The Evolution of Surrogate Partner Therapy
Not Your Grandmother's SPT
The practice of Surrogate Partner Therapy was pioneered by Masters and Johnson starting in 1959 and was introduced to the world with the publication of their book “Human Sexual Inadequacy” in 1970. More than half a century has passed since then, and the practice of Surrogate Partner Therapy has changed and evolved during that time. I spend a lot of time talking with people about the practice, and I’m often surprised at how many of the ideas that people currently hold relate to the way it was practiced at its inception, rather than the way it's practiced today. Even though the practice has changed, many of the conceptions about it have not.
As a result, I believe it’s important to point out the ways the profession has changed over the years. In the same way that the work of an information technology professional was very different in the 60s than it is now, the work of a surrogate partner is also different, and it’s important to recognize those differences and to get clear, when we talk about Surrogate Partner Therapy, whether we are talking about the practice as it was originally conceived back in the 1960s, or about the way it’s practiced in the present day.
I’ll be speaking about general trends in how Surrogate Partner Therapy has evolved. Because different surrogate partners practice and conceive the work in different ways, there are, of course, exceptions to the general trends in any time period. Nonetheless, the practice itself has changed over time in five observable ways, which are summarized in the table below.
Masters & Johnson (c. 1970’s)
Address sexual dysfunction
Improve relationship skills
Reach therapeutic goals
Intention: Not Just for Sexual Dysfunction Anymore
Surrogate Partner Therapy was introduced to the world with the publication of the book “Human Sexual Inadequacy” by Masters and Johnson. Their focus was “the treatment of men and women distressed by some form of sexual dysfunction.”(1) This was made abundantly clear, not only by the title of the book, but by the titles of the chapters, which include: “Premature Ejaculation,” “Ejaculatory Incompetence,” “Primary Impotence,” “Secondary Impotence,” “Orgasmic Dysfunction,” “Vaginismus,” “Dyspareunia,” “Sexual Inadequacy in the Aging Male,” and “Sexual Inadequacy in the Aging Female.” The vast majority of other articles and videos during the 1970s and 1980s describe the primary focus and intention of SPT in the same way.
Some of the clients who needed help with sexual dysfunction did not have a partner. Masters and Johnson conceived of the idea of providing a substitute (surrogate) partner to work with them to help them overcome sexual difficulties. As they write, “It would have been inexcusable to accept referral of unmarried men and women and then give them statistically less than 25 percent chance of reversal of their dysfunctional status by treating them as individuals without partners.”(2) This approach apparently was quite successful. “In view of the statistics there is no question that the decision to provide partner surrogates for sexually incompetent unmarried man has been one of the most effective clinical decisions made during the past 11 years devoted to the development of treatment for sexual inadequacy.”(3)
In the present day, in contrast, the intention of Surrogate Partner Therapy is generally seen more broadly as improving relationship skills. Any aspect of relationship can be included in the goals for a particular client. The relationship skills to be developed or improved may not have anything to do with sexuality, however, sexuality may be included because it is often an aspect of relationship. Even when it is included, sexuality is no longer seen as the ultimate goal as an end in itself, but rather a symptom of deeper issues that are typically relational.
If the cause of sexual dysfunction is purely physiological, Surrogate Partner Therapy is not helpful and should not be recommended. To the extent that sexual dysfunction is emotional, psychological, or relational, focusing exclusively on the sexual dysfunction as a goal is treating a symptom. The focus of Surrogate Partner Therapy is instead to address the root cause, which is typically some form of anxiety, past trauma, shame, or unrealistic ideas about people, emotions, sex, bodies, or relationships formed as a result of cultural conditioning. It’s often when beliefs about who we should be contradict who we actually are. These are all areas that Surrogate Partner Therapy is very effective at addressing.
Success: Reaching Clients’ Goals
In “Human Sexual Inadequacy,” Masters and Johnson did not clearly define what constituted success. Years later, at the 1983 World Congress of Sexology meeting in Washington, D.C., they clarified “that a woman needed to be orgasmic in at least 50 percent of her sexual opportunities to be considered a success.” For the treatment of erectile dysfunction, “the ability to get and keep erections on ‘more than 75 percent of coital occasions’ was defined as successful therapy.” The criteria given by Masters and Johnson for what constitutes therapeutic success were all centered around heterosexual intercourse.
In the present day, the definition of success is more nuanced and subjective. Rather than it being about the ability to successfully engage in heteronormative behavior, success is defined as reaching the objectives that were defined at the start of the therapy, or refined over the course of the therapy. That’s why one of the important roles of the collaborating therapist/clinician on the case is to help the client get clear about their goals, ideally before they even meet the surrogate partner.
Here are examples of some of the clients’ goals I’ve seen over the course of the 11 years I’ve been working as a surrogate partner. All these goals are from cisgender women. Admittedly goals from individuals other than cisgender women may look different, but this list still gives a sense of the variety of objectives that clients have. Although concerns such as these would likely have been addressed as part of the process at the Masters and Johnson Institute, they certainly would not have been acknowledged as the primary goals or presenting issues.
Be able to relax while aroused.
Accept my body as it is.
Know what I like, what I want, and be able to ask for it.
Be able to say “no” when asked for something I don’t want.
Learn to enjoy touch rather than feeling threatened by it.
Understand I matter and what I want matters.
Learn what feels good and bad both emotionally and physically.
Feel safe in intimate situations.
Act for myself and not just for others.
Feel physical pleasure without numbing out.
Retain my own identity in relationship.
Know how to set limits without being afraid of rejection.
Time Period: As Long as it Continues to be Beneficial
Masters and Johnson typically would have a client work with a surrogate partner in a two-week-long intensive. While sometimes this structure is used in the present day, more commonly it happens on an ongoing basis with the pacing customized for each individual client. The majority of clients meet with a surrogate partner, on average, 15 to 30 sessions, however I have also met with several clients more than 100 sessions over more than two years. The process can continue as long as the members of the triad—the client, surrogate partner, and collaborating clinician—all agree that it continues to be beneficial.
Clientele: Fully LGBTQIA+-affirming
Surrogate Partner Therapy at the Masters and Johnson Institute was heteronormative in that the only configuration was a female surrogate partner working with a male client. They didn’t believe a female client could meet the “socioculturally-induced requirements … for a relatively meaningful relationship … in a brief, two-week period.” This caused them to “deny the incorporation of the male partner surrogate into treatment….”(4)
Dr. Masters was not affirming of same-sex relationships. The Masters and Johnson Institute even ran, for a time, a program to convert homosexuals to heterosexuality.
In the present day, there are surrogate partners of all genders and orientations available to work with clients of all genders and orientations. Because the objective is determined by the client’s individual goals rather than the ability to engage in heteronormative behavior, the process is fully LGBTQIA+-affirming.
Title: The Correct Term is “Surrogate Partner”
While Masters and Johnson used the title “partner surrogate” for the therapeutic practice partner, the title that was most commonly used throughout the 1970s and 1980s was “sex surrogate” or “sexual surrogate.” This is forgivable when you consider that Surrogate Partner Therapy at that time was seen as a treatment for sexual dysfunction, and success was measured as heterosexual intercourse. Viewed from today’s perspective, however, in light of the changes I’ve described earlier, calling me or one of my colleagues a “sex surrogate” is misleading and offensive. It trivializes the majority of the work we do. Because it’s misleading, it can create unrealistic expectations in potential clients, in collaborating clinicians/therapists, and in the general public. It’s harmful because it makes the practice less accessible to clients who could benefit from it.
In summary, some peoples’ conceptions of Surrogate Partner Therapy are still flavored by the way it was practiced 50 years ago, even though the profession has changed significantly since then. In the present day, Surrogate Partner Therapy is not just for sexual dysfunction but for helping clients reach a wide variety of goals pertaining to relationships. It is fully LGBTQIA+-affirming, and can continue as long as it continues to be helpful. And don’t call me a sex surrogate. Ever.
(1) Masters, William H., and Virginia E. Johnson. Human Sexual Inadequacy (Boston: Little, Brown and Co., 1970), 1
(2) Masters and Johnson. Human Sexual Inadequacy, 148
(3) Masters and Johnson. Human Sexual Inadequacy, 154
(4) Masters and Johnson. Human Sexual Inadequacy, 156