To Refer Or Not to Refer - Surrogate Partner Therapy

The Renewed Interest and Rekindled Debate Regarding Surrogate Partner Therapy

Definitions, Debates, Questions, Ethical-Legal Considerations, & Resources

By Ofer Zur, Ph.D.

This page provides definitions of Surrogate Partner Therapy (SPT) and outlines the main ethical and legal complexities, as well as standard-of-care questions with regard to psychologists, MFTs, counselors, social workers, psychiatrists, and other mental health professionals who may consider referring psychotherapy clients to Surrogate Partner Therapy. The page also provides a list of resources and research/academic papers on this topic for those who want to explore it further.

The page does not offer legal or ethical advice; it only maps the complex and heatedly debated issues surrounding this controversial topic.

The Renewed Interest and Rekindled Debate Regarding Surrogate Partner Therapy (or Sexual Surrogacy)

The 2012 movie, The Sessions, is based on an essay by Mark O’Brien, a poet paralyzed from the neck down due to polio, who, in his 40s, hired a sex surrogate to have his first sexual experience. Helen Hunt plays the role of the sensitive, intelligent, trained sexual surrogate and John Hawks plays the role of the physically disabled, talented, educated poet. The movie has rekindled interest in the controversial topic of Surrogate Partner Therapy, or what also has been called, Sexual Surrogate Therapy. The original concept was developed and studied by Masters and Johnson in their work, Human Sexual Inadequacy, in 1970. As with many issues related to sex, this is a highly controversial topic. While sexual surrogacy was popular and practiced in the 1970s and 1980s, 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.

What is Surrogate Partner Therapy?

Surrogate Partner Therapy has also been referred to as Sexual Surrogacy and Sexual Therapy, among other names. Following are two descriptions of Surrogate Partner Therapy.

The International Professional Surrogates Association (IPSA)’s Surrogate Partner Therapy is based on the successful methods of Masters and Johnson. In this therapy a client, a therapist and a surrogate partner form a three-person therapeutic team. The surrogate participates with the client in structured and unstructured experiences that are designed to build client self-awareness and skills in the areas of physical and emotional intimacy. These therapeutic experiences include partner work in relaxation, effective communication, sensual and sexual touching, and social skills training. Each program is designed to increase the client’s knowledge, skills, and comfort. As the days pass, clients find themselves becoming more relaxed, more open to feelings, and more comfortable with physical and emotional intimacy. The involvement of the team therapist, a licensed and/or certified professional with an advanced degree, is a cornerstone of this therapy process. Clients often experience apprehension as they begin therapy and when they begin to experience changes. The team therapist assists the client with these and other emotional issues. Sessions with the therapist are interwoven with the surrogate partner sessions in order to facilitate understanding and change. Open, honest, consistent communication between all team members is a fundamental ingredient of successful surrogate partner therapy.

Retrieved from International Professional Surrogates Association (IPSA), Appeared at http://www.surrogatetherapy.org/what-is-surrogate-partner-therapy/

A sexual surrogate may be a Certified Sex Therapist who is a member of a sex therapy team who engages in education and sometimes intimate physical relations or sex with a patient to achieve a therapeutic goal. The practice was formally introduced by Masters and Johnson with their work on Human Sexual Inadequacy in 1970. The team may also work independently of diagnosis and treatment plans based in traditional medicine, for example providing services to the disabled or to couples whose sexuality is a source of distress.

Retrieved from http://en.wikipedia.org/wiki/Sexual_surrogate

Main Questions and Considerations Regarding Surrogate Partner Therapy

The idea of employing surrogate partner therapy in conjunction with traditional sex therapy or other forms of psychotherapy and counseling is controversial and has been very little explored. While some people have a knee-jerk reaction to the concept of mixing sex and therapy, others can see how such interventions can be humane and healing. Yet others view SPT as “a guided in vivo exposure” (Binik, 2009). Since the work of Masters and Johnson in the 1970s and the practice of surrogacy in the 1980s, there has not been much discussion of these issues. One of the few exception has been a debate at a major international sexological conference entitled “Surrogate Therapy Has No Place in the Treatment of Sexual Dysfunction” (Assalian, et. al. 2007) and by the publication of one of the very few efficacy studies articles detailing the use of male surrogates in the treatment of vaginismus (Ben-Zion, et. al. 2007). That has changed since the release of the recent movie, The Sessions.

Following are eight questions and ten most important considerations that seem to be most relevant to the exploration of whether therapists may refer to surrogate partner therapy.

Main Questions

1. How does surrogate partner therapy or sexual surrogate therapy differ from prostitution? (See discussion at Bullet #2, below)
2. What are the legal issues relevant to surrogate partner therapy? (See discussion in section on legality, below)
3. Does this type of referral fall within the standard of care, i.e., when a licensed mental health practitioner (licensed psychologist, social worker, MFT, or counselor), who is trained in sex therapy, and has conducted an evaluation, refers a patient to an IPSA certified surrogate for surrogate partner therapy? (See discussion in section on Ethics of Referral, below)
4. Is it ethical for a mental health practitioner to refer a severely physically disabled client, such as the one depicted in the movie, The Sessions, to an IPSA certified surrogate for surrogate partner therapy if the client requests it? (See discussion in section on Ethics of Referral, below)
5. What would be involved in a risk-benefit analysis when considering referring a client to work with a certified surrogate partner?
6. What is the ethical decision-making process regarding a referral to, and follow up with, a surrogate partner therapist?
7. Are there any legal precedents, case laws, licensing board rulings, or professional associations’ guidelines that are relevant to the practice of psychotherapy and referrals to referrals to surrogate partner therapy by a practitioner of psychotherapy. (See information regarding these matters, below.)
8. Are there certain psychiatric symptoms (or lack of), diagnostic categories, or certain clients that would indicate the possibility of higher clinical risk to the client, or legal or ethical risk to the referring therapist?
9. Does a mental health practitioner have an obligation or ethical duty to make a referral (i.e., to surrogate partner therapy) if he/she evaluates that the client has special needs, and the therapist thinks that a certain treatment is likely to be beneficial to the client and is in the client’s best interest? (See direct quotes from professional organizations codes of ethics, below)

Important Considerations

1. It is extremely important to differentiate between psychotherapists or counselors who are licensed, mental health professionals who conduct sex-therapy, and surrogate professionals who provide surrogate partner therapy or sexual surrogate services. (Obviously, it is illegal and unethical for psychotherapists, counselors and licensed mental health professionals to have sexual relationships with their clients.)
2. The differentiation between SPT and a sex worker or prostitution is, obviously, extremely important for the discussion of the legal, ethical and clinical considerations of therapists referring a client to SPT. The main difference between surrogate partner (SP) and prostitution is that prostitution is focused on sexual gratification, while SPT does not necessarily focus on sexual touch, sexual stimulations, or sexual satrisfaction. SPT, as described above, is focused on helping clients build social and physical self-awarness, consciousness and skills in the areas of physical and emotional intimacy. The Kinsey Institute report states that only “About 13% of a client’s time with a surrogate partner involves physical interaction, such as directly teaching sexual techniques. Some surrogate-client relationships do not involve sexual contact at all, depending on client preference or the nature of the concern.” An SP’s focus is different from a prostitute’s or sex worker’s, in that an SP may specifically address the social, intimate and sexual difficulties and dysfunctions a client may be experiencing, not necessarily emphasizing the client’s genital pleasure per se. Also, the SP is working in conjunction with, or under the supervision of, a licensed mental health professional, while that is obviously not the arrangement with sex workers.
3. Therapists may want to contact their malpractice insurance provider to verify if such a referral is covered under their policy. Clinicians should be aware of the issues surrounding vicarious liability. These are situations where, if a clinician was to make such a referral and harm was to occur, the clinician might be liable for damages. Malpractice insurance may not cover any claims if the activity were deemed a violation of law in the state’s jurisdiction, since it may not protect against criminal acts.
4. In situations, such as surrogate partner therapy, when no recognized standards exist, therapists should attempt to apply the most relevant codes of ethics, such as Beneficence and Nonmaleficence (do not harm), review the available literature (see Resources section below), consult with knowledgeable ethical and legal experts, and seek guidance from their national professional organizations (i.e., APA, NASW, ACA, AAMFT, NBCC) and state professional organizations (e.g., CPA, CAMFT).
5. Therapists, who choose to follow up with a referral to a surrogate, should ensure, to the best of their capacity, that the professionals they refer to (in this case, surrogate partners) adhere to relevant standards (in this case, IPSA’s Code of Ethics).
6. Clinicians should discuss the risks and benefits of such referrals with the client, as well as the controversial aspects of such referrals, in order to ensure that the client is well informed and can make a reasonable, informed decision regarding the proposed referral and treatment.
7. To reduce liability, it is recommended that therapists neither hire surrogates as employees or contractors, nor let them work out of their office, nor avail themselves of the surrogates’ services.
8. Therapists should have the client sign an informed consent that outlines the limitations, risks, and benefits of a referral to surrogate partner therapy, in addition to the necessity of on-going discussions regarding the referral. This is especially important with referrals to SPT since the efficacy research in this area is not strong and there are no clear standard treatments are available.
9. If, after the thorough ethical, clinical, and legal decision-making process, a therapist decides to make a referral to a surrogate partner, he/she needs to pay attention to the following:
   1. Assure that he/she (i.e., the referring psychotherapist or counselor) is trained as a sex-therapist or that sex-therapy falls within his/her scope of practice.
   2. Make sure that the surrogate is, preferably, IPSA certified, which also means that he/she is committed to complying with IPSA’s Code of Ethics and will collaborate with the referring therapist.
   3. After the referral to a surrogate takes place, hopefully the therapist and the surrogate will consult with each other on an ongoing basis (or as needed) and view the intervention as a team approach, consisting of ongoing communication between the referring therapist, the surrogate and the client.
10. Documentation is very important in situations discussed in this paper. Therapists should document their discussions with the client, the risk-benefit analysis, ethical decision-making, and citation of relevant literature and, of course, consultations with colleagues and experts.

Legal Precedents, Case Laws, Licensing Boards’ Rulings, and Professional Associations’ Guidelines Relevant to Surrogate Partner Therapy

One of the most persisting questions regarding Surrogate Partner Therapy is whether this practice is legal. Related questions are whether there are any legal precedents, case laws, licensing board rulings, or professional associations’ guidelines that are relevant to the practice of psychotherapy and referrals to referrals to surrogate partner therapy by a practitioner of psychotherapy.

Licensing Boards:

A couple of experts have informally advised me that in the late 1980’s the Massachusetts Board of Registration had a complaint against a psychologist who employed and made referrals to surrogates. The board was concerned about the fact that the psychologist was potentially violating state laws regarding prostitution and pandering, and that he was putting patients at risk of infection (i.e., STDs or HIV). The board apparently revoked the psychologist’s license and called the case to the attention of the district attorney who prosecuted the case, and put a clear regulation in place as part of “251 CMR” (the Consolidated Massachusetts Regulation chapter addressing such topics). While I could not find any documentation to support the above, it seems that as of Dec. 2012, the issue of referring to sexual partner therapy is no longer in MASS “251 CMR.” It is not clear to me who took it off, when it was taken off, and for what reason.

Note: consistent with IPSA Legal Status, I am not aware of any other state licensing boards’ guidelines or disciplinary actions regarding the issue of psychotherapists, MFTs, social workers, or counselors referring to surrogate partner therapy.

Legality

According to an article in the San Jose Mercury News, Kamala Harris, of the Alameda County DA’s Office, stated the following regarding sex surrogates, ”If it’s between consensual adults and referred by licensed therapists and doesn’t involve minors, then it’s not illegal.” As of 2012, Kamala Harris is California Attorney General.

A posting by the Kinsey Institute states: “Although the profession is controversial, it has been legal throughout the U.S. since 2003, as long as the surrogate partner works under the supervision of a licensed therapist.”

IPSA posted the following “Legal Status” statement on its web site:

The legal status of surrogate partners is undefined in most of the United States and most countries around the world. This means that there are generally no laws regulating the profession. Because there are no governmental licensing or regulations of surrogate partners, IPSA has assumed the responsibility of assuring the therapeutic community and the public that IPSA members have received adequate training, achieved professional competency, and adhere to the highest standards of ethical practice.

Professional Associations’ Guidelines

Major psychological associations, such as APA, ASWB, ACA, CAMFT, NBCC, etc generally do not have an official specified position regarding referrals to surrogate partner therapy.

Similarly, Internet search of the web sites of American Association of Sexuality Educators, Counselors and Therapists (AASECT), Society for the Scientific Study of Sexuality (SSSS), American Counseling Association (ACA), National Association for Social Workers (NASW), American Association of Marriage and Family Therapists (AAMFT), and other major professional organizations did not yield any clear or readily available statements regarding these organizations’ positions on referrals to surrogate partners or on Surrogate Partner Therapy.

According to a report by MSNBC on March 26, 2009, Stephen Conley, Ph.D., executive director of the American Association of Sexuality Educators, Counselors, and Therapists (AASECT), the issue of surrogacy. “…just about split the AASECT board years ago. They could not get consensus. Some people were strongly in favor and some worried about legal implications.” As a result AASECT never adopted a formal policy one way or the other.

In Summary

It seems apparent that there is neither clear guidance from professional mental health organizations nor from licensing boards, legislators, or the courts with reference to the practice of surrogate partner therapy or of mental health professionals referring clients to surrogate partners.

Ethics of Referrals: What do some of the professional organizations’ codes of ethics say about referrals (in general)

The codes of ethics of most major professional organizations discuss the importance of therapists making referrals to other professionals if they can provide specialist-specific services and/or if such services are likely to be beneficial or helpful to the client.

Generally most professional associations’ codes for psychologists, social workers, counselors and marriage and family therapists direct or encourage psychotherapists/counselors to refer clients/patients to other services that cannot be provided by therapists (due to the scope of practice or other reasons) and are in the best interest of the clients or can be helpful to the clients. It can be reasonably argued that SPT would be an example of such reasonable referral for certain clients in certain circumstances. The movie, The Sessions, presents an extreme example of a significantly disabled person who would clearly benefit from SPT.

Efficacy Studies

One of the concerns with referrals to Surrogate Partner Therapy is the fact that, in modern times, there are very few research projects on the effectiveness of SPT. Following are a couple of research papers on the efficacy of SPT:

• Aloni, R., Keren, O. and Katz, S. (2012) Sex Therapy Surrogate Partners for Individuals with Very Limited Functional Ability Following Traumatic Brain Injury, Sexuality and Disability 25(3):125-134.
• Ben‐Zion, I., Rothschild, S., Chudakov, B., & Aloni, R. (2007). Surrogate versus couple therapy in vaginismus. Journal of Sexual Medicine, 4(3), 728-733.