Gary Schubach, Ed.D., A.C.S. – Comprehensive Exam Question Response
You are a sex therapist with a client who is a 45-year-old impotent male without a sexual partner. You (and he) decide to use a surrogate. How would you go about finding one? What would you look for in her? What instructions would you give her? In other words, discuss the use of surrogates in sex therapy.
To begin with, it is necessary to define what we are talking about here and then look at the appropriate options. First, let’s look at what is meant by “impotent”. Impotence is defined broadly by Masters and Johnson as “the inability to have or maintain an erection that is firm enough for coitus.” Within that definition there can be any number of possible causes and manifestations. To be thorough, a full sex history should be taken and a complete physical examination, including testing for STD’s, should be conducted. Diabetes, alcoholism, hormonal deficiencies, prescription drugs, urethral and prostate disorders are among just a few of the possible organic causes of erectile difficulties and should be explored before the question of appropriate treatment is decided. However, it is far more likely that the difficulty is psychologically based or is at least an important major contributing factor.
So what are the treatment options? Until about 1970, the treatment of sexual dysfunctions usually involved the traditional model of a therapist working one on one with a client in an attempt to understand the deep seated psychological roots of the problem and to resolve them through verbal therapy. Then came new viewpoints by such people as Masters and Johnson, Helen Singer Kaplan, and Hartman and Fithian, suggesting that in addition to a psychological causation, it was also possible that there was an educational deficit that might be addressed in a focused sort of way. Many people simply did not possess the social interpersonal communication and tactile skills necessary to create an environment where they and their partner would feel relaxed and comfortable enough to have and maintain an erection. New approaches were developed that saw erectile difficulties not as a “problem” of the male in a relationship but as a joint relationship issue to be addressed by both partners. Intensive strategies were developed to re-educate both partners as to normal sexual function, communications and relaxation techniques. Sensate focus exercises were developed. In these exercises, according to Masters and Johnson, “The purpose of the touching is not to be sexual but to establish an awareness of touch sensations by noticing textures, contours, temperatures, and contrasts (while doing the touching) or to simply be aware of the sensations of being touched by their partner. The person doing the touching is told to do so on the basis of what interests them, not on any guesses about what their partner likes or doesn’t like.”
The problem is that these promising therapies were designed for couples and really need to be done with a partner. What about cases like this one where there is no partner or, if there is a partner, he or she is unwilling to participate? It was in response to this question that the role of the sex surrogate was conceived. A sex surrogate is someone, male or female, who serves as a sex partner as part of the sex therapy team that includes the client and the therapist. The surrogate’s purpose is to teach and aid a client with no partner to work with, to achieve emotional and physical intimacy by using experiential exercises designed to build those skills. This can involve exercises in the areas of social skill training, communication, relaxation techniques and sensual and sexual touching. It also may involve, when appropriate, genital-genital contact but that is a minor portion of the total time spent in the process and usually takes place close to the end of the process after the necessary interpersonal and body sensitivity lessons are learned.
Before I would even make a referral to a sex surrogate, it is important that I would have already established rapport and a sense of trust with the client. Also, I would have already introduced the client to relaxation techniques that might include self-hypnosis, breathing exercise and guided imagery. If the client is resistant to these exercises, then they are probably not a good candidate for the type of sex therapy that would involve using a surrogate. However, from the question given here, I will assume that we have already determined that use of a sex surrogate is appropriate.
Therefore, in this case, the qualities that I would be looking for in a sex surrogate would include comfort with her own sexuality and body, good interpersonal communication skills, warmth, caring, empathy and trustworthiness. It is also important that she have non-judgmental attitudes towards choice of lifestyle, sexual activity and sexual partners. It is essential that she be emotionally mature and able to effectively cope with intimate situations.
So, assuming that the use of a sex surrogate is appropriate for the individual client at hand, where do we go to find one? The professional society for sex surrogates is the International Professional Surrogates Association (IPSA). They offer training for persons interested in becoming sex surrogates as well as on going education programs for their members. Their members subscribe to a highly professional code of ethics. So if I was a sex therapist looking for a trained and qualified sex surrogate, I would definitely call IPSA and request a referral or referrals.
After I located a qualified sex surrogate, she, the client and I would meet to see if we could agree to work together. In that session we would discuss the ground rules for the program of therapy as well as safer sex practices and come to some agreements in those areas.
After that, I would have some instructions for the surrogate, although I would like to think of our relationship as consisting of two trained professionals working together in cooperation for the best interests of the client. It is possible that she may know as much or more than I do about aspects of an effective treatment program and I would certainly be open to her feedback and input.
I will be seeing the client in at least weekly verbal sessions to review how he is feeling about the therapy and discuss any issues that are coming up for him during the process. Also, I will watch for the time when he is ready to progress to the next step in the process and would keep in at least weekly touch by phone with the surrogate to get her feedback and jointly plan the next session.
In dealing with a 45 year old man with erectile issues, the first thing to do is to take his attention off of whether or not he has an erection. In an initial session in my office with the client and the surrogate, it is important for us to make the point that it is impossible to just “will” an erection. Additionally, in order to successfully have erections it is necessary to create an environment of relaxation and comfort, free from the pressures of performance anxiety. An agreement would be made with the client that for the initial sessions with the surrogate that there will be no coitus or attempt to reach orgasm any other way.
I would then instruct the surrogate to begin a series of “sensate focus” exercises with the client. This would involve non-genital touching exercises in giving and receiving, with no specific area of the body to be focused on, no goals to be reached and no pressure to perform. Also, the surrogate will work with the client in communications exercises designed to develop skills in communicating what is pleasurable and what the client or a partner might like differently in the way of touch.
After the surrogate has communicated with me that the client has become comfortable and feels competent with his new touching and communications skills, I would discuss with the surrogate whether the client is ready to move to the next step in the process, to begin to concentrate his and her touching on the sex organs and the surrogate’s breasts. Again, they would be under instructions not to aim for coitus or orgasm. I might instruct the surrogate to have both of them guide each other’s hand to show what is pleasurable to each during masturbation. If an erection occurs, they will be instructed to stop what they are doing until it goes down and then start over again. As this begins to happen more frequently, the client should start to be assured that there is nothing to worry about in losing an erection and as he builds confidence that he can get another one.
After the client and the surrogate have indicated to me that he has overcome his fears of failure and is beginning to have confidence in his responses, I would instruct them to proceed to intercourse in a deliberate and non-demanding way. The surrogate would be instructed to take the initiative, with her on top and to masturbate him until he has an erection. Then, with his permission, she would insert him into her vagina. She would be instructed to remain still for a while so that he can get used to the feeling of being inside her without having to do anything. If he loses his erection, that is fine and they simply begin again. As the client becomes comfortable with simple insertion, the surrogate is instructed to begin movement, stimulating the penis and helping keep it erect. As the client becomes more comfortable with intercourse, I would instruct the surrogate, while still on top, to allow the client to initiate thrusting and moving back and forth inside her, again with no goal of orgasm. Finally, when the client becomes comfortable with this stage, I would instruct the surrogate to begin to allow the client to experiment with various positions.
All of this is flexible and adaptable to each client and his needs. Outcomes statistics for this type of therapy, utilizing a surrogate, have not really been kept and its popularity has faded some with a more sexually repressive period and fears about STD’s. However, I have had experience with this type of therapy and I clearly believe in its effectiveness, used with the right client. My experience has been that the client must not have too many deep-seated anxieties around sex so that it is impossible to surrender to the exercises and the process. The client that I would find appropriate for this type of therapy would be one who is open, willing and even eager to learn new skills and to have a joyful and loving sex life. For that person, sex therapy utilizing a surrogate can be a rewarding and enriching experience.
©1997 by Gary Schubach, Ed.D., A.C.S.
http://www.DoctorG.com
