can go directly to the sexual wound, rather than just talk about it.”
Nelson agrees. “I can’t touch clients or bring them into real-life intimacy situations,” she says. “I can only talk to them about their sexual dysfunction or intimacy challenges. I can give them exercises to try at home, but frankly there’s only so much they can practice. And if the next step in a client’s life is a relational one, that’s where surrogates can come in. They’re trying to fill a gap.”
It’s the kind of gap that a surrogate partner filled for Laurie Mintz and her client Brendan over 40 years ago.
Today, Mintz, now in her 60s, is a certified sex therapist and psychology professor at the University of Florida. She lectures hundreds of future therapists every year about sex and sexuality. And she credits her experience with Brendan and his surrogate partner with her decision to go down this path in her career.
“When we met, doing sex therapy wasn’t even on my radar,” she says. “But this underscored for me how important sex is for people’s lives, for their self-esteem and empowerment.”
Mintz hasn’t worked with a surrogate partner since Brendan. She hasn’t needed to. But she says that wouldn’t stop her from referring to one again, and that any therapist with a client like Brendan should consider surrogate partner therapy as an option. Do your research, she says. Talk to a surrogate partner, or a therapist who’s worked with one.
“Good therapists are masters of nuanced thinking,” she says. “They don’t think in black-and-white terms. So it’s important to realize that surrogate partner therapy isn’t a matter of good or bad. It’s powerful. It’s a resource that can change your client’s life, even if it might seem unconventional.”
Chris Lyford is the assistant editor at Psychotherapy Networker.