Critics see it as an exchange of sex for money. But surrogates and the therapists who work with them say it's the only way to help some clients who would otherwise never experience a caring sexual relationship.
Surrogates administer hands-on sex therapy in concert with a traditional therapist. Their sessions can include genital contact and intercourse — far from the mainstream of sex therapy.
"There's a great misconception that surrogates are escorts with a fancier name," says Tara Livingston, who has worked as a surrogate for 18 years in the Los Angeles area. "But that's like equating a gardener with a truck driver" — in other words, totally different professions.
It often works like this: A man — the vast majority of clients are men — visits a therapist complaining of sexual dysfunction. The man's treatment usually includes "homework" — hands-on exercises for the man and his partner. But some men don't have a wife or girlfriend, and that's where the surrogate enters the picture.
There are at between 25 and 100 surrogates working in the United States, estimates Vera Blanchard, president of the International Professional Surrogates Association. Most are women who treat men, although there are male surrogates who see both men and women, and female surrogates with female patients.
They don't come cheap. Hourly rates range from $50 an hour on up, and total costs including therapist's fees can reach $10,000 or more. Health insurance, needless to say, does not cover sexual surrogacy.
From Talk to Touching
The first session between surrogate and client is usually spent talking, with both parties asking each other a lot of questions.
"A lot of the men I work with have little or no experience being with women," says Vivian Resnick, a veteran sexual surrogate who works in Northern California. So they start slow, with non-sexual touching and communication exercises.
"We move into the more sexual skills," Resnick says. "Masturbation and breathing exercises ... With most clients I go all the way through to intercourse."
"Once we're through the initial three to five sessions, it becomes more like seeing a lover," writes surrogate Linda Poelzl on the anythingthatmoves.com Web site. "It is especially satisfying to see a shy, uptight virgin transform into a lustful, passionate lover." About a quarter of patients who see surrogates are middle-aged virgins.
Most surrogates say the work is more about education than the sex act itself — the patients pay for education, not the experience. Very little research has been done on surrogacy, but one study by a New York University graduate student found that only 13 percent of the average appointment is spent on sexual activity.
For all of the enthusiasm from surrogates and the therapists who work with them, negative views of surrogacy are not hard to find.
"It's a form of prostitution, and it's risky business," says Dr. Gerald Weeks, of the University of Nevada-Las Vegas. "It is unethical, illegal and, from a disease perspective, very risky."
"The code of ethics of the American Psychiatric Association specifically prohibits sexual activity between doctor and patient," says former APA president Dr. Paul Jay Fink. "The fact that you've put [the surrogate] in between doesn't mitigate that."
The American Association of Sex Educators, Counselors and Therapists doesn't take an official stance on surrogacy, according to president Dr. Dennis Sugrue, because there isn't any evidence it harms patients. But he has his doubts about surrogacy's effectiveness.
"Let's say you have a guy who sees a surrogate and he's able to get an erection," Sugrue says. But "what about when you end the therapy? With a surrogate, someone was being paid not to laugh at him, and he didn't have to worry about rejection. But when the man dates someone in the real world, he's right back at square one."
As for the law, surrogacy is explicitly banned only in Texas, and it's a gray area in most of the country. Blanchard has never heard of a surrogate being prosecuted by law enforcement, and in the numerous interviews conducted for this article, none of the surrogates reported any legal problems.
"As long as you're working with a sex therapist, you're essentially covered by the therapeutic umbrella," said Livingston.
But surrogates are clearly different from therapists, and it's not just the sex; unlike psychologists and psychiatrists, they don't shy from creating intense emotional bonds with patients. "The love and affection that develops between surrogate and client makes the therapeutic process ultimately more powerful," says Blanchard.
That can be true even when therapy isn't completely successful. When Blanchard ran into a former client recently, he still wasn't ready to date. "He still couldn't make that leap. But he wasn't making it before, and at least now he's known love, and been loved."