More than 60 years ago, the gurus of modern sexual therapy, Dr William H. Masters and Virginia E. Johnson, assigned their coupled patients some rigorous bedroom homework. Those who struggled to find the clitoris or grasp the “squeeze technique” for suppressing premature ejaculation, were read the manual and then told to go play.

For patients without partners, Masters and Johnson’s bold solution was “surrogate therapy” they provided verbal counselling to a patient who then put the advice into practice with a surrogate partner, trained to simulate a sexual relationship.

Even by the permissive standards of the time, the practice was considered “out there”. It bloomed in the gurus’ hometown of St Louis, Sydney dabbled a little, but Melbourne essentially shunned the therapy as verging on prostitution, and morally fraught. Today, Canberra University psychologist Bob Montgomery sums up the balance of mainstream opinion against surrogate therapy: “Unethical, unprofessional, out-of-date and risky.”

Enter Israeli psychologist Ilan Biran and his Melbourne colleague Brian Hickman two mavericks planning to rock the sexology establishment by opening a clinic that offers surrogate therapy.

The idea is for Hickman, a sex therapist of 15 years experience (and famous, among other things, for marketing a pleasure-enhancing “cosmetic” vaginal cream), to treat patients suffering sexual dysfunction in his East Melbourne rooms under Biran’s supervision. Patients would also have weekly sessions with a surrogate in a city apartment.

Hickman has started to advertise for male and female surrogates in the Leader newspapers. He seeks people with backgrounds in nursing, psychology, social work or alternative therapy, who possess “mature sexuality, a well-organised personality and emotional stability”.

The two stress the clinic’s work is sharply different from the dream-factory business of a brothel. “The relationship with a prostitute is a bargain in which one pays and the other lends her body,” says Biran, a 58-year-old with a hypnotic voice and bushy beard, who usually dresses all in black.

“Here the patients are learning to build mutual relations. This is meant to be the treatment for people who need the laboratory because they cannot deal yet with real life. I am very worried when the patient does not fall in love with the surrogate because it means there is nothing happening in the treatment process.”

Philosophically, surrogate therapy was an extension of the can-do approach of Masters and Johnson, which applied principles of modern behavioural psychology to sexual dysfunction. The emphasis on “sexual functioning and pleasure” threw a bomb under traditional Freudian analysts, who delved a patient’s past to find answers.

Practice makes perfect was the mantra and it applied no less to those with problems to fix but no partner to help. Surrogates worked closely with therapists and patients in a “triangular” arrangement that focused on specific goals. In later decades, such clinical detachment about sex between strangers fit the changing times.

“It was really coming from the free love period of the 1960s, into the ’70s with the women’s movement and gay rights,” says sex therapist Brett McCann, of the Australian Society of Sex Educators, Researchers and Therapists (ASSERT). “It was the right timing for what they were doing.”

McCann says the therapy achieved some prominence in Sydney in the ’70s, thanks largely to the efforts of a charismatic GP-cum sex-therapist Derek Richardson, who trained surrogates to work for him.

But by the 1990s, the wheels had fallen off the world over; the AIDS epidemic introduced risks few could wear, therapists started questioning the efficacy of such a contrived treatment and surrogates grew weary and jaded.

Montgomery says research into the surrogates used by Masters and Johnson suggested they were harmed by being required “as a commercial contract” to be physically intimate with people they may not find attractive. (It has been claimed Masters and Johnson later abandoned the therapy because of legal action taken against them by a patient’s aggrieved spouse.)

Israel remains one country still broadly receptive to surrogate therapy, largely as a rehabilitation treatment for injured soldiers. But the practice was not abandoned entirely in Australia a few Sydney therapists still use surrogates, albeit secretively. The New South Wales branch of ASSERT does not outright condemn the therapy, despite it being banned by other professional associations.

Rindy, 31, a counsellor doing her honours in surrogate partner therapy at Sydney University, has been a surrogate for the past 18 months. She sees up to five patients a month, either in their homes or in a rented flat, for a maximum of eight sessions. The few therapists who refer patients to her tend to insist that she keeps quiet about their association, fearing censure from colleagues.

Many of her patients have physical disabilities, either from birth or as a result of an accident. But men with “attachment issues”, say a fixation on an ex-girlfriend, are weeded out on the basis they are too emotionally vulnerable for the therapy. “They might be someone who’s lost an arm and is thinking how the hell do you put your own penis in when you’re lying on top, balancing on one limb’,” Rindy says. “It might be about getting them to the point where they’re comfortable asking for help.”

Her job is “challenging and rewarding”, although she concedes it puts pressure on her own relationship. “When the sessions end, sometimes people feel a sense of loss, sometimes I feel a sense of loss, too. But you don’t want them to become dependent, not like they do with a sex worker when they keep coming back.

“I’m not there to be their fantasy. The whole point is for them to learn life skills to put into practice with real life partners.”

Melbourne therapists have always been more conservative, Rindy says, although a few have made tentative contact with her via email.

It is believed the Melbourne branch of ASSERT split from its Sydney counterpart during the ’70s, in protest against the association’s tacit acceptance of Richardson’s pro-surrogate therapy stance.

Biran and Hickman could well face a serious hurdle in Victoria’s Psychologists Registration Board, which is empowered to investigate perceived breaches of professional boundaries. President David List told The Age the board would respond if a complaint was made.

“The board usually views the physical boundaries between psychologist and client as sacrosanct,” List says. “The obligation would be on the psychologist to justify his or her use of a form of therapy which involved physical touch.”

There is also the thorny question of whether the psychologists need a prostitution licence to practise their novel brand of healing. According to officials in Victoria’s Consumer Affairs Department, the clinic might need a prostitution licence if therapists manage a group of surrogates and collect commission for referrals.

Biran says his lawyers advised he need not apply for a licence.

Still, not everyone is dismissive, even in Victoria. Some experts, such as Deakin University psychology professor Marita McCabe, believe the therapy can be useful in treating sexual anxiety, provided there is a very clear professional separation between surrogate and client.

But how do you know those willing to carry out such delicate work are right for the job?

This is one of the many problems psychiatrist Lorraine Dennerstein, from Melbourne University’s Centre for Gender and Health, has with the therapy. Other concerns include the shortage of data proving its success and the availability of other, generally effective, treatment options such as encouraging men with erectile problems to masturbate as a way of building confidence.

She recalls hearing some surrogates (most of whom are women treating men) speak at a sex therapists’ meeting a few years ago. “They had aspects of abuse in their own backgrounds, which made me wonder how they could intimately relate to men.”

Rindy, who is planning to undertake a training course run by the International Professional Surrogates Association in California, agrees more controls are needed. The association, established in the early ’70s, recruits and trains surrogates in accordance with a code of ethics. The IPSA’s website carries a warning to improper applicants: “This is not a profession for people who are confused about themselves or who are simply looking for a good time.”

But even with strong and sane surrogates, would therapists be doing more harm than good? Does the answer lie in the source of the dysfunction; whether it can be fixed as easily as flicking a switch, or if it is caused by social factors that will return to haunt once the sessions are over?

One of Biran’s apparent success stories from his Tel Aviv practice is “Gadi”, a 29-year-old who was consumed by self-loathing because of a penis he believed was “deformed”. Gadi presented with impotence, a failed recent sexual encounter and an obsession that all would be well if only his penis were fixed.

His five-month treatment involved weekly therapy with Biran, plus regular sessions with one of his 10 surrogates, in this case “Inbal”, a 32-year-old Tel Aviv psychology graduate who was paid about $US100 ($A177) a session.

Gadi says the gradual process of getting to know Inbal allowed him to accept himself as a sexual being. “Initially you get acquainted by touch feeling each other and massaging each other, first with clothes on and then some clothes off until you progress to being naked,” he says. Sexual intercourse occurred only in the final sessions.

“You don’t just meet to have sex. We also connected on a personal level.”

Gadi’s long-term prognosis is difficult to gauge Biran does virtually no follow-up of his patients on the grounds it would be too intrusive.

As many experts point out, intimacy is a mysterious thing; responses to it, unpredictable. Throwing patients in the deep end, the argument goes, runs foul of a the holiest commandment: therapist do no harm.

Chloe Lovelidge, who heads the sexual counselling clinic at the Royal Women’s Hospital, says: “This mechanical approach, forming that emotional and dependent relationship with someone you are paying . . . If your aim is helping people form satisfying sexual and emotional relationships, then it’s counterproductive.”

One thing is certain: if Biran and Hickman’s clinic manages to get off the ground, debates many presumed had been put to bed long ago are sure to be aroused.

June 5 2003
This story was found at: http://www.theage.com.au/articles/2003/06/04/1054700271752.html