Title: Surrogate , a controversial practice

DR. Dr. Cokorda Bagus Jaya Lesmana, SpKJ (K) Department of Psychiatry, Faculty of Medicine, Udayana University, Bali

Abstract

The recent availability of noninvasive pharmacological remedies for male sexual function triggered an exponential increase in the number of men requesting help in the sexuality area. Surrogate in sex therapy is a controversial and often misunderstood practice. The use of Surrogate Sex Therapy (SST) is viewed as a part of the integral rehabilitation process aimed at improving the quality of life and the fulfillment of basic human intimacy needs. The surrogate is a partner provided by the therapist for an unmarried man referred for treatment who has no one to provide psychological support during the acute phase of the therapy. Surrogate partners are trained according to International Professional Surrogate Association (IPSA) and supervised for every single therapeutic session. The use of SST may provide some answers to individual with as well as allowing the patient an opportunity to experience an intimate sexual relationship that may improve access, opportunity and choice of treatment. Over much of the last 30 years of public exposure, SST has experienced no serious criticism or competition from other professionals and little societal opposition, with the exception of some religious groups. It has become a brand name in the Western world. The factor which makes this form of treatment controversial is the potential explicit expression of sex between a paraprofessional, the surrogate, and her or his client. The debate over the legitimacy of SST will surely make its rounds in the cultural conversation. In order to evaluate the effectiveness of the treatment despite the controversial legitimacy, a basic fund of data must exist which is currently unavailable. Culture implementation is a potential and systematic contributor into holistic and sensitive interventional models for the treatment. It is time in our professional identity development to move away from self-focus to synthesis and integration.

Keywords: surrogate partners, sex therapy, culture,

Surrogate Sex Therapy, a controversial practice

DR. Dr. Cokorda Bagus Jaya Lesmana, SpKJ (K) Department of Psychiatry, Faculty of Medicine, Udayana University, Bali

Background Historically, new therapeutic practices have always posed legal, moral, ethical and clinical questions for both the professional and consumer communities. These questions and the controversies they often engender remain until such time as the data gathered from the work being done can provide some hard line evidence which indicates or contra indicates the continuation and further development of that particular approach or practice. Surrogate Sex Therapy grew out of 's couple-model of sex therapy that was developed from their research on human sexual response. They proposed treatment of the relationship or "marital unit" rather than the single partner manifesting the dysfunction. Unfortunately, they were served with lawsuit by the husband of one of their surrogates. Following an out-of-court settlement and their decision to discontinue utilizing surrogates, the field, which has continued to grow and develop, nonetheless, was covered by a cloud of legal uncertainty. In addition, numerous ethical and clinical controversies have developed both within and outside the field of sex therapy. Surrogate Sex Therapy still remains in its pioneering stage, and although it is being used as a treatment modality by an increasing number of therapists, the cloud of threatening legal, ethical, and clinical questions sustains the sub-rosa status of surrogates and Surrogate Sex Therapy. One of the more significant findings in reviewing the literature on Sexual Surrogate Therapy is the paucity of research (published) in professional journals. Including the articles in the public press, articles based on interviews with well-known sexologists appearing in sexually oriented magazines (and a few non-sexually oriented popular magazines), unpublished copies of papers given at professional meetings and conferences, and unpublished manuscripts of doctoral dissertations and theses, the entire body of literature is impressively small. The recent availability of noninvasive pharmacological remedies for male sexual function triggered an exponential increase in the number of men requesting help in the sexuality area. Surrogate sexual partner in sex therapy is a controversial and often misunderstood practice. The use of Surrogate Sex Therapy is viewed as a part of the integral rehabilitation process aimed at improving the quality of life and the fulfillment of basic human intimacy needs. The major considerations are noted here in question form: are surrogates replacement partners only or co-therapists? what are the effects on transference and counter transference issues? does therapy generalize? is therapy merely a teaching of mechanical techniques? what are the dynamics of the client-surrogate-therapist relationship? how are surrogates to be supervised? is training necessary, and by whom, according to what standards? how is success in treatment determined? what are the causes of "cure"?

Sex therapy William Masters and Virginia Johnson’s contributions to the field of and the birth of short-term sex therapy are based on the first laboratory research into the physiology of human sexual response. Although they were not opposed to the use of additional data sources, they emphasized what became their heralded theoretical foundation, namely, that sex is a natural physiologic function, because their contention was that the physiology must be understood and appreciated before attention can be paid to additional layers of social, psychological, relational and other influences on . After laboratory identification of the physiological patterns of and interviews with laboratory subjects suggested the critical factors associated with sexual functionality, Masters and Johnson applied this knowledge to the treatment of sexual dysfunction. Their approach was based “on a combination of 15 years of laboratory experimentation and 11 years of clinical trial and error”. It was qualitatively different from what had been the customary psychoanalytic process of treating sexual concerns through processing deeply rooted conflicts interfering with healthy sexual expression. Masters and Johnson concluded that effective treatment of non-medical sexual dysfunctions might be accomplished using a short-term, intensive psycho-educational approach coupled with behavioral assignments. This was publicized as “a second astonishing triumph…emerging from the Masters and Johnson clinic—a new psychosexual treatment to rival Freud, with far better results. The theory underlying Masters and Johnson’s perspective has been alluded to previously and rests on the deceptively simple but elegant idea that “Sexual functioning is a natural physiological process…[like] respiratory, bladder, or bowel function”. All natural functions have three characteristics in common: they are processes (1) with which one is born; (2) that cannot be taught; and (3) that are not under immediate voluntary control. However, all natural functions can be influenced by any negative emotional state (such as anxiety), and by distractions (such as spectatoring oneself). While in Western culture we expect that apprehensions and ruminations might keep us from falling asleep, we have difficulty accepting that these similar preoccupations can affect sexual responsiveness. One of the most common distractions affecting sexual functioning is fears of performance. This expresses itself as trying to make sexual desire, arousal, and/or happen. This is an example of the more general, paradoxical principle characterizing all natural functions: the more one tries to make them happen directly and at a particular moment in time, the less likely they are to happen.

Surrogate sex therapy was conceived in the St. Louis laboratories of Masters and Johnson but took root and is flourishing in the moral pluralism of the California climate, then jumped across the country to New York and is beginning to find a place in the heartland. Masters and Johnson's publication of Human Sexual Inadequacy, reported the utilization of 41 partner-surrogates in the treatment of 54 men and 3 women during an eleven-year period (13 men and all the women brought replacement partners). Not until five years later did any data collection indicate the growth of surrogate utilization, again evidencing the absence of research following and reflecting the tenuous legal and ethical status of Sexual Surrogate Therapy marked by the Masters and Johnson lawsuit. Nevertheless, growth was undeniable. Surrogate Sex Therapy (SST) is viewed as a part of the integral rehabilitation process aimed at improving the quality of life and the fulfillment of basic human intimacy needs. Individuals without partners promised less than 25% chance of reversal of their dysfunction status. Surrogate Sex Therapy is slow and thorough, moving at a pace designed to assure the client's progress. Exercises are graduated and concentrate on body-awareness, relaxation, and sensual/sexual experiences that are primarily non-genital. The emphasis is on helping the client learn to fully experience giving and receiving sensual pleasure in explicitly non- demand sessions. Intercourse is not allowed for many (often, most) of the sessions with the surrogates. It is suggested for a specific therapeutic purpose, but in terms of the overall therapy, "sex is the least of it”. The surrogate is a partner provided by the therapist for an unmarried man referred for treatment who has no one to provide psychological support during the acute phase of the therapy. Surrogate partners are trained according to International Professional Surrogate Association (IPSA) and supervised for every single therapeutic session. 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. The use of SST may provide some answers to individual with sexual dysfunction as well as allowing the patient an opportunity to experience an intimate sexual relationship that may improve access, opportunity and choice of treatment. Surrogates have had 85-95%, success in treating male impotence and close to 100% treating premature . 95-98% of cases are successfully treated and that problems also respond well to treatment, but take a longer period of time

Controversial practice Over much of the last 30 years of public exposure, SST has experienced no serious criticism or competition from other professionals and little societal opposition, with the exception of some religious groups. It has become a brand name in the Western world. The factor which makes this form of treatment controversial is the potential explicit expression of sex between a paraprofessional, the surrogate, and her or his client. The debate over the legitimacy of SST will surely make its rounds in the cultural conversation. Surrogates are not used by university researchers or many sex clinics mainly because of the legal uncertainty. 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.) Boundary between therapist and client will rise professionalism question. It is 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 is that prostitution is focused on sexual gratification, while SST does not necessarily focus on sexual touch, sexual stimulations, or sexual satisfaction. SST, as described above, is focused on helping clients build social and physical self-awareness, 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 '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. 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. Situations, such as surrogate sex therapy, when no recognized standards exist, therapists should attempt to apply the most relevant codes of ethics, such as Beneficence and Non maleficence (do not harm), consult with knowledgeable ethical and legal experts, and seek guidance from professional organizations. American Psychological Association (APA) Code of Ethics, Standard 3: Competence, section 2.01 Boundaries of Competence states: "(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients and others from harm." 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. In order to evaluate the effectiveness of the treatment despite the controversial legitimacy, a basic fund of data must exist which is currently unavailable. Culture implementation is a potential and systematic contributor into holistic and sensitive interventional models for the treatment. It is time in our professional identity development to move away from self-focus to synthesis and integration. However, SST must be offered according to legal, professional, and ethical standards.

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