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Linda Poelzl

Keeping the "Sex" in Sex Therapy

My Work as a Surrogate Partner

by Linda Poelzl

I sat facing Roy, taking notes as we got acquainted. He was my first client, a 38-year-old "technical virgin," never having had penetrative sex with a woman. Shyly, he related what he considered the "primal incident" that caused him to become impotent.

"She started going down on me -- giving me oral sex -- while I was driving. I got so excited, but nervous, that I had to pull over. By then my erection had disappeared. I thought there was something wrong with me. I've had this problem ever since. Do you think you can help me?" he asked, looking at me through sad, blue eyes.

I smiled reassuringly and put down my pen. Our work had begun...

I am a surrogate partner. They used to call us "sex surrogates" -- a term that became sensationalized in the '60s and '70s, probably due to a mistaken link to prostitution.

Surrogate work is a form of sex therapy. The client is referred by a therapist for an educational process that focuses more on building intimacy and communication than on immediate sexual gratification. There is no "contract" for intercourse or any sex act. Conversely, prostitution and other forms of legal sex work (i.e., peep shows, lap dancing) are seen more as entertainment. The client negotiates for a specific sex act or service, and the contact is usually short term.

The Birth of Surrogate Partner Therapy

Sex researchers William Masters and Virginia Johnson began using sex surrogates in the late '50s and early '60s. After completing 11 years of laboratory research and determining what "normal sexual functioning" was1, they developed a two-week therapeutic treatment program designed primarily for married couples with sexual dysfunctions. For single clients (mostly male) without partners, or married ones who for some clinically significant reason could not do the program with their partners, they trained "partner surrogates" to stand in.2 The treatment was primarily behavioral, using relaxation and touch exercises, and it proved helpful for many couples, but was not universally effective.

In the '80s and '90s, sex therapy began to evolve from the Masters & Johnson model. Medical and pharmacological treatments, particularly for erectile dysfunctions, were developed (Viagra being the most recent), and therapists began focusing more attention on interpersonal dynamics in the couples' relationship.3

Surrogate Work Today

Surrogate partner work today consists of a three-person team: the client, the therapist -- who has evaluated and referred the client -- and the surrogate. In order for the therapy to be successful, the three must communicate openly. The surrogate's task is to build rapport and create a space for a trusting relationship to develop with the client, so that the client can work on his or her sexual concerns. For the therapist, who will usually see the client between every one or two sessions with the surrogate, the task is to guide the process, to identify and address the psychological issues that arise, as well as to support the client and the surrogate throughout the course of therapy.

People usually turn to sex therapy because they are dissatisfied with their sexual lives (or lack thereof). Women are usually dissatisfied with orgasm or penetration. Men most commonly seek assistance with rapid ejaculation (previously called "premature ejaculation"), and erectile concerns (formerly known as the dreaded "impotence"). Since the term "impotent" tends to refer almost to a character defect, while the term "erectile dysfunction or difficulty" puts the problem in more of a medical category, these less stigmatizing, more politically correct terms are now used most often. This helps the surrogate and therapist frame these common problems and their treatment in a more positive, less pathological light for the client. (In 1980, the disorder of "impotence" was removed from the DSM-III, the diagnostic manual for psychiatric professionals, and replaced with "male inhibited sexual excitement."4) Both men and women share concerns about social anxieties or inexperience (40-year-old virgins are more common than one might think); fear of intimacy; low levels of arousal or lack of sexual desire; shame about sex; negative body images or physical disfigurements; physical disabilities; sexual trauma or abuse (rape or incest); sexual orientation concerns; underdeveloped social skills; and lack of social/sexual confidence.

The most common gender combination, not surprisingly, is the heterosexual male client with a female surrogate partner. For homosexual or bisexual clients, as well as heterosexual clients who need more of a "mentoring" experience, same-sex combinations can be appropriate. Heterosexual female clients, for example, can benefit from having a supportive relationship with another woman in which they can get more comfortable with their own bodies and self-pleasuring. A female surrogate can assist a client in learning how to better achieve orgasms by demonstrating how she masturbates. Clients who are transsexual/transgendered sometimes work with surrogates to develop comfort being sexual in their "new bodies" following surgery or hormone therapy.

Surrogates usually follow one basic therapeutic program, adjusting and building on it as necessary for each individual client. This program focuses on enhancing a set of foundation skills which help to develop a positive, healthy sexuality. These include breathing and relaxation (a relaxed body and mind are more receptive to sexual stimulation); focus and "grounding" (many people are distracted, anxious, and in their heads rather than their bodies during sex); communication (the most important aspect of all and often the ultimate solution to any interpersonal problem); and touch (including the most fundamental touching skills of stroking and caressing the skin). When appropriate to the client's goals, the latter may proceed to the sexual skills of genital touch, oral sex and intercourse.

This program generally requires at least seven to ten two-hour sessions, because a client's goals rarely can be met in less time. In fact, some clients need many more sessions -- I once saw one client for 52 sessions!

As a surrogate, I design the first few sessions to build rapport and trust with my client. Concerns about attraction often come up here; male clients are frequently worried if they don't immediately feel a strong sexual attraction for the surrogate. What I have found, since I rarely feel a strong immediate sexual attraction for a client, is that the important thing in the beginning is to feel some rapport, or the potential for it. In my experience, as we begin touching and getting more intimate, attraction and arousal naturally build. But sometimes as I watch a client climb the long flight of stairs to my apartment, inwardly I think, "How I am I ever going to get there with this client?" This is where the idea of willingness comes in. I am willing to be open to intimacy and sexuality with the client, and I trust that the process will allow for that to naturally emerge. Rarely has this failed to happen. Of course it's natural to feel more attraction to some people than others. There are some clients that I can't wait to fuck (and have to use all my professional skills to contain and channel that energy!). Then there are others that I never feel much arousal with (thank the Goddess for lubricant!), but we manage to do the work, and the client still benefits from the experience.

As the work progresses, clothes come off and the touch becomes more sensual and then sexual. In one session, I focus on education (officially called "the sexological" session), where I show pictures, answer questions about male and female sexuality, discuss safer sex and HIV/STDs, and then do a show and tell that is sort of like playing doctor -- only, hopefully, sexier. I even have a speculum ready in order to offer the client a view of my cervix. Few turn down this opportunity, since they'll probably never have the chance again. Most people don't find it erotic. Rather, they are amazed at how much like "insides" it looks, maybe giving them a visual experience of how vulnerable and trusting the act of allowing penetration is for a woman.

Once we're through the initial three to five sessions, it becomes more like seeing a lover. The final sessions become more sexual. Here is where the lover begins to emerge, and we can allow emotions and passions to flow freely. For me, it is especially satisfying to see a shy, uptight virgin transform into a lustful, passionate lover. My explanation may sound clinical, but surrogate work can be very hot.

With all this passion and intimacy happening, is there a danger of getting too attached or falling in love? The truth is that both partners usually do develop feelings of fondness, caring, and love. And yes -- the closure is built in and accepted from the beginning. Most relationships do end, even if we thought we were going to "live happily ever after." Ideally, when the client's goals have been achieved, we prepare for the closure session, where we can acknowledge and process all our feelings. In my experience, the closure is more often celebratory -- although often a little sad as well -- because the client can see how far he/she has come.

Questions of legality often come up; many people wonder how surrogate work is different from prostitution. I'd like to state for the record that I have a great respect for sex workers of all kinds, legal and illegal. I support decriminalization of prostitution, and I most certainly see myself in fact as a sex worker. Fortunately for me, the United States and most other countries have not legally defined surrogate work, and generally consider it "not illegal" as long as we uphold specific professional standards (i.e., always working with a licensed therapist). The International Professional Surrogates Association (IPSA) was first formed in 1973 as a support group for surrogates. By 1977 they had created a code of ethics and were training new professionals. Current IPSA President Vena Blanchard has never heard of a surrogate or therapist being sued, censured, or arrested for the work.

About the Case Studies

In presenting the case studies (below), I chose three focusing on sexual orientation concerns. Being bisexual has sometimes influenced or directed my work with clients, although most of the time it is a non-issue, since I don't automatically come out to clients. Personal disclosure for the surrogate is tricky. Since we are somewhere on the continuum between therapist and lover, it is appropriate to share personal feelings and information to some extent.

Whether or not I disclose my sexual orientation depends on how this could affect the client's process. For some clients, dealing with the fact that I am bisexual would simply be unnecessary added stress and would interfere with the therapeutic goals. And then there are other situations where the client was specifically referred to me because I am a bisexual woman and am usually out to other therapists I work with.

All three cases involved misunderstandings about bisexuality and rigid ideas about sex roles, relationships, and how families are formed. Unfortunately, I see these attitudes often in my practice. Either/or thinking is also very evident. Eileen felt she either could be with her partner and be happy with him, or find out she was attracted to women and become a lesbian. Arthur shrugged off his feelings for men and wanted to just "get functional" with women.

Nurturing a Rich Sexuality

In the perfect sexual world that I like to envision, none of these clients really had a problem. They could just be honest with their partners, explore options for relationships (polyamory, non-monogamy, etc.) and enjoy the richness of their sexuality. Eileen could happily enjoy sex with women and bring her stories and experiences back to John. She might even discover that accepting her attractions for women and beginning to act on them would reduce the obsessive nature of her desires and allow for a more balanced perspective. If Arthur could be honest and open about his attractions and experiences with men while maintaining his desire to have a committed relationship that included children, he would find partners with whom he could work out a mutually desirable arrangement. If Karl could let go of his urgency about getting functional with women, and focus on discovery and playfulness, he might actually have more fun with the process.

In my work, I strive to provide a very accepting, sex-positive environment in which my clients can let their sexuality blossom, rather than simply helping them decide if they are bisexual, heterosexual, or homosexual. I could certainly model that kind of straightforward acceptance, but it's not very applicable to the real world. Because of biphobia and misinformation, how many partners are likely to welcome the information that a new romantic interest of theirs is also interested in the same/other gender? Unfortunately, not that many.

Despite the challenges, I love the work. For me, it is very fulfilling and satisfying. As a surrogate partner, it's exciting to see my clients blossom as their sexual energy emerges and starts flowing stronger and clearer. I am honored to be a part of their process. I also see a spiritual component to the work, as I'm sure many other sex workers do. As a Pagan, part of my personal preparation for a session includes invoking Aphrodite. I ask Her to help me turn the shining, loving face of the Goddess on each man or woman who comes to me in pain -- and believe me, they are in pain by the time they've walked up those 32 steps to my door!

In addition, my spirituality helps me access my own physical desire and arousal, which allows me to do my work better. By seeing the God/dess in each person, I am able to see beyond their physical presence. Even if they are not someone I would ordinarily be attracted to, through Her eyes they are beautiful and desirable. Everyone's inner (and outer!) beauty becomes visible when they are turned on, because sexual energy is so powerful and healing.

Finally, as a bisexual woman I can add to my work the richness and perspective of being a sexually positive person and a sexual visionary. I imagine a different world and am working with people who don't fit comfortably into the accepted paradigm of our culture as it is now. Changing paradigms is a gradual process. I'm doing my part, little by little, person by person.

Case Study: Karl

Karl is a 49-year-old man who wants to get comfortable being sexual with women. He came to me as a "technical virgin" (no actual penis/ vagina sex), since he had had only affectionate contact -- i.e., hugging, kissing, dancing -- with women. Although the bulk of his sexual contacts had been with men, he did not identify as gay, since he had never had a love relationship with a man and felt "closer" to women. He described his sexual experiences for the most part as being orgasmic but lacking in passion or heat. In fact, most of the sex he'd had in his life had been with himself.

When we started our work, Karl immediately wanted to move fast, hoping that accomplishing penetration would change his feelings. Not surprisingly, it didn't. His desire to fuck me was based not on genuine lust but on an urgent need to prove that he could do it. In truth, he had no erotic feelings for women, but wanted to "get close" to them. He was "curious" and "in awe" of female bodies.

Right now, we are working on accepting what is true for him and exploring becoming more physically and emotionally intimate by allowing trust, sexual curiosity, eroticism and lust (which we haven't yet achieved) to develop naturally. It has been developmental; he felt like a little boy when we started and is now enjoying his adolescence. With Karl, my bisexuality is an advantage, because I can encourage him to honor his desire for both men and women and assure him that there are women out there who can appreciate that. Being one of those women, I can model that with complete sincerity. Most of all, I can remind him to honor himself and allow his own authentic sexuality to emerge.

Case Study: Eileen

Not all surrogate work proceeds so positively. Eileen was in her mid 30s and had never had sex with a woman but was obsessing about it constantly. She was in a five-year relationship with a man, and her growing desire for women had begun to interfere seriously with their intimacy. Her partner had encouraged her to see a surrogate even if it threatened their relationship, since it was already in such turmoil due to her confusion about her feelings for women. Eileen was reluctant to date women, thinking that she would just be using them to experiment. Despite her need to imagine an erotic fantasy involving females in order to achieve orgasm, she insisted that she was still sexually attracted to and in love with her partner, John. Her therapist, who had been working with her for some time, felt that Eileen had been obsessing long enough -- time to take some action.

Eileen came to see me for only one session. She was extremely anxious, so we spent time talking, doing relaxation breathing, and then touching and caressing arms and hands. Afterwards, she said that she'd compared my touch to John's and found it not that different. (Perhaps she expected to be transported to instant ecstasy by the touch of a woman, since she had fantasized about it for so long!) We didn't go any further than sensual touching. Eileen feared that having sex with a woman would cause her to "go off the deep end" -- to leave John and become a lesbian. I attempted to discuss other possibilities, as her therapist had also done, but she couldn't conceive of anything but an either/or situation.

Needless to say, Eileen didn't return. In fact, she stopped seeing her therapist as well, who got a call from her a few weeks later saying that she had started taking Prozac again and was feeling much better. Personally, I wonder how long that lasted.

Case Study: Arthur

Arthur, a 35-year-old man, had primarily been sexual with men, but claimed to like women and wanted to become more comfortable sexually with them. He didn't find his sexual encounters with women that pleasurable mostly due to his own concerns about penis size -- he was smaller than average -- and body image -- he was overweight. He also had an extreme aversion to body fluids, his own as well as his partner's. Never having been in love with a man, he could only imagine that kind of relationship with a woman.

During our work, Arthur developed more comfort in being sexual with me, at least about his skill level. He didn't really want to identify as bisexual, assuming -- despite my efforts to reassure him -- that most women would reject him. His plan was to get skillful enough at being sexual with women that he would feel confident dating one, getting married and having a family. He seemed to think his attractions for men would fade away or not be an issue.

I suggested instead that he "include" his desires for women, rather than trying to eliminate or erase his natural attraction to men. Arthur chose to leave therapy before these issues were resolved satisfactorily.


  1. Masters, William H., and Johnson, Virginia E. Human Sexual Response. Boston: Little, Brown & Company, 1966. (return)
  2. Masters, William H., and Johnson, Virginia E. Human Sexual Inadequacy. New York City: Bantam Books, 1970: p. 143. (return)
  3. Leiblum, Sandra R., and Rosen, Raymond C. ed. Principles and Practice of Sex Therapy, Update for the '90s. 2nd Edition. New York: The Guilford Press, 1989: p.5. (return)
  4. Rosen, Raymond C., Ph.D., and Leiblum, Sandra R., Ph.D. Erectile Disorders, Assessment & Treatment. New York: The Guilford Press, 1992: p.8. (return)

Linda Poelzl is a certified sex educator and surrogate partner who lives, loves and works in San Francisco. To find out more about surrogate partner therapy, contact IPSA at (323) 469-4720 or link through her Web site at:

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