SURROGATE PARTNERS’ EXPERIENCES WORKING WITH SEX THERAPY

CLIENTS: A MULTIPLE-CASE STUDY

Jeffrey A. Bechthold

MIKE DOOGAN, PhD, Faculty Mentor and Chair

KENT FRESE, PhD, Committee Member

AMANDA LA GUARDIA, PhD, Committee Member

Elizabeth Riley, PhD, Dean of Psychology

Harold Abel School of Social and Behavioral Sciences

A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Capella University

April 2020
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© Jeffrey Allan Bechthold, 2020
 Abstract

This research study investigated how surrogate partners understand their experience working

with sex therapy clients. Surrogate partners and surrogate partner therapy (SPT) have been

neglected by scientific literature over the past half century. There is insufficient information on

the practice of SPT and there is no information on the contracted clinical confederate role of a

surrogate partner as described by the International Professional Surrogates Association (IPSA) in

the United States. This study used Yin’s embedded multiple-case study methodology from a

positive psychology theoretical perspective predominantly from the work of Seligman and also

from Forgeard, Jayawickreme, Kern, and Seligman. Surrogate partner experiences were viewed

with an exploratory perspective due to the general lack of recent information in the literature. A

cross-case data analysis generated six themes (Altruism, Professionalism, Treatment not

provided by clinicians, Unique calling, Being authentic, and Meaningful work) and supported all

areas of PERMA that included interactions of the areas to explain data (Meaning-Achievement,

Relationship-Achievement). The results of the thematic and pattern matching analysis supported

a statement of lessons learned to answer the research question: surrogate partners experience

their work as a calling, taken with the seriousness of a helping professional who has

therapeutically bonded authentic relationships as part of a complex and dynamic intervention

involving touch. This study improved theoretical knowledge in general psychology and positive

psychology. Research generalizability was supported through a defined sample containing many

similarities.
 Dedication

Dedicated to the glory of God, that those who suffer will find relief and that those who

relieve suffrage will persist in conviction.

iii
 Acknowledgments

Thank you to my family and life partner, who freely gifted the space and resources

required for dedication to this research.

Thank you to my mentor, Dr. Mike Doogan, your patience and positivity provided an

encouraging dialogue throughout this journey.

Thank you to Dr. Brian Guthrie, your mentorship laid a solid foundation from which my

research interests could grow.

iv
 Table of Contents

Acknowledgments.................................................................................................. iv

List of Tables ........................................................................................................ vii

CHAPTER 1. INTRODUCTION ........................................................................................1

Background of the Study .........................................................................................2

Need for the Study ...................................................................................................8

Purpose of the Study ................................................................................................9

Significance of the Study .......................................................................................10

Research Question .................................................................................................13

Definition of Terms................................................................................................13

Research Design.....................................................................................................15

Assumptions and Limitations ................................................................................16

Organization of the Remainder of the Study .......................................................211

CHAPTER 2. LITERATURE REVIEW ...........................................................................22

Methods of Searching ............................................................................................22

Theoretical Orientation for the Study ....................................................................25

Review of the Literature ........................................................................................29

Synthesis of the Research Findings .......................................................................73

Critique of Previous Research Methods ................................................................77

Summary ................................................................................................................83

CHAPTER 3. METHODOLOGY .....................................................................................85

Purpose of the Study ..............................................................................................85

Research Question .................................................................................................87

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 Research Design.....................................................................................................87

Target Population and Sample ...............................................................................90

Procedures ..............................................................................................................91

Instruments ...........................................................................................................101

Ethical Considerations .........................................................................................106

Summary ..............................................................................................................110

CHAPTER 4. PRESENTATION OF THE DATA..........................................................112

The Study and the Researcher..............................................................................112

Description of the Sample ....................................................................................116

Research Methodology Applied to the Data Analysis .........................................117

Presentation of Data and Results of the Analysis ................................................123

Summary ..............................................................................................................155

CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS ..................157

Summary of the Results .......................................................................................157

Discussion of the Results .....................................................................................160

Conclusions Based on the Results .......................................................................166

Limitations ...........................................................................................................174

Implications of the Study .....................................................................................176

Recommendations for Further Research ..............................................................177

Conclusion ...........................................................................................................178

REFERENCES ................................................................................................................180

vi
 List of Tables

Table 1. Clustered Pattern Codes .....................................................................................124

Table 2. Supported Themes .............................................................................................136

Table 3. PERMA Pattern Matching .................................................................................152

vii
 CHAPTER 1. INTRODUCTION

Surrogate partners are a specialized group of professionals who work with a clinician for

the benefit of clients who have conditions typically resistant to other mainstream treatments;

clients usually have several failed treatments before referral to a surrogate partner (Aloni,

Dangur, Ulman, Lior, & Chigier, 1994). According to the American Association of Sexuality

Educators Counselors & Therapists (AASECT, 2013), there is insignificant information about

surrogate partners and the therapy methods they employ. According to Apfelbaum (1984), the

use of surrogate partners have been suggested to originate in the 1960’s as most popularly from

Masters and Johnson (1966; 1970) and less popularly from Wolpe (1958), but the Hartman and

Fithian (1972; 1974) model is suggested as having a lasting impact through becoming the

underlying theory taught by the International Professional Surrogate Association (IPSA, 2020).

Surrogate partners have been termed universally with other names over the past fifty years

because of the sexual acts that may be therapeutically incorporated; such as a stand-in partner,

sexological bodyworker, sex surrogate, or individual bodywork sex therapist. Within the context

of professional clinical work (e.g., psychologists, psychiatrists, medical doctors), the use of a

surrogate partner is notably different due to the focus on relationship, communication skills, and

self-image (IPSA, 2020). Clinicians have not readily adopted the use of surrogate partners, in

part due to a lack of legal status, stigma, and risk factors associated to referring clients to have a

potential sexual experience as part of therapy (AASECT, 2014). Within this contentious context

for a therapeutic method (Holzum, 2015), there has not been significant research development.

1
Despite underdeveloped research and proportionally low usage, surrogate partners continue to be

a therapeutic method of public and professional interest (AASECT, 2013).

This research study investigated surrogate partners’ experiences working with sex

therapy clients. The existing research on this topic is limited and dated, as is demonstrated in a

literature review presented in Chapter 2. A case study (Yin, 2014) research methodology was

used to investigate this topic within the positive psychology (Seligman, 2000; Seligman &

Csikszentmihalyi, 2011) PERMA model (Foregeard et al., 2011; Seligman, 2011), as is

procedurally outlined in Chapter 3. A review of the data analysis is presented in Chapter 4, and

the research study conclusions are discussed in Chapter 5.

This first chapter introduces why an investigation of surrogate partners’ experiences

working with sex therapy clients is needed and provides an overview of the research conducted.

This introduction reviews the topic background, purpose, and current significance to the field of

general psychology. An overview of the research design is provided with theoretical orientation,

definition of terms, as well as the study's assumptions and limitations. This chapter closes with

an explanation of how the remainder of the research study will be presented.

Background of the Study

Surrogate partner therapy (SPT) is a treatment method used to improve relational and

sexual functioning. SPT is a supervised treatment method that originated from research

performed by Masters and Johnson (1966; 1970) half a century ago. Masters and Johnson first

described a stand-in partner who performs intimate and romantic acts within a controlled

environment and limited relationship. Current definitions of SPT involves a surrogate partner

(who has specialized skills) working as part of a psychotherapy team (specializing in sexuality)

to support a client’s therapeutic goals (IPSA, 2020), which is also consistent with how other

2
researchers (Dannacher, 1985; Noonan, 1984; 2000) have defined the term. Surrogate partners

provide interactions different than a medical professional (e.g., doctors, or physiotherapists) or

talk therapist (e.g., psychologist, marriage and family therapist, etc.); touching physical areas

associated to sexual stimulation on patients is not condoned for psychology professional

(AAMFT, 2015; AASECT, 2016; APA, 2010; CPA, 2017). Contact with a client’s genitals to

treat a perceived sexual problem is infrequent among professional associations; only described in

literature on pelvic physiotherapists (Cacchioni & Wolkowitz, 2011; Rosenbaum, 2005).

However, surrogate partners are not trained as medical or psychological practitioners but are

someone who can support client treatment goals through working in conjunction with a clinician.

Despite controversy concerning therapeutic sexual contact between surrogate partners and

clients, sexual touch is reported as only a small portion of the therapy (ICASA, 1998; Noonan,

1984).

Over the past 50 years, there has been no government required certification or registration

developed for people working as surrogate partners. There is also a lack of organizational

authority in SPT; there is no certification right required to use the term or concept of SPT, which

is unlike the term psychologist, doctor, or psychiatrist. IPSA (2020) operates as a prominent

professional association for surrogate partners in the United States with voluntary membership,

but there are no legal consequences for practicing SPT without their membership. For example,

Rotem (2019) has continued to operate under the SPT name despite actions attempted when

clients and therapists reported ethical violations to IPSA; IPSA could only remove Rotem from

their membership and could not prevent him from joining other associations. Despite not having

state or national recognition, SPT has benefited from IPSA through the promotion of education

3
and training of surrogates within the bounds of a licensed practitioner therapeutic team (Noonan,

2000).

Individuals who practice as surrogate partners are professionally unknown to the

scientific literature. Surrogate partner perceptions of the work they do has been obscurely

referenced in scholarly literature (Dannacher, 1985), and only surrogate partner self-reports have

appeared in scientific journals (Poelzl, 2000; 2011; Shapiro, 2017). The amount of scholarly

publications related to how a surrogate partner views anything is unlike the plethora of research

that has been done on people who practice psychology; likely due to the small number of

surrogate partners nationally and that SPT is not a scientific field dedicated unto itself (i.e.,

psychology is both a treatment practice and a scientific discipline), whereas SPT and surrogate

partners fit into a very small area within/between psychological and medical disciplines. The

knowledge base of SPT is easier to access in the form of periodicals (e.g., Evans, 2016; Garelick,

2015; Patz & Roberts, 2003) and popular media (e.g., Ashford, 2013; Lewin, 2012; Shalom-

Ezer, 2008). A criticism of these sources is that they fail to provide an adequate view of SPT not

only due to a lack of rigorous scientific design but also because these sources are bias to provide

marketable entertainment or use articles to improve advertisement revenue. However, due a lack

of scholarly research available, periodicals have been required to inform the research performed,

but with the information provided being held with reservation due to the unknown reliability.

The research area of SPT and surrogate partners has presented itself as a scientific void in need

of further discovery.

SPT and surrogate partners as an area of scientific inquiry is an unexplored area, but

potential researchers can be detracted from pursuit due to sampling challenges. As stated by

AASECT (2013), there is need for further topic inquiry but the number of people registered as

4
surrogate partners in a voluntary association is publicly listed as less than two dozen (IPSA,

2020), making this a very niche population. SPT has a very strong case for exploration due to

the unique potential benefits of improving client and societal understanding of this treatment

method, which has otherwise been informed by popular media (e.g., Ashford, 2013; Evans,

2016; Garelick, 2015; Lewin, 2012; Shalom-Ezer, 2008). In the United States, SPT is not a

service covered by healthcare plans and presents considerable costs to clients (IPSA, 2020;

Peredo, 1977). A client seeking out these services can be in a place of significant vulnerability

due to the power differential that a surrogate partner has the potential to exploit; clients are

typically in a desperate state for help and the cost can be considerable, such as two weeks of

intensive therapy at the school for Intimacy Consciousness and Self-Awareness (ICASA, 1998),

or referrals facilitated through IPSA (2020) cost approximately $8000USD. This position of

financial benefit for providing a service to vulnerable clients creates a potentially exploitive

relationship (Freckelton, 2013), which prompts questions about the surrogate partner’s financial

benefit, sexual satisfaction, or other things gained through the interaction. Potential client and

societal benefits need to outweigh the risks inherent to any intervention (APA, 2010; CPA,

2017), but this becomes especially important when vulnerable persons and sexual contact make

the legality and ethics questionable (Zur, 2019). Physical contact between a clinician and client

is not acceptable in ethical codes of conduct (APA, 2010; CPA, 2017) and failure to abide can

result in sanctions (e.g., Loriggio, 2017), which is why a third party to the clinician is required

for SPT. Scientific literature lacks unified procedures that demonstrate all parties (Client,

surrogate partner, and clinician) as protected by adequate safeguards; there were no peer-review

articles that addressed safeguards sufficiently other than Aloni, Dangur, Ulman, Lior, and

Chigier (1994) who describe how their Israel clinic tests clients and surrogate partners for

5
disease and infections, along with an honor agreement to practice safer sex with any other

partners. Given how little is known, basic information needs to be collected to frame the

relationship and nature of therapeutic intervention from a scientific perspective. While

improvement to SPT literature is needed, a detractor for performing this research was the

challenge of accessing participants who could provide firsthand experiences. As mentioned

earlier, there is no state or national registry, nor a single association where all people practicing

SPT can be found. For example, IPSA (2020), which has a relatively high influence (i.e.,

member stories have been featured in Hollywood films/national news outlets, published books,

and presentations to ASSECT), displayed 22 surrogate partners in their public membership

registry and recent total surrogate partners in the USA were estimated at only 75 (Scheers, 2016).

There is a significantly smaller sample population to draw from when compared to conducting

research that involves interviewing mental health professionals (e.g., psychotherapists, medical

doctors, psychiatrists). Despite the need for SPT research, the work involved to prepare for a

study that may not be successful due to low sampling rates may help to explain the lack of

independent scholarly research being published. A small number of research articles were

recently published in scholarly journals within close succession with support from Aloni (Aloni

et al., 1994; Aloni & Heruti, 2009; Aloni, Keren, & Katz, 2007; Ben‐Zion, Rothschild,

Chudakov, & Aloni, 2007; Rosenbaum, Aloni, & Heruti, 2014), who operates a clinic in Israel

that incorporates the use of surrogate partners; there was no evidence of a clinical setting being

currently used in the United States and therefore these studies may not generalize. Additionally,

Aloni (2020) stands to directly benefit from publishing in scholarly journals by virtue of self-

promoting treatments that are unique to that clinic. As well, Poelzl (2000; 2011) and Shapiro

(2002, 2017) as surrogate partners stood to benefit from validating their work with scientific

6
journal publication. This research performed on surrogate partners provided a new contribution

of understanding that was only possible through the efforts of independent research.

This research explored how surrogate partners understand their experiences using

positive psychology’s PERMA model (Forgeard et al., 2011; Seligman, 2011). Due to the low

number of scholarly research articles on surrogate partners, the prior research failed to provide a

sufficient framework to inform of potential general psychological theories; previous publications

particular to surrogate partners lacked theoretical relevance as seen in Poelzl’s (2000) description

of her own SPT work or Dannacher’s (1985) quantitative methodology that tested the

relationship between the knowledge base on one’s work and self-concept. The psychological

theory for the research performed were selected based on general information available about

surrogate partners describing that they enjoy their work for the sake of the work itself, describing

the work to provide positive emotions, authentic connections with others, and a sense of meaning

or purpose by how they are helping others (Patz & Roberts, 2003; Poelzl, 2000). Published

surrogate partner descriptions of their positive work experience had a direct parallel to the

PERMA model; feeling positive emotions, engagement, authentic connections, accomplishment,

and purposeful existence (Foregeard et al., 2011; Seligman, 2011). Conversely, these

publications (Patz & Roberts, 2003; Poelz, 2000) may not have included or been able to get

someone who had a negative work experience with SPT, but the use of PERMA as a theoretical

framing for this research remained relevant because an opposing view could still be framed as an

antithesis. The use of the PERMA model is not only positivistic, as it can also show deficiency,

such as the person does not have a sense of accomplishment due to not achieving anything they

deem as worthwhile in their work. An implication of using PERMA is that the participant data

collected was sectioned into areas that fit the model, which bolstered the focus of the analysis

7
findings. The PERMA model informed the research design to frame this case study (Yin, 2014)

with data collection, analysis of data, and conclusions. This research provided a descriptive

baseline of how a group of surrogate partners experienced and understood the therapeutic model

they work in. By implication, future researchers may have a better understanding of how to

approach data collection and research design in the area of SPT.

Need for the Study

There was a swell of research interest early in the development of SPT, but literature

since Masters and Johnson (1966; 1970) has remained scarce. Early research (such as Jacobs,

Thompson, & Truxau, 1975; Kaplan, 1988) focused on the application of surrogate partner

therapy to various client concerns and the methods that surrogate partners employed as part of

treatment. Within the SPT framework, a male had been treated with systematic desensitization

for anxiety towards talking, kissing, and touching a woman (Zentner & Knox, 2013). Aloni

(2020) is a prolific publisher, contributing many research articles concerning the use of SPT as

part of a health practice located in Israel. The treatment center assists clients with developing or

restoring sexual function for a variety of concerns (Aloni et al., 1994; Aloni & Heruti, 2009), a

few that have been published on traumatic brain injury (Aloni et al., 2007), vaginismus (Ben‐

Zion et al., 2007), and pain disorders (Rosenbaum et al., 2014). However, Aloni’s research may

not generalize to the United States due to application differences between the Israel treatment

center and SPT in the United States, which is practiced outside of clinical settings (IPSA, 2020).

Other contributions to SPT literature have been indirectly related to the treatment model

and have been used to promote sex positive attitudes. Holzum (2015) examined therapist

attitudes towards SPT in a master’s thesis, which had significant attention to how sex has been

framed negatively through societal repression and harmful effects. Dannacher’s (1985) thesis

8
explored measures of self-concept and sexual adjustment in female surrogate partners that was

found to be higher than a random sample; this is expected given that the rating scales on sexual

adjustment consisted of knowledge of or experiencing a wide variety of sexual experiences.

Despite being over thirty years old, Noonan’s (1984) master’s thesis has continued to support

literature on what surrogate partners spend their time doing. According to Noonan’s early

(1984) and later update (2000), most therapy time is spent on non-sexual touching activities,

sensuality, and body awareness. Surrogate partners were also framed as individuals who are

interested in helping others with social and sexual concerns, motivated by altruism (Jacobs et al.,

1975; Patz & Roberts, 2003; Poelzl, 2000). However, these few articles failed to provide

adequate and up to date insight into surrogate partners or the current practice of SPT.

Purpose of the Study

The purpose of this study was to understand more about surrogate partners who practice

within a SPT triadic model of a clinician and client. This research investigated the perceptions

surrogate partners had about themselves and the therapy work they performed. In 2013,

AASECT called for greater inquiry into SPT so that clinicians could be informed of the potential

client treatment benefits. Therefore, a main goal for this research was to take an exploratory

view of surrogate partners due to the lack of recent scholarly literature. The data collected

provided details from a PERMA model (Foregeard et al., 2011; Seligman, 2011) perspective on

what surrogate partners do in therapy, how they feel and experience the work they do, and the

meanings and purposes constructed by working in the area of SPT. The findings of this research

expected to improve the scientific psychological knowledge base, clinicians, SPT clients, and

SPT knowledge.

9
 Significance of the Study

The research findings held significance for the main stakeholders who lack current

scholarly information about surrogate partners. The research community has a small scientific

knowledge base for the area of SPT. Clinicians and SPT clients have less information from

which to make decisions because SPT as a method needs more information to improve upon its

effectiveness and general society misunderstands SPT as akin to prostitution due to a lack of

knowledge (Hutchins, 2011). Improving knowledge on surrogate partners is part of improving

an overall understanding of SPT.

This research serves to inform the scholarly body of knowledge in understanding

surrogate partners, SPT as a treatment modality, and informing future research. Whether or not

SPT remained a reasonable area for scientific inquiry was considered with questions about the

current level of societal interest, the current state of research literature, and what stakeholders

have stated about further inquiry. Societal interest appears renewed in the past decade, with

examples seen in documentaries (Dennett, 2017; IPSA, 2013), films (Ashford, 2013; Lewin,

2012; Shalom-Ezer, 2008), books (Cohen-Greene, 2012), internet first person account videos

(Cohen-Greene, 2013; Heartman, 2018), and articles (Colley, 2018; Evans, 2016; Garelick,

2015; Patz & Roberts, 2003) attesting to SPT as an issue of current relevance. Although there is

little scholarly research in the area of SPT, there has been a resurgence in recent years (e.g.,

Aloni, 2020), which suggests that the topic is still important. Stakeholders such as ASSECT

have expressed the importance of SPT as a treatment modality to be further understood in

publications (2013) and by inviting the IPSA president to speak at their conference (2014).

The impact of informing scientific literature has the greatest potential effect for clients

receiving treatment and clinicians who decide on what methods are likely to provide potential

10
therapeutic benefit for their clients. Providing scholarly information about surrogate partner

understandings of SPT will improve decision making for clinicians investigating the method, as

the most current information is predominantly within popular culture media. SPT as a

therapeutic modality can improve upon itself through understanding the people who have chosen

to practice as surrogate partners. The availability of understanding SPT will improve through

how this research can provide more up to date information about surrogate partners. Consider

the differing effect the literature would have on informing SPT clients if this research confirmed

altruistic ideas found in other publications (Dannacher, 1985; Poelzl, 2011) as compared to if

surrogate partners were found to be predominantly motivated by their own financial or sexual

benefit. SPT benefits from this research by the ability to make more informed decisions through

greater understandings of surrogate partner activities and how surrogate partners view their own

work.

Surrogate partners and SPT conceptualization shows disparity in the most commonly

attributable repertoire. The exchange of money for services that may contain sexual stimulation

is the typical focus point for people who associate surrogate partners with prostitutes (Freckelton,

2013). However, prostitution is not a truthful comparison if sexual contact is only a small

portion of SPT (Noonan, 1984). According to theories in discursive and social constructivism

(Potter & Hepburn, 2008; Wetherell, Taylor, & Yates, 2001; Wetherell, Taylor, & Yates, 2010),

people construct interpretive repertoires to group ideas and constructs, but are prone to use the

most readily available repertoires instead of creating new ones that are more suitable (Potter,

1996). The descriptions of SPT in the research literature provides other interpretive repertoires

where surrogate partners are like social skills coaches (Zenter & Knox, 2013), systematic

desensitization exposure therapists (Hosie, 2017), or pelvic physiotherapists (Rosenbaum, 2005).

11
However, as Holzum (2015) has stated, there is prejudice surrounding the activities of sexual

contact that makes the use of prostitution in a negative context more likely to be the repertoire

chosen. This research was based on an assumption that surrogate partners would most closely

relate to the interpretive repertoire of a social skills coach (i.e., Gabriel, Read, Young, Bachrach,

& Troisi, 2017; Souma, Ura, Isobe, Hasegawa, & Morita, 2008) applied to the areas of

relationships and sensuality. Social skills coaching holds very close parallels to SPT given the

significant relational building involved in romantic relationships (Gottman, 1999; Zenter &

Knox, 2013; Zilbergeld & Ellison, 1979); social skills and sexual function were known as related

factors (Stravynski, 1986) around the time of first applications of SPT to single men (Masters &

Johnson, 1977). Social skills coaching involves direct and explicit practicing of any goals

related to improving social skill functions; such as practicing a conversation, shopping at a store,

or going to movie. Based on a comparison to social skills coaching, surrogate partners were

expected to explicitly practice any goal that related to improved functioning as a romantic or

relational partner. Concerning the influence of psychological conditions (e.g., anxiety,

depression, distorted schema), the clinician’s guidance was expected to influence the surrogate

partner to set goals with the client and agree on practices that had potential therapeutic benefit.

This research on surrogate partners contributed to the field of general psychology.

General psychology covers a large content area, defined as

The broad study of the basic principles, problems, and methods underlying the science of

psychology, including areas such as behavior, human growth and development, emotions,

motivation, learning, the senses, perception, thinking processes, memory, intelligence,

personality theory, psychological testing, behavior disorders, social behavior, and mental

12
 health. The study is viewed from various perspectives, including physiological, historical,

theoretical, philosophical, and practical. VandenBos, 2015, p.453

This research also utilized positive psychology’s PERMA model (Seligman, 2011) to understand

surrogate partners’ experiences. Understanding the ways that a surrogate partner understands

their experience from a general and positive psychology perspective served to improve the

theoretical knowledge in these areas of psychology.

This research expanded and improved upon the understanding of positive psychology’s

PERMA theory (Seligman, 2011) application to a case study methodology (Yin, 2014). A

significant value to positive psychology is the promotion of factors known to improve

individuals and communities. These research findings are available for the stakeholders (e.g.,

researchers, clinicians, clients, policy makers, etc.) to improve upon existing theories and to

make more informed decisions. This study also provided information from a sample population

that is more closely defined due to sharing the same membership, code of ethics, and the United

States as a country of practice, something which has not been delineated in previous research.

Therefore, an additional significance for this research was how the sample population had more

in common with one another and therefore the data set is believed to more closely highlight

commonalities of the theoretical orientation as applied to the area of surrogate partners.

Research Question

How do surrogate partners understand their experience working with sex therapy clients?

Definition of Terms

Key terms for this study are included below:

Sensate focus. An active intention within oneself to attend to and focus on the sensations

of receiving and giving touch. This can refer to touching objects or another person, or being

13
touched by another person or object (Masters & Johnson, 1970). This is an exercise based in

mindfulness and is utilized by therapies of various disciplines.

Sexualized touch. Being touched or touching another person for the purposes of sexual

excitation (Rosenbaum, 2005). The use of touch from one person to another is highly

interpretive, which means that the intentions of the parties involved will create a different

context of interpretation. For example, the way a person is touched on the shoulder can provide

a sexualized touch, whereas touch to the genital areas is unlikely to be sexual in the clinical

nature of a pelvic exam.

Stimulating touch. Excitation of receptors in the nervous system and expected

physiological responses. Touching any area of the body sets off a chain reaction that is tempered

by the central nervous system. The use of stimulating touch describes the contact of body parts

for the purpose of providing a stimulus that a physiological response can be observed and

therapeutically interacted with. This may or may not include areas typically associated to sexual

excitation (Rosenbaum, 2005).

Surrogate partner. The use of surrogate partner in this research is defined as someone

who received specialized training for the purpose of treating physiological and psychological

concerns, adheres to an agreed upon code of ethics within an association of qualified

membership, and provides client treatment with in a triadic model (Client, surrogate partner,

clinician) (Noonan, 1984; 2000).

Surrogate partner therapy. The use of the term SPT in this research was limited to

therapeutic interventions occurring within a triadic model (client, surrogate partner, clinician),

which is consistent with prior research definitions. SPT is understood to treat conditions related

to relational and sexual function but may not include sexual intercourse (Noonan, 1984).

14
 Research Design

The research design utilized a qualitative embedded multiple-case study methodology

(Yin, 2014) using a theoretical perspective from positive psychology’s PERMA model (Forgeard

et al., 2011; Seligman, 2011). Qualitative research design (Creswell, 2013) provided an

advantage of using nonprobability sampling, which enabled a stronger focused search for a

sample population that possessed specific surrogate partner characteristics. Criterion based

purposive sampling (Wengraf, 2004) also guided the sampling techniques, which limited

participants by ensuring they possessed the desired characteristics (i.e., working within a

clinician triadic model, length and recency of experience), while also being able to omit

participants with undesired characteristics (non-professional triadic model). A goal of the case

study method of inquiry (Yin, 2014) is to provide greater in-depth understanding of a topic using

multiple data sources, to provide layered evidence during the data analysis. Data was collected

through guiding question interviews (allowing for divergent conversation, but maintained

theoretical guidance), as well as other sources of data presented by participants or as observed by

the researcher. This research used case study’s embedded design, meaning that the analysis was

on the individual participants each as cases before a cross-case synthesis was performed

thematically. Data analysis procedures included thematic analysis (Braun & Clarke, 2013) and

pattern matching (Yin, 2014) according to the individual areas of the PERMA model. Yin warns

that case study design appears deceptively simple but is far more rigorous due to the prescriptive

design elements and the need for theory integration to provide a defined structure. In other

qualitative methods such as phenomenology, generic, or grounded theory, multiple participants

are providing data sets that consecutively expanding and inform the researcher of the area of

inquiry. Whereas, Yin’s case study approach binds cases where each participant provides a data

15
set for an individual analysis against a theoretical model. Within this research, each surrogate

partner’s data (e.g., interview transcript, case notes, profile information, etc.) was analyzed

individually using thematic analysis and pattern matching to the PERMA model first, after which

an expanded comparison was made across and between each of the surrogate partner data

findings in a cross-case synthesis. Therefore, interview data sets could use unique

understandings for each participant to contribute to the whole group understanding. This

research design provided evidence on the positive psychology theoretical orientation and

surrogate partner area of research within the discipline of general psychology.

Assumptions and Limitations

The multiple-case study (Yin, 2014) methodology and positive psychology PERMA

model (Forgeard et al., 2011; Seligman, 2011) provided assumptions and limitations, along with

those congruent to surrogate partner data based on a review of the literature (See Chapter 2:

Review of the Literature). The assumptions and limitations of this research were important to

denote because qualitative research allows for differing interpretations, meaning that the reader

could make alternative assumptions otherwise. The researcher was an instrument that processed

data and therefore was part of the research methodology; the potential effect is significant given

the many choices made concerning the design, interpretation, and implementation of theoretical

understanding. Below is a discussion of the assumptions and limitations of this research

conducted on surrogate partners.

Assumptions

Ontological assumptions define how reality is interpreted within the basis of the

measured experience or phenomenon. Ontological assumptions range from the belief that there

is only one reality to the belief that each person has their own reality apart from everyone else.

16
Positive psychology theory (Forgeard et al., 2011; Seligman, 2011) supported a constructivist

position for this research, which means that people understand their reality based on the

constructions available or created by them (Potter, 1996). This research viewed surrogate

partners as each experiencing their own individual reality but with significant overlap due to

similar social constructions that are provided from similar experiences (e.g., location in the

world, SPT, agreeable to research participation, etc.). Additionally, discursive social

constructivism (Potter, 1996; Potter & Hepburn, 2008) informed the ontological assumptions of

reality as being constructed from the discourse(s) available to the social contexts therein.

Meaning that the linguistically anchored data provided a reality that constructs meanings apart

from the actual experiences themselves; this is due to differences between each person’s

understanding of their socially and discursively constructed reality (i.e., the researcher may or

may not have had the same understanding of what a participant’s words mean, and the words

available could only provide a portion of understanding by the descriptions given). In the

practice of case study (Yin, 2014) research, there was an attempt to narrow the ontological gap

through gathering data in multiple ways for the areas of analysis and the use of member checking

to provide data that is potentially more stable through adding a time and participant confirmation

dimension to the data. Although objective reality is unknowable, this research assumed that a

reasonable understanding of surrogate partners could be gained from the commonality of socially

constructed discourse among participants.

Epistemological assumptions are the basis of how knowledge is formed, which applied to

this research is a discussion of how much influence the participant and researcher had on the data

collected. An assumption can be made on a range from the researcher and participant being

completely separate or entirely intertwined. This research assumed that the participant and the

17
data collected therein was influenced by researcher interactions, which is why researcher bias

and beliefs were important to disclose. Given the guided interview style of this study, the

participant undoubtedly provided data that was influenced by the researcher; further evidenced

by how the researcher attended to and followed up on select information. The participant was

also assumed to influence the researcher, meaning that there was a mutual effort on how and

what information was attended to. Within the PERMA model (Forgeard et al., 2011; Seligman,

2011) underlying theory and multiple-case study (Yin, 2014) research methodology, the

assumption of influence was attempted to be minimized through the categorical focus of the five

areas of analysis with multiple sources of data.

Axiological assumptions are the extent that a researcher's values and biases influence the

research. The range of influence can be considered as none at all to completely altering, which

within qualitative research, and case study particularly, the researcher values and biases are

thought to influence the data and conclusions (Yin, 2014). The researcher’s values and beliefs

were declared to improve the validity of the research so that the readership could understand

sources of potential influence. Axiological assumptions that may influence this study was that

the researcher believed surrogate partners to typically pursue their work as a professional activity

and for altruistic reasons. The researcher also declared that the pursuit of this topic required

defending the validity of SPT as a therapeutic technique, which then served to embed a sense of

advocacy for improve understanding around the topic of SPT. Concerning the influence of the

researcher on theoretical understandings, the researcher also declared that his practice as a

psychologist was informed by a positive psychology orientation (Seligman, 2011).

The methodological assumptions of a qualitative multiple-case study (Yin, 2014) and

positive psychology PERMA model (Forgeard et al., 2011; Seligman, 2011) provided

18
information about the ability to generalize, establish causality, and logic. Generalizations are

permissible within case study research according to the similarity of the variables and group

comparisons being made; this research attempted to succinctly define the sample group by

explaining their similar characteristics to assist with such types of generalizations. Causality, as

a narrowly defined sequence of how something is influence by another (e.g., success rates in the

use of antibiotic for the treatment of bladder infections) is appropriately addressed by

quantitative studies, whereas this research study was interested in describing, understanding, and

explaining something (e.g., how a person being treated with antibiotics feels throughout the

course of treatment). The ability to establish causality is linked to differences between

qualitative and quantitative logic, such as Yin’s (2014) description of qualitative research

(Creswell, 2013) being primarily inductive and quantitative research using deductive logic. In

general terms, this research assumed an inductive logic that provided interpretations and

meanings where generalizability is only limited to a researcher’s conception of sample

comparability (Yin, 2014). This research was also shaped by positive psychology’s PERMA

model (Forgeard et al., 2011; Seligman, 2011) by how the focus was on factors that promote

individuals and communities to thrive versus other theories that have a problem focus (i.e.,

factors of maladaptation, injury, or disorder).

Limitations

Limitations to this research study as related to the research design and as well as the

delimitations of uninvestigated research topic areas are discussed in this section. The

ontological, epistemological, and axiological assumptions of qualitative inquiry create

methodological limitations on the objectivity of data and findings. Bias can arise from

participant interview data, which would be different if participants were only provided question

19
sheets they responded to, but the data would then risk lacking the richness and details needed to

address the research question (Creswell, 2013). The selected theoretical orientation served to

limit data to the relevance of the PERMA model (Forgeard et al., 2011; Seligman, 2011), which

means that other interesting elements within the data were discarded in favor of a narrower

focus. However, narrowing of data was important for this qualitative research so that the

findings could be specific enough to make a valuable contribution to the theoretical and topic

area. This design did not address concerns of participant deception or collusion, as there was no

practical way to check if the information provided had been untruthful or unduly influenced; to

add such a design element would have likely also reduced rapport by assuming socially negative

attributes of deception. In summary, the use of case study (Yin, 2014) as an established

methodology had sufficient objectivity as has already been established within its own

methodological tradition. Limitations to impartiality were also tempered by the research design

through declared bias, member checking, and third-party reviews (See Chapter 3).

Some delimitations of this study were intentionally used as protective factors for the

surrogate partner participants and the general area of SPT, as well as to improve the general

nature of inquiry on this topic area to be scientific instead of voyeuristic. Services like sex

coaching (Goddard, 2013; Stein, Britton, Gunsaullus, & Dunlap, 2017), bodysex workshops

(Dodson Foundation, 2019), and other genital contact services for sexual function improvement

(Hutchins, 2011) or pertaining to disability and sexual access (Mintz, 2014; Perlin & Lynch,

2014; 2016; Timmins, 2017) are not covered by this research; investigation was limited to

surrogate partners working within a triadic model. The use of collected data that would

otherwise be taken as overtly salacious, scandalous, or otherwise outrageous was believed to

propagate a damaging social construction of surrogate partners and SPT, further engendering an

20
inaccurate and negative view; as was evidenced in a review of popular media, speaking with

representatives from IPSA (2020) and ICASA (1998), and also came up in discussions with

surrogate partners within the United States and as well as out of country. Although acts

involving genitals are implicit to SPT, this research deliberately avoided presentations of such

acts as they were not the focus content of this study. What a surrogate partner spends their time

doing within this therapy model was not sufficiently addressed either, which was due to client

activities not being a focus area for the research performed. Client responsiveness to treatment

and outcomes were also not sufficiently addressed, as this research investigated surrogate partner

perceptions of their experiences in SPT and did not include therapeutic measures.

Organization of the Remainder of the Study

This first chapter has provided an overview of the research on surrogate partner

experiences working with sex therapy clients. Details were highlighted from the topic

background, purpose, significance to the field of general psychology, and provided an outline of

the research design, theoretical orientation, definition of terms, as well as the study's assumptions

and limitations. Chapter 2 will review the literature to extensively discuss and evaluate the

current and historical research literature. Chapter 3 addresses research methodology, providing

details on the design and theory, research question, sample population, sample collected, and

procedures therein. Chapter 4 discusses the research findings, including: sample descriptions,

the research methodology and theory applied to data collection, the analysis, and findings.

Chapter 5 summarizes the research findings, discusses the results, and conclusions, followed by a

final discussion of the research limitations, implications for SPT, and recommendations for

future research.

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 CHAPTER 2. LITERATURE REVIEW

This chapter discusses the background and elements underlying to the research study

conducted. The use of positive psychology’s PERMA model (Forgeard, Jayawickreme, Kern, &

Seligman, 2011; Seligman, 2011) will be discussed in terms of background and how it serves to

inform this research; PERMA is an acronym for Positive Emotion, Engagement, Relationships,

Meaning, Achievement. A review of the literature relevant to the research area of surrogate

partners and SPT is presented and examined, including procedures used to find literature.

Literature on SPT is sparse, which required broad collection methods as discussed in tiers of

quality and reliability. This chapter is arranged by first describing the methods of searching,

theoretical orientation, and a review of the literature. The latter portion of this chapter will

provide a synthesis of the research findings and a critique of the research methods previously

used within in SPT.

Methods of Searching

The research literature used to inform this research has been predominantly obtained

from Capella University's library database access. The Capella University library common

summons search bar was used, as well as psychology specific journals like Academic Search

Premier, Dissertations and Theses Global, ProQuest Central, PsycBooks, SAGE, and Worldcat.

The information available on SPT was limited, so other methods of searching were used but

remained unsuccessful at significantly uncovering new information; this included web searching

(i.e., Google Scholar, Google, Bing, Yahoo) and then changing the requesting computer IP

address in conjunction with a web translator tool for outside of North America searches. From

22
the small number of existing research articles found, all relevant references within these article’s

reference lists were searched and reviewed for topic relevance. The primary and supporting

authors of the known SPT research articles were used to search for other potential research

articles based on abstracts and titles to form a basis of a more detailed review for relevance; this

method added some articles, but had limited relevance to the topic by virtue of overlapping sites

or similar but not directly relevant information to SPT. The articles that provided SPT literature

reviews served to inform the researcher of further names and organizations that could potentially

provide information to inform this research, such as Cheryl Cohen-Greene (2012; 2013) and

IPSA (2020). The personal/professional webpages of people and organizations related to SPT

served to provide references to other informational sources (scholarly and otherwise). The

names of organizations and people listed as practicing SPT were searched in Google, Capella

University Library, Worldcat, and bookstores to uncover further articles of relevance; this type

of searching led to obscure findings such as a former SPT client’s positive review on

Amazon.com. Many of the sources related to SPT were older and unavailable (even to Capella

Library interlibrary loan); which then required searching for out of print copies in university

libraries (many were being purged or were no longer available) and wholesale purchasing of a

print copy that had been retired. The process of gathering information for the literature review

had been exhaustive to the best knowledge of the researcher and ended when sources only

referred back to already known sources.

There is an overall underwhelming amount of literature on the topic of surrogate partners

and SPT. This topic area has remained underdeveloped and recent studies on surrogate partners

continues to be uncommon. Keyword searches for surrogate partner therapy in Google Scholar

on October 21, 2016 produced few returns for publication after 2012: surrogate partner therapy,

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20; surrogate partner, 91. Other search terms were used as found within the literature already

uncovered, search terms for sex surrogate, sexual surrogate, and bodywork therapist (Tiefer,

2006) uncovered limited resources. Wider search terms have failed to find significant research

directly relevant to surrogate partner therapy: pelvic physiotherapy; bodywork; sexological

worker; sexological therapy; sacred intimate. On July 14, 2019, the same search terms failed to

provide additional relevant literature, but rather produced articles concerning opinions on SPT

from people that had no direct experience or education on SPT (e.g., Denton, 2018) and other

articles that have referenced the word surrogate partners with a nonrelevant definitional context

of a different phenomenon such as artificial intelligence (Kostopoulos, 2018) or child sexual

abuse constructed as the child acting as a partner for an adult (Christensen, 2017). Consultations

with Capella University librarians did not uncover additional literature other than what was

already known to this research. Consultation with Capella University specialization chair, Dr.

Weston Edwards, confirmed that there is very little current literature on SPT, and therefore much

older references would be needed to bring context to the sparsity of current literature. The most

current information available is from popular media such as first-person accounts, books, or

movies, which are shaped by news writers, the entertainment industry, or just personal opinions

(e.g., Evans, 2016; Roberts, 2018). The low amount of scholarly inquiry is unmatched to the

popular media interest seen in recent years (Ashford, 2013; Dennett, 2017; Lewin, 2012;

Shalom-Ezer, 2008), which infers the need to establish current scholarly research to reflect

changes occurring since the inception of surrogate partner therapy half a century earlier (Masters

& Johnson, 1970). Without current scholarly research, clinicians and clients are left to

understand surrogate partners and SPT from the information most readily available in popular

media.

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 Theoretical Orientation for the Study

This section describes the PERMA model within positive psychology (Forgeard et al.,

2011; Seligman, 2000; Seligman 2011; Seligman & Csikszentmihalyi, 2000), applications within

scholarly literature, and discusses the suitability as an underlying theoretical orientation for this

research. The PERMA model comes from a theory on wellness and is the result of significant

research on factors known to improve individuals and communities. The PERMA model has

been used in various contexts and in different cultures (Lambert D’raven & Pasha-Zaidi, 2016;

Watanabe et al., 2018), further bolstering the universality of the theory. The research area of

surrogate partners has mainly focused on descriptions (Poelzl, 2000) or opinions within a

treatment context (Holzum, 2015, Richardson, 1990). However, information provided on

surrogate partners (Dannacher, 1985; Poelzl, 2000) indicates a high level of compatibility to the

PERMA model.

Positive Psychology’s PERMA Model of Well-Being

This section expands on the PERMA model as a theoretical orientation from positive

psychology (Forgeard et al., 2011; Seligman, 2000; Seligman, 2011; Seligman &

Csikszentmihalyi, 2000). Positive psychology is a theoretical understanding that focuses on

factors that promote wellness. This position of promoting wellness is fundamentally different

than deficiency models that have focused on the absence or presence of diseases or disorders.

Over the history of positive psychology, five areas of PERMA emerged from groupings of

variables known to relate to well-being; PERMA is a mnemonic for positive emotions,

engagement, relationships, meaning, and achievement.

The initial focus of positive psychology was predominantly on positive emotions (i.e.,

cheerful, joyful, content) or feeling good. The category of positive emotions not only relates to

25
observable experiential elements (e.g., smiling, laughing), but also the self-assessment of one’s

overall situation. What a person mentally focuses on is known to impact emotional states

(Killingsworth, 2010), therefore cognitive processes such as the ability to maintain optimism

despite challenges are included in this category by extension. The benefits of experiencing

positive emotions are well documented as improving many other aspects of a person, such as

physical health, clarity of thought, and improved life satisfaction (Seligman & Csikszentmihalyi,

2000).

The second area is engagement and is also described as finding flow. Engagement is

more of a difficult concept to understand because it relates to being absorbed into an activity that

can also involve the enactment of mastery or levels of interest. The category is not about

performing mundane tasks, but where the task takes a level of skill that the person possesses and

enjoys matching their skill to a task. As described by Pascha (2020), “engagement stretches our

intelligence, skills, and emotional capabilities (p.2),” this can include many things like hobbies,

work, or creative expressions (e.g., art, music).

The third area is relationships and is also described as authentic connections. Having a

connection to others, feeling loved or cared for, and being a valued part of a social structure are

all facets of the relationship category. Recent revisions to this category included statements

about relationships being worth their pursuit outside of wellness and can also relate to other

categories such as positive emotion or meaning (Seligman, 2011). The benefit of quality

relationships is also consistent with a survival instinct within human evolution, which is to say

that people are more vulnerable in isolation and therefore need social connections (Pashcha,

2017). The relationship category holds an overall idea of being connected to others in ways that

are advantageous and feel beneficial in a broad sense.

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 The fourth area is meaning and can also be described as purposeful existence. The idea

of meaning is highly constructivist because this relates to what a person values or their beliefs.

Meaning relates to answering questions about why a person behaves as they do or what is the

meaning of their life (Seligman, 2011). Life meaning can be derived from actions like

volunteering and promoting causes but can also relate to ideals like those found in religion or

spirituality (Pascha, 2020). Attributes of the meaning category can be thought of as the degree of

satisfaction with how a person sees their actions relating to what they value.

The final area is achievement, or a sense of accomplishment. Achievement relates to

progress made towards a goal evaluated by external or internal markers. Stated implicitly or

explicitly, achievement relates to the ability a person has to enact changes that are personally

meaningful. Achievement is also seen as related to mastery and success (Forgeard,

Jayawickreme, Kern, & Seligman, 2011). The idea of achievement is constructivist, as it relates

to the intrinsic value placed on success by the individual.

Validity and Application of PERMA as a Theoretical Lens

The validity and application of PERMA as an underlying theory for research and the

practice of psychology is well established. Cross cultural studies using PERMA have shown

results consistent with increased well-being. Watanabe et al. (2018) validated a PERMA based

profiling tool to successfully measure well-being in Japanese employees. In the United Arab

Emirates, the PERMA model was found to successfully align with students’ descriptions of

happiness (Lambert D’raven & Pasha-Zaidi, 2015). These studies exemplify the robustness of

PERMA as a theory across diverse sampling.

The versatility of PERMA as a theoretical lens is seen in various research articles such as

these discussed below. Well-being was measured using the PERMA framework within a large

27
sample (N = 516) of students (Kern, Waters, Adler, & White, 2015) but also in a case study

design involving a single autistic student (Roncaglia, 2018). The use of PERMA in larger and

smaller sample contexts is consistent with the model’s interest with individual and community

well-being. PERMA has also been used in the development of employee well-being evaluation

questionnaires (Kun, Balogh, & Krasz, 2017). Ascenso, Williamon, and Perkins (2017) used the

PERMA model to better understand a group of professional musicians and how they experienced

well-being. Ascenso et al.’s research on a highly defined group within a professional context

holds significant similarity to this research performed on surrogate partners because their data set

served to significantly inform the literature of their experiences. The use of PERMA as a

theoretical lens in this research serves to provide a narrow and more relevant focus.

Fitness of PERMA as a Theoretical Orientation for Surrogate Partner Research

Support for a psychological theoretical orientation directly used in the area of surrogate

partners or SPT is not explicit within the scholarly literature; likely related to the extremely

limited amount of research. However, the use of the PERMA model appears to be implicit to

literature on surrogate partners themselves. Surrogate partners were described within

Dannacher’s (1985) research article as having a high level of sexual adjustment, which is

congruent with positive psychology’s investigation of how people thrive (Seligman, 2011).

Poelzl (2000) displays her experience as a surrogate partner performing SPT as fulfilling,

rewarding, and altruistic, which relates to elements known to positive psychology as important to

wellness. The most explicit record of surrogate partner understandings to date has been in a

Psychology Today article, where eight surrogate partners provided first-person narratives about

their perceptions and experiences as related to SPT (Patz & Roberts, 2003). The eight surrogate

partner narratives contained themes of purpose, accomplishment, relational connections, positive

28
emotions, investment in SPT as a cause, concern for healing the pain of clients, and conflict with

the social stigma; all these themes relate to the PERMA model. Research on surrogate partners

fit within the PERMA model from positive psychology based on these examples that indicated

high levels of satisfaction while working as a surrogate partner.

A theoretical orientation informs the research study methodology and design. Case study

(Yin, 2014) is a unique qualitative method because of how the theoretical orientation affects the

use of the methodology. Case study design holds increased theoretical testing rigor because the

theory that informs the research is required to form a basis for data analysis; meaning that the

focus is on how the data is processed rather than the data itself. Applied to the research design of

this study, the PERMA model guides participant data by what is filtered in or out of focus. The

data was collected in arrangement to the PERMA model through the guiding questions and in the

analysis of data. Participant data sets were examined for the five categories of the theoretical

model: positive emotions, engagement, relationships, meaning, and achievement. Each data set

analysis was considered a separate repetition of the same experiment that evaluated data based

on the underlying theory. After all data sets were fully examined, data findings were considered

across all separate data sets and between each of the separate data sets. Therefore, a case study

methodology served to bolster the influence of the PERMA theoretical orientation within this

research.

Review of the Literature

Sex as an area of scientific study grew immensely after the Kinsey reports (Kinsey,

Pomeroy, & Martin, 2003; Institute of Sex Research & Kinsey, 1953) and Masters and Johnson

(1966; 1970) further popularized the topic through publicizing their research findings. Sex is

demonstrated as important to western societies through portrayal in media, advertisements, and

29
education but has historically been scientifically reasoned as part of a long-term relationship

(Meston & Buss, 2007). According to positive psychology theory (Seligman, 2011), sexual

functioning contributes to overall well-being. The level of a person’s sexual activity has been

determined to be a strong predictor of happiness by Killingsworth and Gilbert (2010), while

Ganong and Larson (2011) demonstrate sexual dysfunction to be associated with increased rates

of depression and that a person’s emotional state directly impacts their physical health (Salovey,

Rothman, & Steward, 2000). Perceived sexual concerns can be due to self-related concerns or

partner-related concerns, as is seen in lower satisfaction with sex by partners of people who

experienced a stroke (Seymour & Wolf, 2014). However, sexual functioning is not the only

factor for well-being, but is moderated by other factors, such as the quality of relationship

satisfaction or personality attachment type (Stephenson & Meston, 2015). Quality of life and

sexual well-being are undoubtedly related, meaning that sexual well-being should be understood

as an aspect of general health (De Silva, 1994).

Sex therapy as a treatment modality distinct from other forms of treatment became more

prevalent in the 1960’s. Treatment methods involving physical and mental exercises known as

sex therapy were first developed as a distinctly separate area of research and treatment by

research pioneers of human sexual functioning (Hartman & Fithian, 1972; 1974; Institute of Sex

Research & Kinsey, 1953; Kaplan, 1988; Kaplan, Fyer, & Novick, 1982; Kinsey at al., 2003;

Masters & Johnson, 1966; 1970; Wolpe, 1958; 1969). The timing of sex research also coincided

with America’s sexual revolution, where Masters and Johnson and other researchers of the time

were in the middle of a debate about sexual importance among the traditional view of sex as a

sacred and private matter. Consider the culture of this time period by bearing in mind that only

in the last few decades laws governing sexual conduct between unmarried partners have been

30
repealed (e.g., Harris, 2016). However, the rise of sex research aided growth of interest in

healthy sexual functioning because people began to have more accurate knowledge about human

sexual functioning. As interest in sexual wellness publicly increased, couples could be divided

on the importance of sexual issues, as is discussed by Masters and Johnson (1970) as an

uncooperative partner or Zilbergeld (1980) who provided clinical case examples of couple issues

that prevented conjoint interventions. To summarize, the area of sexual function was seen by

professionals in the context of procreation prior to the rise of sex research and then as a separate

distinct area of specialization as scientific sex research became more widespread.

Current medical, physiological, and psychological professionals have knowledge and

expertise about sexuality incorporated into general knowledge practices. Clinicians need to

understand some level of sexual function theory, given the level of importance sexual health has

on well-being (Killingsworth & Gilbert, 2010). Binik and Meana (2009) discuss sex therapy as

requiring an integrated approach by accusing sex therapy as lacking method unification or a

robust underlying theory. Current treatment methods for perceived sexual concerns commonly

involve individual or couple psychotherapy combined with medical interventions. Within

psychotherapy, treatment commonly includes processing thoughts and practicing different

exercises or tasks between sessions (Gottman, 1999). Kilmann, Boland, Norton, Davidson, and

Caid (1986) provided a description of common treatment methods from AASECT treating

professionals as: communication skills, sex education, sensate focus, systematic desensitization,

masturbation training for females, and the start/stop method and squeeze methods for males.

Within the medical area of pelvic physiotherapy, men and women work with a physiotherapist to

improve sensation and control over genital areas (Cacchioni & Wolkowitz, 2011; Rosenbaum,

2005). The most common medical treatments involve medications (e.g., Viagra, Cialis) with

31
dosage adjustments based on patient self-reports (Sadovsky et al., 2011; Shamloul & Ghanem,

2013); less common are surgical modifications, such as penile prothesis (Segal, Camper, &

Burnett, 2014). Anxiety and depression comorbidity with sexual dysfunction are well

established (Rajkumar & Kumaran, 2015), which requires clinicians to be informed by a wide

knowledge base. De Silva (1994) prudently stated that clinicians dealing with mental health

need to have knowledge of sexual problems and that sexual health is no longer an elective

specialization. Therefore, although sex therapy was once an area of specialization, treating

clinicians need to offer a multidisciplinary approach that includes sexual knowledge.

Sexual concerns can require a clinician to have additional specialization in the areas of

sexual dysfunction. Client concerns requiring specialization are typically resistant to other forms

of treatment, which requires the use of lesser known and less widely utilized methods such as

psychotherapy in conjunction with SPT. SPT integrates the psychological and physiological

experience of a romantic relationship as a therapeutic adjunct to psychotherapy. SPT provides

clients with experiences tailored with the direction of a referring therapist; which can include

practicing social skills like having a conversation, going on a date, sensate focus, or sexual

intercourse (IPSA, 2020; Noonan, 1984). Some clinicians have used prostitutes for clients to

practice sexual treatment exercises with, such as Simpson, McCann, and Lowy (2016), but this is

claimed as due to lacking access to trained surrogate partners. While surrogate partners as

therapy team members were first used in the 1950’s by Masters and Johnson (as cited in

Dannacher, 1985), little is scientifically known about the clients, surrogate partners, or the

current state of SPT as a treatment method.

The following sections provide a comprehensive review of journal articles and

authoritative sources that are directly relevant to people working as surrogate partners or SPT.

32
The arrangement of this review in divided into three main parts. The first main division

discusses articles that have a purposeful focus on SPT or surrogate partners. The second division

includes commentary on SPT from studies that are indirectly related but still relevant to the

contextual area. The third division discusses organizational contributors as authoritative sources

that have informed the field of study on SPT. The number of scholarly articles published on

surrogate partners and SPT is sparse, failing to adequately describe a topic area that has existed

for over half a century. The literature included in this review has followed the research

definition of SPT being a method of treatment within a triadic model using direct client contact

(IPSA, 2020). For the purpose of this review, the terms sex surrogate, somatic bodywork

therapist, somatic sex expert, or alike has been considered interchangeable with the term

surrogate partner; provided that an operational definition of a trained third person working in

conjunction with a licensed clinician for treatment of client concerns is maintained. Information

on surrogate partners and SPT from additional sources are discussed later in the critique of

research findings to provide a greater context and fill in gaps left by the scholarly information

available.

Directly Relevant Content From Scholarly Journals

This section will discuss SPT and surrogate partners as found in scholarly sources

according to four thematic areas. The first section reviews journal articles that discuss, evaluate,

or make recommendations for SPT and surrogate partners. The second section reviews research

on opinions people have on SPT and surrogate partners. The third section reviews SPT treatment

of perceived sexual dysfunctions or social concerns. The final section reviews literature on

surrogate partners and articles published by surrogate partners. Attention is given to how the

33
literature defines SPT and surrogate partners, which bolsters an argument of how the literature

has incongruence and requires new contributions in even the most basic of forms.

Discussions on surrogate partner therapy. The articles discussed in this section cover

what SPT is, recommendations for application, and concerns clinicians need to be aware of. This

thematic area is a grouping of professional understandings on the topic of SPT and has been

primarily arranged alphabetically by author. Given the contentions on this topic, it is surprising

that there are not more scholarly publications found. An overall review indicates the need for

surrogate partners to work within a therapeutic triad as a professional team member, but more

information from additional sources outside of scholarly journals was required to understand the

current state of SPT.

Aloni, Dangur, Ulman, Lior, and Chigier (1994) described SPT with the term surrogate

therapy, providing their own review of literature that suggests a high rate of success, but that

usage is low due to legal/protective concerns and lack of trained surrogates. Aloni et al. goes on

to describe recommended practices from their clinical center in Israel (opened in 1991) that

addressed legal concerns, medical procedures to mitigate health concerns of sexual contact,

surrogate training standards, and reducing treatment stigma through logistics and location. Legal

concerns were addressed through defining agreements between all parties as therapeutically

based intentions so that malpractice insurance could be valid; however, this may be unique to

Israel and not generalizable to other countries. Medical testing for communicable conditions in

surrogates and clients occurred prior to first session and every three months thereafter, as well as

signed commitments on practicing safe sex during therapy and in outside relationships.

Surrogate partners received 85 hours of training and interviews with a social worker,

psychotherapist, and sexologist to determine suitability to the work. The location of treatment

34
was within a multidisciplinary center, which Aloni et al. believed to encourage the view that

surrogate therapy is an integral part of the rehabilitation institute. Interesting to note is that the

use of surrogates is cautioned for only a specific population and that the significant cost of the

program was also considered to be a deterrent to those not actually requiring it. Additionally,

only unmarried people could become surrogate partners because concern was expressed about

religious groups, and furthermore, there were no recommendation for female client treatment

despite having surrogate men trained. The article provided a surface overview of SPT within a

multiple-disciplinary treatment center but was unique because the center coordinated and

provided all services to the client; this could be desirable due to relieving the individual clinician

and surrogate partner from sole responsibility of their actions with a client. The context of

people who work at the treatment center publishing treatment information as well as including

the treatment center contact information within the International Journal of Adolescent Medicine

and Health appears to serve self-promotion aspects more than just providing the scholarly

community with information on a treatment method. Given that the center had already been in

operation for three years, a reader may have expected greater detail, pitfalls to avoid, the types of

concerns treated, or even the response rate of clients recommended for this treatment. A critical

comment could include questions about the financial success of the investment made by the

center and if there is a surplus of treatment available. However, given that there are no other

descriptions of SPT in a treatment center within scholarly literature, Aloni et al. has made a

valuable contribution to informing the field of research.

In contrast to the more critical comments made above, Aloni and Heruti (2009) published

more general information 15 years later. A translation of the article from Hebrew was not

possible to find, so information was based on an English translation of the abstract. The use of a

35
triadic model therapeutic team that met in sequence of each treatment session was identified as

paramount. The article professes to also describe ethical concerns and the types of clients who

are responsive to SPT. They make a general explanation of SPT being based on methods from

Masters and Johnson (1970) to ethically include treatment of uncoupled singles who have sexual

dysfunction. Surrogate therapy is explained as a form of mentoring and a one-on-one

relationship using behavioral methods to improve social and intimate skills. For those familiar

with Masters and Johnson’s 1970 description of surrogate partners, they understand this to be a

different definition of SPT, but this definition is consistent with a general evolution of the term

and accompanying therapy practice. In Aloni and Heruti’s defense, there is a lack of unified

definitions among scholarly literature as the treatment method has evolved, as is further

explained by Apfelbaum (1977; 1984).

Apfelbaum (1977) positions Masters and Johnson’s (1970) description of surrogate

partners as an outdated and inadequate model, attempting to position his treatment definition of

individual bodywork sex therapy as superior. Apfelbaum worked as a director of a sex therapy

group in Berkeley, California, and provided an in-depth analysis of Masters and Johnson’s work

with surrogate partners. A surrogate partner is described as a clinical partner requiring no needs

of her own to be met, in a relationship lacking emotional responsivity and that is emotionally

deprived. The use of prostitutes was discussed to be a method of similar value but as also being

misguided to only increase therapeutic strain for a client. Apfelbaum is correct in making a

compelling argument in describing Masters and Johnson’s surrogate partner as holding less

therapeutic value due to the lack of training, authority, and therapeutic leverage to manage client

resistance. The recommendations made by Apfelbaum for bodywork sex therapy are important

to note, as they represent the first scholarly record of changes made to the development of

36
relationships between a surrogate partner and client; which are described by IPSA (2020) as

being in current use. This new form of therapy, which is only an evolutionary development of

SPT, recommends the use of a clinically trained professional, in conjunction with a supervising

clinician, to allow a full range of emotional and physical responses to the client, and for a

reflexive client relationship where self-disclosure of the experience can be of therapeutic benefit.

This type of description is significant because it is the first counter to the original Masters and

Johnson definition of a surrogate partner as holding a predominantly passive role that is

encouraging for a client.

Seven years after Apfelbaum (1977) critically analyzed the surrogate definition, he

provides a more in-depth discussion of individual bodywork sex therapy using five clinical

examples from ten years of experience with 407 clients (1984). The framework of his method is

discussed along with the failings of the model, showing objectivity in his review and the need for

further improvement. A comparison of three models is made based on descriptions of a general

behavioral model, the Hartman and Fithian (1974) model (a sexual enhancement approach

through training processes), and the ego analytic model of individual bodywork sex therapy.

Apfelbaum argued that the ego analytic model of individual bodywork sex therapy is primarily

different by focusing on the experience of anxiety in small manageable doses rather than to

overcome anxiety through blunting desensitization exposure in the behavioral model. Important

to note is that these three models are considered to be within the same type of treatment category

and are only thought of as variations by Apfelbaum, which further bolsters the would be

influence of his work as seen in the current definition of SPT (IPSA, 2020). While Apfelbaum

explained that IPSA originated from training in a Hartman and Fithian (1972; 1974) model, the

current version of SPT appears to incorporate elements from all three of the models he describes;

37
perhaps bolstering an argument for his influence in developing the topic area. This journal

article is detailed in how it provided theoretical understanding, outcome ratings of treatment, and

further exemplifies application in five case examples. A significant element that appeared

unique to the bodywork description of SPT was that the surrogate partner positions sexual and

relational tension to be important aspects of a typical sexual relationship where the sexual

relationship between two people is responsive to one another and not independent. Such a

description suggested harmonizing between couples as an anxiety provoking goal to cope with,

rather than a skill or response deficit as suggested by the other treatment variations. In summary,

Apfelbaum (1977; 1984) made a strong case for future surrogate partners to receive specialized

trained, operate as part of a therapeutic team, and be sensitive/reflexive in observing a client with

psychological and physiological understanding; all of these elements can be seen in the IPSA

(2020) definition of SPT.

Dauw (1988) presented a version of SPT used at Sexual Enrichment Counselling Services

in Chicago, and further provided an evaluation of the effectiveness for male clients. The method

uses a client centered approach that included surrogate partner self-disclosure, unconditional

acceptance, empathic statements, and active listening to encourage the client to discuss their own

perceptions of their concern. Dauw described a behavioral based approach that used training

exercises and treatment of interpersonal concerns (e.g., anxiety, depression, self-confidence,

social issues), but incorrectly made a comparison to being similar to Apfelbaum (1984) despite

differences in anxiety desensitization. Critical components of the treatment described by Dauw

is that clients are given psychoeducation (i.e., books, videos, and audio), homework assignments

(i.e., social skills, masturbation practices), and treatment occurred within a triadic model of

surrogate partner and psychologist. The surrogate partners are described as holding at least a

38
master level of graduate education in a helping profession, completing 100 hours of surrogate

training, and were supervised by a clinical director and surrogate supervisor. Dauw described

similar results to Apfelbaum (1984) where 90% of client treatments were at least moderately

successful. An important aspect to note is that the surrogate partner is being described as

receiving ongoing supervision and that training and experience are seemingly related to client

success rates, meaning that a surrogate partner needs both experiential and theoretical knowledge

much like other helping professionals. However, surrogate partners are not recognized as

professionals and lack even the simplest of legal status to set them apart from prostitutes.

Freckelton (2013) presented a broad overview of SPT in all types of sources (scholarly,

periodicals, books, websites) from a legal perspective as a barrister in Australia. His review

commented on the general lack of scholarly studies, the insufficient publication of SPT

effectiveness, and that the sources he referred to were less complete than presented. A

considerable amount of the information used by Freckelton to define SPT was based on personal

opinions found in self-published books (Cohen-Greene, 2012; O’Brien, 1990; 2003), films (Fiske

& Scott, 2011; Lewin, 2012), popular website media (many that have since been removed), and

organizations that support formalized practice (Aloni, 2020; ICASA, 1998; IPSA, 2020).

However, his use of these less scholarly sources were required to fill in gaps that were absent

from peer-reviewed sources, such as how surrogate partners and their clients feel about the work

or even what the current definition of SPT is. Freckelton (2013) debates about the seemingly

altruistic motives presented about those acting as surrogate partners; that they are working with a

licensed clinician in preset session formats and there is a goal to end the services as soon as

possible, which is unlike prostitutes who benefit from continued visitation. As with many points

discussed herein, he resigns to the fact that there is not enough information available from

39
scrutinized sources to make an accurate judgement on the nature of the interaction between all

parties involved with SPT; surrogate partners lack formalized status in any part of the world and

exist in a grey area of the law. An interesting point discussed here is the liability of the referring

therapist and the duty to protect the client by making sound judgement in the selection of a

surrogate partner, which inferred liability for any potential damages. A similar statement is also

found in the practice standards for psychotherapists of Ontario, Canada (CRPO, 2016), which

places suitability of referral and quality of surrogate partner within the discretionary capability of

the referring clinician. A prudent recommendation from Freckelton is that clinicians using SPT

need to balance the professional risks with the perceived client benefits and risks through

informing their decision as much as possible. An obvious and agreed upon point made

throughout this paper is that the area of SPT remains controversial (ethically, morally) due to a

lack of clear empirical knowledge on treatment effectiveness and standardization.

SPT has been plagued with lacking empirical knowledge for many years, something that

Noonan (1984; 2000) attempted to improve as part of a master’s-level thesis (1984) and had

added greater clarification with bracketed insertions (2000). Noonan had greater access to the

sample and specialized information due to practical experience of working as a surrogate partner.

His summary of professional literature was brief, the most relevant sources were isolated to

published books (e.g., Brown & Chary, 1981; LoPiccolo & LoPiccolo, 1978), further proving the

point that there was a lack of scholarly information available. As discussed by Apfelbaum

(1977; 1984) and Freckelton (2013) as well, Noonan (1984) describes the general public’s

knowledge of SPT to be overly salacious and sensationalized, which is still seen today in popular

media (e.g., Ashford, 2013; Clark-Flory, 2011; Evans, 2016; Garelick, 2015; Ghose, 2017;

Scheers, 2016; Stone, 2013; Thompson, 2016; Tobin, 2017). Noonan hypothesized that

40
surrogate partners mainly spend therapeutic time on non-sexual activities, testing the theory

through surveys to find that only 13% of surrogate-client time involved sexual contact. Close to

90% of contact is non-sexual to provide experiential exercises, talking to provide education and

support, and social skill improvement; meaning that surrogate partner contact is significantly

different because prostitution that focuses on genital stimulation. It is also important to note the

average characteristics of the surrogate partners who participated in the study were college-

educated midlife single European American females residing in California with four years of

experience while averaging 27 clients yearly. Implications for these findings emphasized the

need for surrogate partners to be professional sexual health workers through adequate training

and supervision, as well as more research to improve understanding of SPT.

Rosenbaum, Aloni, and Heruti (2014) reviewed the use of SPT with case examples from

the Israel clinic. Aloni was described as a field expert given her experience in training and use

of surrogate partners for rehabilitation services; which is a very reasonable assertion given the

other studies she has published. A significant point made by this article was that SPT is a legal

and accepted practice in Israel but legally ambiguous to the rest of the world. As proof of

support, military personnel treated with surrogate partners were cited to receive state funded

treatment. The previous literature reviewed was minimal but showed high treatment efficacy

(63-100% success rates); however, these are retrospective studies, meaning that the ability to

address design flaws is exceptionally limited. Despite the high success rates described by

Rosenbaum et al., it is important to note that there is not a standardized measurement tool being

utilized and that success is based on a self-report measure that may be self-deprecating when

answered correctly (e.g., embarrassment of continued erectile dysfunction or vaginal pain despite

paying for expensive treatment). This article does well to define a surrogate partner as someone

41
who acts on the direction of therapeutic goals and not the client’s desires (as would a prostitute),

and that the cost of surrogate partner treatment is considerably higher. Protective procedures

were described as requiring the use of safe sex practices (including personal life), regular testing,

vaccination against hepatitis B, only using unmarried individuals for surrogate partners (religious

group concerns), and full disclosure of treatment to spouses of clients. As compared to Aloni et

al. (1994), the description of the clinic remained similar but added specific details, such as

surrogate partner treatment begins with a dating environment that is social (e.g., coffee shop)

before moving to a specialized apartment setting (equipped with lotions, lubricants, oils,

condoms, showers, clean linens, and toiletries). Rosenbaum et al. agrees with Apfelbaum (1984)

that the stressful role of a surrogate partner as described by Masters and Johnson (1970) should

be validated by exposing emotional needs and attachment between client and surrogate partner

during and when the relationship is terminated. Based on the overview and average treatment

course descriptions, it was surprising that the first case study described what appears to be a

more extreme case; the client had significant medical history, experienced a short-failed

marriage followed by a second marriage involving extra-marital sex and threesomes with his

wife’s lesbian partner. However, the second case example was less complex, treating a late-life

female virgin with vaginismus that was a barrier to romantic relationships when sex became

expectant. The article cautions that SPT treatment is less suitable for individuals who have ease

in establishing relationships, are in a committed relationship, have psychiatric instability, or view

SPT as a method of having risk free sex. As with the other studies reviewed in this section,

Rosenbaum et al. (2014) concluded that further research on SPT is required.

Opinions people have on SPT. The articles reviewed in this section discuss opinions

various people have on SPT; psychotherapists, psychology students, and health professionals.

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While there are other opinions published on the use of SPT (e.g., AASECT, 2013), they are not

within a peer-reviewed journal, which allows greater susceptibility to unchallenged inaccuracies.

The previous section discussed SPT as a contentious topic, therefore negative views were

expectant within publication, but such negative reviews are surprisingly absent from scholarly

literature (except for minimal comments made within related studies, as is described in the

section titled: Commentary on SPT). The review of this section has been arranged according to

date, as to highlight any evolutionary differences in opinion.

Six years after Masters and Johnson (1970) publicized their book describing surrogate

partner work with uncoupled single men, Malamuth, Wanderer, Sayner, and Durrell (1976)

surveyed health professionals on their consideration of referring a client to SPT. 87% of 111

professional respondents indicated they would be willing to refer a client if SPT was clearly

legal, of which, 28% indicated that they had already utilized SPT. Malamuth et al. concluded

that the gap between willing to and already referring clinicians is accounted for by the current

lack of legal status. This, however, is an incorrect assumption, as there could also be other

reasons that may account for the differences, particularly considering that some surveys were

given out at an event organized by IPSA to introduce health professionals to SPT; this

methodological context suggests that if a person is attending an event introducing SPT, that

attendees are interested in but currently lack experience in SPT. However, advertisements for

the survey were also placed in newsletters directed to mental health workers, so other

respondents could have been interested in voicing a negative view of SPT but instead were

positive.

Len and Fischer (1978) provided information about clinician attitudes towards SPT. The

sample was collected through directly mailing a request to complete an enclosed survey.

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Approximately one third responded, providing a sample of 46 participants. The survey

attempted to address questions about sex therapy, particularly relevant to clinicians touching

clients and how a surrogate partner would alleviate the ethical concerns of a registered mental

health professional. A clinician engaging in sexual touch with a client was not condoned by the

authors or the respondents, which was expected based on the codes of ethics within their

respective fields at that time. The study found that 69% of the clinicians endorsed the usefulness

of SPT for clients but that none had used the therapeutic method. Len and Fischer provide an

explanation for the low usage as relating to legal concerns, unknown training or competence of

surrogate partners, and a preference to use existing relationship partners over surrogate partners

unless the client was uncoupled. The disparity between acceptability of SPT use and actual

practice for clinicians was anticipated by similar differences found in social workers (Schultz,

1975), and furthermore, the usage of SPT is prevented by the lack of a standard organization,

certification, or supervision of surrogate partners (Humo, 1974, as cited in Len & Fischer, 1978).

While IPSA started in 1973 (along with other organizations), the exchange of information would

have likely taken longer during this time period and there were other organizations also posturing

for a position to provide authority for SPT (Noonan, 1984). The use of this survey study was

isolated to the Hawaiian Islands in hopes of providing a more homogeneous sample, but this

does not appear to be relevant given that similar results of practitioner interest in other studies

are shown at 87% (Malamuth et al., 1976) and 70% (Holzum, 2015).

Richardson (1991) described the use of SPT as originating from Masters and Johnson

(1970), and then later being distorted to the public by salacious novels and magazines. This

article takes the form of an editorial to Australian clinicians that explains the use of SPT,

dysfunctions treated, legal status, and anecdotal success. Richardson mentioned IPSA and the

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use of SPT follows descriptions made previously (i.e., that clients are uncoupled and in need of a

homework practice partner). Richardson added that the version of SPT he is familiar with

departs from Masters and Johnson, in that surrogate partners need to explicitly train or teach

sexual practices (e.g., romance, sensuality, foreplay) to clients. Worthy of special mention is

how SPT clients are appraised as failing many other therapeutic methods prior to being cured or

improved through this last option referral to a surrogate partner. Being that this is written in an

editorial commentary style, the content is cautioned to be representative of Richardson’s clinical

opinion but also that it survived the scrutiny of the journal reviewers.

Interest in SPT became renewed after the successful Hollywood film, The Sessions

(Lewin, 2012), which has been mentioned in numerous articles including Mintz (2014). Mintz

described the socio-political concerns related to SPT through a common comparison made to

prostitution. His argument for SPT is made through a discussion of sexual access rights for those

who have disabilities. The article is well written from the perspective of convincing a reader of

the aspects important to equal opportunity and in summary of SPT. However, the position that is

argued, that individuals with disabilities should have rights of access to sexual experiences, is in

fact a sexual commodification of the use of SPT despite that he provides a description of SPT as

education. In his arguments for equality for individuals with a disability, he is not arguing for

the right to receive a sexual education or rehabilitation but that people should be able to

experience families, pleasure, and partnership. Therefore, it is difficult to appreciate the

argument made for the use of surrogate partners when Mintz frames disability sexual access with

words like one’s access and fair share, indicating possession rather than skill acquisition,

education, training, or treatment.

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 Master’s student Holzum (2015) explored attitudes towards sex positive therapy and SPT

among licensed mental health professionals. The full thesis was available, allowing for greater

scrutiny of the questions asked and the answers given by the ten participants. A negative

response pattern saturated participants’ belief of the overall mental health professional

community to feel about sex positive therapy and SPT; less than half believed that their

professional community had knowledge of SPT and those that did had negative sentiments.

Among the participants interviewed, and of interest to this research study on surrogate partners,

70% had positive reactions to SPT; they considered it as a valid modality but that licensure

ethical guidelines inhibited referral. The last question asked by Holzum proposed that a licensed

clinician could act as a surrogate partner (which completely departs from definitions made earlier

in his study), begging the question as to why this would be included if only to draw the

participants back to a conclusion that SPT needs to be maintained in a triadic model. The

intentional use of deception seemed unnecessary and furthermore represented an ethical problem

for Holzum to break confidence if a participant disclosed breaking their ethical code pertaining

to sexual touch of a client. A valuable contribution made by Holzum is that, according to the

clinicians interviewed, SPT still has relevance to the field of mental health and that further

research is still required.

Denton (2018) explored graduate student attitudes toward the use of SPT in a doctoral

dissertation. While the focus of this research is on sexual education and its moderating effects

on sexual attitudes, it still presents an opinion on SPT. The literature review was succinct, using

larger review articles to capture previous publications on the topic, omitting many other readily

available scholarly sources mentioned in the reference list of the articles she reviews. An

erroneous statement is made about Aloni’s clinic using call girls for some clients, when the

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intention made by Aloni, Keren, and Katz (2007) was that the type of client who is only

interested in their own pleasure does not fit their treatment program and will be excluded; this

point is further demonstrated in other sources published on the Israeli clinic, that the use of their

surrogate services for primarily sexual rewards are not condoned and unethical to continue

treatment if discovered (Aloni et al., 1994; Rosenbaum et al., 2014). Within the findings of

Denton’s study, the sample population was found to have more openness to refer a client to SPT

when they had more sexual education and scored higher on sexual permissiveness. Lack of

competency was the main reason participants provided for not wanting to be the supervising

therapist working with a surrogate partner, which leads to the conclusion that education in the

area of sexuality and SPT was required to exercise reasonable clinical judgement.

Treatment of perceived sexual concerns. This section contains peer-review literature

that specifically addresses the treatment of perceived sexual dysfunctions with SPT. There are

other results published on SPT, such as those of Masters and Johnson (1970), but those are in the

form a published book, which intentional escaped the rigor and challenge of colleagues or field

experts. Other authors, such as Apfelbaum (1977; 1984), Aloni et al. (1994), Dauw (1988), and

Rosenbaum et al. (2014) published treatment results but within the context of demonstrating an

argument for defining the operational use of SPT. Many of the studies available (as discussed

below) were provided through retrospective analysis but still provided insight into how SPT can

be applied to a variety of conditions, but only in absence of more rigorous empirical data. A

main contributor to this area comes from Aloni’s (2020) Israeli clinic, which needs to be kept in

mind when considering generalizability to the United States model where surrogate partners

work with a variety of clinicians through freelance contracted referral services. The literature in

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this section is primarily concerned with addressing the treatment of sexual dysfunctions with

SPT and is arranged according to the date of publication.

Martin Cole (1977) was an early contributor to the area of SPT, publishing several

articles on the treatment of sexual dysfunctions. As mentioned by Freckelton (2013), Cole

practiced SPT out of a clinic in Britain, which much of his writings were based upon. Within the

abstract available, Cole (1977) presented a summary of 100 male clients as mainly suffering

from concerns with erectile dysfunction, premature ejaculation, or heterophobia. While the

principle investigation was upon causative factors, none were found, leading to the conclusion

that socio-sexual characteristics are multifactored and that clients may have vulnerabilities that

predispose them to dysfunctions. Demographic questions showed that 15% of the sample

attempted suicide as compared to the national average of 4%, inferring that a sexual dysfunction

stressor could be associated to increased risk factors. Cole described his treatment as involving

psychotherapy, behavioral, and pharmacology methods. The use of surrogate partners was

advised for the treatment of concerns found in a population when clients present as uncoupled or

without a willing partner. Cole described treatment success rates in males of being 85%, while

being able to generalize to new or existing partners 63% of the time. Anecdotally, Cole also

mentions the use of male surrogate partners for a sample of six females who reported success.

However, the remark about female success should be tempered by the unknown definitions of

success, and unknown methods of recording responses. Within this time period, females often

experienced societal pressure to cater themselves for successful male copulation rather than

concern for their own pleasure; this is discussed by Masters & Johnson (1970) as female socio-

sexual characteristic differences and why he believed SPT for females would have limited

success. In Cole’s female case example, the male surrogate partner may have been considered to

48
provide successful therapy if the client allowed his penis to successfully enter her vagina but not

necessarily for her experience of pleasure or in complete absence of pain.

Joseph (1991) described a clinical treatment process and personal experience (beginning

in 1985) that led to referring one of his male clients with cerebral palsy to a surrogate partner.

The client is described as a male with severe disability in speech (Wechsler Verbal IQ score of

78), mobility through assisted wheelchair, and involuntary muscle control concerns. As is

discussed by Mintz (2014) and Shapiro (2002; 2017), sexuality is important to many populations

but often overlooked in populations with disability. Joseph described the asexual treatment of

people with disabilities contributing to isolation and that the individual becomes a passive

recipient of human touch by those assisting or providing treatment; a sentiment which is also

described informally by O’Brien (2003). The therapy took course by talking the client through

various concerns, including education and homework to expand sexuality. Therapeutic treatment

problems arose when the client wanted to begin dating but was unsuccessful at attracting a

partner. Despite encouragement, the client began to regress into a depressed state due to

thoughts about not being considered desirable by others, which further impeded his confidence.

The use of a prostitute was considered by the client but was decided against after safety concerns

were voiced by the therapist and family members refused to help. After every possible treatment

consideration was attempted (described by Richardson (1991) as common), the therapist found a

surrogate partner he believed to be acceptable for treatment of his client. Details were not

provided by Joseph on the conversations had with the surrogate partner but that the treatment

was described as working collaboratively. The results of incorporating the surrogate partner led

to the client feeling as though he was finally an adult and became a truly sexual being. While

this article is a retrospective commentary on treating a client with cerebral palsy, it serves to

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illustrate the unique needs of sexual treatment among populations of clients with disability and

the therapeutic benefit of surrogate partners.

Aloni, Keren, and Katz (2007) described the application of SPT among severe need

clients who had a traumatic brain injury. Unlike other articles written on SPT explored so far,

the focus is on describing the traumatic brain injury client parameters with very limited

functional ability. Aloni et al. described sexual dysfunction in this population as difficult to

understand etiologically, but that neurological deficits, socio-survivor interactions, and

premorbid personality seemed to be main factors. Some main concerns for treatment included

reduction of inappropriate behaviors (e.g., unwanted sexual remarks or touching of others), as

often cited as a source of concern for family or caregivers. The surrogate partner role in this

therapy was described as non-verbally joining the client to teach reciprocal pleasure principles

(i.e., giving and receiving pleasure), boundaries, reduction of anxiety, and emotional

cooperation. Aloni et al. provided an excellent discussion on the many factors and options to

consider when treating this population with SPT but that emotional benefit is a primary marker

of evaluating success. As discussed earlier by Denton (2018), the use of call girls is an option

outside of Aloni’s clinic if believed to be most fitting for maintenance of a client’s sexual needs.

The case study described a referral due to inappropriate touching of family and friends by a

client with a traumatic brain injury. The surrogate partner work was considered successful in

emotional, cognitive, and physically challenging experiences. However, generalizability to

future partners or appropriate behavior at home were not discussed and only implied. Aloni et

al., discussed the importance of understanding the client in terms of their needs and functional

capacity, as those without intimacy desires may not benefit from this type of treatment regardless

of genital function. Although obvious, treatment must be determined by the importance of either

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providing basic needs (e.g., nutrition, hygiene) or therapy for well-being that is restorative or

enhances performance in a variety of areas.

Another article was published during the same year when Aloni’s clinic (2020) compared

SPT and coupled therapy for cases of vaginismus (Ben-Zion, Rothschild, Chudakov, & Aloni,

2007). This article was significant for two reasons, first because it is the first major study on

SPT effectiveness that included a control or comparison group with quantified sample

characteristics. Secondly, that female sexual dysfunction was given importance within surrogate

partner treatment. The method of SPT was used the same way as described in other studies at

Aloni’s clinic; the surrogate partner begins with dating exercises before moving to non-erotic

touch, sensate focus, and then genital touch. As is discussed by Masters and Johnson (1970),

treatment of vaginismus utilized accommodators of increasing size to allow progressive dilation

of the vaginal opening, which was an exercise practiced by both sample groups before insertion

of own fingers, partner fingers, and then a partner’s penis. All female participants treated by

SPT were able to achieve penile intercourse, whereas only 75% in coupled participants.

Confounding variables to account for group differences could be previous treatment experience

being higher in the surrogate partner group (75% vs. 31%), the presence of male sexual

dysfunction in the coupled treatment group (38%), the surrogate partner group did not have a

history of interpersonal tension and fully cooperated in treatment (only 56% of coupled males

participated fully), and the lack of standardization or reporting of penile size between groups.

The study appeared to be carefully designed and presented minimal group differences, such as

the level of motivation between uncoupled and coupled females presented no significant

differences.

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 In the case of a late life male virgin suffering from anxiety, Zenter and Knox (2013)

described treatment methods used to enable the pursuit of a romantic relationship. A primary

presenting concern for the client was the reduction of anxiety to enable comfort with learning

social behaviors of talking, holding hands, and kissing a female. The surrogates for this study

were known to the therapist and had psychological treatment knowledge. Therapeutic parameters

for treatment shared similarities with other definitions of SPT (e.g., Dauw, 1988; IPSA, 2020)

where surrogates were introduced as therapy team members, contact outside of therapy was

prohibited, sessions had preplanned goals, and psychotherapy sessions occurred between

surrogate sessions with discussions about the therapeutic process between all three persons.

Payment for surrogate services occurred through the clinician so no payment would transpire

between client and surrogate, which was also the case for Aloni’s clinic (Aloni et al. 1994).

Zenter and Knox described a behavioral based experiential intervention, much like Masters and

Johnson (1970), where the anxiety of the client is maintained at a low level through slow

exercise progression. A unique feature of this study was the use of three separate surrogates with

whom the client practiced social skills of talking and holding hands. As an outside observer, the

clinician appears to have practicality in mind when assigning exercises in kissing only with the

last surrogate who was 42-years of age and married, and not with the two college aged

surrogates; further demonstrating the need of the practice partner to primarily be a

knowledgeable therapy team member and not necessarily the client’s vision of an attractive date.

The clinical therapist deserves appreciation for recognizing that access to her through therapy

sessions reinforced resistance to the client reaching his goal of talking with, touching hands, and

kissing a woman in his social network. The therapist cleverly continued to support the client

through email until his goal was reached. This study was very important to the literature because

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it discussed the importance of experiential learning to acquire romantic behavior skills and

overcome associated anxiety within a framework not involving the contentious issue of nudity or

touching genital areas; which is often a focal point for critics of SPT (Holzum, 2015; Noonan,

1984).

The most recent discussion of SPT treatment is in post gender assignment surgery

(Tarsha, Xantus, & Arana, 2016). The authors wrote this article as an editorial to the Journal of

Sex and Marital Therapy, describing the concerns transsexual clients may have after gender

confirmation surgery. Tarsha et al. proposed that SPT could improve stress coping with issues

presented post-operative, such as genital appearance, sensation and orgasm differences, arousal

differences, gender role changes, and establishing comfort with a new sexual baseline. Although

the presentation of SPT treatment within this population seemed to make sense, there was no

evidence that improvements noted would be better than with psychotherapy alone. A seemingly

fair comment made by Tarsha et al., implies that surrogate partners should not advertise services

for this population until formal research is performed. However, their comment seems to be

misguided given that SPT has continued to survive as a therapeutic treatment method over the

last half century despite lacking sufficient research in the field of SPT. Their comment also

implied the wrong message because a referral for surrogate partner services needs to come from

a treating clinician who has adequately evaluated the risks and benefits of such treatment instead

of clients contacting a surrogate partner directly. This article demonstrates the lack of

understanding and lack of standardization in the practice of SPT, despite that the surrogate

partner being quoted by Tarsha et al., as being registered with a professional association.

Surrogate partner literature. The articles reviewed in this section discuss people who

act in the role of a surrogate partner to therapeutically benefit clients. These helpers are

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considered specialized people either by training or experience and may be referred to as a

surrogate partner, or by other names like sex surrogate or bodywork therapist. However, a

unifying characteristic is that they work within a therapeutic triad with a clinician to resolve

socio-sexual client concerns using experiential methods. The views of surrogate partners are

well known through dramatizations (Lewin, 2012; Shalom-Ezer, 2008), first-person accounts in

books (Cohen-Green, 2012) and magazines (Patz & Roberts, 2003), or educational videos

(Cohen-Greene, 2013; Heartman, 2018), but there is less information on surrogate partners that

has undergone the scrutiny for inclusion in a scholarly journal. The following two sections

review surrogate partners in reviewed articles: researcher perspectives on surrogate partners and

surrogate partner publication of self-experiences. These sections have been arranged according

to authorship.

Researcher perspectives on surrogate partners. This section discusses a dissertation and

journal article, both which utilized third party reviewers. Dannacher (1985) explored attributes

of surrogate partners by comparing self-concept and sexual adjustment to a non-surrogate partner

population of women. Surrogate partners were expected to be comfortable and responsive with

their sexuality as reviewed by Dannacher in Masters and Johnson (1970) and less scholarly

sources like Playgirl Advisor. A surrogate partner was described as someone who had

specialized training, was a member of the therapy team, and who shared their personal

experience of therapeutic interactions with the therapist and client. The surrogate partner took

on the role of mentorship, teaching and coaching clients in goal directed activities. These

activities included sexual education, social skills, non-sexual touch, and sexualized contact as

well. The results of the research found that surrogate partners had a higher level of sexual

knowledge, more varied sexual activities, and attached more pleasure to sexual activities. Given

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that Dannacher positioned surrogate partners as having great comfort in talking about and

experiencing a range of sexual practices, the findings were expectant. As compared to the

sample group, the surrogate partners with a greater level of experience and comfort with a

variety of sexual activities would only make sense; as is seen in the t-test results, surrogate

partners had significant (p < .01) more enjoyment from touching their own genitals with a

partner present, touching partner genitals, homosexual experiences, being tied up by partner,

joined by a third person, a partner being rough, the use of vibrators or household items with a

partner, and the use of vibrators or household items alone. This conclusion may not seem very

enlightening by current standards, but given that these questions were approved for university

research in 1985, this information was likely considered an important contribution to the

knowledge base, which unfortunately would have had limited circulation based on information

data systems available at that time. In terms of what this 35-year-old dissertation contributes to

current research, the demographic data collected is important for constructing an understanding

of surrogate partners in the United States for this time period. The 18 surrogate partners were

European American women between 23 and 56 years of age, 72% heterosexual and 28%

bisexual, only six described SPT as their primary occupation, and that 14 had other employment.

The financial potential of working as a surrogate partner revealed earnings below $24,999

yearly, with the majority (66.6%) earning less than $8,000; to put these numbers in perspective,

the poverty line in 1985 was $10,989 (U.S. Census Bureau, 1987a) and the average household

income was $27,735 (U.S. Census Bureau, 1987b), which implied that working as a surrogate

partner as a sole occupation is impractical for many and unlikely to provide fiscal motivation.

Jacobs, Thompson, and Truxaw (1975) provided information about SPT from informal

interviews with three practicing surrogate partners and a director of a behavioral therapy center.

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The surrogate partners (2 female and 1 male) were described as individuals having unique sets of

competence and intervention methods. Furthermore, these surrogate partners were selective with

what client referrals get accepted as based on personal considerations (e.g., obesity, cleanliness).

Interviews revealed that surrogate partners exist underground, have varying levels of training and

supervision, but that ideally there would be a standardized training program with ongoing

supervision in the future. Each person only accepted clients through a written referral from a

licensed mental health worker, required clients to sign a legal release (if applicable, a spouse

signature was also required), with treatment sessions usually occurring in the surrogate partner’s

home, and payment being accepted directly. The treatment course is slow (usually 2 hours per

week with a 10-week baseline), providing social skill training, sexual education, and somatic

exercises for several sessions before introducing erotic touch. The public comparison of SPT

with prostitution is discussed in terms of therapeutic intention, that surrogate partners focus on

achieving a cure instead of pleasure and that sexual intercourse is not always part of the

therapeutic intervention. Interviews by Jacobs et al. described the difficultly of maintaining

effectiveness if devoting more than 6-10 hours per week as a surrogate partner, but that it is

unlikely to have that many referrals so most surrogate partners have other sources of regular

income. This article was written like an editorial for mental health professionals, where content

is anecdotal but appears to have generalizable validity given the similarities to surrogate

descriptions by other researchers like Dannacher (1985). Validity can also be considered by the

recommendations for surrogate partners made by Jacobs et al. were was similar to other

researchers of this time period (e.g., Apfelbaum, 1977): working within a triadic model with

supervision from the referring clinician and to receive ongoing training, and that further legal

clarification and studies on effectiveness are required.

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 Surrogate partner publication of self-experiences. This section discusses journal

articles published by three surrogate partners. Greene (1977) described her role as a bodywork

therapist instead of a surrogate partner like Poelzl (2000; 2011) or Shapiro (2002; 2017);

however, the characteristics of Greene’s work maintained the same definition used for present-

day surrogate partners (as discussed previously in this review) and is therefore included in this

review section. The arrangement of the articles is according to grouping multiple works

according to surrogate partner authorship.

Greene (1977) wrote this article from an insider-outsider perspective on other surrogate

partners, as she identified herself as a bodywork therapist; which was a competing term

signifying a variation of SPT. Her article argued against the use of surrogate partners as defined

by Masters and Johnson (1970) by providing examples of the stress and failures in surrogate

partner colleagues. Her written perspective appeared to have been heavily influenced by

Afelbaum’s perspective (1977; 1984), which makes sense because Greene was on staff with

Apfelbaum at his Berkeley Sex Therapy Group clinic. Although the point of this article seemed

to be the resurrection of a new or competing term, it also represented changes in surrogate

partners during this timeframe. Greene described a surrogate partner as someone who was

primarily passive, offering encouraging support to the male client without consideration of her

own needs or voicing critical appraisal. This newer version of a surrogate partner (bodywork

therapist) was considered improved by upgraded status to a therapy team member who has

specialized training and who acts as someone who confronts, teaches, and directs client

interventions. Greene’s description of surrogate partners is obvious within the newer

descriptions found after Masters and Johnson (e.g., Dauw, 1988; IPSA, 2020; Noonan, 1984),

but this time period shows that SPT was still being experimented with to find the most useful

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model. Greene, as well as Apfelbaum, were correct in their criticism of a surrogate partner

having less therapeutic value if only acting as a sexual instrument or to allow clients to continue

errant behavior patterns by not directing therapeutic meetings. Despite having experience with

over 60 clients during a four-year period, confronting negative client behavior instead of

smoothing was cited as difficult to achieve. Greene presented a compelling case for how

examining the tension of these moments with a client is more therapeutic; which was an

intentional form of modeled instruction applied to social skills, relationship skills, and the

interaction with how sexual concerns can be addressed by a couple. This meant that the

surrogate partner actively discussed what prevented the client from enjoying being stroked

instead of a reorientation to concentration (i.e., sensate focus); whereby this interaction served to

expose and then diffuse tensions that are distracting the client from sexual engagement. The

surrogate was described as needing reflexivity, being aware of what she is feeling in the moment

and looking for therapeutic hypothesis to redirect the process when required; such as not feeling

turned on before intercourse led to discussions with the client who uncovered feelings of

rejection, judgement, and depression. Greene’s first-person clinical case narrative provides a

strong argument for surrogate partners to be psychologically trained and to be an active therapy

team member.

Poelzl (2000; 2011) wrote about her experience as a surrogate partner and the influence

her sexual orientation has in a professional journal. The first publication (2000) described the

concerns of clients questioning their sexuality, provided treatment recommendations,

summarized the history of SPT, and used vignettes to exemplify treatments. Surrogate partners

were firmly described as participating as therapy team members working in a triad, directing

therapy sessions, and using personal insight from client experiences. Poelzl’s work with

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therapists is revealed in her descriptions of sharing therapeutic vision on the direction taken and

a closing session after client work was terminated. She described the use of 7-10 sessions at two

hours at a time being a typical baseline for treatment to be structured around, with the first three

to five sessions having more structure before moving into more of a dating role. The

specialization of her treatment (i.e., sexual orientation concerns) showed that surrogate partners

were likely to provide services reflecting their own unique understanding and expertise, but that

adjustment is necessary to tailor the experience according to client goals. Baseline treatments

reflected commonality with other descriptions (Dauw, 1988; IPSA, 2020), which included sex

education, physiological education, social skills, sensual and sexual experiences. Poelzl

described five treatment strategies for working as a surrogate partner with sexual orientation

concerned clients: expand the client’s view of sex and relationship possibilities, support the

client in clarifying their sexual orientation, provide a supportive environment for non-

judgmental, non-demand exploration and contact with the feminine, self-acceptance and sexual

self-esteem, and the use of education and resources. Acceptance of personal experience and

perception were demonstrated as important through concern for the meaning making of clients

when considering active choices on how they will live out their sexual self-understanding; such

as the Filipino male who primarily enjoyed sex with men but still wanted a family with

biological children. Poelzl’s second article (2011) was a reflective commentary on the first

publication using a case example involving a two-year treatment of a lesbian women who

recently divorced her husband. A prominent point within the case example was that great liberty

was taken to tailor the therapy to client goals, such as going on longer public outings to lower

social anxiety and improve comfort with acting as a lesbian in public; described as socializing

the person to their sexual orientation. This intervention process shows the surrogate partner as

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someone who shared a significant portion of their personal self with the client to facilitate a real

relationship experience.

Lawrence Shapiro wrote in the context of advocating for funding from the government in

Ontario, Canada to assist individuals with disabilities to access surrogate partners for issues

relating to sexual self-esteem (2002). The article was written as a position paper to a journal on

disabilities, suggesting that the government should first start a pilot program for lesbian women

to access surrogate partners for improvement to sexual health. He reasons that sexuality is

inherent to humanity, surrogate partners are a professional and provide a therapeutic

intervention, and that lesbian women have received less attention. Shapiro referenced IPSA and

discussed professionalism of surrogate partner work but failed to provide an adequate definition

of their current work or how the therapeutic work would be substantially different between

persons with debility and those without. An interesting aspect of this article was the claim of

gathering anecdotal evidence from sex workers in Toronto, Ontario, Canada, which although

focused on genital stimulation, was evidently discussed and tailored to the uniqueness of person

with disabilities. The context of this first paper made considerable more sense after the second

publication made by Shapiro (2017) revealed personal details about his struggles with sexuality

as a person with disability and a decision in 2015 to be trained by IPSA to become a surrogate

partner subsequent to experiencing life changes through SPT himself. This second article is a

first-person narrative that exposed the personhood of a surrogate partner with disabilities,

providing a more vulnerable view of what it was like for him to undergo the training. Shapiro

had an above-the-knee amputation and survived cancer, describing the effects medicalization of

his personhood had on his sexuality. Within the training, Shapiro described the power of touch,

and how touch is medical for many persons with disabilities in residential care. Highlights of the

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training material reflect Shapiro’s unique life understanding through disability, commenting on

the body mirror meditation and sensate exploration as empowering a sense of self-love and

challenging social conceptions on body image. He described working with a female client who

uses a wheelchair by adapting exercises from Touching for Pleasure: A Guide to Sexual

Enhancement (Kennedy & Dean, 1986). Within meeting and providing treatment to this client,

Shapiro reflected on this as a political shift on able-bodied people helping disable-bodied people,

breaking a paradigm that would otherwise be reinforced. Shapiro is indisputably correct in his

reflections on the far-reaching effect that living with a disability has on the social interpretive

quality of interactions. A strong argument is therefore obvious that persons with disabilities will

gain unique therapeutic qualities when using a surrogate partner whom they can disability

identify with.

Commentary on SPT From Scholarly Journals

This section provides an overview of commentary on SPT from journal articles as an

aside to their main stated purpose. For example, Binik and Meana (2009) published an article

that described the conceptual evolution of sex therapy and contained a few comments on SPT;

the use of SPT was a lessor point being made and was not described as fully as the articles

reviewed in the previous section. Therefore, this section is arranged thematically and discusses

the sources with an integrated approach. The discussion starts with prevalence, comparisons

with prostitution, and the ethical and legal concerns of SPT.

There is a lack of information regarding the prevalence of clinician utilization of

surrogate partners. Reynolds (1991) quoted a study as stating that only 2% of sex therapy clients

receive SPT and that surrogate partner therapy has limited availability, which is part of framing a

recommendation for clinicians to use his Personal Potential audio cassettes as part of treatment.

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However, this survey of AASECT providers was seemingly misquoted, as the 2% refers to

therapy focused on SPT, leaving interpretation on how therapy intervention time is divided

instead of use or non-use of surrogate partners (Kilmann et al., 1986). The providers sampled

may not have been a true reflection of the clinicians performing work with SPT, such as Cole

(1986) mentions that the population of single men attending treatment at his clinic seemed

disproportionate, hypothesizing that it was due to his clinic being known for integrating the use

of surrogate partners. The use of a SPT based intervention remains small, with only biofeedback

and hypnosis reported as being of less use (Kilmann et al., 1986). Differences were found

between positive perception (49.1%) and use of surrogate partners (1.8%) by social workers

(Schultz, 1975), but that the usage of SPT was prevented by legal concerns (Humo, 1974, as

cited in Len & Fischer, 1978). Considering the underground nature of SPT (Noonan, 1984),

Binik (2009) makes a reasonable inference that there is far more prevalence than what is

reflected in professional literature. The idea of non-reporting surrogate partner use is reasonable

when considering the number of clinicians who indicated concerns with licensure or legal

consequences (Freckelton, 2013; Holzum, 2015; Len & Fischer, 1978; Malamuth et al., 1976);

an explanation that is further bolstered by how FOSTA-SESTA is believed to negatively impact

surrogate partner work (Emelianchik-Key & Stickney, 2019).

Ethical and legal concerns for SPT are widespread, being a topic of nearly each article

written on the treatment method (See Freckelton for an in-depth discussion). Binik and Meana

(2009) described the primary ethical and legal issues of SPT as expanding from a lack of

regulation and legal ambiguity. SPT lacking regulatory requirements means that anyone can

advertise themselves as a surrogate partner regardless of qualification (e.g., education, training,

experience, supervision), inferring that the clinician is therefore liable for determining

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competency of the surrogate partner for a referred client; this is also plainly stated in the code of

ethics for the College of Registered Psychotherapists of Ontario, Canada (CRPO, 2016). De

Silva (1994) argued for caution when considering SPT by citing an issue with Cole’s (1988)

study about the ethics of married men becoming sexually involved with a surrogate partner but

not informing their wives; an issue which could be avoided by requiring the signature of a spouse

(Jacobs et al., 1975). Additionally, de Silva argued that there is a lack of knowledge about the

ability of the treatment scenario generalizing to another partner. Moreno, Gan, Zasler and

MacKerral (2015) prudently recommended clinicians to make a careful appraisal of the client,

partner, and familial context due to contentious views of SPT.

The unregulated and multiple-definitional nature of SPT creates concerns for those

considering the service ether as a client or clinician, and complicates political policy making.

Zilbergeld and Ellison (1979) described a client who worsened after receiving SPT but made

significant improvement through their own social skills training program. However, the nature

of the interaction defined by SPT terms was unknown because not all uses of the term describe a

therapeutic triad with a licensed mental health practitioner. The definitional aspects of SPT has

evolved since inception, one which was viewed as a person whom a client will practice sex with;

this is far from the conclusions made by Noonan (1984), that surrogate partners spend minimal

time in genital contact. But authors like Simpson et al. (2016) and Wotton (2017) described the

service of surrogate partners as equal or similar to prostitutes. Within such definitions, Levine

(1977) rightfully objects to the limited benefit that a sexual experience without emotionality may

hold for a client and the moral conflict a clinician may have with pimping. However, this does

not mean that sexual experience alone cannot be therapeutic, but this is not the definition that

SPT has evolved to. When Simpson et al. (2016) had a client arrange for and pay a sex worker,

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he withheld the therapeutic intention and there was no contact with a therapist; therefore, it is

surprising to read their depiction as, “the sex workers were therefore utilized as informal

[surrogate partners]” (p. 286). The context of Simpson et al. (2016) using a surrogate partner

description appears to either be based on the lack of uniformity of definitions or intentionally to

soften the stigma associated with recommending a client to have sex with a prostitute in a

medical journal on treatment of a traumatic brain injury. By contrast, in Tiefer’s (2006)

description of Sex Therapy as a Humanistic Enterprise, surrogate partners were described as

“teaching matters of the heart more than genitalia” (p. 364). There is considerable disagreement

on even the most basic aspects of SPT as a topic, but there is considerable scholarly knowledge

that agrees with the authoritative sources that exist outside of peer-review journals.

Authoritative Sources

The most authoritative sources on SPT are the treatment centers and organizations who

have developed and supported this treatment intervention. Information from these groups has

been revealed in self-published or co-authored books, websites, and training programs. The first

treatment published on the use of a surrogate partner has been attributed to Wolpe (1958) by

Apfelbaum (1984), but SPT is primarily accepted as originating out of the research performed by

Masters and Johnson (1966; 1970) in the majority of other sources (e.g., Ben-Zion et al., 2007;

Dannacher, 1985; Noonan, 1984). Variations on Masters and Johnson’s original use of surrogate

partners (1970) includes the methods described as bodywork therapy (Apfelbaum, 1977; 1984;

Greene, 1977; Williams, 1978), Cole (1977), Dauw (1988), Hartman and Fithian model (1972;

1974), and the Center for Sexual Recovery in New York City (Margolies, 2001; Torosian, 2012)

but there is a lack of information available to discuss the treatments they provided. The Hartman

and Fithian (1972; 1974) model was described by Apfelbaum (1984) as originating out of a

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treatment center and then transferred by the same surrogate partner trainers to become part of the

IPSA structure. IPSA (2020) as an organization for surrogate partners has influence over the

current practice of SPT, as is evidenced by ICASA (1998) in the UK and in the literature

describing Aloni’s clinical use of surrogate partners in Israel (Aloni et al. 1994; Aloni et al.,

2007; Aloni & Heruti, 2009; Ben-Zion et al., 2007; Rosenbaum et al., 2014), and is also

described by various authors as being the most authoritative source on SPT across a significant

period of time (Holzum, 2015; Mintz, 2014; Noonan, 1984). The most relevant and available

information on the development and support of SPT is discussed chronologically: Masters and

Johnson (1970), ICASA (1998), The Dr. Ronit Aloni Clinic in Israel (Aloni, 2020), and IPSA

(2020).

Masters and Johnson. There is a disproportionally large impact to the eight pages (pp.

146-154) dedicated to a discussion on surrogate partners, as relative to the other 393 pages

written by Masters and Johnson (1970). Treatment interventions were based on their previous

research that developed a four-phase model in both men and women to describe their sexual

response pattern as excitement, plateau, orgasm, and resolution (Masters & Johnson, 1966). The

use of volunteer women for the role of a surrogate partner was described in non-salacious terms,

along with clients who brought their own replacement partners with whom they had an existing

social relationship. Providing surrogate partners to unpartnered men was defended as the only

ethically viable choice due to the low success rates of individual treatment (>25%), which would

have otherwise forces the treatment center to refuse unpartnered referrals. Prostitutes were not

used for therapeutic goals due to the role requiring more social and emotional support beyond

physically intimate interactions. The non-use of male surrogate partners for women was said to

be based on the historical social conception that male sexual failure results in diminishment of

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male purpose whereas women are typically primarily interested in a social connection in order to

facilitate sexual expression, which was why unmarried women brought a supportive replacement

partner instead.

The women who fulfilled the role of a surrogate partner were interviewed by multiple

team members to ensure suitability in the role, only 13 women were utilized over a period of 11

years (Masters & Johnson, 1970). The team used psychosocial interviews and a medical

examination to determine that the women were fully sexually responsive and indicated no

concerns with their participation. The 13 surrogate partners were described as at least graduating

from high school (3), with the remaining receiving specialized training including graduate

degrees. The group had other interests with full-time employment (10), volunteer work (1), or

caring for young children (2). Nine women described their desire to help others in treatment due

to a personal experience of sexual dysfunction within their immediate family, suggesting

altruistic ideals. One of the women was a physician, who acted a surrogate partner out of

conviction for its required effectiveness among uncoupled men; she was described with gratitude

for contributing to the shaping of the practice of surrogate partner treatment.

All treatments were supervised by trained clinicians who were responsible to outside

licensing organizations. Masters and Johnson (1970) described the use of a surrogate partner as

supervised and her contribution was unique to the specifics of her life experiences (i.e., social,

heritage, personality, education); which were considered while matching clients. The surrogate

partner treatment began by meeting in a social environment (e.g., dinner, casual evening) to build

rapport with the client, much like a date. Once comfort was established, the surrogate would

attend to the client in all therapy aspects that a cooperative wife would (e.g., homework, couples

conjoint therapy sessions, etc.). A significant treatment difference between wives (or

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replacement partners) was that surrogate partners were included in therapeutic team discussions

to inform her treatment role; which was a detail included by Masters & Johnson but renewed as

significant by Apfelbaum (1988) and Dauw (1988). The use of surrogate partners was described

within the context of deviation from a regular treatment course, meaning that treatment between

married couples and those with a surrogate partner or replacement partner remained very similar.

The steps within the treatment followed: history taking, clinical interviews, medical and physical

examinations, round table discussions between couple and conjoint therapists, sensate focus

exercises, special-sense discussion (couple discussion in sensate experience), a second

roundtable, sexual education and instructions (education, introduction of genital touch without

climax expectation), and then the course of therapy diverted to individual specialization

according to the concerns presented.

The controversy surrounding the research methods used by Masters and Johnson (i.e.,

direct observation and film documentation of males and females engaging in activities intended

to produce orgasm) prevented open and public dialogue due to the contentious nature of their

subject matter during that time period. Masters commented on peer-review publication as being

impossible, that the scholarly and public contentions would have prevented the research from

ever developing (Masters, Johnson, & Kolodny, 1977). Masters’ initial research site was even

sued by the husband of a volunteer surrogate partner for how public perception of his character

as a businessman led to loss of income (Peredo, 1977). The research and treatment center closed

when Masters retired, which could hold meaning in the accomplishment of his research causing

sexuality to be integrated into most clinicians’ practices (De Silva, 1994) and that treatment

centers are not a practical business in the United States now.

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 The Center for Intimacy Consciousness and Self-Awareness. The Center for

Intimacy, Consciousness, and Self-Awareness was established in 1994 for the treatment of

psychogenic sexual concerns (ICASA, 1998), as mentioned in Freckelton (2013) and was listed

in the IPSA client referral directory (2019). David Brown, founder of ICASA, still operates the

treatment center while publishing books, posting self-help writings, and speaking at conferences

on sexual health. Prior to the establishment of ICASA, he and his wife worked as counselors for

a rehabilitation center, then he traveled alone to the United States to treat sexual dysfunctions

before finding his life work in treating psychogenic sexual problems in the UK. In 1993, Brown

and his wife worked to treat clients and to hone a treatment program that became the center’s

foundational ten-step program. The techniques and training program steps were described as

building safety, touch, nudity, desire, healing the genitals, the kiss, sexual energy and the

orgasm, mutuality, sexual intercourse, lovemaking, and taking action (Brown, 1994). A central

idea to Brown is that the experience of the mind is what people experience as real (meaning that

dysfunctions arise out of mental experiences) and that relearning through an idealized experience

can be the most effective treatment (Brown, 2019). The clinic offers a self-paced study program,

personal mentoring, treatment with surrogate partners, and personal treatment programs based on

personal consultation (Brown, 2013). The cost of surrogate partner services (including

counseling therapist) are billed at £240 per hour. A significant element to ICASA is that all

treatment occurs at the center, much in the same manner as described by Masters and Johnson

(1970) and Aloni (2020). The ICASA website (1998) states different sexual concerns that are

commonly treated while indicating the significance of a person’s emotional and cognitive

components.

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 Making a critical review of ICASA (1998) presents difficulty because the nature of how

the clinic began is substantially different from others that have incorporated SPT; the majority

that were mentioned in the literature fail to exist today (Apfelbaum, 1984; Cole, 1977; Dauw,

1988; Masters & Johnson, 1970). Brown opened his clinic as a response to what he believed to

be a spiritual calling to improve the lives of others, which is central to the idea that a person’s

sexual being is important to nearly every aspect of life. Hallam-Jones (2008) presented a critical

review of Brown’s book Sexual Surrogate Partner Therapy (2007) concerning the level of

scholarly theoretical basis, lack of critical evaluation, and lack of research. However, the

purpose of the book appears to be directed to a different audience; Brown is attempting to reach

people who are suffering from ongoing sexual concerns, not researchers or practitioners. Further

to the point of professionalism, Brown is an AASECT and IPSA (2020) member, as well as part

of an interfaith minister’s association, but none of these are required as part of a government

sanction to establish legal authority or to ensure public safety through practice standards. While

Brown refers to SPT in research and has IPSA training from 2001, the purpose of ICASA

appears to be primarily based on helping others through methods gained by his experience rather

than formalized research or a clinical orientation based on theory originating from directorial

boards or state registration that provide ongoing supervision of clinic practices.

The Dr. Ronit Aloni Clinic. The Dr. Ronit Aloni Clinic seemed reasonably well known

based on journal articles published by Aloni and the use of those articles by many other authors.

In addition to journal articles on Aloni’s clinic in Israel, the center has a website (Aloni, 2020)

from which this section presents her practice. The website was in Hebrew, so the information

taken from a web browser translation tool has been limited to general knowledge items being

compared to existing literature knowledge. The clinic utilized multiple forms of therapy, which

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included a staff of about 40 people (including interns) who incorporated expertise from

psychiatrists, physiotherapists, physicians, psychologists, gynecologists, sex therapists, art

therapists, coaches, and surrogate partners for men or women. Aloni’s clinic treated a variety of

concerns for men, women, couples, and families in the context of sexual and relational issues;

the clinic has published the success of couple treatment (75%) and surrogate partner treatment

(100%) of vaginismus (Ben-Zion et al., 2007). The clinic treated female specific concerns (e.g.,

vaginismus, vaginal pain), male specific concerns (e.g., erectile or ejaculation concerns), and

general concerns (e.g., anxiety, intimacy, genital confidence, self-esteem) that stem from

physiological, psychological, or medical conditions. Family counseling was offered as part of

difficulty of adjusting to another family member’s condition; Aloni, Keran, and Katz (2007)

described family support when treating a traumatic brain injury client who inappropriately

touched family members, and in the website this is offered with the example of understanding a

family member who has homosexual tendencies. The clinic appears to have customized

treatments to match the needs of their clients, such as in the case of an Orthodox Jewish couple

who had not consummated their marriage (Rosenbaum, De Paauw, Aloni, & Heruti, 2013).

Surrogate partners were trained at the clinic and modeled the use of a triadic relationship

(alternating sessions between surrogate and clinician) with the clinician supervising and guiding

the surrogate partner treatment process (Aloni et al., 1994). No significant differences were

found between the journal articles and the information displayed in the clinic webpages.

This section describes the expected course of treatment a client would receive based on a

review of the clinic website (Aloni, 2020) and the literature available about the clinic (Aloni et

al., 1994; Aloni et al., 2007; Aloni & Heruti, 2009, Ben-Zion et al., 2007; Rosenbaum et al.,

2013; Rosenbaum et al., 2014). The clinical process was described in a similar manner to that

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described by Masters and Johnson (1970), where the couple/client has a diagnostic meeting

together and then individually. The information from the diagnostic meeting is used to inform a

team to plan treatments to address physiological, psychological, and medical conditions.

Therapy is described as being guided by a personal therapist who oversees the whole process and

other team members who treatment the couple/client. Treatments typically were scheduled

weekly at the clinic, with homework assignments for couples but surrogate partner treatments

almost always occur at the clinic in an apartment like therapy space. The clinic offered a 40-

hour training course for people wanting to become a surrogate partner. Surrogate partners hired

by the clinic received ongoing supervision, attended team meetings, and are included in case

discussions on their client; which describes an active therapy team member according to earlier

recommendations in the literature (Apfelbaum, 1984; Dannacher, 1985; Freckelton, 2013). The

clinic also has contracts with the Israel government to treat military personnel, which supports

surrogate partners as an accepted method of treatment.

International Professional Surrogates Association. IPSA (2020) is an indisputable

authority on SPT and has operated as a nonprofit organization since 1973. Early publications on

SPT began to describe IPSA as a network organization that offered training and certification for

surrogate partners (Apfelbaum, 1984; Dannacher, 1985; Noonan, 1984) and is a trend that

continues in more recent publications (Freckelton, 2013; Holzum, 2015; Mintz, 2014;

Rosenbaum et al., 2014). IPSA’s mission statement described supporting the practice and

availability of SPT through the training and support of surrogate partners and therapists, as well

as providing referral and treatment information to prospective clients. Their code of ethics

attempts to address issues that serve to protect the client, surrogate partner, and clinician, but

furthermore state that members must uphold the professionalism of IPSA outside the practice of

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SPT as part of upholding a professional reputation; ideas which are similar to psychologist ethic

and practice standards (APA, 2010; CPA, 2017). IPSA offers membership for the role of

clinician and surrogate partner; both roles require a referral from an existing IPSA member in

addition to other qualifications. In order to receive training, a 3-step process is followed through

an application (based on questionnaire, personal essay on sexuality, letter of interest and intent,

and letters of recommendation from professionals), a personal interview by the training

coordinator, and if successful, applicants are waitlisted for the next training offer. Level one

training is a 100-hour (didactic and experiential) course covering intimacy and human sexuality,

sex therapy, SPT, and professional issues relating to self-care, ethics, and SPT private practice.

Shaprio (2017) congruently described his level one training experience as involving self-study

prior to a two-week training in California involving lecture and experiential-based learning; he

cited the use of a university-level textbook (Crooks & Baur, 2017) and an illustrated experiential

handbook (Kennedy & Dean, 1986). Level-two training involved internship with an experienced

IPSA surrogate partner mentor who supervises and evaluates progress along with the client’s

supervising clinician. Certified surrogate partner members receive referrals through IPSA and

can also be listed publicly on the IPSA website or maintain a private listing; meaning that the list

of surrogate partners on their website is not an indication of membership numbers. IPSA also

offers a 100-hour personal enrichment program for people looking to improve sensuality,

intimacy, and eroticism.

SPT is described by IPSA as a therapy practice originating from the work of Masters and

Johnson (1966; 1970). The IPSA president describes a surrogate partner as someone within a

three-person therapeutic team that provides structured and unstructured experiences to improve a

client’s physical and emotional intimacy self-awareness and skills (AASECT, 2014). Client

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concerns were described as ranging from specific sexual dysfunctions to generalized anxiety,

which shapes the specific therapeutic intervention selected. Surrogate partners were described in

terms of teaching, modeling, sharing experiences, and assessing progress towards stated goals.

Sexual contact between a surrogate partner and client are displayed as a minor portion of therapy

(if at all); which is confirmatory of much earlier statistics (Noonan, 1984; 2000). A client-

surrogate partner relationship is stated as authentic but is limited to remain within therapeutic

boundaries; meaning that both people should expect to experience real emotions, social aspects,

and develop attachment. Surrogate partner sessions are typically set for one or two hours in

length, with other work between sessions that involve a client-clinician meeting and surrogate

partner-clinician meeting to discuss client progress and therapeutic direction. Intensive sessions

are an alternative format that use daily meetings over a weekend or a period of several weeks

(provided that the clinician and surrogate partner believes this method is advisable for the

client’s therapeutic goals). The typical cost of a two-week intensive at the surrogate partner’s

location is $8100USD (includes therapist, surrogate partner, and meeting space); Thomson

(2016) flew from Australia to the United States and described his intensive to be life changing.

The end of the surrogate partner relationship is stated at the initial triadic meeting through

establishing therapy goals; an example of goal completion could involve the preparedness to

begin personal relationships within the client’s social environment, successfully manage anxiety

when with a person of romantic interest, or maintaining sexual excitation during intercourse.

Synthesis of the Research Findings

The literature reviewed on SPT over a fifty-year time period is sparse, but surrogate

partners and SPT only comprise a small niche treatment that continues to be sought out by clients

through referring clinicians. Masters and Johnson (1966; 1970) are credited as first awakening

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the medical community to scientific research on experiential treatment of sexual concerns with

surrogate partners. Masters and Johnson are nearly universally accepted as the creators of SPT

(Kaplan, 1988; Kilmann et al., 1986), although Apfelbaum (1977) counters that Wolpe (1958;

1969) had utilized third parties in the treatment of sexual dysfunctions prior. Masters and

Johnson provided a new perspective on old problems, as even the acknowledgement of a sexual

dysfunction being important to a person’s general health was revolutionary during that time.

Their theory held that sexual dysfunction impacts a couple, being created or maintained by one

or both members of the couple, which is why treatment must involve both people (Masters &

Johnson, 1970). Treatment for sexual inadequacy (e.g., impotence, ejaculatory issues, orgasmic

issues, vaginismus, dyspareunia) involved either a physiological or psychological condition that

manifested physiological symptoms from phobic reactions (Kaplan, 1980) or anxiety (Kaplan,

1988), leading to an aversion to sexual contact (Crenshaw, 1985; Leigh, 1989); individuals and

couples who suffered from sexual dysfunction would avoid participation. The development of

sexual dysfunction as a social response is exemplified by case examples; a man suffered

secondary impotence after being masturbated from childhood to adulthood by his mother

(Masters & Johnson, 1970), a man prematurely ejaculated on account of feeling judged and

rejected by previous sex partners (Greene, 1977), and vaginismus developed when attempting to

consummate a marriage due to the adverse reaction of parents over a decade earlier concerning a

boy showing his penis to her (Rosenbaum et al., 2013). Masters and Johnson (1966; 1970)

treatment protocols required various exercises to be practiced as a couple. Due to the severely

limited success of individual sex therapy (Abernethy & Daniel, 1982), Masters and Johnson

(1970) were prompted to defend the ethics of providing a more effective therapy for single

clients; which was to allow uncoupled clients to bring a supportive substitute partner or for the

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center to provide a surrogate partner for uncoupled men. The treatment program remained

nearly the same for couples or singles with a substitute or surrogate partner, with slight

modifications for surrogate couples to first have structured social outings.

Revisions to the Masters and Johnson surrogate partner model within a clinical

environment were made by others but largely remained similar in treatment aspects (Apfelbaum,

1977; 1984; Cole, 1986; Dauw, 1988). However, Apfelbaum argued that the Hartman and

Fithian model (1972; 1974) was fundamentally different because of the emphasis on a step-by-

step educational approach involving self-study, instruction, modeling, and experiential practice

(34 steps described). The benefit of clinical touch in the treatment of clients was rising in

popularity but remained an unethical act (Coleman & Schaefer, 1986; Hall & Hare-Muston,

1983) and continues as part of discussions today, such as the ethics of a clinician holding a

client’s hand (Toronto, 2002). The use of surrogate partners in the United States changed after

concerns about the legal status challenged when client referral was appropriate (Hall & Hare-

Mustin, 1983), which was also in a time when sexual research was still under significant scrutiny

(Masters et al., 1977) and despite the effectiveness, there was a lack of access to treatment

specific centers (Dannacher, 1985). The rise of sexual transmitted diseases and human

immunodeficiency virus (HIV) also served to challenge the use of surrogate partners through

inferring liability for referring clinicians (Noonan, 2000). The later use of surrogate partners in

the United States changed into a relationship of freelance confederates for clinicians, which has

been described by Joseph (1991) and Zenter and Knox (2013) in the development of customized

treatments of a single client. Outside of the United States, The Dr. Ronit Aloni Clinic of Israel

(2020) and ICASA in the UK (1998) both practiced a clinical treatment center model where

surrogate partners are trained by and therapy usually occurs on-site. The use of the Hartman and

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Fithian (1972; 1974) model (i.e., primarily educational through experiences) and a surrogate

partner as a contracted freelance confederate for clinicians is seen in the present-day descriptions

of SPT in the United States (IPSA, 2020).

Established in 1973, IPSA (2020) has built a reputation as the most recognized

organization for the training, certification, and regulation of surrogate partner members, which is

why they are a recognizable international authority for the practice of SPT (Aloni et al., 1994;

Aloni et al., 2007; Apfelbaum, 1984; Ben-Zion et al., 2007; Dannacher, 1985; Denton, 2018;

Freckelton, 2013; Holzum, 2015; Jacobs et al., 1975; Malamuth et al., 1976; Mintz, 2014;

Noonan, 1984; Poelzl, 2000; Richardson, 1991; Rosenbaum et al., 2014; Shapiro, 2002; 2017;

Tarsha et al., 2016). There is no scholarly research available specific to IPSA, or on any other

professional association for surrogate partners in the United States. The Dr. Ronit Aloni Clinic

(2020) has considerable research conducted (Aloni et al., 1994; Aloni et al., 2007; Aloni &

Heruti, 2009, Ben-Zion et al., 2007; Rosenbaum et al., 2013; Rosenbaum et al., 2014), but this

could also be a reflection of both a state approved legal status in Israel and the need for self-

promotion. Knowledge about professional associations in the United States is required because

the clinical model practiced by Aloni may not generalize due to American culture differences

and the United States model involves a surrogate partner as a freelance contractor rather than a

clinic employee. IPSA certified surrogate partners have written narratives from their perspective

that have been published in journals (Poelzl, 2000; 2011; Shapiro, 2017), and members of IPSA

have comprised some of the participants in prior research studies (Dannacher, 1985). There are

no other studies that have exclusively focused on the practice of SPT or the experience of

surrogate partners within a profession association membership in the United States. Information

on any surrogate partner professional association is not found in journal articles or treatment

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books but is rather isolated to websites; For example, the IPSA president speaking to clinicians at

a conference (AASECT, 2014) or an informational video (available on the IPSA website for the

price of shipping). The current leading knowledge is diffused among surrogate partner member

contributions as seen in periodicals (Evans, 2016; Hosie, 2017; Patz & Roberts, 2003; Peredo,

1977; Scheeres, 2016; Thompson, 2016; Tobin, 2017; Tolle, 2019), media (Heartman, 2018;

Reilly & Reilly, 2018; SurrogateTherapy, 2011), documentaries (Dennett, 2017; IPSA, 2013),

websites (Braendle, n.d.; Chao, 2019; Cohen-Greene, n.d.; Fernandez, n.d.; Heartman, 2019;

Poelzl, n.d.; Shattuck, 2018; Tara, n.d.; Tolle, 2011; Wadell, 2019), and books (Cohen-Greene,

2013). While the topic area of SPT lacks significant scientific study, surrogate partners within

professional associations in the United States as a focus of scientific investigation has been

completely absent. Therefore, this research study was fortunate to address the most significant

literature gap by investigating the experience of surrogate partners within a professional

association.

Critique of Previous Research Methods

The International Professional Surrogates Association (IPSA, 2020) is referenced by

many of the articles published within the last 44 years as the international authority on SPT and

as a governing body for surrogate partners (Aloni et al., 1994; Aloni et al., 2007; Apfelbaum,

1984; Ben-Zion et al., 2007; Dannacher, 1985; Denton, 2018; Freckelton, 2013; Holzum, 2015;

Jacobs et al., 1975; Malamuth et al., 1976; Mintz, 2014; Noonan, 1984; Poelzl, 2000;

Richardson, 1991; Rosenbaum et al., 2014; Shapiro, 2002; 2017; Tarsha et al., 2016), but there

are no research studies that have investigated IPSA as an organization or surrogate partners

within any other professional association. A lack of independent peer-review literature on IPSA

is astonishing when considering that international journal articles declare IPSA and its

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membership to be the most authoritative group on SPT, providing a model for practice standards,

surrogate partner training, and ethical code. This research study addressed this significant lack

of information by performing an independent and purposeful initial exploration of how surrogate

partners within a professional association in the United States experience their therapeutic role

using the PERMA model.

The Existing Literature

The failure of existing literature has already been integrated in the section above (see

Review of the Literature) but critical concerns as related to this research study is succinctly

highlighted here. Reliance on the existing literature to reasonably inform discussions on the

current state of SPT and surrogate partners continues to expose the literature as severely dated

material. The practice of SPT in the United States has likely been impacted by social changes

like feminism, acceptance of sexual diversity, and technology advancements to social

communication. This research also found the following methodological concerns in journal

publications: principle authors had conflicts of interest due to the financial benefit of self-

promoting themselves or their clinics through discussing positive aspects of SPT; many

publications were based on professional opinions, moralization, or acceptability but not from the

perspective of surrogate partners; surrogate partner participants were limited to females in all

studies except one study at Aloni’s clinic (Ben-Zion et al., 2007); treatment of client concerns

are typified by medical sexual dysfunction terms (e.g., erectile dysfunction, vaginismus) that

present generalizability challenges due to etiological differences; treatment outcome studies were

performed as retrospective analysis (e.g., Apfelbaum, 1984; Ben-Zion et al., 2007; Dauw, 1988).

The last two decades of research on the practice of SPT and surrogate partners were within a

clinical treatment model (Aloni et al., 2007; Ben-Zion et al., 2007; Rosenbaum et al., 2014)

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versus a professional contracted clinical confederate in the United States as described by IPSA

(2020).

Subjective Sources

This section will critique how subjective sources provided the timeliest information

available on the topic of SPT and as containing the only source of expansive information on

surrogate partners in the United States. Surrogate partners, SPT clients, and clinicians utilizing

SPT have a media presence that demonstrates the treatment method as effective and professional.

IPSA (2020) as an organization and as a body of surrogate partners was demonstratable as

having significant influence over the perception of SPT in the United States through their

contributions seen in subjectively sourced materials (e.g., documentaries, movies, conference

videos, interviews, magazines, books, websites, blogs). Clients, clinicians, and surrogate

partners who have been part of the SPT therapeutic triad contribute to the current understanding

of the treatment method.

O’Brien (1990; 2003) famously described his late life sexual experience with surrogate

partner Cheryl Cohen-Greene as part of his struggle with a disability and how SPT was part of

him becoming fully human; the story is famously retold through The Sessions (Lewin, 2012) and

has served to rekindle interest in SPT (Freckelton, 2012), which was also released closely to

Cohen-Greene’s memoir (2013) and the television series Masters of Sex that dramatized the

work of Masters and Johnson (Ashford, 2013). SPT and surrogate partner attention by subjective

sources increased after positive Hollywood media attention; unlike the film Surrogate released in

Israel by Shalom-Ezer (2008) who depicted the psychological problems clients may have in a

scene where a surrogate partner is lit on fire before being beaten by the client. Clinicians

describe the use of SPT positively as containing primarily educative intentions (Roberts, 2018),

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surrogate partners as an outsourced resource by an AAMFT team (Ghose, 2017), legal and

transparent, and mainly involving the reduction of anxiety (Savage, 2018; Tobin, 2017). After

The Sessions, many people involved with SPT came forward to speak about their experiences, a

selection of articles that used direct quotes is discussed next.

The clients of SPT have generally given a positive review of their experience, but more

importantly, they provided understanding about the nature of the relationship between a client,

surrogate partner, and clinician. Stone (2013) provides a negative retrospective view of being

referred in 1980 by a psychiatrist for conversion therapy, but the surrogate partner accepting him

as gay improved his life dramatically; no connection to a professional association is mentioned,

nor were the methods of the interaction similar to the models known to this research (Apfelbaum,

1977; Dauw, 1988; Hartman & Fithian, 1974; IPSA, 2020; Masters & Johnson, 1970). A 44-

year old woman described her avoidant anxiety treatment at Aloni’s clinic as creating a real love

relationship with a surrogate partner that opened her understanding of what relationships can

offer (Garelick, 2015). Thomson (2016) detailed his experience of flying to the United States for

treatment of premature ejaculation and being cured within a 3-week period for an issue he

suffered with for 24-years. Documentaries (35-year apart) display client issues (severe anxiety,

phobic reactions) as resistant to other therapy treatment methods, and the surrogate partner

relationship as a caring professional (working with a clinician) who provides deliberate

instruction followed by experiential exercises, of which, sexual touch is a small component

(Dennett, 2017; IPSA, 2013). These client stories provide an understanding of surrogate partners

as well intentioned, compassionate, instructive, and in a professional context of working with a

clinician.

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 Surrogate partners were found in documentaries, interviews, to write about their own

experiences, speak at conferences, and use media to advocate for SPT. Surrogate partners are

prominently found in subjective sources to display their work as professionally ethical and

demanding in magazine interviews (Patz & Roberts, 2003; Peredo, 1977) and professional

websites linked from the IPSA (2020) website (Braendle, n.d.; Chao, 2019; Cohen-Greene, n.d.;

Fernandez, n.d.; Heartman, 2019; Poelzl, n.d.; Shattuck, 2018; Tara, n.d.; Tolle, 2011; Wadell,

2019). Some surrogate partners complete IPSA training but also have a wide variety of external

training ranging from unique life experiences (Shapiro, 2017) or formal education like masters

(Chao, 2019) or doctorate degrees (Reilly, 2019). A review of information in subjective sources

that was directly attributable to 11 different surrogate partners who held membership with a

professional association (Cohen-Greene, 2013; Heartman, 2018; Peredo, 1977; Thompson, 2016)

revealed themes congruent to positive psychology’s PERMA model: experiencing positive

emotions, engagement, relationships, meaning, and achievement. Examples of this can be seen

in Cohen-Greene (2012; 2013) describing her work with many positive emotions, how important

she believes the work is (i.e., meaning), achievement in improving the lives of clients, and the

relationship with clients appeared to be an authentic connection. Heartman (2018; 2019;

SurrogateTherapy, 2011) discussed his work as missional (i.e., meaning; purposeful existence)

by advocating for SPT and helping to reeducate clients through awareness, boundaries, and

communication (primarily women); Heartman’s website has a client testimony from a 69-year

old women finding freedom from trauma caused by her uncle when she was 5-years old.

Shattuck described himself as being emotionally involved with clients (i.e., relationships), and as

receiving a sense of achievement and meaning through seeing clients go on to form relationships

of their own (SurrogateTherapy, 2011; Thompson, 2016). In interviews with multiple surrogate

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partners (Patz & Roberts, 2003), all five thematic areas of the PERMA model seemed to be

present. The PERMA model was apparent in the subjective sources from surrogate partners

practicing in the United States, which supported the use of positive psychology (Forgeard et al.,

2011; Seligman, 2011) as an underlying theory.

Reliance on subjective sources to make professional decisions for treatment or research

would not be ethical due to reliability issues, therefore this research study held assertions

tentatively. Peer-review journals are more reliable because they are less prone to being used to

promote bias, and third-party review can eliminate errors and prevent publication of flawed

research. Subjective sources are typically biased to their publisher, who stands to gain by virtue

of entertainment revenue or advertising value, or the collection of new business (as is the case

for materials published by surrogate partners or their representatives); consider how article titles

can influence the context of information: More Than a Helping Hand-Job (Thompson, 2016) or

Here’s an Inside Look at the Therapists Who F#ck Clients (Evans, 2016). The reliability of

information on websites is also subject to change without notice, some changes were noted after

2016 by removal of personal webpages and significant changes to professional websites that

previously included a surrogate partner directory. Information displayed by media is not always

correct or correctly dated, such as Rotem is described in favorable terms as a surrogate partner

working with IPSA (Evans, 2016; Scheeres, 2016) despite resigning membership after ethical

violations were brought forward and the issue subsequently posted on the IPSA website in 2014.

Verification of information can also prove to be difficult, as the source of the information is

often not disclosed, such as Reilly (2019) posts an estimate of surrogate partners in the United

States on her website as 19, but well in excess of that number in her conference video (Reilly &

Reilly, 2018). However, information from subjective sources can also serve to verify

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information through triangulation, such is the case of Aloni’s publication in journals (Aloni et

al., 1994, Aloni et al., 2007; Ben-Zion et al., 2007; Rosenbaum et al., 2014; Rosenbaum et al.,

2014) matching her website (2020) and matching interviews on her clinical use of SPT (Hosie,

2017; Tobin, 2017). Interest in helping others from a clinical and advocate perspective is found

triangulated in surrogate partner Linda Poelzl’s journal articles (2000; 2011), websites (1999;

2012; n.d.), and interview (Denton, 2012). The use of subjective sources to inform this research

study has therefore been limited to information that could be triangulated or followed a similar

perspective of the research prior.

Summary

This chapter provided a discussion of the scholarly and authoritative literature relevant to

surrogate partners and SPT, including an explanation of the underlying theory used by this

research study. The last two sections concluded with a synthesis of the research findings and a

critique of previous research methods, explaining why subjectively sourced material have been

considered when reviewing and designing this research. Based on a thorough review of the

available literature on surrogate partners and SPT, this research concluded that there is a

complete lack of scientific information on the present practice in the United States. The review

supported IPSA (2020) as an authority in the area of SPT for surrogate partners internationally

and in the United States, and therefore served to guide methodological preparations. The lack of

information on surrogate partners in the United States prompted the consideration of more

subjective sources, but only maintained consideration of materials that could be attributable to

direct quotation or were authored by surrogate partners and could be supported through prior

research or data triangulation. The similarity of the PERMA model to the most recent directly

quoted material from surrogate partners in the United States supported the use of positive

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psychology (Forgeard et al., 2011; Seligman, 2000; 2011; Seligman & Csikszentmihalyi, 2000)

as an underlying theory for this research study. Therefore, this research study investigated the

experiences of surrogate partners who were part of a professional association in the United

States.

The next chapter will outline the research study methodology. Describing the research

design, research questions, target population, sample, procedures, and ethical considerations.

The role of the researcher is discussed in terms of a qualitative methodology (Creswell, 2014)

and the specific application of case study (Yin, 2014) with a sample population of surrogate

partners from the same professional association. Chapter 4 displays the research data collected

and initial findings. Chapter 5 presents the most relevant findings and conclusions made by this

research.

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 CHAPTER 3. METHODOLOGY

This chapter provides an overview of this research study’s purpose (See Chapter 1:

Introduction) and then describes details of the methodological procedures followed according to

an embedded multiple-case study research design (Yin, 2014); described in terms of sampling,

procedures, instruments, and ethical considerations of a qualitative case study. Target population

sampling was informed by the literature review (see Chapter 2: Review of the Literature) and the

sample was defined through unique attributes of the responding members from the target

population. Methodological procedures describe how participants were selected and protected,

the way data was collected, transformed, and then analyzed. The researcher as the primary

qualitative research instrument is discussed in terms of qualifications, bias potentials, and how

internal validity threats were minimized. Ethical considerations of this research study are

presented through anticipated and unique challenges that arose from sample population

characteristics.

Purpose of the Study

The purpose of this study was to use scientific methods to discover how surrogate

partners understood their experience working with sex therapy clients. Surrogate partners and

surrogate partner therapy (SPT) has been vastly neglected by scientific research; a review of the

literature over the past half century revealed insufficient information on the practice of SPT and

an absence of information on the contracted clinical confederate role in the United States (see

Chapter 2: Review of the Literature). Surrogate partners are limited in scholarly literature to

measures of self-report perceptions (Dannacher, 1985) and self-descriptions of their experience

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working in SPT (Poezl, 2000; Shapiro, 2017). The target sample population was difficult to

estimate in size and recruitment access strategies were challenging due to lacking a state or

national registration (no government body in Canada or the United States has sanctioned SPT

with a professional registration body). The estimated number of surrogate partners are low:

IPSA (2020) as the most renowned SPT association only listed 22 surrogate partners in their

public registry, subjective media source estimated 75 (Scheers, 2016), and earlier researchers

suggested 150 (Noonan, 1984), which suggests that the actual number of surrogate partners is

unknown. However, these estimated number of surrogate partners was disproportionate to the

high influence seen in subjective sources like films/national news, published books, websites,

and conference presentations (see Chapter 2: Critique). Given the potentially small target

population of desired unique characteristics, the sampling method required a non-probabilistic

criterion-based design (Wengraf, 2004) and relied on referral sampling methods (Patton, 2015) to

access the portions of the target population that were otherwise unknown or hidden.

Due to the general lack of information available this research was exploratory in nature.

An initial reinvestigation of SPT was believed to be most suitable to a qualitative research

method that used inductive investigation methods to capture data in the form of descriptions

(Creswell, 2013). The use of the case study method (Yin, 2014) was a good fit due to the

structure provided through integrating a theoretical orientation and the ability to use multiple

data sources as applicable. Authoritative sources and subjective literature (see Chapter 2:

Review of the Literature & Critique) supported the use of the PERMA model as a theoretical

orientation (Forgeard, Jayawickreme, Kern, & Seligman, 2011; Seligman, 2011) due to

congruences found in prior surrogate partner media interviews. Stakeholders have expressed the

importance of SPT as a treatment modality to be further understood (AASECT, 2013) while

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Canadian and United States surrogate partners have only provided their experience in scholarly

sources through a few first-person accounts (Poelzl, 2000; 2011; Shapiro, 2002; 2017). This

research study served to provide more up to date information about surrogate partners working in

the United States IPSA model from an independent research perspective. The impact of

informing scientific literature improves clinician access to more current knowledge, which can

potentially improve access for clients who could benefit from receiving SPT and for supporting

knowledge of surrogate partners providing therapeutic services. The generalizability of this

study is expected to be strong due to the sample population being defined by many similarities

through sharing the same professional membership and country of practice. General psychology

(VandenBos, 2015) theoretical knowledge is contributed through PERMA model application to

surrogate partner males and females working in the same treatment area, emphasizing the use of

a positive psychology theoretical framework (Seligman, 2011).

Research Question

How do surrogate partners understand their experience working with sex therapy clients?

Research Design

The research design used a qualitative embedded multiple-case study methodology (Yin,

2014) using positive psychology’s PERMA model as a theoretical perspective (Forgeard et al.,

2011; Seligman, 2011). Qualitative research designs (Creswell, 2013) are advantageous because

they allow for nonprobability sampling, which enabled this research study to form a stronger

focus on surrogate partner sample populations that holded specific characteristics, such as

defining surrogate partners as working with a clinician in therapeutic triad as. Sampling

techniques included criterion based purposive sampling (Wengraf, 2004) to limit participants to

desired characteristics (i.e., working within a clinician triadic model, length and recency of

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experience), while also being able to omit participants with undesired characteristics (not enough

experience, not recent enough of experience, or non-professional triadic model). Yin’s (2014)

case study design should not be confused with the informal use of the term case study to discuss

a person or group (often found in newspapers, or even mistakenly titled in some journals).

The case study method of inquiry (Yin, 2014) provided greater in-depth understanding

about the topic through using multiple data sources to provide layers of evidence during data

analysis: guiding question interviews, data presented by participants, and observational data by

the researcher formed the body of data for each participant. The term case study, as used by this

research, is a methodology of assumptions, prescriptive design elements, and theory integration

that provided a defined structure for the research design. This research study used an embedded

design within Yin’s (2014) case study methodology, which means that the analysis was

performed first on each participant data set before an analysis across the whole sample grouping.

The analysis used inductive and deductive reasoning according to data processing techniques

outline by Yin (2014); first using an inductive thematic analysis (Braun & Clarke, 2013) and

then deductive pattern matching on each individual participant and cross-case data.

The use of the PERMA model theory (Forgeard et al., 2011; Seligman, 2011) was

explicitly used in pattern matching, but was also implicit throughout all stage of analysis due to

the data collection through guiding questions being designed to gather data according to the

respective categorical areas. PERMA’s overall theory concerning optimal/peak experience is

divided into five areas, which provided five layers for analysis: positive emotions, engagement,

relationships, meaning, and achievement. Unlike other qualitative methods (e.g.,

phenomenology, generic, grounded theory) where data sets expand upon and inform the inquiry

successively with each new collection point, Yin’s case study provided individual data sets for

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analysis against a theoretical model; Yin’s assumption for analysis is that each individual

participant has a data set that must be analyzed before a comparison across the group can be

made. Therefore, additional questions and different areas of inquiry were not added to the

research protocol that would not comprise questions for the whole group; although questions

could have been added in a second interview, valid reasoning for including such a measure was

not required to answer the research question.

This research study’s design analyzed each surrogate partner’s individual case data (i.e.,

interview transcript, case notes, profile information, artifacts) individually using thematic

analysis (Braun & Clarke, 2013) and then pattern matching with the PERMA model (Forgeard et

al., 2011; Seligman, 2011). After individual data sets were analyzed, a comparison expanded

across and between each of the individual participant data findings to provide a whole case

understanding. A unique feature of utilizing case study design for this research was that unique

understandings for each participant could be preserved before more general information was

established from the whole case collectively (Yin, 2014). This two-stage analysis provided the

opportunity of answering the research question differently for each participant, while also

answering the research question for the whole group overall; meaning that an individual

participant maintained their data findings independently from the group findings. The topic area

of surrogate partners and SPT is investigative due to the lack of current research, which is why

allowing for individual findings can help inform the topic better than just overall findings across

all participant. Application of case study research design provided evidence for both positive

psychology theoretical orientation (Seligman, 2011) and surrogate partner research within the

discipline of general psychology (VandenBos, 2015).

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 Target Population and Sample

The target population sample access strategy used non-probabilistic criterion based

purposive sampling (Wengraf, 2004). Potential sample group characteristics were difficult to

predict due to the lack of information available being significantly dated (e.g., Noonan, 1984)

and based on the limited perception in subjective sources. Capella University Institutional

Review Board approved a proposal of 8-15 participants based on data saturation. This research

study required 10 participants as the final sample based on data saturation and dissertation

mentor approval.

The sample characteristics comprised from the target population was unknown during the

research proposal stage, which also became a reason to support the use of Yin’s (2014) case

study design due to flexibility in case definitions. A review of the literature revealed surrogate

partners as contracted workers (see Chapter 2: Review of the Literature), but there was a

possibility of discovering other organizations or treatment centers during the recruitment phase.

Yin’s case study methodology held an advantage over other qualitative methods because the

definition of what comprises a case was allowed to remain a theoretical plan until the collected

sample became complete. Although the sample was expected to consist of a wide variety of

surrogate partners practicing in various areas, the actual sample was comprised of surrogate

partners working in the United States and belonging to the same professional association.

Population

The target population consisted of people who identified with the definition of a

surrogate partner working with a clinician in a therapeutic triadic. Research participation

criterion included surrogate partners who worked within a therapeutic team, often described as a

therapeutic triad (client, clinician, surrogate partner). The therapeutic team referred to one

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individual or a group of helping professionals who had recognized credentials within their

respective field. The target population was required to work with a registered health professional

for at least one year within the past two years. The sample came from a population of surrogate

partners within the United States who shared membership within a professional association for

people practicing SPT.

Sample

The men and women who participated in this research study were asked for confirmation

of eligibility based on specific inclusionary criteria at three points of the recruitment process:

initial invitation to participate, return email inline text and in the attached informed consent, and

before the research interview was conducted. There was one person who contacted the

researcher with interest to participate but did not reply to the researcher’s email response

(containing recruitment follow-up and informed consent) or subsequent follow-up. There was

one person who was removed from the study due to a later discovery of not meeting inclusionary

criteria. All participants were surrogate partners within the same professional association for

people practicing SPT within the United States. Each of the participants characterized their role

as a professional treatment team member that was contracted to clients through referral from the

client’s treating clinician.

Procedures

This section describes the procedures used for this research study. These sections cover

how participants were selected and protected, the use of research experts in the revision of

researcher-designed interview questions, and the procedural steps involved with data collection

and data analysis. The details provided should serve to assist other researchers who may want to

replicate this study or portions therein.

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Participant Selection

This research study utilized a non-probabilistic criterion based purposive sampling

technique (Wengraf, 2004), which also included provisions for referral sampling. Random

sampling was not considered due to the target population of surrogate partners being very low;

surrogate partners in the United States were estimated between 16 (Reilly, 2019) and 150 people

(Noonan, 2000), with other memberships or non-membership surrogate partner population

estimates being unknown. Consideration was given to widening the population parameters but

the existing research and authoritative sources provided a narrow definition of what a

professional therapeutic surrogate partner is and is not (IPSA, 2020); to widen population

parameters would also result in losing generalizability of findings due to not having a specific

enough participant population. Specific criteria for participation was that the person was a

surrogate partner who worked within a therapeutic triad (client, clinician, surrogate partner) with

a registered health professional for at least one year within the past two years. Less specific to

the target population but still relevant criteria were that participants were willing and capable of

providing informed consent (legal age of majority in their location, mentally stable), could

articulate their experience in a language common to the researcher, consented to recording of

their interview, had a method of contact for communication with the researcher, were willing to

describe their experience, and did not revoke their consent to participate. The population was

first recruited for in Canada, then the United States, and then outside of Canada and outside of

the United States.

Recruitment techniques approved by Capella University IRB included contacting the

target population directly through their own advertisements for SPT services, but referral

sampling was the most successful. Referral sampling (snowball sampling) is when a participant

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(or potential participant) directs someone else within the target population to participate in the

study; referral sampling recruitment methods work well when a target population is not easily

accessible or is hidden (Patton, 2015). A preliminary investigation of surrogate partner service

providers at the time of research planning in 2015 revealed a significant number of

advertisements that provided contact information for surrogate partners. However, by the end of

2018, the majority of surrogate partner contact information was removed, websites disbanded,

and identifying information was removed. The recruitment process plan remained successful by

first looking for surrogate partner advertisements in Canada, then the United States, and then the

remainder of the world. A member of a professional association for surrogate partners in the

United States was contacted, who shared recruitment materials with other surrogate partners and

then referral sampling took over the remainder of the recruitment process. The final participant

sample only contained surrogate partners with the same professional association membership

practicing within the United States.

All potential participants contacted the researcher through email. All potential participant

emails were replied to with a letter that reaffirmed inclusionary details, invited the person to

share a few times they were available and the best methods of contact, and included an

attachment with information on informed consent. A reminder email was sent to non-replies;

one reminder email was not replied to and ended further contact. Potential participants who

replied with a preferable interview time and method were replied to by email to confirm the time

and method of contact. At the time of the scheduled interview, the researcher reviewed

inclusionary requirements and offered to answer questions about informed consent, the consent

process, the research being conducted, and the researcher. All potential participants indicated

that they met inclusionary criteria at the time of initial interview. Verbal confirmation of consent

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to participate in research was collected and noted in the field notes of the corresponding

participant.

Protection of Participants

Psychological research like the Stanford Prison Experiment (Haney, Banks, & Zimbardo,

1973) and “Behavioral Study of Obedience” (Milgram, 1963) prompted concern for how

research can cause harm to participants, which helped to promote changes to improve protection

of research participants. The Belmont Report (United States Department of Health, Education,

and Welfare, 1979) discusses ethical challenges involved in conducting research with human

subjects; the term human subjects has been replaced by the term participants to emphasize the

voluntary nature of consenting to research participation and the right to revoke earlier consent

given. The Belmont Report guides research involving humans by the ethical principles of respect

for persons, beneficence, and justice, while providing example applications through informed

consent, assessment of risks and benefits, and selection of subjects. Ethical principles are a

common feature of ethical codes of conduct (e.g., APA, 2010; CPA, 2017) because the intent of

the guideline is more evident as compared to a list of rules. Respect for persons is based on an

ethical conviction that individuals should be treated with autonomy, and require protection if

autonomy is diminished. The ethical principle of respect for persons in this research has been

applied to participant confidentiality and privacy, and the selection of human participants. These

areas were partly addressed through an informed consent process, ensuring that the individual

understood that they were under no obligation to participate in the study and there was no reward

offered for participation that would otherwise coerce a non-agreeing person to consenting on the

basis of self-benefit. Limits to confidentiality and privacy were outlined in the research

informed consent, which was also confirmed by the researcher during verbal confirmation.

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Further details on steps taken and challenges mitigated to maintain confidentiality of participants

are explained later in this chapter (see Ethical Considerations).

The ethical principle of beneficence incorporates doing no harm and maximizing

potential benefit while minimizing potential harm; researcher are obligated to a participant’s

well-being. The Belmont Report (USDHEW, 1979) provides a discussion about the difficulty of

balancing current risks of research and the potential benefits for the participants; the target

sample group from which the participants were derived and to society in general. According to

Capella University IRB, only minimal risk is acceptable for dissertation research, therefore, this

research study was designed in a way that participants would be subjected to minimal risk;

otherwise stated, a similar amount of risk that an average person encounters in everyday routines.

This study posed minimal risk to participants, potentially triggering memories from retrospective

and introspective questioning. As part of informed consent, participants were advised on their

ability to stop participation at any time and that they could do so without providing reason. If a

participant appeared distressed, counselling referral information would have been provided.

Within the topic area of SPT, there is a complete absence of client perspectives in professional

literature, but the risks inherent to research on a vulnerable population would have been too high.

Interviews with surrogate partners focused on their experience in their working role as anyone

else could have been asked about career or employment, as to reduce risks related to

interpersonal probing questions.

The ethical principles of justice and beneficence relates to the fairness the research

presents to individual participants and the grouping that they represent. The Belmont Report

(USDHEW, 1979) describes examples of injustice from the medical field as financially

disadvantaged individuals were subjected to experimentations that only improved treatments for

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affluent individuals. The target population and resulting sample were directly related to the

potential benefits of the research conducted, improving understanding of the treatment method

they practiced and to potentially improve access for potential clients. The design of this research

study does not appear to create injustice for participants through undue benefit or unjust burden.

Reducing researcher bias is also important to preserve principles of justice and beneficence,

because inaccuracies of reporting and recommendations could create injustice and potential to

harm participants. As a mitigating factor, the researcher solicited feedback from each participant

through member checking (Patton, 2015) of the informational data collected and thematic

findings to ensure unbiased reporting. The research data findings were also reviewed by the

dissertation mentor and a committee to lessen the effects of researcher bias on data analysis.

Expert Review

The researcher-designed guiding interview questions were subjected to a three-person

panel holding doctorate credentials and research experience. A panel review resulted in

changing the wording of questions and addition of three questions in order to make the PERMA

model (Forgeard et al., 2011; Seligman, 2011) categorical data collection more explicit.

Question revisions were approved by the expert panel on February 27, 2019 and then approved

by Capella University IRB on Mar 7, 2019.

Data Collection

Data collection within a case study design (Yin, 2014) incorporates multiple data points,

where this research primarily consisted of semi-structured interviews, data gathered from

participants, and researcher field notes. Interviews were conducted from a rented office space

through audio or audio and video technologies. Participant interviews lasted between

approximately an hour and two hours and participants presented to be located within the United

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States in private spaces (e.g., office, home). Once a participant verbally agreed to informed

consent and being recorded, the interview was recorded for transcription. Interviews were

recorded using computer software as the primary method (e.g, Skype, Icecream Screen

Recorder) to be used for interview transcription after. Backup recordings were achieved through

a digital recording device placed between the researcher and the speakers used for hearing the

participant.

The primary research question guided semi-structured interviews through a list of open-

ended questions. The guiding questions were asked to each of the participants but the ordering

of questions was altered as appropriate to the topic of conversational flow. The researcher used

reflective listening, summaries, follow-up and clarifying questions to solicit more understanding

(Poorman, 2003). Time was given to the participants as needed to formulate answers, including

an offer to take a moment to consider questions to alleviate any momentary pressures the

participant may have experienced. After the guiding questions were believed to be sufficiently

covered, each participant was offered the opportunity to share anything else they wanted. Once

the participant indicated that they had shared everything they wanted to, they were offered the

opportunity to email or setup a second meeting if they had more information they wanted to

share with the researcher. Additionally, each participant was invited to share additional

information about themselves and their experience of being a surrogate partner through emailing

relevant artifacts (e.g., case notes, websites, writings, client feedback) to the researcher. All

participants were thanked for their participation and reminded that the information taken from

the interview for the research study would be provided back to them prior to publication

(member checking).

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 Measures were taken to protect participant confidentiality. Interviews were conducted in

a private office space using private electronic devices with password protection. The devices

and printed information about the participants were stored double locked when not on person

(within a locked room, in a locked filing cabinet). Backups of the electronic data were stored on

a cloud service and on an electronic storage device that was double locked. All participant

information within this study was scheduled for destruction after a period of seven years (data

wiped from electronic storage and verified as irretrievable with software, physical items

destroyed with fire), unless permission from the participant(s) would otherwise be granted.

Data Analysis

The analysis consisted predominantly of recorded and transcribed interview data, but also

included field notes and additional information provided by participants (i.e., case notes,

reflective narratives, webpages, audio, journals, client feedback forms). The case study method

(Yin, 2014) provided the advantage of allowing multiple data points for analysis, which varied in

content for each participant. The interviews were all performed virtually through internet

services that provided video/audio or audio transmission. The electronic audio files were edited

in Adobe Premier to improve audio clarity and to remove portions from the start and end of the

recordings (i.e., testing of the recording levels, after the end of the interview). The electronic

files were electronically submitted using an encrypted internet connection for upload to a pay per

minute online transcription service (www.rev.com). A verbatim transcription was performed by

a person who signed confidentiality agreements with Rev. Completed transcripts were

downloaded in both Adobe Acrobat Reader and Microsoft Word formats. Copies of transcripts

were made and saved into a separate file to become working copies for the purpose of editing.

The researcher verified and edited each transcription for accuracy by reading along while

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watching/listening to recordings. Additional materials submitted by participants were

reproduced into text documents when possible and pictures when appropriate. Field notes were

copied directly with exception of actual participant names being censored. The names of the

participants, clients, unique places, or otherwise identifying information was removed and a

substitution was noted by square brackets. Original audio recordings of interviews, the

transcriptions, additional information provided by participants, and field notes were digitized and

saved to a password protected file system on an encrypted hard drive that was double locked in a

password protected computer. Working copies of interview transcripts, copies of additional

information, and copies of field notes provided the final data to be analyzed by this research

study. Yin’s (2014) analysis relied on the researcher to use deductive and inductive reasoning,

and to present convincing arguments to demonstrate the researcher as a subject matter expert.

The analysis procedurally followed the steps as outlined in the approved dissertation research

proposal: encoding recorded spoken data to textual data; reviewing each case and writing first

impressions; identification of descriptive categories in each case; member checking and

integration of information; creation of word tables to identify commonality between cases;

synthesis of between case descriptive category word tables; assignment of meanings to the word

table descriptions; synthesis of case meanings to construct lessons learned.

The data was analyzed using Yin’s (2014) case study general analysis strategies and

specific analytic strategies. The inductive analysis strategy for this research study utilized

thematic analysis (Braun & Clarke, 2013) that involved Yin’s analysis suggestions of working

the data from the ground up, developing case descriptions, and examining rival explanations.

The deductive analysis strategy for this research utilized Yin’s general strategy of using a

theoretical proposition and a pattern matching analytic technique. Both inductive and deductive

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strategies examined individual participant data sets before cross-case analysis. The PERMA

model (Forgeard et al., 2011; Seligman, 2011) was used for analysis as a five-tiered theoretical

proposition in combination with pattern matching and cross-case synthesis. Pattern matching

was investigated across each of the five categories of the PERMA theoretical model: positive

emotions, engagement, relationships, meaning, and achievement. Each data set analysis was

considered a separate event and subsequent data sets were considered a repetition of the same

experiment that evaluated the data based on the underlying theory. This required each

participant data set to have separate analysis information on the five categories of the PERMA

model. Investigative allowance was made in analysis of each participant as cases and all of the

participants together as a case; the final sample of participants for this research study matched

closely to Yin’s example of a case study within a case study (p. 167) that required consideration

of two bounded system case definitions. The analysis process was aimed at fulfilling the four

principles outlined by Yin: attending to all the evidence, addressing all plausible rival

interpretations, focusing on the most significant aspect of the cases, and incorporating the

researcher’s prior expert knowledge level.

The analysis involved two stages, the first was an inductive analysis and the second was a

deductive analysis where the individual data sets were fully examined before the data findings of

the individual data sets were considered across the whole group in a cross-case synthesis. The

analysis process involved reviewing the data in a significant way in order to create researcher

immersion. Immersion of the researcher in data is helpful within a qualitative study because the

researcher is an instrument that analyzes data (Creswell, 2013). An analysis strategy for the

researcher involved first reviewing each of the interviews within a few days after the interview

and writing case notes. The next stage was watching/listening to each of the interviews and

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reviewal of the corresponding case files at the same time while making notations in case notes.

The transcripts and additional information were also reviewed for corrections and privacy

revisions, creating another opportunity to become immersed in the data. The analysis methods

were assisted through the use of word tables, making case notes on researcher observations, and

coding. Once the individual data sets were analyzed, the complete findings were considered as a

whole through cross-case analysis. Cross-case analysis involved looking for common or

alternative patterns of each participant data set according to the thematic analysis (Braun &

Clarke, 2013) categories generated and according to the PERMA model (Forgeard et al., 2011;

Seligman, 2011). The final portion of analysis involved binding the analysis findings to the

evidence found in the data sets to prepare for a discussion of lessons learned and concluding

implications in the final chapter.

Instruments

This section describes the instruments used in this research study. The most significant

instruments used for data collection was the researcher as an instrument and the researcher-

designed guiding interview questions. To a lesser extent there were devices and software that

assisted with data collection, case file storage organization, and analysis. However, these

devices were only extensions of the researcher as a human who has limitations (e.g., memory,

retention of abstract and logical reasoning) because the researcher maintained control over the

interpretive qualities and meaning making derived from assistive apparatuses as seen in the use

of: electronic recorders (i.e., phone app based, computer software microphone based, audio

recorder), transcription display and storage (i.e., .PDF & .docx files), data analysis tracking of

PERMA theoretical model pattern matching, themes and word coding, case descriptions, and

rival explanations (e.g., Excel file word tables, Post-it notes, white-board, etc.). The role of the

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researcher as a research instrument and the guiding questions are described in the subsections

below.

The Role of the Researcher

The methodological design of this research study places the researcher in a crucial role of

acting as the filtering device through all data findings are to be made known in the results (Yin,

2014). The researcher’s effect on this study is seen through decisions on study design (i.e.,

research question, methods of sampling) and as an instrument with a level of procedural ability

(i.e., interviews conducted, data attended to or ignored, patterns and meanings found). As

discussed in greater length earlier (Chapter 1: Assumptions and Limitations), the methodological

assumptions of a qualitative embedded multiple-case study design (Yin, 2014) creates

assumptions for the researcher, such as the axiological assumption that the researcher and

participant engage in a relationship of mutual influence. The remainder of this section will

discuss qualifications and role of the researcher as an instrument and how researcher bias was

mitigated.

A qualitative researcher fulfills a crucial role, requiring a reasonable level of skill

according to the needs of the research study (Yin, 2014). This research study required the

researcher to arrange interviews in a virtualized environment (i.e., email, internet based

audio/video communication, data storage management), compile case file data (i.e., audio

interviews for transcription, additional information provided by participants, and observations

collected in field notes), create interpretations from analyzing the case file data (i.e., filtering

large data sets into relevant and concise information), and incorporate participant feedback

through member checking (i.e., potentially revising or adding information). Theoretical

knowledge of these research skills through graduate courses should be evident in doctoral level

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researchers, however, practical application is also required. The researcher held a wide variety

of skills acquired through a variety of previous formal and informal educational experiences.

Formal education at the graduate and undergraduate level included psychology courses involving

supervised video interviews with verbatim transcription and technical elective courses in CTSR

(cinema, television, stage, and radio) provided a technical background for video/audio digital

processing that also included interview experience. The researcher had written, produced, and

edited promotional videos for three different social compassion organizations, all which involved

interviews with content analysis. A research interest in discourse analysis methods (Potter,

1996; Potter & Hepburn, 2008; Wetherell, Taylor, & Yates, 2001; 2010) and their social

application (Bavelas & Coates, 2001; Bavelas, Chovil, & Coates, 1993; Coates, Bavelas, &

Gibson, 1994) led to interpretive and analytical experience through a master’s-level thesis,

Retelling Rape: A Discourse Analysis of 2010 Canadian Court Trial Judgments (Bechthold,

2011). Publication of “Non-Suicidal Self-Injury Literature Review” (Bechthold & Nuttgens,

2014) provided an understanding of the iterative process involved with improving research

through incorporation of field expert feedback. Further interviewing skills and discursive

management were acquired through specialized public and employee relations courses while

working as a manager with Mercedes-Benz. Discussions with the dissertation mentor reaffirmed

readiness and a sufficient skill level to proceed with qualitative dissertation work where the

researcher functions as a research instrument.

The researcher as a research instrument in qualitative research is known to contain

inherent predispositions (Creswell, 2013), therefore steps were taken to mitigate bias. Bias in the

research design has been tempered by Capella University specialization chair member reviews,

and dissertation mentor and committee members review of interview and data procedures.

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During the interview, participants were advised about the intentions of the research and how the

researcher viewed contentious issues implicit to the practice of SPT. Participants were also

invited to ask about the research and the researcher, providing the opportunity for additional

transparency. Based on the literature review, the researcher expected participants to display

positive emotions towards their field of work; participants would enjoy helping others through

building relationships (Patz & Roberts, 2003), suggesting that the work experience described was

something meaningful and engaging based on an internal sense of accomplishment. The prior

knowledge bias was recorded and alternative views would have been accepted with reflexivity if

a contrasting case was present (e.g., if a participant had stated that the best part of being a

surrogate partner is having sex with strangers and getting paid for it). The researcher bracketed

personal thoughts during data collection and data analysis (recording own thoughts in the

margins, journaling), while also discussing thoughts about the research with the supervising

dissertation mentor. To prevent researcher prior knowledge (i.e., the literature review) from

affecting the analysis of data, feedback was solicited from each participant through member

checking to ensure unbiased reporting. The research study data findings were subjected to third-

party review by the dissertation mentor and dissertation committee members, and the completed

research required Capella University approval. Researcher bias was believed to be minimized

through the measures taken and had insignificant effects on the research study findings.

Researcher-Designed Guiding Interview Questions

Using guiding questions within a semi-structured interview format allowed for the

researcher to lead the conversation rather than just recite the same questions to each person in the

same way (Patton, 2015). Follow-up questions were asked to probe deeper into the areas relating

to participants’ experience of being a surrogate partner. Using a guiding question format

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provided flexibility to modify questions in ways that seemed best fitting based on the evolving

conversation. The use of guiding question interviewing fits within the case study methodology

(Yin, 2014) and were based on the PERMA theoretical model (Forgeard et al, 2011; Seligman,

2011). The researcher-designed guiding interview questions were designed to elicit participant

information in the five PERMA model categories: positive emotions, engagement, relationships,

meaning, and achievement (see Chapter 2: Theoretical Orientation for the Study).

1. How did you get into surrogate partner therapy work?

2. What happens in a surrogate partner session?

3. What is the surrogate-client relationship like?

4. What interactions do you have with the sex therapist?

5. How do you describe the work that you do?

6. What is most enjoyable about the work you do?

7. What is most challenging about the work you do?

8. What advice would you give to someone considering surrogate partner work?

9. What does working as a surrogate partner mean to you? What does this work mean

for society?

10. What do you achieve or accomplish for yourself in surrogate partner work? How do

you think providing this service helps society?

11. What are the times that you find yourself immersed, and what you are doing feels like

it just flows?

The PERMA model had influence in the overall interview design but also particularly

through the guiding questions in the following ways. “How did you get into surrogate partner

work?” prompted for contextual and meaning related data to provide understanding on

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circumstances/reasons why people have become surrogate partners while also providing their

level of engagement. “What happens in a surrogate partner session?” prompted for information

related to engagement and relationship interactions between surrogate partner and client. “What

is the surrogate-client relationship like?” aimed at understanding how surrogate partners view

their relationship role but also pertained to meaning and achievement. “How do you describe the

work that you do?” prompted to understand the meaning making in a surrogate partner career.

“What interactions do you have with the sex therapist?” sought to understand the nature of

relationship, and quality of interaction that is expected to be goal achievement orientated. “What

is most enjoyable about the work you do?” aimed to discover what the participant viewed as a

providing positive emotions. “What is most challenging about the work you do?” was to

understand what is less satisfying or hard about their work but potentially meaningful. “What

advice would you give to someone considering surrogate partner work?” attempted to understand

how the participant views their work meaning from an insider perspective. “What does working

as a surrogate partner mean to you? What does this work mean for society?” prompted for the

participant’s meaning making and achievement in their work. “What do you achieve or

accomplish for yourself in surrogate partner work? How do you think providing this service

helps society?” mainly prompted to understand their sense of achievement through their

employment. “What are the times that you find yourself immersed, and what you are doing feels

like it just flows?” looked at engagement with working as a surrogate partner and if there were

certain areas of the work that stood out.

Ethical Considerations

This research required Capella University IRB approval, integrated ethical principles

from the Belmont Report (see section: Participant Protection), and adhered to APA (2010)

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research guidelines. The research study proposal was reviewed by Capella University

dissertation committee and received IRB approval, with subsequent changes to the study also

being reviewed and approved by the IRB; the most up to date approval was dated March 7, 2019.

Surrogate partners could be considered an ethically challenging topic due to what is

considered by some to be a sensitive topic; genital or erotic contact between a professional and

client. However, the population sample had considerable comfort with the topic and did not see

the topic as sensitive; this attitude was predicted by reviewing prior interviews (Patz & Roberts,

2003). Recruitment materials were created with professional sensitivity, using preferable terms

reflected in the literature review such as surrogate partner instead of sex surrogate or sex worker.

Additional challenges to confidentiality were anticipated because the target population had

numerous examples of acting as advocates for their surrogate partner activities while revealing

their personal identity. The presented data findings were searched for and would have removed

any unique elements that could triangulate participant identities through media exposure,

conferences, written and visual materials, or websites. To prevent identifying information from

being triangulated, member checking also included providing participants with all information

that would be published so they could determine if anything reduced their anonymity; this also

implied that they need to be aware that future disclosure of these data could compromise their

anonymity. The actual sample composed of only surrogate partner members within the same

professional association presented a unique challenge to not disclose participation to other

members, as some participants would ask the researcher if a named member had already been

interviewed or not; the researcher prepared a response that communicated the inability to reveal

other participants in the study or discuss other participant details even if participation is known.

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 Risks to participants were mitigated in several different ways. Ethical recruitment meant

that the participant needed to not feel undue pressure to volunteer for the study (Patton, 2015),

which is why the researcher contacted participants through a recruitment email and referral

sampling. The ethical risks related to running a research study included the use of technology to

transmit data, the need to lower the possibility of interception by unintended recipients, and the

safe destruction of data (see section: Data Collection). Improving anonymity included measures

like asking for permission of preferred contact, only speaking to the participant about the study if

someone else answered their preferred contact method. Deidentifying the information collected

to comprise the case study data files also reduced potential identification if a file was physically

or electronically stolen. Questions on personal experiences during the interview phase reduced

potential negative reactions by limiting questions to those that were common to any field of work

or career. In the unlikely event that an adverse reaction would have been encountered, safety

planning through referral for supportive services and a mutual contact person were available for

use. The researcher as an instrument of the research study could have experienced negative

effects during the research process, therefore, mentor debriefing and counseling services were

made available.

There were potential ethical challenges due to slight differences in multiple ethical codes.

The researcher was a provisional psychologist in Alberta, Canada which is therefore governed by

the Canadian Psychological Association (CPA, 2017) and College of Alberta Psychologists’

(CAP, 2019) codes. As well, the researcher is conducting research with an American university

that is responsible to the American Psychological Association (2010). Fortunately, there is

considerable agreement with the principles of ethical treatment of research participants and

conducting research. In Capella University IRB consultation (Nov 5, 2016), there were no

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significant concerns of being an international student and the use of an international research

form was determined not required. Adherence to the general principles as outlined by the APA

(2010) and CPA (2017) are in agreement for this research. From the APA Code of Ethics, three

areas relate to an ethical commitment to the participant as a human being and research

participant, and also a commitment to the ethical conduct of psychological research. The APA

ethical standards that applied to this research are in the areas of Human Relations, Privacy and

Confidentiality, and Research and Publication.

• 3.01 (unfair discrimination)

• 3.02 (sexual harassment)

• 3.03 (other harassment)

• 3.04 (avoiding harm)

• 3.05 (multiple relationships)

• 3.06 (conflict of interest)

• 3.08 (exploitive relationships)

• 3.09 (cooperation with other professionals)

• 3.10 (informed consent)

• 4.01 (maintaining confidentiality)

• 4.02 (discussing limits of confidentiality)

• 4.03 (recording)

• 4.04 (minimizing intrusions of privacy)

• 4.05 (disclosures)

• 4.06 (consultations)

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 • 4.07 (use of confidential information in didactic or other purposes)

• 8.01 (institution approval)

• 8.02 (informed consent to research)

• 8.03 (informed consent to recording voices and images in research)

• 8.06 (offering inducements for research participation)

• 8.08 (debriefing)

• 8.10 (reporting research results)

• 8.11 (plagiarism)

• 8.12 (publication credit)

• 8.13 (duplicate publish of data)

• 8.14 (sharing research data for verification)

Ethical consideration was given to the effectiveness of this research study to make

potential contributions. The target population was small, and failure to provide reasonable

beneficence for participant contribution could impact future research in negative ways.

Considerable investment has been made to improve generalizability of the research findings by

offering thorough explanations of the participant sample and research methodology. The details

provided in the data analysis and findings are believed to accurately improve understanding

about surrogate partners and SPT. Suggestions for future research are also discussed to

effectively promote further inquiry.

Summary

This chapter provided an understanding of why and how this research study had been

conducted. The methodological design was described through providing a detailed description

of the procedures used to assist future researchers in replication and generalization of methods.
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The target population and sampling strategies were in response to the unique challenges of this

time period of gaining access to participants for recruitment and selection. Given the significant

obscure and hidden qualities of the target population, participant protection and ethical

compliance procedures were discussed as part of improving data collection quality through

establishing a trustworthy rapport. This research study holds the unique qualities contained by

the researcher acting as the instrument for recruitment, data collection and analysis, and ethical

decision making. Significant efforts were made to limit researcher effects through informal

bracketing, regular updates and discussions with the dissertation mentor, and the use of third-

party review.

Chapter 4 will explicitly present the data analysis findings according to Yin’s (2014)

embedded multiple-case study using a PERMA model (Forgeard et al., 2011; Seligman, 2011)

theoretical foundation. This next chapter also includes a thorough description of the research

sample, methodology, and data analysis with sufficient details to facilitate stronger external

validity through generalization details. The results of the research study data analysis are

presented with supporting evidence from participant interview quotes, additional information

provided by participants, and researcher field notes. Chapter 5 will discuss the most relevant

data analysis findings and conclusions made by this research.

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 CHAPTER 4. PRESENTATION OF THE DATA

This chapter discusses the data collected, details of the analysis, and findings of the

research study. Before presenting the analysis, the first sections of this chapter provide

contextual understanding through reviewing the study and the researcher, a description of the

research study participants, and the procedures of analysis. The analysis was performed

according to a case study design, applying inductive and deductive qualitative analysis methods

to within and across the case (Yin, 2014). The findings are presented with evidence from

participant data case files, including multiple sources of data as applicable. This chapter

concludes with a summary that transitions to the final chapter that discusses the conclusions and

applications of the data analysis findings.

The Study and the Researcher

This section discusses the data analysis context of the research study and the researcher

conducting the research. The research study design has influence over how the data analysis is

conducted and interpreted, therefore a description of the study is provided as contextual to data

analysis within this chapter. The researcher as the study designer and as an instrument that

collected and analyzed data is discussed to provide understanding of research motivations and

abilities. These sections are included to temper concerns of partiality and bias in data analysis

presentation.

The Study

The presentation of data in this chapter is significant because it demonstrates an

application of the three chapters preceding it. Chapter 1 provided an understanding about the

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background and nature of the problem this research study attempts to address. Chapter 2

demonstrated the PERMA model from positive psychology (Forgeard, Jayawickreme, Kern, &

Seligman, 2011; Seligman, 2011) as a good fit for the theoretical basis of this research study and

a detailed a review of surrogate partner therapy (SPT) literature that defended the need for

scientific inquiry. Chapter 3 outlined the case study (Yin, 2014) methodological assumptions

and procedures utilized by this research. This chapter provides a detailed account of the analysis

conducted as based on the preceding chapters and presents the analysis findings. The data

analysis information presented in this chapter is the source of data to discuss application,

implications, and conclusions in Chapter 5.

This research study proposed to answer the research question: how do surrogate partners

understand their experience working with sex therapy clients? A qualitative design (Creswell,

2013) permitted recruitment based on unique characteristics within a non-probabilistic criterion-

based sampling design (Wengraf, 2004); allowing the researcher to contact people who are

known to practice as surrogate partners. An embedded multiple-case study design (Yin, 2014)

provided methodological assumptions, such as how the conception of a case could be bound to

include multiple participants individually or as an embedded whole as seen in the participants all

practicing as IPSA members in the United States. Yin’s case study also allowed for the use of

multiple layers of analysis, including inductive thematic analysis (Braun & Clarke, 2013) and

deductive pattern matching (2014) according to the PERMA model (Forgeard et al., 2011;

Seligman, 2011). The data analysis provided information based on the above design elements

and would likely present differently if a different research question, a different theoretical

framework, or if a different methodological design was incorporated. Understandings gained

from the data analysis presented in this chapter should be considered with the above in mind.

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The Researcher

The researcher effected the data analysis and data findings through designing the research

study and was as an instrument that collected and analyzed data. The researcher designed the

research study and developed a topic understanding of surrogate partners over a seven-year

period. The time period and the understandings available to the researcher (see Chapter 2:

Review of the Literature) may have impacted the participants available in the target population

and the design elements that were based on researcher topic understandings (e.g., areas of

inquiry, guiding questions). Data was collected through participant interviews, observations, and

participant artifacts before being analyzed by the researcher. The study design and data analysis

were extensively reviewed by Capella University dissertation mentor and committee members as

part of ensuring suitability of the research study and reasonability of findings according to the

methodological procedures followed.

The researcher became interested in the topic of SPT after watching The Sessions (Lewin,

2012) due to intrigue over self-ignorance of a treatment method claiming to be half a century old.

Investigation of SPT revealed the topic as undeveloped despite popularity in recent media (see

Chapter 2: Critique of Previous Research Methods), providing an opportunity to make a valuable

research literature contribution. The topic area of SPT also matched with the researcher’s

general topic interests of sexuality, power differentials, and legal systems. The researcher

indicated concern for social disadvantage and disenfranchisement through prior participation in

social compassion organizations (see Chapter 3: Role of the Researcher), which related to the

clients SPT claimed to benefit. Furthermore, the researcher believed choosing a topic area of no

prior understanding would improve the quality of the study because impartiality would be easier

to manage as compared to topics where prior experience was significant. A personal stake in this

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research study primarily related to the researcher’s ability to become an author of an

unresearched area, which was believed to increase the likelihood of becoming distinguished in a

topic area.

The researcher developed predisposed views on SPT as a result of the literature review

and contact with people involved with SPT, meaning that another researcher conducting a review

of the literature (see Chapter 2) and speaking to other people may have come to understand the

topic differently. Therefore, the researcher declared that the view of SPT and surrogate partners

developed during the initial research investigation was a source of bias. The researcher’s

opinion of SPT as a legitimate therapeutic intervention was formed from the literature available

at the time of this research study and would consider revising such opinion if alternative

information were presented. The researcher also declared perceiving surrogate partners as

people who find altruistic benefit in helping others, believing that the risks inherent to SPT (e.g.,

sexually transmitted infections, legal ambiguity) seemingly outweighed any other form of direct

benefit (e.g., fiscal, sexual, relational), but would consider revising such opinion if alternative

information were presented. The researcher declared bias according to application of practice

standards (CAP, 2019) and ethical codes of conduct for the profession of psychologists (APA,

2010; CPA, 2017); opinioned that SPT clients are a group of vulnerable persons who have not

been afforded adequate safety or adequate treatment due to a lack of academic or clinical

research on SPT. The researcher declared an overarching opinion that the present state of SPT

understanding available to clinicians in professional literature is a social concern due to the

vulnerability of clients seemingly suitable for SPT.

The researcher’s accreditation as suitable to perform this research study relates to

education, experience, and supervision. At the time of the study, the researcher had formal

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education in research methods and prior supervised research experience (see Chapter 3:

Instruments). The researcher was determined by Capella University faculty as qualified for

research under the supervision of a dissertation mentor. The dissertation mentor provided

direction through regularly scheduled meetings and overall guidance throughout the research

study process. Effects of bias were mitigated through the researcher declaring and bracketing

bias (i.e., journaling and mentor discussions), and review by the dissertation mentor and

committee members.

Description of the Sample

This section describes the sample of participants that formed the cases according to an

embedded multiple-case study methodology (Yin, 2014). A sample size of 8-15 participants

(based on data saturation) was approved by Capella University Institutional Review Board

(IRB). There were 11 participants who were interviewed for the study, but consultation with the

dissertation mentor resulted in removing one participant from the study due to discovery of them

not working with a qualified clinician. A final sample of 10 participants was attained based on

data saturation and consideration for potential for dropouts. A description of the participants

must adhere to the ethical requirement of ensuring participant anonymity; a description is

presented in a group format to reduce the risk of a specific participant being matched (or

supposedly being matched) to a surrogate partner who is revealed by media sources and/or

websites (now or in the future) regardless of any participant actually being published or not

published by media sources and/or websites.

The participants within the sample had many attributes beyond researcher anticipation at

study onset and are described here. All participants described referrals for surrogate partner

services occurring through clinicians or their professional association that would involve client-

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clinician contact prior to a triadic meeting (client, clinician, surrogate partner). All participants

were members of a professional association, where they had received certification through

instructional training with a supervised practicum component and practiced in the United States.

The ten participants were composed of both men and women who had various forms of

meaningful romantic relationships (e.g., dating, matrimony, polyamory), some who had children

at home or adult children and participants did not have children. The participants described a

range of sexual partner preferences (same-sex, separate-sex, mixed-sex), which did not

necessarily match the type of client they would become a surrogate partner for. There was no

specific age range of participants, varying widely between expected working years of United

States citizens (mid-20’s to 70-year-old’s). All participants had some type of specialized

education prior to becoming a surrogate partner, which included educational certificates up to

unfinished doctor of philosophy studies. Participant education included areas of study

compatible to helping professionals (e.g., bachelor of arts in social sciences) and areas unrelated

to helping professions (e.g., computer technology, business); which were also congruent with

work experiences in their respective fields. The sample description was constructed from

information provided directly from research participants to the researcher.

Research Methodology Applied to the Data Analysis

Yin’s (2014) case study research methodology guided the data analysis (see Chapter 3:

Procedures: Data Analysis) and is discussed in the following sections in terms of the actual steps

taken to perform analysis and outlines any deviations from the original plan. The following

sections discuss data analysis according to three conceptual stages: general data processing,

inductive analysis, and deductive analysis. The inductive and deductive analysis followed a

format of performing a within-case analysis and then a cross-case analysis. Member checking

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was performed after the analysis procedures were completed, which provided a re-analysis

comparison.

General Data Processing

The first stage of data analysis formed general data processing and related to the nature of

the researcher acting as an instrument. An important strategy for qualitative work is data

immersion (Creswell, 2013), which was intentionally designed into the way data was initially

processed. The researcher, as an instrument, began analysis of data from the first moment of

contact with participants, which was recorded as researcher observations in the corresponding

case files. The researcher’s observations and perceptions continued to be recorded in the form of

notes and added to the files from the point of first contact through to the last point of contact

during member checking (Patton, 2015). Researcher notes were recorded during the participant

interviews conducted, which provided researcher reflections on participant interviews. Some

participants also provided additional information (i.e., case notes, emails, reflective writings) that

was added to the corresponding case file, including researcher notes concerning these items. The

researcher reviewed recordings of each interview and made corresponding notes. The interviews

were transcribed by an online service (www.rev.com), and then reviewed by the researcher for

accuracy by following the transcript with the recoding playback. The researcher recorded notes

about the topics discussed with the dissertation mentor as part of reducing bias and improving

analytic impartiality. General data analysis was considered to cover the point from initial

participant contact up to the start of formalized data analysis procedures according to specific

strategies, but also included any further researcher observations (added into case file notes) or

bracketing of bias (journaling, mentor debriefs) occurring until the end of participant member

checking.

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Inductive Data Analysis

An inductive data analysis procedure was first performed to allow the data to speak for

itself; this served to reduce the likelihood of influencing data analysis outcomes according to

theoretical and prior knowledge concepts. The inductive data analysis was performed according

to Yin’s (2014) general data analysis strategy of working the data from the ground up, while

using thematic analysis (Braun & Clarke, 2013). A within-case analysis was performed by the

researcher observing the recorded interviews, reading transcripts, and artifacts noting anything

that appeared to be of significant meaning to the participant and the study purpose. The noted

participant data was then examined for potential ideas, word clusters, and descriptions to form a

set of codes limited to the scope of research question relevance (surrogate partner experiences of

working with sex therapy clients). The coded list of ideas, word clusters, and descriptions were

exhaustive, which required the researcher to refine the codes while preserving the initial

descriptive meanings. The codes began to form cluster arrangements to thematic ideas, but these

were held loosely until the cross-case analysis could provide a larger breadth of meaningful

evidence. This process was repeated for each of the case data sets (transcripts, presented

artifacts, researcher notes) that provided a list of data anchored evidence with supported codes,

concluding the within-case analysis.

A cross-case synthesis was performed according to Yin’s (2014) analytic description and

thematic analysis (Braun & Clarke, 2013) using the within-case data analysis results. Each of

the cluster patterns were reviewed across each of the cases and cross-case commonalties were

recorded. Cluster patterns were arranged into elements of commonality and differences between

cases. Common thematic codes were experimented with by various arrangements until support

of six larger thematic ideas generated (i.e., thematic immersion) a wide breadth but remained

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defined enough so conclusions would not be too general (Braun & Clarke, 2013). Data set

evidence was arranged into the cluster patterns according to the six thematic ideas generated but

were maintained separately according to individual participant case files. Exemplars from each

participant data sets that seemed to capture the essence of the six thematic ideas were separated

and culminated into a cross-case composite. The researcher reviewed the culminated case file

codes and thematic patterns to further consider alternative explanations, patterns, and integrated

meanings. The researcher noted support for common ideas that emerged to form the lessons

learned. Four categories of lessons learned were found to be supported by the cluster patterns

and themes generated from the cross-case composite. Inductive analysis concluded by selecting

exemplars from each participant data set (transcripts, presented artifacts, researcher notes) and

cross-case composite to support a presentation of the themes and lessons learned as an answer to

the research question.

Deductive Data Analysis

A deductive data analysis strategy was performed according to pattern matching (Yin,

2014) of the theoretical proposition of PERMA (Forgeard et al., 2011; Seligman, 2011). Using

the lists of meaningful participant data created in the first inductive analysis steps, the researcher

deductively coded individual areas of the PERMA model: positive emotion, engagement,

relationships, meaning, and achievement (Forgeard et al., 2011; Seligman, 2011). Evidence from

the participant data sets were recorded, provided that they supported both an area of PERMA and

contributed to answering the research question concerning surrogate partner experience of

working with sex therapy clients. Evidence from the participant data sets were then culminated

together as evidence to support a cross-case analysis of pattern matching according to the

PERMA model.

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 Data analysis evidence of PERMA (Forgeard et al., 2011; Seligman, 2011) was expected

due to the use of guiding questions that proposed to gather information according to the PERMA

model. The researcher considered how PERMA areas were coded to the data, considering

different explanations (Yin, 2014) by how they were combined and arranged. The researcher

considered how the areas of PERMA may interact with each other or could further explain

various cluster patterns. Exemplars that demonstrated the results of the PERMA analysis were

selected for a discussion of the data analysis results. The results of the cross-case PERMA

analysis were considered with the lessons learned developed from the cross-case thematic

analysis (Braun & Clarke, 2013) results.

Member Checking

Member checking (Patton, 2015) was performed after the researcher completed all levels

of analysis. The participants were invited by email to provide feedback to the researcher on the

codes and their data evidence as used by the research study. Member checking the codes,

themes, and final evidence (coded materials and exemplars selected for publication) purposed to

both validate the research findings and provide participants with transparency in how their

information would be used. Member checking the actual quoted evidence additionally

strengthened an ethical commitment to anonymity by offering to provide participants with their

actual evidence shared so that they can avoid future unintentional self-disclosure through

triangulation. The feedback received from participants was then integrated into the data analysis

findings.

All participants responded to the request for member checking, and their feedback was

incorporated into the presentation of the data analysis. There was no disagreement to the codes

and themes generated by this research study; the only changes were related to censorship,

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editing, or providing additional emphasis to existing codes or themes. The validation of the

codes and themes were stated as “all appears to accurately reflect our conversation and my view

of the work,” “the themes you've captured are a good fit for my understanding of myself in the

work,” “totally good with that,” “read through these and they look great,” “yes, you captured my

sentiments accurately,” “the content is good,” and participants indicated endorsement of themes

and codes while in discussion. Censorship of materials occurred in parts of the transcript that

were used for creating the coding but not in the exemplars already selected; censorship did not

affect the results of the research study findings. The edits within the material were minor, such

as the change of two words within a transcript, but the changes did not affect the inherent

meaning or context of the material.

Member checking provided additional evidence that strengthened Professionalism and

Meaningful work by added emphasis. A participant remarked about how it is unethical to not

provide SPT to a client who requests it when it is the best option and suggested that clinicians

receive self-benefit of preventing a referral by prolonging talk therapy billing. Member checking

discussions also indicated that clients can be in talk therapy for decades and can be refused

access to SPT solely due to a clinician’s personal opinion. The use of SPT was discussed by the

participants in terms of being used when therapeutically indicated as appropriate. The model of

SPT in the United States was discussed as being different than the model practiced by ICASA

(1998) and The Dr. Ronit Aloni Clinic (2020), citing differences in the emphasis of the

relationship between the surrogate partner and the client as most therapeutic versus an emphasis

on therapeutic exercises. A conclusion of member checking was that all participants agreed with

the themes and codes generated by this research study, and transcription changes (edits,

removals) did not alter initial findings.

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 Presentation of Data and Results of the Analysis

This section presents the data and the results of the analysis. These sections are arranged

according to the sequence of analysis to demonstrate how the findings developed from specific

instances within cases to general messages across cases that can relate to the group. A broad

description of the analysis can be taken as meaningful evidence was collected from all the case

files, directly interpreted before interpretive meanings were given, case file contents were then

coded and cluster patterns generated, the cluster patterns were given thematic expressions, and

then reviewed in a cross-case synthesis that formed the basis of how the lessons learned were

formulated as a response to the research question. The analysis was performed using inductive

and deductive logic according to a combination of Yin’s (2014) general strategies (working data

from the ground up, theoretical propositions, examining rival explanations) and analytic

strategies (cross-case synthesis, pattern matching). Exemplars from each of the case files served

to demonstrate how the data analysis was performed and to support the data findings.

Thematic Analysis

The thematic analysis utilized an inductive approach to generate themes that were

supported by pattern clusters (Braun & Clarke, 2013) coded to the participant data in the case

files (Yin, 2014). The cross-case data analysis results of coded exemplars are presented in Table

1, and the themes supported by pattern clusters are presented in Table 2. The following sections

discuss how the coded data supported the pattern clusters and descriptive themes. The

presentation of the data analysis results are organized according to when the thematic pattern

arrangement was made certain.

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Table 1. Clustered Pattern Codes

Pattern Code Exemplars

For inner satisfaction “I’m fulfilled by the process itself” (P3).

“I've worked in corporate America, uh, made six figure salaries, I started companies
and never have felt more satisfied in the work that I've done than this work now” (P4).
“I'm so proud of the work and I think it's incredible and amazing. And- and I'm so happy
to talk about it and share about it” (P5).
“It's very satisfying, and rewarding, and meaningful uh, when it all comes together”
(P6).
“I'm able to integrate my emotional intelligence and my processing brain and my body
awareness. Um, and u-, and use those tools to help people. And that's incredibly
satisfying to me” (P9).
“I do other things in my life that I feel like affect me similarly in my personal growth,
but I would say that this is the one that is the most consistently fruitful” (P10).

Not motivated by financial “I'm not like destitute, but I make enough money to pay my bills, basically like... I'm
or sexual gain not rich” (P5).
“You can't see enough clients throughout the day to make this your moneymaking
business. You know, you can't pay your bills” (P7).
“I am one of the lucky ones who is able to support myself just doing surrogate partner
therapy. I'm also incredibly frugal in a ridiculous way” (P10).
“I was shocked when I felt arouse. I was, I was shocked when I, um, you know,
actually had an orgasm. You know, what, what, what a delightful bonus” (P7)?

Feel benefit in helping “Something I feel like I can help a lot of people with” (P1).
others
“One of the sort of life purposes is to help people, particularly men out of the um, self-
shaming by becoming conscious of that societal shaming and rise up and own our
sexuality as a beautiful, wonderful thing” (P2).
“A genuine desire to help people” (P3).
“The most beneficial thing for me is when I see a woman who has been able to
completely turn her life around as a result from the work we did” (P4).
I've contributed to someone's like, biggest growth and their biggest learning and
something that is, that can propel them to, you know, the future of their dreams,
whatever they may, that might look like. Um, you know, that, that's, those are
the things that feed me. (P7)
The researcher noted the P10 to smile and become more lively when speaking
about clients who sent ‘thank-you letters’, which was interpreted as experiencing
pleasure from helping others achieve success.
Part of what I love is that there... there is this completely tangible moment where
you're putting something into practice, like, right there in front of you, and
you're seeing it happen and you're seeing the gears click into place, and it's, it's
just such tangible progress. It's really beautiful. (P11)

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Table 1. Clustered Pattern Codes (Continued)

Pattern Code Exemplars

Excited about client It sometimes happens in the simplest of things, you know, and session eight he
breakthrough/progress walks in and for the first time gives me a real heartfelt hug. Ugh. Something has
shifted in him and he's able to let go of holding back and just give himself. (P2)
“Probably the most enjoyable part is, whenever someone has this realization where they
start to see something differently than they had before” (P3).

It's just amazing to me that I ... it is in a sense, like it sounds cheesy, but a
privilege to get to do it, you know, and an honor like I was saying to get to
witness the transformation of the clients. (P5)
“I love it when things click with a client. When there's like an a-ha moment” (P9).
I had a client who I saw for only six sessions, and like, we didn't get very far in
terms of, like, sexual acts or anything like that. But he was able just within those
six sessions to like, find that, sometimes I call it like a well of pleasure. He's able
to, like, find that in his body, and he's like, ‘Oh shit, I'm good.’ (laughs) He like,
left and got into this relationship, and I was really exciting for him. (P10)

Like being a parent- I'm more worried about the ones that you feel like you're sending them off into
wanting best for client, the world and, uh, like you're sending your kid off to college kind of thing. But
trying to prepare them, or then you don't necessarily know how successful they are at college. So it's like
emotionally invested it's great when you hear back from some people that ... that tell you ‘Hey, I'm
dating’. (P1)
“This is like the, the kind of excitement parents must feel when they watch their child
learn to stand up and balance” (P2).
I liken it to send your kids off to college. You know, they were- they were with
you for 18 years or so, and now it's time to send them off to school, and it's sad
that they're not gonna be living with you anymore but you're also happy at the
same time that they're able to fly the nest and become creative, self-reliant
human beings. And that's what I want for my clients. (P4)
“It's like mama bird is- Pushing baby bird out of the nest, and it's like, Oh! Flap those
wings” (P6)!
Not to be paternalistic about it, but there's, there's something to that. Of like,
‘Here, I taught you the things that you need to do to have a happy, healthy life.’
‘And go off on your own and do good things’. (P9)

Use of therapeutically “It's like, ‘Whoa, whoa. Slow down here. What did you come for? You came here so
indicated interactions you could figure how to be more in your body and figure out if you could enjoy and
have more pleasure’” (P1).
[Speaking about a client who is wanting to have sex immediately] “…Nor do I think it
would be useful and I think it would be unethical for me to do that” (P2).
If there comes a point in the therapy where, um, sexuality is indicated according
to those, um, those conditions, right? Where it's necessary for the client to reach
their goals. And, um, we've created, uh, an environment where it can be healing
and transformative. (P3)

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Table 1. Clustered Pattern Codes (Continued)

Pattern Code Exemplars

Use of therapeutically “Well, eventually, if they desire, we get to intercourse. And again, I'm always working
indicated interactions with a therapist on this” (P4).
(Continued)
“You only move forward if, you know, in physical intimacy, as much as you've built
the emotional intimacy to support it” (P5).
“A good surrogate is always gonna have a little clinician in the back of their head-
saying, ‘Is this sane? Is this therapeutically relevant’” (P9)?

Use of professional “This is what Masters and Johnson did uh, back in 1970. This is basically the idea that,
association treatment um, sensate focus, even if you just Google it, is basically the, the basis of all surrogate
protocol & client specific partner work is sensate focus” (P1).
interventions
“The normal sequence. It's really, it's kind of a protocol that is very adaptable” (P2).
I mean we go through a process right. So and then we move as quickly or slowly
as the client is ready to go. So, depends, you know. My first client was a woman
actually. And I mean it took her weeks till we could touch hands. So, we moved
very slowly, you know. (P5)
We probably had five weeks of preparing for the mirror exercise, and when he
really, finally saw himself, I mean it was really a metaphor for seeing his life,
seeing you know. It, it... he was able to... he was sort of forced to confront how...
what his... how his decisions have um... his life decisions and his history, have
recorded in his body. (P6)
This is what we do, we just practice. We just do it. Over and over and over
again, in little steps. You know, we, we do it in s-, in silly ways in the very
beginning, you know? Asking like if I could sit down on like the sofa next to her
a little bit closer or something like that. (P9)
“I totally agree with the stages, and I've actually, like, conceptualized what those stages
are for myself” (P10).

Logistics (Space, supplies, I see my clients in my apartment. I see them in my living room. We are in my
business aspects) bedroom, in my bed. So this is my home. This is- here you are. I don't have an
office that you come to which a lot of surrogate partners have. (P1)
“How we, how we structure that contact time might be hu- ... They mostly do with
logistics. You know, where do they live? Where do I live? How far or how do we get
together? How often” (P2)?
We always practice safer sex practices so I wear condoms. Uh, if I do oral sex
with her, I use a dental dam. Uh, if she's doing oral sex on me, we use a
condom… uh, kissing, we'll, we'll just flat out kiss. (P4)
It's just funny stuff that you wouldn't have to worry about with another job and
when people wouldn't understand like you know, like 'cause if I see a client, you
know, after work, like I'm kind of sweaty and like, ‘God, I wish I brought a
change of underwear’. (P5)
“People often do like, uh, a 90-minute sessions once a week. They do mini intensives,
uh, so either the full day intensives or weeklong, weekend intensives maybe once a
month” (P9).
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Real relationship/ It's hard to go down the path and, uh, part of the fact is, you know, some of the
professionally bounded clients I've had is like, wow, I've really fallen hard for them like damn. I’d love
to see this person again out- outside the therapy but, you know, it's just really not
as professional and as cool to do that. (P1)
“You're developing a, a relational basis to the whole thing. And it should be, in my
view, it should be friendly and still have a kind of, um, professional clarity about it”
(P2).
It is like any other relationship, the things that distinguish the surrogate client
relationship from other relationships is that it's, um, goal driven, right, with it's
driven by specific therapeutic goals that are determined at the start of the
therapy. Um, it's temporary and will be completed, you know, whenever those
goals are reached, ideally. And it also has, um, very specific and well-defined
boundaries. (P3)
When I'm talking about the whole process, absolutely, I talk about fact that we
will probably fall in love with each other and that's okay. The emotion is fine.
And you know, I'm married. Uh, I've got a [Colleague] who also does surrogate
partner therapy work. Uh, so it's our agreement that we're going to do this. I'm
not going to interact with them outside of the boundaries of the, the space that
we're working in and during our session. Uh, if I happen to run into them outside
of session in town, then I will not ignore them but I won't acknowledge them
unless they acknowledge me first. (P4)
“I very much conceptualize myself as the one holding the container, and holding the
container for them” (P10).

Reflexivity You have to be able to be ready if your partners says squeal like a dolphin to me
while we're having sex. You can't... You need to either be able to say, ‘Well, I'm
not comfortable doing that’ or ‘Yes, I will’ but you can't laugh at them and say,
‘That's the most inappropriate thing I've ever heard’. (P1)
“This woman who was with me for only six months, her big thing was that she wanted
to have sex at the window where people could potentially see her because she was so
shy about it” (P4).
I mean at first, it was like, [text removed] And that reminded him of a time as a,
as a child of being [text removed]. I don't even know all the details of what
happened to him because I don't want him to have to relive it with me. (P5)
I mean, it is tough. You know, like if you're not calling me or you're blowing
off, you know, a, a, a meeting/date/session, you're going to hear from me, you're
gonna hear from your doctor. You're gonna hear from your therapist, but you're
going to hear from like…I get to act as if I'm that pissy girlfriend. (P7)
“What we ended up realizing that he needed, uh, was mothering… Where he would,
like, lay on my lap and, um, feel that, that care and affection that he never got as a
child” (P10).

Client concerns have “There's, you know, women who are victims of, you know, child abuse or incest or, uh,
clinical impact rape victims when they're teenagers” (P1).

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Client concerns have “Some of them come with physical anxiety, some with emotional anxiety, some with
clinical impact kind of a completely shut down personality. Some of them, uh, slightly autistic…”(P2).
(Continued)
“Fear of intimacy, uh, fear of being vulnerable, um, performance anxiety. And a lot of
these happen as a result of past experiences that were traumatic” (P3).
“I've had half anxious people where there's some component of just, you know,
overwhelming fear. Like inhibitory fear” (P6).
“His early childhood trauma was so significant. Um, you know, it was very difficult to
move past even the rudimentary stages of touch” (P7).
“This older man, who has suffered some pretty severe abuse in his childhood…he's
never really been able to experience hugs” (P9).
“He was, um, sexually abused and raped by both his parents. Um, physically tortured,
like, it's just- it's like that level, where, yeah-. It's unbelievable” (P10).

Creating safe space for “So really creating a safe space for women, uh, to help them build that trust and, and
vulnerable persons learning that they can have pleasure too” (P4).
“Try to make it as, as safe and relaxed and comfortable as possible, that it's okay for
them to, to fumble or, you know, for things to not go exactly as planned” (P5).
“It's to show people, like, no, it's okay. You can cry in the middle of sex and I'm still
gonna be here. No, you can 100% fall apart right now and I'm gonna be here” (P11).
Goal orientated for client’s “You’re giving them the skills to, you know, tell them that like you're gonna be the best
future relational person to go out and have the most communication in a future relationship with a, with
functioning a partner of your own choosing” (P1).
“We're helping people have the skills to handle future sexual relationships” (P3).
“That while we had had a great relationship, it's time for them to go out into the world,
and put their new skills to the test” (P6).
“Part of the closure experience is appreciating the relationship for what it was. Um,
understanding that it's not built to continue. Um, and then saying, ‘Okay. Go out into
the world and do good things’” (P9).
I typically see a person nine separate sessions before we ever even start taking
clothes off. And it's like, that's... I think that says something. That says
something really important about, this is about relationship. This is about skill-
building. It's not about getting naked and practicing, right? (P11)

Clinician-surrogate partner That's part of my job then as a, as a surrogate partner is to let the therapist know
relationship as that they [client] have a distorted sense of what their touch feels like. Or they
collaborative have a really strong reaction to what my...To my touch on them. (P2)
“Typically the three of us meet together in one room at the start of the therapy. And,
uh, and get a really clear sense of what the goals are” (P3).

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Clinician-surrogate partner So if I see the client on a Monday, then as soon as the session is over, I'll contact
relationship as the therapist, say, ‘Okay, here's what happened. Here's what we did. Uh, here's
collaborative (Continued) what I think we should go in the next session.’ And then the client will talk to
the therapist and the therapist will get back to me and say, ‘That sounds great. I
agree.’ Or, ‘here's some things that came up’, uh, -between the two of them. (P4)
“Under the best circumstances, um, the therapist and the surrogate are really peers.
With different tools in their toolkit, and we bounce off each other. I've been lucky
enough to have some really great therapists that I work with” (P9).
“I am incredibly engaged with the therapist. I mean, if I have a session with a client, uh,
I always write up a clinical note” (P11).

Being “on” and providing Oh, am I doing a good job? No. Am I, am I up to this task? Literally, can I get it
the best up for this client? Is that going to ever happen? He needs me to f- ... He needs to
feel desired. But boy, he's not very desirable right now. (P2)
“Sometimes, I'm really tired though starting. And I think, ‘God, how am I gonna do
this?’ Like I don't have a lot of energy right now. And I need to be on” (P5).

Professional association And [collegue] was my mentor and she ... We reviewed all of my notes to that
member whole process and she said, "You've got it. This is exactly what the work is."
You know? So I was certified … And, the training also identifies ... The training
to be a surrogate identifies the weak areas. (P2)
“I try to not they give them information but to kind of engage them in how to think
about, um, the process therapeutically and clinically, you know, how to think about this
to make decisions to move ahead” (P3).
“You need people behind you, supporting you, when you're doing the work. So, I've
graduated to full membership, but I still call my mentor all the time” (P6).
“I recently had a conversation with my, my mentor about how to broach some of these
subjects with a client if they’re just really loaded” (P9).
Researcher noted all participants as being professional association members,
completing classroom and practicum training with supervision requirements.
Direct modeling “What I am offering is a, an example of what an appropriate and healthy relationship
can be” (P7).
There're places where, um, obviously people would be triggered because of the
history of the clients that I've worked with, the very, some of the very first
exercises like the May I/Will You exercise… Um, I've, I've had clients cry
during that. Cause they've never been able to say “no.” And feel like that “no”
would be respected and honored. (P9)
Times when you're just laying in bed naked after whatever you just did or in the
middle of processing something, and you're just laying there laughing, and
someone who has never had that kind of relationship goes, oh, fuck. This is what
it's about. It's not about the sex. It's about this. (P11)

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Direct touch We're needing to clarify always, here I'm touching your, your foot for my
pleasure and does that feel good? And they have all kinds of other reactions to it.
So there's, there's a lot of need for communication around touch and that's part
of what a surrogate partner teaches. (P2)
“There are a lot of things that I can do that a verbal therapist can't do. Um, and one of
those is touch, um, and we employ a lot of sensate focus in the work” (P3).
It could be anything from touching hands to having intercourse (laughs)
basically. Yeah- talking, processing also. Um, we do a lot of neat activities also.
Um, just ... Yeah, I don't know I can tell you about them all, but anyway.
Different activities with our bodies, dancing and moving in different ways. (P5)
So, it's, we just include genitalia in the body as a body part. Um which is
extremely foreign to people. Because our sexual parts are so sanctioned off, and
we have special clothing for them, and everything else. But um, that non-sexual
part, which includes full naked body touch and uh, caressing, and spooning. (P6)
“Work can bring in that, like, "Oh, I get to just allow myself to be held." That's uh,
something that I've seen lately that's really fascinating to me” (P10).
Experiential exercises It's a very slow process to get, you know, to the point of being naked in bed.
That's basically as far as we've got in a year. But when she first came on board
that was, you know, pre- pretty outside her realm of experience or something
that she could ever imagine herself doing. And now, you know, when we have
our sessions, we, you know, at least get naked in bed and kinda can touch each
other. Maybe not genital arousal or eroticism involved but just, you know, being
comfortable in bed. She realizes that hopefully that will move to something a
little more erotic which she's never really felt. (P1)
You have two people and one person makes a request of the other, the other
person gives an answer. And then the first person says, thank you, and then, and
then we switch roles. So, um, if I were doing this with you, I might say, um,
‘May I run my fingers through your hair?’ And, and you would have an answer
and I was, and then you'd make a request of me. (P3)
But also teaching her how to use condoms and how to put one on uh, what
happens after a man's ejaculated and how to make sure that doesn't fall off. What
happens if breakage happens, and all that stuff. So really educating. (P4)

Active coaching She was very involved. She doesn't have any hang-ups about sex. She had... Her
hang-ups were about her disability and her, um, you know, not being able to-
Comfort level with her body. And, you know, by me saying, you know, you
have a very, you know, sexy body, it just doesn't move the way you want like a
lot of other people do, and you can't really walk very well, and you have things
to help you get around and maneuver, but no. I mean you, you know, you have
parts and you're very sensual and sexy. (P1)

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Active coaching For some of these men, just like saying, ‘Hey, you know what? Your penis looks
(Continued) fine actually. You've got a great penis. And it's really ... It's functioning the way
it probably should be functioning.’ And, sure, penises- don't always do what you
want them to do, but to have like a sex therapist could talk to them about lots of
things and say, ‘Hey, you know, you know,’ could say … But they can't actually
say, ‘Hey, you got a great penis. Look at that’. (P5)
Spread-eagle in front of them, and, like, you give the anatomy of, like, and here's
the outer labia and the inter labia and the clitoris and the clitoral hood, but I'm
also talking about, like, and here's what I like. Here's how I like to be touched
here. That's not generalizable information. You should always ask. (P11)

Unique self- “I've been very attuned to others' needs, being kind of the helper personality to a certain
understandings have extent, being very patient” (P1).
led/prepared me for this
I feel like I am, you know, as far as I have good information, I, I could put
work
people at ease, I ... non-judgmental, you know, all these things, um, but then,
this also includes not just that intellectual component, you know, sort of ... But it
... There's an emotional intelligence. (P5)
I sit and meditate is in order to be able to withstand um, strong emotions. You
know, so that I can cope with uh, you know, that I can engage more deeply in
my relationships because I feel safe in myself, and I have the wherewithal to
survive. (P6)
“I, kind of, have it in my head is just the... deep healing that can come from, just like
that touch, from that connection” (P10).
Life experience has I think everything that I have been and done and the people that I've loved and
prepared me for this work the way I've engaged in relationship was part of what built a framework of who I
am, who I see myself to be. And the kind of relational skills that I have. (P2)
“It was also through these workshops that I became part of a sex positive community
where I found out about the work” (P3).
“Another reason why I felt like I could this job is because ... And I ... And others ...
almost all my jobs aside from this have also been somewhat emotional” (P5).
“I was practicing as a sex therapist, a traditional formal, uh, sex therapist. Using the
medical model of, you know, sexual dysfunction” (P7).
“I have done a lot of processing with partners. Um, and walking them through the, the
healing of the tra-, the trauma and abuse that they've had in the past” (P9).
I've had these experiences where just small encounters can be hugely
transformative. So for example, there was a, it's some kind of random story, but
this person at a New Year's Eve party who I ended up hooking up with, and we
you know, spent this great night together, and he said and he told me about, you
know, how he had this fiancée who left him and all this kind of like trauma
around this breakup, and in the morning he said, ‘Because of you, I think I can
love again’. (P10)

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Life experience has “Having a sort of in the distance at this point history of sexual trauma, I am very, very
prepared me for this work sensitive to consent issues. Which typically works beautifully with surrogate partner
(Continued) therapy because we're doing so much very, very clear consent” (P11).
Not everyone can do this I think you just... You have to be super confident with your own, uh, sexuality
work and sensuality. You have to be able to find something attractive in everyone.
You definitely have to be able to, um, be patient with people who have deep-
seated, um, issues related to relationships and communication, um, and their,
and their own bodies. (P1)
“You have to kind of handle a lot of that stuff before you're ready to, to put yourself
physically but also emotionally into this relationship and um, hold the container for it,
but give yourself fully to it” (P2).
“Finding people that, um, are a good mix of cerebral and geeky and, um, permissive
about human sexuality in general. You know, very, very aware of their bodies. Um, it's
kind of a, it's kind of a hard mix” (P9).

Real relationship “To do this work, you can't, you can't fake it. You have to have an authentic
relationship with these people” (P1).
“I really like the term surrogate partner therapy, it's for really creating a partnership
with the client, not just the sexual aspect of it… The surrogate partner's actually
creating that relationship” (P4).
“But it's so real. And I have real feelings too, you know... for them” (P5).
“Even though supposedly ‘I'm a pro’, um, you know, I'm still a woman in the room
who is nervous about taking off her clothes for the first time in front of a partner” (P7).
“It's really fucking authentic, yeah. Um, and I, I don't know if it's just like, how I'm
wired or whatever, but I really love being able to connect with clients in that container”
(P10).

Sharing self-perceptions We can have open conversations about our feelings and what's going on. And I
don't hide that I fall in love for a client when I do. Um, and I can tell them how
you know, I'm enamored with them and, and that at the end of our time, I will
say goodbye and there will be tears and it will be sad. (P4)
I'm there to give them really good feedback. ‘This is what's going on with me
right now. When you do that, I feel like this.’ You know, I, I'm there to tell them
how I'm being affected by what's going on every step of the way. (P6)
“And I said to her, I said, ‘That,’ like, ‘That is really turning me on.’ And the look on
her face was amazing. It was, she was like, ‘You're, you're really enjoying this?’ Like,
‘Yeah’” (P9).

Client attachment I mean I definitely care about all my clients. There's no way you could do it if
you didn't care, (laughs) you know... and develop like some affection but, you
know, with him, I feel like, like I really do... I, I kind of miss him when I don't
see him. (P5)

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Pattern Code Exemplars

Client attachment So I just, you know, talk to my supervisor I was like, ‘I can't do it.’ And she
(Continued) said, ‘Yes you can.’ And I did and I bawled my eyes out when I had to say
goodbye to him, we bawled our eyes out. (P7)
I had a client not too long ago who I just, oh, completely fell head over heels for,
and there is no absolutely no reason why we would never date in the real world.
And so that was hard… And for me it was really important to say, here are all
the reasons why it would be the worst thing for you and the, you would
backslide so hard if I stayed. Like, I can't stay. (P11)
Requires all of self to do “I have to be able to let my person, um, my body, you know, all of me be part of this
well therapeutic process- And it really takes total commitment” (P3).
“It's not just your mind, or your body, or your emotions; it's everything. It's your mind,
and your body, and your emotions, and you've gotta be on the ball, you know, you... it's
great. It's just... yeah it's everything” (P6).
“So much of what I bring to the process, to the therapeutic process, to the client's
growth process, is being an authentic person who they get to be in relationship with”
(P11).

Impacted by client “So one of my be- my favorite joys is when the relationship turns juicy. And I started to
really feel something for this other man, either empathy or real turn on, real kind of
excitement” (P2).
“You're there with them, holding, holding their hand through that, and- It can be rough
and- rough and tumble, with your emotions” (P6).
But I mean, it's, it's a, like, heartbreaking, and But, I feel so incredibly honored.
That I get to be with this person, right? That I get to, like, hold the immensity of
this trauma in a space of compassion. This person can now finally feel safe.
Like... I, I have to be like, the luckiest person (laughs) because it's just the
highest honor. (P10)

Client relationship as “And I work as a partner, um, and often initially as a coach, to help them learn the
dynamic skills that they'll eventually want to have” (P2).
“Um, but eventually the goal is to get to a place where we are, you know, it's not a
imbalance of, of skills, it's not a teacher and a student, it's a genuine relationship of
peers” (P3).
In the very beginning, we don't share a lot about ourselves. Because that's not
what it's about. But, the relationship, especially as, you know, if the client goes
all the way through erotic work and full process, the relationship slowly shifts.
So it's less student/teacher, and more something that looks a little bit like a peer
relationship. (P9)

Challenging work Then getting stuck and figuring out how with the therapist. How do we get them
around this wall or over this wall or through this wall? And the frustration level
of that is really difficult. So you'd keep rocking your brain of, you know, how to
deal with that. (P1)

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Pattern Code Exemplars

Challenging work I had a client once say that I was being defensive, um, in, in, uh, in a session.
(Continued) And so, so the challenging part is, you know, how do you respond to that?... So
like no matter what I do, I'm perceived as defensive. And not only am I
perceived as defensive, but I'm kind of reinforcing the projection. (P3)
I still haven't figured out how to let go of my clients' stories and trauma, and...
like, the heaviness that they sometimes bring in. And also, like, when I'm at
work, I put, I, like, I'm there. Right? Like, I just 100%, I'm with this person, and
I love that. I absolutely love it. And I love that depth of intimacy, and... there's
something that I, that I've, that I carry with me. (P10)
“I don't want to be an outpatient clinician, this sounds boring. But when I heard about
this, I realized the kind of connection and the kind of vulnerability that it takes is so
intense” (P11).

Advocate role Well, that's a horrible expectation to put on a woman. Um, she's just not ready.
If she's not ready, she's not ready. If she's worth, you know, having some self-
worth and know what you want for yourself, you're gonna hopefully find a man
who will respect that. (P1)
“I think it, it uh, supports the idea that everyone has a right to a, a sexual experience,
and a sexual part of their life that uh, sexuality is part of being human. It's part of the
human experience” (P6).
It is the best and only practice for those that are asking for it. And I think it's a
crime that therapists, if it's not within their wheelhouse or if it's not within their,
um, their own social morale, then- then get the client to who- who can do this
work, um, with them. (P7)
“I'm such a proactive advocate. You know, why I go around and give lectures and do
workshops and educate people about the work, because I think it is such beautiful stuff-
that our society's really lacking” (P9).
Concern for A lot of men feel pressured to want to head into having sex in the third date or
influence/impact of fourth date. So when women are in the position of saying I'm ready to give
societal views myself to you to have sex, they're not used to having a man say, a man say I'm
not ready for that because men are also programmed to like, oh, yeah, I'm
supposed to wanna have sex all the time. (P1)
How we handle it, the social, social things around it are kinda messed up in our
culture, not just our culture. Every culture probably. Um, messed up in different
ways. Um, this is, this work is a piece to help the most vulnerable clients. (P2)
“The state of our political, social, cultural, you know- dynamic is so, excuse my
French, fucked up around sex” (P7).
“I've talked to guys who are like, ‘Do you know how long it took me to get comfortable
with the idea that I like larger women? Because that's just not a thing you're allowed to
like’” (P11).

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Client improvement is “I'm helping someone relieve their shame and become a more fully realized human
beyond sexual being” (P1).
“The inability to sort of form healthy relationship connections carries over into many
areas of a person's life, you know. A lot of these people have struggled with, you know,
every aspect of their life because of this” (P5).
So I did my first session with a, with a disabled client and the therapist called me
up afterwards, after they had had their, their next session together, and she was
like, ‘I don't know what you did, but the entire session is different.’ Like how
she, like how she, how she perceives herself and talking and, um, how she's
viewing the world. (P9)

Helping the world one Maybe they are a wonderful uh, parent or a potentially wonderful parent, but
person at a time they are so messed up around this relationship stuff that they have been dragging
their children through one horrible relationship after another. Help them, you
know, resolve that and get into uh, taking care of themselves in better ways. It
helped take care of others and better ways of raising the next generation and
offering different role models for the people around them. (P2)
“They may get that torch and they will go out and teach their future partner, partners,
um, a about, them, their own bodies” (P7).
I think it's getting people a bit unstuck (laughs) from within those conventional
and often oppressive understandings that are out there, those oppressive and
awful scripts. And honestly, I feel like a huge part of my work is just inviting
people to love themselves, which I think is-... hugely beneficial, and, that's
(laughs), that's beneficial to the world. Like, I want that shit to spread. (P10)

Client progress unlikely She had literally been in verbal therapy 25 years and still found [herself] unable
without SPT or ethically to date. Um, and so, um, the first point I wanted to say is that, you know, a lot of
required people have tried a lot of other things and haven't really found a way to break
through. (P3)
“To me, it's unethical because they will be working with some of these clients for years
and the talk therapy isn't really getting anywhere” (P4).
“There's nothing else, you know. Some of them have had years and years of talk
therapy and like nothing shifted. And now, things are shifting” (P5).
I really have had the opportunity to make, um, a, a difference in their lives, a
difference that that would not be made unless they were with me. So an
undescribable- That opportunity to make a life, a, a life changing, uh, whatever
is not offered to any other modality when they can't get anywhere else. (P7)
Empowerment or reducing It's our deep craving for all of us human... In our human souls to have intimacy.
shame How we look for that and where we find that is different for us, but I wanna help
these guys find their way into what is real intimacy for them. That they can only
find by unpacking the baggage of anxiety, of shame and, uh, self-worth issues.
(P2)

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Empowerment or reducing “I describe it as the most empowering work that I do. The women that I work with, I
shame (Continued) take them from a place where they feel like they're broken, they're shut down
completely” (P4).

Table 2. Supported Themes

Themes Pattern Codes

Altruism For inner satisfaction; Not motivated by financial or sexual gain; Feel benefit in
helping others; Excited about client breakthrough/progress; Like being a parent

Professionalism Use of therapeutically indicted interactions; Use of professional association

treatment protocol & client specific interventions; Logistics; Real relationship/
professionally bounded; Reflexivity; Client concerns have clinical impact; Creating
safe space for vulnerable persons; Goal orientated for client’s future relational
functioning; Clinician-surrogate partner relationship as collaborative; Being “on”
and providing the best; Professional association member.

Treatment not provided by Direct modeling; Direct touch; Experiential exercises; Direct coaching
clinicians
Unique calling Unique self-understandings have led/prepared me for this work; Life experience
has prepared me for this work; Not everyone can do this work

Being authentic Real relationship; Sharing self-perceptions; client attachment; Requires all of self
to do well; Impacted by client; Client relationship as dynamic

Meaningful work Challenging work; Advocate role; Concern for influence/impact of societal views;
Client improvement is beyond sexual; Helping the world one person at a time;
Client progress unlikely without SPT or ethically required; Empowerment or
reducing shame

Theme 1: Altruism. The theme of Altruism was composed of five coded descriptions:

Code A is For inner satisfaction, Code B is Not motivated by financial or sexual gain, Code C is

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Feel benefit in helping others, Code D is Excited about client breakthrough/progress, and Code E

is Like being a parent. The codes were clustered by how descriptions revealed the participant’s

self-understanding of their motivation or desire to work as a surrogate partner. The pattern

clusters revealed significant similarity among the cases, which described overall intrinsic

motivational gains through selfless actions. The researcher case notes revealed a commonality

among participants where they would all express a sense of attachment to client success,

whereby the participant attached pleasure to client successes. The theme of Altruism was found

to bind the aforementioned codes based on the intentionality of the ideas described and defenses

made towards perceived criticism of their work as a surrogate partner. The following paragraphs

present excerpts that discuss multiple codes as embedded to the data collected.

Participant 2 presented his thoughts with intensity and seriousness in responding to what

he accomplished by working as a surrogate partner:

The sense, and I'll come back to this idea that my whole ... All, all through my adult life,
I've been asking what is my purpose? How do I meet this big sole purpose of this
lifetime? And because this work, arrived in front of me and I said, "That's it. That's what I
wanna be doing. That's what I am meant to be doing." Jesus, everything that's about my
life has been preparing me for this. I am really ready to be doing this, not just
professionally ready, but personally this is something I'm very capable of. And so doing
that, which is my purpose, it's a huge um, win for me. I'd say the, the, ... My main
disappointment is not doing it more…. Not nearly as much of, much time doing this work
as I would like to be doing.

His intentions of working as a surrogate partner were revealed as being worthwhile based on

fulfilling an inner desire (Code A). The inner desire was said to be fulfilled based on sharing his

talents that were developed throughout the course of his life (Code C). The overall context of

this type of response demonstrates the group consensus, which implied gaining inner satisfaction

through helping others with surrogate partner work (see Table 1. Exemplars). However, the

gains received through helping others were not based on requiring maintenance of a client

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relationship but that there is satisfaction when the client experiences a breakthrough or

progresses to higher levels of wellness (Code D) and is able to move on from SPT. Participant

11 demonstrates this selfless desire for client wellness as,

I've met plenty, plenty of clients get to the place where their anxiety is so managed that
they start coupling naturally in the world before we even get there, and that's like, okay,
great! Awesome. Call me if you need me. Like, this is... It becomes this really, really
natural hand-off where then they're comfortable enough, like, bringing their new
girlfriend into session with their sex therapist and talking about, like, where we are in
sensate work, and... Where they can pick up where they left off.

The surrogate partner revealed a desire for the client to have their own independence in

relationships and found pleasure in those successes. This excitement for client progress also

related to a comparison made to being like a parent (Code E), where the surrogate partner is

trying to prepare the client for a launching into the world phase but has emotional investment and

attachment,

But I liken it to send your kids off to college. You know, they were, they were with you
for 18 years or so, and now it's time to send them off to school, and it's sad that they're
not gonna be living with you anymore but you're also happy at the same time that they're
able to fly the nest and become creative, self-reliant human beings. And that's what I
want for my clients. (P4)

The pleasure gained from using a unique skill set to help others is contrasted to when participants

made defenses against societal perceptions of SPT as something where the provider is motivated

by financial or sexual gains (Code B). Case notes indicated Participant 7 as having significant

anger concerning the societal ineptitude of client characteristics found in SPT referrals; the idea

of a person becoming a surrogate partner for sexual gains is ridiculous when considering that

many clients are anxious avoidant of touch, have significant inexperience, and have significant

barriers to forming natural relationships in their social surroundings. Given that surrogate

partners worked within the field of SPT as part of a contracted business model, the researcher

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case notes reflected that it was unexpected that participants did not speak of financial gains.

However, the participants did make comment on how financial gains were minimal,

Yes, it can be a little bit of money, but making a living out of it is probably not gonna be
your thing. You're gonna have something else to complement that. Um, you're gonna
have to be a, you know, a massage therapist or do therapy or something else or whatever
you're doing, uh, outside of that. So to me that... You need to move yourself out of that if
you think this is a career, quote unquote, a career. Yes, there are a few people that do
that, but I try not to mention that. But they're also living in a house with like six people
and they have very low cost of living and... (laughs). You know. It's a, it's a different
lifestyle. It's definitely got to be a calling. You knew you're not doing this for the
money. You're not doing this to, um... You're not doing this to have any kind of sexual
fulfillment either. (P1)

All participants provided evidence of the principle benefits received as being related to an

internal satisfaction anchored to providing benefit to others.

Theme 2: Professionalism. The theme of Professionalism was supported through: Code

A is Use of therapeutically indicted interactions, Code B is Use of professional association

treatment protocol & client specific interventions, Code C is Logistics, Code D is Real

relationship/professionally bounded, Code E is Reflexivity, Code F is Client concerns have

clinical impact, Code G is Creating safe space for vulnerable persons, Code H is Goal orientated

for client’s future relational functioning, Code I is Clinician-surrogate partner relationship as

collaborative, Code J is Being “on” and providing the best, and Code K is Professional

association member. The codes were clustered by surrogate partner descriptions of their work

that shared ideas common to working as a helping professional. The pattern clusters were

distributed throughout the participant cases and all contributed to things related to working as a

professional. The codes that contributed to the theme of Professionalism were noted by the

researcher as the category most contributed to by participants (see Table 1). The theme of

Professionalism bound the aforementioned codes based on the work of a surrogate partner being

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a skilled and licensed activity for the participants interviewed. The following paragraphs present

excerpts that discuss the codes as embedded to the data collected.

The codes within the theme of Professionalism first began to emerge as a collection of

work activity descriptions of a surrogate partner, including business aspects (Code C; see Table

1. Logistics) like using client feedback forms to understand satisfaction with things ranging from

the room environment to their results in treatment (P10). The excerpts also supported an idea

that specialized knowledge while being accountable to a standard was required to provide ethical

treatment, which appeared similar to the framework used by clinicians and other helping

professionals but with different definitions therein. Participant 11 described the surrogate

partner framework as,

You also have to be ethical, you also have to be professional, and in a way, I think, like,
we have to be beyond fucking reproach if we are gonna be able to say, what I do is
legitimate and I do it in a way that is safe for me and safe for my clients.

The researcher additionally noted that all participants received course room based and supervised

practicum training (Code K). The participants described training as using a theoretically based

therapeutic protocol (see Table 1. Use of professional association protocol and client specific

interventions). Participant 7 provided a treatment overview (Code B) that discussed how the

surrogate partner relationship (Code D) helps improve client future functioning (Code H),

What I like to say is we're modeling, uh, healthy, and appropriate, uh, relationship within
the carefully constructed confines and very specific compounds of the model of the
surrogate partner model. This is never meant to be sustainable. It's meant to launch a
person into what it is they wish and desire and dream for themselves in terms of
relationship. Um, what I am offering is a, an example of what an appropriate and healthy
relationship can be. So that, that starts with the beginning phase of, you know, dating and
uncertainty and not knowing each other and getting to know each other and then moving
into a, there's an educational piece that comes after that. Like, oh, what, what part of the
body is what, um, you know, do they, how much do they know about their bodies? It
seems to be a little bit more clinical and then we introduce, um, uh, it some touch, uh,
sensual touch, uh, non-erotic, although for most people, any form of touch, given that
we're a touch starved society. Uh, most of it is arousing and, and that's when I would
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 provide a lot of education. That arousal does not equate to sexual arousal in all instances.
Try to really parse that out, um, and then from there we would move into whatever the,
the deepest form of intimacy that the, that the client wanted to attain. Um, some clients,
you know, want certain things and others don't. And so when we reached that peak and
can no longer, and are, are in that peak for a specific period of time, we come into the
fourth and final phase, which is, you know, me launching them. I want to say termination,
um, but we end the relationship and I launch them out into their own private world. Um,
and that, that happens when the therapist, the clients and then me and we can no longer
answer the questions, what's next or what's left. And then we say, uh, incredibly
beautiful, um, conscious, honest goodbye, where we review what, where they came, what
we went through together and where, where, and how they're leaving. Um, it's always a
celebration, a lot of times there are tears. And then we have a strict policy of no contact
for, um, quite, uh, a, a long period of time, um, before the client can, um, contact me
directly.

The relationship between the surrogate partner and clinician is collaborative, where both sides

interact with the client differently to achieve a therapeutic outcome (Code A, I), as demonstrated

in the following case note artifact provided,

After the shower, I transitioned us to the sexological body tour. I started, so sat him with
his back against the head of bed and I lay in front of him. I gave him a tour of my body,
showing and naming errogenous zones and my genitals, sharing details about what feels
good to me. I also provided some guidance on what of those details is broadly
generalizable information and what is not likely to go over with other partners. Notably,
I was still very wet and [Client C] was quite enamored with that. I was proud at how
comfortable he got talking about my body and looking at it in detail. When we switched
places and roles, he was less comfortable. In true [Client C] fashion, he used his humor
and charisma to play off his anxiety. He said “so…. I have a this and two of those and
that’s about it.” I teased him playfully about this and asked questions to get him engaged
in talking about what he likes. He continued to demonstrate more by touching specific
areas of his cock or balls, but I was sure to pretty matter-of-factly reflect back using
terminology (e.g. so you are really sensitive on the underside of your cock right below
the head). (P11)

The use of nudity was described with having intentional therapeutic benefit for the client, so that

they were able to learn about human physiology in a practical manner. The relationship a

surrogate partner has with a client was also described in terms of ensuring safe space (Code G),

I mean, that's, I very much conceptualize myself as the one holding the container, and
holding the container for them. So, and in fact, uh, another piece which I thought, which I
think is interesting is... when I am sexual with my clients, I teach my clients, right, to just
let go into their own sensation. To completely just let go. And, I've realized that I cannot
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 do that, that (laughs)... right, when I do that, then I'm no longer holding the client as well.
And that, a part of me always needs to really be present with the client. So that's an
interesting difference between like, my personal sex life and my sexual experiences with
clients. (P10)

Managing client interactions as therapeutic and doing no harm is in consideration of the

individual histories and concerns being treated (Code F) (see Table 1. Client concerns have

clinical impact). Examples were given of client reactions during a SPT session that

demonstrated how a surrogate partner needs to be alert and aware of the client (Code J) in order

to respond reflexively (Code E) when required: “If he's like reverting to his childhood, he starts

shaking. And I mean, like he's disassociating. He's leaving mentally. He's somewhere else. He's

scared. He's super scared. Um, you know, he's in his fight or flight or freeze syndrome” (P5). A

significant attribute of the professionalism theme is that all participants provided understandings

about their role as someone who manages their client relationship as a therapeutic intervention,

which reflected professionalism through training, responsibility to an overseeing association, and

working collaboratively with a clinician.

Theme 3: Treatment not provided by clinicians. The theme Treatment not provided by

clinicians consisted of Code A as Direct modeling, Code B as Direct touch, Code C as

Experiential exercises, and Code D as Direct coaching. This pattern cluster of codes were

generated from descriptions of activities that the participants do as part of the SPT approach and

those where clinicians are unable to ethically engage in with clients. The codes provided

examples of how the nature of the relationship is different between a client and their surrogate

partner or clinician. A clinician as a licensed helping professional who is ethically bound by a

set of codes that allowed for a discussion or prescription of relationally and erotically based

therapeutic exercises related to modeling, touching, experiential exercises, and coaching

retrospectively. However, a surrogate partner will actually perform those therapeutic

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intervention exercises with a client, which can involve modeling, touching, experiential

exercises, and coaching during observation or participation. This theme is a descriptive

expression from more specific data that also supported Theme 2: Use of professional association

treatment protocol and client specific interventions. The following discussion uses data

examples to demonstrate the thematic cluster pattern of a treatment that cannot be provided by

clinicians.

Researcher case notes reflected that participants contributed significant content and time

to discuss the therapeutic interventions provided to clients. The context of these descriptions

was believed to be influenced by how the researcher-designed interview questions addressed

SPT as a job, and therefore the activities of working as a surrogate partner were implicit to a

discussion of their work. Participant 3 described the role of a surrogate partner when they take

turns giving and receiving touch (Code B) in sensate exercises (Code C) with a client,

We combine the talking with other sorts of things. Um, because there's also a great way
to get to know someone through touch. Right. And so it's really important that we
distinguish between our role and the role of the verbal therapist. So I would never have a
complete session that involves just talking. Um, however, um, there are a lot of things
that I can do that a verbal therapist can't do. Um, and one of those is touch, um, and we
employ a lot of sensate focus in the work. And, um, the sensate focus is a great way that a
safe environment through this gentle nurturing touch that the client can start to pay
attention to, uh, physical sensations that they find pleasurable. And it also becomes a
form of body image work because so many times people relate to their body, by the way
it looks visually as compared with idealized objects like movie stars and models.
Whereas if you close your eyes and have someone touch you, you can start to experience
pleasure regardless of what your body looks like. Right. Regardless of whether you
weigh a 100 pounds or 400 pounds.

The purpose of the interaction is to engage the client in an exercise that stimulated their senses

both as receiving touch and giving touch while the surrogate partner provided feedback about the

touching interactions (Code B, D). As noted by the researcher, surrogate partners used their

body as a nude and perception model for the naked body tour and part of the mirror exercise

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where they described positive yet honest self-perceptions of their own body. Participant 7

described modeling (Code A) and experiential exercises (Code C), “the naked body tour and I

was the naked one standing in the room alone, and then he was naked with me.” Modeling,

touch, experiential exercises and active coaching were found together in interactions that involve

sexuality by how the surrogate partner is modeling a relationship while using touch as part of an

experiential exercise, such as condom education (see Table 1. Experiential exercises, P4) or

while working to improve communication during sexual activities,

I've had some disabled clients and, um, like cerebral palsy where, um, they're... they
potentially, they've ha- maybe had sex when they're younger but not had in a long time
and they're trying to figure out. Uh, they're ready to kind of get out in the world and date
to a certain extent. But they don't know how to like maneuver into sexual things. I have
one client where we just figured out how she could communicate to me when, you know,
I would get her, would get her on the bed. We'd communicate fully clothed about, you
know, okay, what kind of positions can we get into have intercourse. And so we kinda
like, you know, pulled out the Kama Sutra kind of thing and like let's figure out different
positions that might be comfortable for you, you know. And then I... teaching her to
communicate with me and say, ‘Oh, can you move my leg over this way or can you move
my arm this way’ 'cause she can't necessarily move in a lot of different ways. And say,
"Oh, let's try this." And so we tried a lot of different ways. Um, and we ended up getting
naked and we ended up actually having intercourse because she really wanted to
experience that in a more full-on way. (P1)

The explicit practice of sexual acts involving touch (Code B), Experiential exercises (Code C),

and coaching is displayed in an email artifact between Participant 2 and a clinician,

Thanks for reaching out to me. We met today. We identified two areas to explore when
you meet on Friday. The issue really important to [Name redacted] is the attractiveness of
his penis. He feels his own view is possibly distorted and he very much wants to know
what is likable about it and what is unlikable. I think that's a good thing to discuss with
him. I suspect his viewpoint is distorted and continues to cause him too much anxiety.
[Partner’s name redacted] comments about his penis were very emasculating to [Name
redacted]. Secondly, he does not allow himself or struggles to enjoy receiving pleasure
from someone else. I think that would be a great thing to work on and worth continuing
to meet until he can enjoy receiving pleasure from someone else. Thanks for everything
you've done for him.

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This email demonstrates the interplay between a clinician and a surrogate partner where they

fulfil separate roles to provide therapeutic benefit for a client. These cluster patterns provided

evidence of an overall emphasis about how a surrogate partner fulfills a role that cannot be

performed by a clinician, particularly due to content involving relational or erotic experiences.

Theme 4: Unique calling. The theme of Unique calling is composed of multiple ideas:

Codes A is Unique self-understandings have led/prepared me for this work, Code B is Life

experience has prepared me for this work, and Code C is Not everyone can do this work. The

codes were clustered by the participant’s descriptions of how they were uniquely prepared for a

task that other people were not able to perform. Evidence of uniqueness came from self-

understandings or prior experiences that prepared them to work as a surrogate partner and

comments about the nature of the work demanding a person with a set of attributes not typically

found in other people. The pattern clusters described an overall idea that surrogate partners

perceived themselves as different from most other people, and that they believed that has

developed as a result of life experiences and introspection. The theme of Unique calling was

bound to the aforementioned codes as based on a belief that the uniqueness served as preparatory

of becoming a surrogate partner. The following is a discussion of how thematic cluster patterns

were embedded to the case file data.

Participants indicated different experiences that helped to develop their skills and self-

perceptions in a way that made them uniquely prepared as a surrogate partner. These ideas were

expressed in education and life experiences involving relationships, and that they were different

as a result, which prepared them for being a surrogate partner. Participant 9 described himself

as, “I am better at creating a safe space for, for people than most. I have done a lot of processing

with partners. Um, and walking them through the, healing of- the trauma and abuse that they've

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had in the past.” The comment linked his ability to create safe space for clients with experiences

he had with trauma survivors. This described an experience as positively improving his future

ability as a surrogate partner (Code B) and implied changes in self-perception (Code A).

Communication and deliberate relationship building through education and experiences were

described as impacting Participant 3’s work as a surrogate partner,

There were two factors that were the most important, the one is that I had been doing
workshops by an organization called the [Organization name redacted], they offer
workshops in love, intimacy and sexuality. And it was these workshops that basically
gave me a lot of the skills and awareness that I presently use in my work. And it was also
through these workshops that I became part of a sex positive community where I found
out about the work. When a friend of mine told me of her intention to become a
surrogate. … And another part of this picture is in 2000, oh... So in the year 2000, I met a
woman and she and I started dating and we formed a relationship that lasted six years.
Now she had been, um, raped just a few months before we met. So she was still, um,
reeling from the impact of this, um, sexual trauma. And, um, so she and I were getting to
know each other at that time, and I started to see how scared she was, you know, but also
how there was mutual attraction there. And I realized that if I came at her with an agenda
or with a strong sexual, um, energy that she would withdraw. She would get scared and
runaway, and then neither of us would have the connection that we wanted. I learned the
necessity of pacing right, of meeting her where she was at. And that has become really, I
think, the most important, um, aspect of my work because I work with, uh, female clients.

The description provided an understanding of how a surrogate partner developed a uniqueness,

not that they sought out to be certified or to deliberately learn something, but that their

development resulted in greater preparation. An awareness of possessing unique attributes as a

result of an experience that led to a desire to help others using their full body was demonstrated

by Participant 10 (i.e., Life experience has prepared me for this work) and Participant 6, “When I

first encountered this kind of work it was like. Um. I can't believe that this is really a thing, and

I'm perfect for it, and it's perfect for me!” The experiences and self-understandings led to the

knowledge of being unique, demonstrated here by Participant 5,

Not everybody could, could do it, you know- um, this kind of, uh, work. And I just felt
like I could…. So, I just kind of … But I was able to have compassion for him and sort of
see the kind of pain he was in, you know.
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Using a person’s full body, including sexual experiences, was only one aspect of doing

something that not everyone can do (Code C), but also included therapeutic abilities like holding

space for someone as indicated by Participant 2. The researcher noted that surrogate partners

had a high level of comfort with themselves, sexuality, body concerns, and client concerns. This

thematic pattern cluster held an idea that surrogate partners were prepared through a variety of

experiences so that they were able to do the work.

Theme 5: Being authentic. The Being authentic theme is composed of: Code A is Real

relationship, Code B is Sharing self-perceptions, Code C is Client attachment, Code D is

Requires all of self to do well, Code E is Impacted by client, and Code F is Client relationship as

dynamic. The codes were clustered by case file data that provided descriptive elements that

displayed the participants as being genuine, real, or otherwise acting as themselves while

working as a surrogate partner. The pattern clusters described an overall idea that surrogate

partners perceived themselves as acting in a similar way with clients as they would in their

everyday life, but with constant perspective taking on how interactions needed to be

therapeutically beneficial to the client (also described by the code Real

relationship/professionally bounded in the theme of Professionalism). The theme of Being

authentic was bound to the aforementioned codes through evidence of acting in genuine

relational ways where there is a bi-directional social-emotional impactful relationship being

formed. The following is a discussion of examples that demonstrated the coded cluster patterns

as embedded to case file data.

Evidence of Being authentic during client interactions came forward by how participants

shared themselves and how they felt connected to clients, such as, “with the surrogate partner,

you're sharing like 80% of your personal self with this person. Your heart is open to them” (P1).

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The descriptions given about the relationship suggested that a surrogate partner cannot act or

pretend, but that engaging in authentic ways was actually a requirement of SPT (i.e., Real

relationship, Requires all of self to do well). In many ways, the participants communicated a

sense of bringing as much of themselves into the relationship as was therapeutically possible and

would still be beneficial to the client. All of the clustered codes of being genuine were

demonstrated in the following excerpt from Participant 11,

So part of the balance is that so much of what I bring to the process, to the therapeutic
process, to the client's growth process, is being an authentic person who they get to be in
relationship with. So I cannot, like, sterilize my personality out of this relationship. I'm
not supposed to. It's not helpful if I do. And so, there are these kind of delightful playful
natural things that happen when we are, in our platonic space, but also when we're in our
sexy space that, that comes out and that... really is about being connected to not only a
person but this person, and that that is really important to hold onto I think, and that's
something that... that I think a lot of people don't get. People say, well, what if your client
falls in love with you? And I'm like, well, of course they're gonna fall in love with me.
Like, that's what it's about. Like... How do you have that, especially when you've never
had it before, how can you have that kind of deep vulnerability and not... not want to just
fall completely into that space- But to say, how do we practice putting it in a safe spot,
knowing what those parameters and boundaries are, how do we practice constantly
revisiting the fact that this is a relationship that is gonna happen in a specific way for a
specific kind of growth, and then it's gonna be over. And that that piece, I mean, I talk
about termination day one, probably day four, probably day 12, probably day 25, it comes
up all the time, and that you're constantly having this conversation, of, this is gonna be
really hard to let go. Yeah! Absolutely! It's gonna be hard to let go, just like a real
relationship is hard to let go, and you have to figure out, where do I house that narrative
in myself that helps me move forward with the next relationship in the best way possible.

The surrogate partner is revealed as someone who develops a real relationship with a client,

using themselves in very full ways that are impactful. Her description of falling in love with

clients was presented as a natural consequence of the relationship building process of SPT that

fosters intimacy. The bringing a substantial portion of oneself into the surrogate partner-client

relationship is further evidenced by the introspective effects of attachment (Code C) and being

impacted by the client (Code E),

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 I mean, parts of it are fun, but a lot of it is not fun at all. Um... (laughs) It's hard. I mean,
how often do you cry normally, in normal life? Like, probably not that often. How often
do you cry surrogate partner therapy like, you know, (laughs) more often. Both because
you're talking about painful stuff in your history, and also because, you know, whatever
you are... you, yourself are feeling sad, or whatever. The client's saying something that
just drags your heart out of your body. …. you're there with them, holding, holding their
hand through that, and- It can be rough and, rough and tumble, with your emotions. (P6)

The surrogate partner is shown to have experienced significant emotions as a result of their

relationship connection with clients. The researcher notes provide reflection on how the

participants would speak with a range of emotions that matched their client’s emotional state

(i.e., speaking of client triumph showed excitement and client struggles were spoken with

compassion and concern, revealing a greater connected influence than a clinical appraisal). The

being authentic pattern cluster held an overall idea that surrogate partners experienced a variety

of real relationship experiences (social, emotional, and physical) and were personally connected

to and impacted by their client.

Theme 6: Meaningful work. The Meaningful work themes consisted of Code A as

Challenging work, Code B as Advocate role, Code C as Concern for influence/impact of societal

views, Code D as Client improvement is beyond sexual, Code E as Helping the world one person

at a time, Code F as Client progress unlikely without SPT or ethically required, and Code G as

Empowerment or reducing shame. The codes were clustered by how descriptions revealed the

participants as understanding their work as a surrogate partner to be important to them. The

researcher case notes revealed a commonality where participants emotionally expressed how

societal views negatively impacted clients, indicating a concern important to them. Meaningful

work was bonded to the aforementioned codes based on values intrinsic to the actions and views

described in the case files. The following paragraphs present excerpts that discuss the pattern

cluster codes as embedded to the data collected.

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 The participants described working as a surrogate partner to be challenging but also as

something they were able to succeed in. The context of challenges in the work (Code A) were

based on helping a client to overcome concerns as sometimes being a difficult task to

accomplish, suggesting that overcoming difficulties adds to the work being meaningful (i.e.,

Challenging work). The work of SPT is displayed as important and worthwhile based on how it

could improve other people in meaningful ways. Participant 9 recalled how a communication

exercise helped to empower a client (Code G) in social interactions (Code D) by changing their

interactional pattern with social views (Code B, C),

So I did my first session with a, with a disabled client and the therapist called me up
afterwards, after they had had their, their next session together, and she was like, ‘I don't
know what you did, but the entire session is different.’ Like how she, like how she, how
she perceives herself and talking and, um, how she's viewing the world. And we just- The
only thing we did was we, we worked on how she can communicate yeses and no's and
her desires better. Yeah! But, but when you think about it, someone with disability is
constantly reliant on someone else to facilitate their existence. So, so consent gets really
twisted. Those yeses and no's always have to be filtered through, ‘Am I going ...’ ‘Is my
request going to be too much and this person's gonna eventually abandon me.’ So when
you start talking about that, like that plays out in relationships like you wouldn't believe!
(P9)

The idea of taking actions to improve the lives of others through working as a surrogate partner

was evidenced as part improving the world through one person at a time (Code E),

It's the only thing to do culturally and as a society is to, you know, give people, we teach
them how to drive cars. You know, we teach them how to use heavy machinery. You
know, we don't teach anybody how to, if we have better sex education, we probably
wouldn't need this but we don't, we don't have any form of real education. So it's a, it's
our moral, moral and ethical duty to get this out to the world. And it is, it is life altering,
it will change societies. (P7)

Improving the lives of others was accomplished through teaching improved relational

functioning to people. The use of SPT to help people was displayed as the only option for some

people and therefore an ethically required therapeutic modality (Code F). The participants

revealed themselves as advocates for the use of SPT and as passionate about the injustice of not
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offering the treatment to people who could benefit (i.e., Client progress unlikely without SPT or

ethically required). The descriptions of acting as an advocate provided a sense of the values that

supported the idea of being a rescuer, “I want to learn how to hold and be held, you know, oh

God, it's hard to. Um, you know, and it's like, are, are you kidding me?…How can I not do this

work?” (P7). Although the surrogate partner therapeutic relationship was demanding, the benefit

to clients and society provided meaningful purpose to the challenge and demands of the work,

It's helping people so much and each individual you help, you know ... I mean you are
helping the world. And they're spreading out. I mean they're just becoming fully realized
human beings, you know. And that's showing up in lots of ways in their lives. So, they're
better able to, you know, just have better communication and, and function better and
function better in their families which would make friendships, be in community. Maybe
get a job if they need that. I mean I've had lots of clients who don't have jobs because like
they never quite figured out how to have a job or career, you know because their lives
were falling apart in lots of ways, not just the lack of a relationship, you know. (P5)

The researcher noted that many of the participants promoted positive sexual messages beyond

SPT work through informal (e.g., P2, P10, P11: social gatherings) and formal means (e.g., P4,

P7, P9: conference speaking, teaching clinicians); their efforts appeared evangelistic, like they

were driven to complete a mission or working towards a special purpose extending beyond client

work. The Meaningful work cluster pattern presented the idea that surrogate partners believed

that the challenges of working in SPT were important to pursue as based on their value for client

and societal improvement.

PERMA Model Pattern Matching

A pattern matching analytic strategy (Yin, 2014) compared case file data excerpts to the

PERMA model in positive psychology (Forgeard et al., 2011; Seligman, 2011). The purpose of

this analysis step was to investigate how the PERMA model framed the surrogate partner data

findings in comparison to the earlier performed thematic analysis (Braun & Clarke, 2013). The

full PERMA model of well-being was found in a cross-case analysis and in all participant case
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file data sets. Exemplars of single instances of the PERMA model patterns are presented in

Table 3. Participant interview excerpts revealed the presence of multiple PERMA coded areas

simultaneously when taken within the context of a larger quote. PERMA as coded to the data is

discussed through examples in the remainder of this section.

Table 3. PERMA Model Pattern Matching

Model Pattern Exemplars

Positive Emotions – She was smiling and dancing around in her seat while retelling a client
Feeling good success story (P10 Researcher case notes).

Engagement – Finding “And I go, ‘Ah, yes, this is lovely. That feels so good. Let's go with this. No, we're
flow not gonna shift gears yet. I had other things on the agenda, but let's stick with this
because this is really important’” (P2).

Relationships – Authentic “To me, those are the most powerful moments. It has no- It's not about the
connections sexual part or the touching part or them being aware that they've had their
first orgasm. Those aren't the moments that are the memorable. The most
memorable ones is when you feel that trust and, uh, connection happen
when they realize they actually have a relationship with you.” (P1)

Meaning – Purposeful “What it means is I get an opportunity to help a woman become a whole human
existence being” (P4).

Achievement – A sense of “I feel like I have a much better idea of what's happening in my relationships when
accomplishment they're... when, when it's happening. Um, but what the, the big change for me was
what I want out of a relationship” (P6).

Evidence of positive emotions, engagement, and meaning is found in Participant 2’s

discussion of what SPT is,

Well, it's a piece of ... Or, and you know, a toolkit for therapists and the therapeutic
community to use to help clients who are really struggling-... with things very deep ... I
mean human sexuality is a human need. It's not something that we can sort of push to the
background or push off to the side. It's a, an essential need of being a person with a body.
How we handle it, the social, social things around it are kinda messed up in our culture,
not just our culture. Every culture probably. Um, messed up in different ways. Um, this
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 is, this work is a piece to help the most vulnerable clients. The most-... uh,
uncomfortable, damaged, um, helpless, um, frustrated, confused of our members of
society, uh, to find their way into more comfort and ease. More possibility in having uh,
intimate relationships and a better relationship with themselves. And intimate
relationships with a partner or partners that they choose eventually that brings them out of
their little uh, balled up corner and into some part of relating with the world. And that to
me, to the degree that this work can do that for my clients is saying, ‘Okay, let's free
these people to be who they potentially can be.’ This is holding them back. Let this, let
this help them move forward and out into the world and get connected. And even if it
isn't, relationship may not be the main thing about what they offer the world. At least it's
not something that's keeping them from offering what they have for. So, maybe they are
a, some kind of brilliant scientist, but they will be a more humanistic scientist if they
learn to deal with their humanity more.

Participant 2 was noted by the researcher to show positive emotion through enthusiasm, smiling,

and intonation starting at “Okay, let's free these people….” Engagement was implicit to the

conversational flow and content, where Participant 2 demonstrated their expertise and comfort

within the topic of a surrogate partner providing therapeutic benefit to clients. Meaning was

displayed by how Participant 2 presented different emotions according to the content of client

concerns and their improvement, and by the content of their message that positioned them as

improving the lives of their clients in significant ways. Participant 6 discussed an appraisal of

things they have done and how it related to their personal development,

I've been in computers for, you know, 25 years now. It's great. Um, it's not contributing
to the world. It's not contributing to my personal development. My experience here on
earth as a human. Um, I feel... I've always had this sort of long quest, like I don't know,
15 years. This real quest for what do I find meaningful? What sort of activities in my life
can I inscribe meaning to? And it... for me it came down to relationships. And it was like
it's... for me it's about human connections. Time that I spend with my friends. Time that I
spend with other people. And then, that sort of transformed in to, "How can I um..." I
think this is probably true for a lot of other people as well, that, you know, and I think
whether they know it or not- relationships are a really important part for everyone just
being human. I think it's part of the human condition. Um so it just came to me like, "
What sort of service can I provide around relationships?" And I have the unique, I think,
ability to be able to engage and be vulnerable and, you know, part of my new spiritual
philosophy is, you know.

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The excerpt demonstrated multiple codes, most significantly in the area of relationships and

achievement. Participant 5 described achieving something for himself as an improved ability,

“to engage and be vulnerable.” Participant 11 described her inner experience of working as a

surrogate partner as,

I think... because we are tracking our clients on so many levels at the same time, it, it
feels the same to me as when I was doing [Redacted modality name] therapy and I would
be working with like a whole room of family members at the same time, and, like, man,
when you hit every fucking thing in just the right moment and I hear what you're saying
and I can speak to you in a way that speaks to you and I've got this and I see that dynamic
happening over there and I'm managing it, like, it feels like a fucking symphony. And it's
amazing to feel like I've got this all beautifully balanced, and I feel exactly the same way
about partner surrogate work because we have all of these layers about, like, yes, there's
the, like, we're doing sensate focus and we're doing, may I/will you. We've got these very
concrete layers of skills. But there's all of this deep experiential stuff, and then there's the
boundaries, and then there's the self-awareness and the awareness of other, and then
there's the balance between self and professional.

The excerpt had an overall coding of engagement because her description matches the idea of

finding flow, where there was a level of effort required before things begin to align and feel

easier. However, the areas of positive emotions, meaning, and achievement were also implicit to

the message provided. The trend of multiple areas of PERMA being present within the data was

revealed in almost all the cross-case composite examples.

The researcher found interesting patterns through analyzing the PERMA cross-case

composite’s coding patterns while considering alternative explanations (Yin, 2014). The data

was experimented with using different PERMA code clusters and considered new explanations

of the content. This analysis step resulted in discovering how different coding patterns presented

the data differently: Meaning-Achievement; Relationship-Achievement. The Meaning-

Achievement code combination was present among descriptions of client concerns being treated,

which offered to explain treatment efforts as being worthwhile and that success of those efforts

resulted in a sense of accomplishment for the surrogate partner. This was demonstrated in,
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 There is, like, for me, not to be overly dramatic, but it's, there's kind of a terrible beauty
to that. You know? Human, human experience is not all like sunshine and rainbows.
And to have that kind of cathartic grief that completes a cycle is really important. (P9)

The Meaning-Achievement combination was related by the tensions between the effort or work

(i.e., bearing the emotion of the client) and what is accomplished (i.e., client catharsis).

Relationship-Achievement code combinations provided new information about the priority

dynamic the surrogate partner had as a treatment professional while also engaging authentically

as the client’s partner.

There was a part of me that was very much in love with a part of him and that... When we
were in that space, it was really easy to be 100% there, and also there were a million
reasons why we should never date in real life. Right? Not only to mention that it would
be completely inappropriate from an ethical perspective… And for me it was really
important to say, here are all the reasons why it would be the worst thing for you and the,
you would backslide so hard if I stayed. Like, I can't stay. (P11)

The above example showed authentic connection with strong emotional attachment but also a

requirement to maintain a professional treatment boundary in order to achieve a sense of

accomplishment. Combining both dynamics of Meaning-Achievement and Relationship-

Achievement provided interpretive qualities about the surrogate partner; the surrogate partner

fulfilled a sense of accomplishment through authentic relationship connections with clients and

whose presenting concern treatment were believed to be meaningful. In summary, consideration

of how PERMA is coded to the data offered alternative understandings that enriched the

understanding of the themes found and lessons learned.

Statement of Lessons Learned

Surrogate partners experience their work as a calling, taken with the seriousness of a

helping professional who has therapeutically bonded authentic relationships as part of a complex

and dynamic intervention involving touch.

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 Summary

Chapter 4 presented the data analysis and data findings of this research study and

explained the context of the study and researcher on the data analysis. The analysis was

presented according to a case study design that applied inductive and deductive reasoning in an

analysis within-cases and across-cases (Yin, 2014) while utilizing thematic analysis (Braun &

Clarke, 2013). The analysis resulted in six thematic ideas and endorsed the presence of the five

areas of PERMA (Forgeard et al., 2011; Seligman, 2011). The data analysis evidence

significantly supported four lessons learned; surrogate partners experience working with sex

therapy clients as: a calling, helping professional significance, therapeutic constrained authentic

relationships, a complex and dynamic intervention. The next and final chapter presents a

discussion of the research study results with interpretations and recommendations for further

research. Interpretations of the data analysis are discussed with a comparison to the declared

theoretical framework, literature review, and implications for the current practice of SPT.

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 CHAPTER 5. DISCUSSION, IMPLICATIONS, RECOMMENDATIONS

This final chapter presents a summary of the research findings in a discussion of how this

research study addressed the research question: how do surrogate partners understand their

experience working with sex therapy clients? The first section provides a summary of the

research study results and discusses the connection to the field of surrogate partner therapy

(SPT). Next, the conclusions and results are compared to the theoretical framework of positive

psychology’s PERMA model (Forgeard, Jayawickreme, Kern, & Seligman, 2011; Seligman,

2011) and the previous literature. The study concludes with a discussion of limitations,

implications, and recommendations for future research.

Summary of the Results

The purpose of this section is to provide a contextual orientation for the two main

sections: discussion of the results and conclusions based on the results. This section begins with

an outline of why the study was needed and the significance of this research. Next, a review of

the theoretical orientation of PERMA and case study (Yin, 2014) methodology are provided.

Lastly, a brief summary of the literature reviewed on SPT is presented before the data analysis

findings are concisely reiterated.

This study addressed a neglected area of psychological research through investigating the

question: how surrogate partners understand their experience working with sex therapy clients.

There is an absence of information on a surrogate partner’s role in the United States as a

contracted clinical confederate (see Chapter 2: Review of the Literature). This study improves

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SPT literature by describing how surrogate partners within a professional association experience

their work with sex therapy clients.

This research is significant because there is no other independent research that

investigates how surrogate partners understand their work. The current discourse on SPT has

been attended to by popular media and opinion-based articles (see Chapter 2: Critique of

Previous Research Methods), which fails to provide treating clinicians with reliable information

about a potential treatment method for their clients. The clients of surrogate partner therapy are

described as desperate for help (Brown, 2019), which indicates that clients are potentially

vulnerable and therefore in need of greater protection (APA, 2010; CPA, 2017). This study has

significance to clinicians and general society by providing information about surrogate partners

to help assess the potential risks and benefits for clients. Understanding the descriptions given

by surrogate partners and the safeguards used by a surrogate partner professional association

member allows for better evaluation of client safety and benefit. Providing scholarly information

also allows society to make more informed choices when comparing information in subjective

sources; SPT is unlike prostitution and therefore should not be regarded as such in legal terms.

A review of the literature was conducted on the theoretical framework of positive

psychology’s PERMA model (Forgeard et al., 2011; Seligman, 2011) and the topic of SPT.

PERMA has previously been used in research to provide understanding of people working as a

musician (Ascenso, Williamon, & Perkins, 2017), student happiness (Lambert D’raven & Pasha-

Zaidi, 2015), and employee well-being (Kun, Balogh, & Krasz, 2017). PERMA was used in this

research study as a basis for the researcher-designed guiding interview questions and as a pattern

matching theory for data analysis according to the respective five areas: positive emotions,

engagement, relationships, meaning, and achievement. This research study utilized an embedded

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multiple-case study qualitative methodology (Yin, 2014) using the PERMA model from positive

psychology (Forgeard et al., 2011; Seligman, 2011) to explore surrogate partner understandings

of their experience working with sex therapy clients. Much of the research data was composed

of transcriptions from guiding question interviews. The interview transcripts, artifacts presented

by participants, and case file notes were analyzed inductively with thematic analysis (Braun &

Clarke, 2013) and deductively using pattern matching (Yin, 2014) to the PERMA model.

The research literature reviewed on SPT included scholarly, authoritative, and subjective

sources. The scholarly literature on SPT was dated to half a century earlier in the works of

Masters and Johnson (1970) and later innovators of the treatment method (Apfelbaum, 1977;

1984; Cole, 1986; Dauw, 1988). A resurgence of literature was produced from authors operating

in an Israel clinic (Aloni, Dangur, Ulman, Lior, & Chigier, 1994; Aloni, Keran, & Katz, 2007;

Aloni & Heruti, 2009, Ben-Zion, Rothschild, Chudakov, & Aloni, 2007; Rosenbaum, De Paauw,

Aloni, & Heruti, 2013; Rosenbaum, Aloni, & Heruti, 2014) but is different than the role of a

surrogate partner in the United States (IPSA, 2020). IPSA was described as the longest standing

authoritative body guiding the practice of SPT in the United States (Aloni et al., 1994; Aloni et

al., 2007; Apfelbaum, 1984; Ben-Zion et al., 2007; Dannacher, 1985; Denton, 2018; Freckelton,

2013; Holzum, 2015; Jacobs, Thompson, & Truxaw, 1975; Malamuth, Wanderer, Sayner, &

Durrell, 1976; Mintz, 2014; Noonan, 1984; Poelzl, 2000; Richardson, 1991; Rosenbaum et al.,

2014; Shapiro, 2002; 2017; Tarsha, Xantus, & Arana, 2016), where the surrogate partner fills the

role of a contracted clinical confederate (IPSA, 2020). A few surrogate partner members had

published personal accounts of working with clients (Poelz, 2000; 2011) and the experience of

undergoing training through a professional association (Shapiro, 2017). Subjective sources held

contributions from surrogate partners in periodicals (Evans, 2016; Hosie, 2017; Patz & Roberts,

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2003; Peredo, 1977; Scheeres, 2016; Thompson, 2016; Tobin, 2017; Tolle, 2019), media

(Heartman, 2018; Reilly & Reilly, 2018; SurrogateTherapy, 2011), documentaries (Dennett,

2017; IPSA, 2013), websites (Braendle, n.d.; Chao, 2019; Cohen-Greene, n.d.; Fernandez, n.d.;

Heartman, 2019; Poelzl, n.d.; Shattuck, 2018; Tara, n.d.; Tolle, 2011; Wadell, 2019), and books

(Cohen-Greene, 2013). But there were also considerable portions of subjective sources that

disproportionately focused on the sensual or sexual aspects of SPT to advertise an overtly

salacious context to viewers (e.g., Evans, 2016; Thompson, 2016). The results of the literature

review concluded that there had been no recent independent scholarly research exclusively on

surrogate partners within professional associations who practice in the United States.

The research findings were culminated in predominant themes and pattern patching to

create a statement of the lessons learned (Yin, 2014). A cross-case thematic analysis (Braun &

Clarke, 2013) of the participant case files generated six significant themes: Alturism,

Professionalism, Treatment not provided by clinicians, Unique calling, Being authentic, and

Meaningful work. Pattern matching (Yin, 2014) to the PERMA model (Forgeard et al., 2011;

Seligman, 2011) revealed that all areas of PERMA were supported by participant case file data

and demonstrated uniqueness between Meaning-Achievement and Relationship-Achievement

codes. The results of the thematic and pattern matching analysis supported four areas of the

lessons learned: surrogate partners experience their work as a calling, taken with the seriousness

of a helping professional who has therapeutically bonded authentic relationships as part of a

complex and dynamic intervention involving touch.

Discussion of the Results

This section presents how this research study answered the research question: how do

surrogate partners understand their experience working with sex therapy clients? This research

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presented information to explain, define, and clarify the experience of a surrogate partner. An

analysis of the data was culminated into a lessons-learned statement, which is discussed

according to four main areas surrogate partners experienced their work: as a calling, as a helping

professional, in authentic relationships within a therapeutic boundary, and using multifaceted

therapeutic interventions including touch. The following paragraphs discuss these four areas and

how the results of this research study sufficiently answer the research question.

Working as a surrogate partner was described as a calling. The idea of a calling brings

together multiple ideas participants had about being a surrogate partner. The experience was

described as intrinsically meaningful according to their values by how they helped clients. This

type of helping role was believed to be possible as a result of unique life experiences (e.g.,

Unique calling). The fulfillment received from helping clients was expressed as the main

motivator (e.g., Altruism). The idea of fulfilling a calling was present in how participants

described finding the profession as something they found to fit well, which related to discovering

a new fulfilling life aspect (e.g., Unique calling). The sense of fulfillment was also gleaned from

the data analysis according to the PERMA (Forgeard et al., 2011; Seligman, 2011) model’s

meaning and achievement categories (See Chapter 4: Presentation of Data and Results of the

Analysis), where evidence of a passion, advocacy, and sense of importance led participants to

want to contribute to SPT as a cause. The idea of SPT as a cause was supported by statements

made concerning the need for better understanding of human sexuality (e.g., Advocate role,

Concern for influence/impact of societal views) and that human relational functioning (including

sexual) is an important part of the human experience (e.g., Client improvement is beyond

sexual). The ability to engage with the aforementioned ideas as a surrogate partner provided a

way to achieve inner fulfillment, which was likened to the idea of fulfilling a personal calling

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through altruism. This area, a calling, answered the research question by describing the work of

a surrogate partner as something engaged in based on a value system and desire to help others.

The results would have been different if data were presented concerning alternative self-benefits

(e.g., financial, sexual) or the work as non-fulfilling. An important context to these data results

is that participants were either capable of or were already working in careers and had other

satisfactory intimate relationships, further supporting that working as a surrogate partner was for

intrinsic reasons. Participants used language that described the work as requiring skill and effort,

indicating that benefits received were indirect. Guiding questions that inquired about what was

enjoyable, challenging, or self-achieved, contributed significantly to this area. By phrasing of

the researcher-designed interview questions, disconfirming ideas could have been presented but

were not. A description of working as a surrogate partner as a calling is believed to be well

supported and emergent from the data analysis.

Working as a surrogate partner was described as being a helping professional. The

description of being a helping professional provides understanding the role a surrogate partner as

needing to provide therapeutic benefit to clients. Being a helping professional is intended to

make a comparison of surrogate partners shared attributes with other helping professionals (e.g.,

counselors, doctors, physiotherapists). Working as a surrogate partner was presented with a

seriousness of considering personal fitness for the role (e.g., Being “on” and providing the best,

Unique calling). There was a focus on the client receiving therapeutic benefits that improved

future functioning (e.g., Goal orientated for client’s future relational functioning), similar to

psychotherapy goals for clients should extend beyond a therapeutic session. Like other helping

professionals, surrogate partners described life experience as preparing them for an interest in the

work before receiving formal training and mentored practicum experiences. Abiding by an

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ethical code, being responsible to a professional association, and working with qualified

clinicians were defining characteristics (e.g., Professional association membership). Client

interventions were described as being based on a treatment protocol from training their

professional association and also required the use of clinical judgement in collaboration with a

clinician (e.g., Clinician-surrogate partner relationship as collaborative). The ideas presented

above supported surrogate partners as helping professionals with relational expertise. This area,

helping professional, answered the research question by describing a surrogate partner as

providing therapeutic benefice to clients like other helping professionals. The results reflect a

commonality of participants being trained by their professional association and adhering to their

related code of ethics that indicates expected standards for practice. The use of psychological

theory-based interventions, supervision, clinician triad model, and mentorship are characteristic

of their professional association’s membership requirements. A substantial part of framing

surrogate partners as helping professionals is supported by how they were responsible to a

professional association and working with a clinician (i.e., qualified mental health practitioner).

A description of surrogate partners as helping professionals likely would not have been

supported if the sample characteristics were missing Professional association membership as a

unifying aspect to bind the case.

Working as a surrogate partner was described as having authentic relationships within a

therapeutic boundary. The description of authentic relationships therapeutically bonded provides

understanding of the relationship surrogate partners have with clients. Having a relationship

with clients was described as a central feature of the therapy (e.g., emphasized during member

checking) and the effectiveness was related to interacting authentically with the client as a

romantic partner (e.g., Real relationship/professionally bounded). The relationship was

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described as requiring intimacy, vulnerability, attachment, emotional connection, and enjoyment

of each other (e.g., Being authentic). A client relationship was described as intentionally

developed by the surrogate partner according to the individual needs of the client, with a focus

towards meeting the agreed upon triadic goals. The surrogate partner is in a full relationship

with the client (e.g., feeling, expressing, sharing) but is dually responsible for guiding the

relationship to therapeutic goals. The therapeutically bonded relationship was described as a real

relationship held in a specific container by the surrogate partner, meaning that the relationship

develops according to client progress (i.e., starting as a coach moving towards peers) and there

are boundaries (i.e., it is a temporary relationship, no contact outside therapy sessions,

information is shared between clinician and surrogate partner, etc.). The aforementioned ideas

supported surrogate partners as experiencing a dual role of being in a real relationship with

clients but also guiding interactions to be therapeutic. This area, authentic relationships

therapeutically bonded, answered the research question by describing the qualities of a

relationship shared with clients. This aspect of the lessons learned reflects the surrogate partner

as being in a dual role of a relational partner and a guide to clients. The bidirectional ability of a

client and surrogate partner to mutually influence the relationship (e.g., Being authentic, Real

relationship, Impacted by client, Client attachment) while also providing therapeutic guidance

(e.g., Direct modeling, Direct touch, Experiential exercises, Direct coaching) were binding to this

idea. The idea of authentic relationship could have potentially been maintained if the participant

sample did not have psychological theory integration or a triadic clinician component but would

have lost the therapeutic component due to the unknown intentions or results of client

interactions. Interactions that benefit client future functioning (e.g., Use of therapeutically

indicted interactions, Goal orientated for client’s future relational functioning) is important to

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defining the relationship as therapeutic and not as an entertaining experience unto itself. A Real

relationship experience that is intentionally therapeutic may not have been present if sample

participants were not part of a professional organization or did not practice in concert with

clinicians; meaning that membership practice standards likely influenced the descriptive quality

of the client relationship.

Working as a surrogate partner was described as involving many different client

intervention aspects, many which required the surrogate partner to adjust their interactions in the

moment based on their perception of a client (e.g., Client relationship as dynamic, Challenging

work). The description of multifaceted interventions that can include touch provided

understanding of the therapeutic interactions provided by surrogate partners (e.g., Treatment not

provided by clinicians: Direct modeling, Direct touch, Experiential exercises, Direct coaching).

Sharing an authentic relationship with a client was described as a central therapeutic intervention

(e.g., Being authentic, Treatment not provided by clinicians), meaning that surrogate partners

believed that developing a real relationship was central to client interactions, which was

emphasized by participants during member checking. Surrogate partners described the

professionalism of their relationship as a tool where they could model, teach, coach, and practice

with clients (e.g., Use of professional association treatment protocol & client specific

interventions). Client interventions included communication, body awareness, sensation,

sensuality, and sexuality as therapeutically indicated and agreed upon with the referring clinician

(e.g., Treatment not provided by clinicians). Clinicians are not able to use direct touch with a

client (i.e., standards of practice, ethical codes), but surrogate partners can use touch for different

meanings like sensation, sensuality, sexuality, and mutuality (e.g., Treatment not provided by

clinicians). The multiple ways that a surrogate partner works with a client were complex,

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described as requiring significant skill and effort to make the interactions therapeutic (e.g.,

Reflexivity, Challenging work). This area, multifaceted interventions can include touch,

answered the research question by categorically describing interventions that surrogate partners

used with clients (e.g., Treatment not provided by clinicians, Use of professional association

treatment protocol & client specific interventions). This aspect of the lessons learned indicated

that a surrogate partner is someone who orchestrates many elements to provide clients with a

therapeutic experience (e.g., “We are tracking our clients on so many levels at the same time… it

feels like a fucking symphony… because we have all of these layers… this deep experiential

stuff”, P11). A key component is that surrogate partners were intentional in client interactions,

that is, they were purposeful and planful (e.g., Use of therapeutically indicted interactions, client

specific interventions) according to the stated triadic goals. The therapeutic quality of the

interaction shaped the interpretive understanding of the surrogate partner interactions with a

client, which included exercises of mutual eroticism like penetrative intercourse. The

preparatory influence (i.e., training, planning, clinician consultation) and therapeutic intention

(e.g., Goal orientated for client’s future relational functioning) supported the surrogate partner

experience of client interventions as complex and dynamic. Client interactions as complex and

dynamic interventions would have been unlikely without other sample characteristics of

professionalism originating from adherence to a professional association practice standard or

working with a clinician.

Conclusions Based on the Results

Applications of this research study’s conclusions are discussed in these sections. The

first section compares the theoretical framework and previous literature to the research study

findings. The second section provides an interpretation of the findings and discusses the

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contextual meanings according to the literature review. These sections discuss the research study

findings with focus on the existing knowledge base and therapeutic community of SPT.

Comparison of Findings With the Theoretical Framework and Previous Literature

This section discusses the research study findings with the literature reviewed and

theoretical framework utilized (see Chapter 2). This study was needed to improve insufficient

information on surrogate partners and SPT (see Chapter 1: Need for the Study), and the research

study results discuss improved definitions of surrogate partners and SPT. This research study

used positive psychology’s PERMA model (Forgeard et al., 2011; Seligman, 2011) as a

framework that was found present in participant data sets and a cross-case synthesis. Given the

varied perspectives over the past half century (Aloni, 2020; Apfelbaum, 1977; ICASA, 1998;

Masters & Johnson, 1970), there are points of agreement and disagreement with the study

results. The findings of this research study most significantly contributed to an understanding of

definitional aspects of a surrogate partner role in SPT when a member of a professional

association in the United States. The following is a comparison of the results with prior

literature and the theoretical framework.

The first description of a surrogate partner role was discussed by Masters and Johnson

(1970) as stressful due to the need to be ever encouraging to the client while withholding their

own needs. Subsequent literature conversely suggested that a surrogate partner’s emotional

needs and attachment should interact with the client (Apfelbaum, 1984; Rosenbaum, Aloni, &

Heruti, 2014). Greene (1977) argued that the client would benefit most from a surrogate partner

who is a therapy team member with specialized training, who confronts, teaches, and directs

interventions. This research study confirmed descriptions after Masters and Johnson, where the

surrogate partner guides the relationship and interventions using an understanding of their own

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emotional connection and feelings for the client to provide therapeutic benefit. The description

of surrogate partners found by this research study is closer to Apfelbaum’s (1977; 1984)

description of bodywork therapists who are a clinically trained professionals who treat clients in

conjunction with a supervising clinician, while allowing a full range of emotional and physical

responses (touch, sexuality) within a reflexive client relationship. Apfelbaum’s future

recommendations (1984) were seen in this research study’s description of surrogate partners as

helping professionals, in an authentic relationship yet therapeutically bound, and who offer

varied therapeutic interactions including touch. The results of this research described all

participants receiving specialized training and mentorship from their professional association

while only working in a clinician triad (see Chapter 4: Description of the Sample). Dauw (1988)

described his clinic based surrogate partners as holding graduate degrees in a helping profession

(e.g., master of arts in social work, psychology, etc.), completing 100 hours of surrogate training,

and practicing under clinical supervision and with a surrogate supervisor. Only some of the

research sample had master’s level degrees in a helping profession (see Chapter 4: Description of

the Sample), but the element of a trained professional was akin to the likeness of Dauw’s (1988)

and Apfelbaum’s (1977) description. This research revealed that the overall understanding of a

surrogate partner changed from Masters and Johnson (1970) but continued to use trained

clinicians for supervision and that surrogate partners contribute to the client relationship in ways

that were unique to the specifics of their life experience.

This research study found consistency with previous literature on the nature of the

surrogate partner and client relationship. The theme of Treatment not provided by clinicians is

evidenced by Aloni and Heruti’s (2009) explanation of surrogate partner interactions as a form of

mentoring, a one-on-one relationship using behavioral methods to improve social and intimate

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skills. The same thematic finding confirmed that surrogate partners explicitly train or teach

sensual and sexual practices to clients (Richardson, 1991). The codes of Direct modeling, Direct

touch, Direct coaching, and Experiential exercises reflected that surrogate partners mainly spent

time on non-sexual activities (Noonan, 1984), but this study did not collect quantifiable data to

make a direct comparison. The time surrogate partners spent with clients on sexual activities is

implicit to Freckelton’s (2013) discussion of the SPT field having a controversial comparison of

surrogate partners as prostitutes (Levine, 1977; Simpson, McCann, & Lowy, 2016; Wotton,

2017), which queries if vulnerable clients receive reasonable protection from exploitation.

However, this research confirmed surrogate partner motivations as being altruistic (Freckelton,

2013) and therapeutically based (Jacobs et al., 1975), as evidenced that surrogate partners

worked with a licensed clinician towards completing therapeutic goals to end client services

(Goal orientated for client’s future relational functioning). The need to work with a clinician and

use exercises designed for therapeutic benefits that extend towards future functioning served to

disconfirm the use of surrogate partners for sexual access (Mintz, 2014).

This research study did not specifically investigate concerns presented by clients, but

participants provided general information that is discussed in comparison to client concerns

presented in prior literature. The treatment description by Zenter and Knox (2013), that enabled

an anxious male to pursue romantic relationships, held remarkable similarities to the coded

pattern findings of this research where surrogate partners were: introduced as therapy team

members (Treatment not provided by clinicians), outside contact was prohibited (Real

relationship/professionally bounded), sessions used preplanned goals (Use of therapeutically

indicted interactions, Goal orientated for client’s future relational functioning), psychotherapy

sessions alternate with surrogate partner sessions, and the triad openly communicates (Clinician-

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surrogate partner relationship as collaborative). This research study found descriptions of client

concerns generally related to anxiety, phobic reactions, and sexual organ function but often in a

clinical context of psychological treatment for traumatic experiences, need for explicit training of

social or relational skills, or unique barriers to coupling. This study confirmed similarity to

Cole’s (1977) main concerns of erectile dysfunction and premature ejaculation, but not

heterophobia (possibly due to changes in the acceptance of non-heterosexual relationships).

Also, this research confirmed the use of SPT as in the literature of a client with cerebral palsy

(Joseph, 1991) and acute brain injury clients (Aloni, Keren, & Katz, 2007), because the context

was therapeutic (i.e., to improve future functioning) unlike a disability population seeking sexual

access (Mintz, 2014). The use of SPT for sexual access as suggested by Mintz was not found

demonstrated, because goals of contact required that interactions were selected based on

therapeutic benefit (e.g., Use of therapeutically indicted interactions, Goal orientated for client’s

future relational functioning, Client improvement is beyond sexual), which means that sexual

contact was not guaranteed.

This research study confirmed that surrogate partners used interventions that were theory-

based (e.g., Use of professional association treatment protocol & creation of client specific

interventions). There was not enough information about the professional association protocol to

make a comparison to Hartman and Fithian’s (1972; 1974) step-by-step educational approach or

Apfelbaum’s (1977) therapy approach. In general terms however, the use of self-study,

instruction, modeling, and experiential practice were described by the participants. Jacobs et al.

(1975) described surrogate partners as having a unique set of competence that can also be seen in

the analysis results (e.g., Unique calling). These research study results also reflected similarity

to the literature published by a surrogate partner (Poezl, 2000; 2011) who described adapting

170
interventions to client goals (e.g., Use of professional association treatment protocol and client

specific interventions) and sharing a significant portion of herself in a real relationship with

clients (e.g., Being authentic). Shapiro’s (2017) description of how persons with debility require

specialized intervention due to unique socialization influences was also confirmed by this

research in participant quotes (e.g., “Someone with disability is constantly reliant on someone

else to facilitate their existence. So, consent gets really twisted”).

The findings of this research study validated positive psychology’s PERMA model

(Forgeard et al., 2011; Seligman, 2011) as a theory useful for framing a case study (Yin, 2014) in

general psychology. The five individual areas of PERMA were found in the cross-case analysis

and among individual data sets (see Chapter 4: Table 3). The dichotomous nature of PERMA

categories filtering data for confirming or disconfirming evidence allowed gathering alternative

information from participants as well as interpretive qualities about the experience of well-being.

The experience of surrogate partners in subjective sources (Cohen-Greene, 2013; Heartman,

2018; Patz & Roberts, 2003; Peredo, 1977; Thompson, 2016) also appeared to confirm the

presence of PERMA, which could be considered a confirmation of similarity to this research, but

the unknown standard and unknown reliability of those subjective sources makes the discussion

moot. Relationships, meaning, and achievement categories were the most prominent areas

supported by the data analysis (e.g., “Not to be overly dramatic… human experience is not all

like sunshine and rainbows… cathartic grief that completes a cycle is really important”). The

use of PERMA provided a theoretical understanding of surrogate partners as people who gained

a sense of accomplishment through forming authentic connections that held purposeful existence.

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Interpretation of the Findings

The research study's findings provided interpretive qualities from a psychological

research perspective on where this research relates to stakeholders in the literature, theoretical

orientation, and research methodology. An important finding of this research study was the

uniqueness of the surrogate partner model in the United States. There were only three

authoritative sources found during the literature review that were still in operation (i.e., Aloni,

2020; ICASA, 1998; IPSA, 2020). However, no specific understandings to the United States

were found published among the scholarly literature. The closure of treatment centers described

previously (i.e., Cole, 1977; Dauw, 1998; Hartman & Fithian, 1972; Masters & Johnson, 1970)

could be related to the area of sex therapy being absorbed into general practices (de Silva, 1994),

which was also reflected by surrogate partners stating that referrals were typically from

therapists operating in general practice and not from a clinician specialized in sex. The treatment

methods of ICASA (1998) and The Dr. Ronit Aloni Clinic (Aloni, 2020) were explained by

research participants as helping people in similar ways but that their practice of SPT was

different. Statements made during member checking specifically supported that ICASA and

Aloni provide their training for their own surrogate partners. These differences were reflected in

the results of this study where surrogate partners discussed strong relationship bonds with

clients; ICASA (1998; Brown, 1994) and the Aloni clinic (2019) descriptions of the method

emphasized the client experience of exercises more prominently.

The flexibility of the PERMA model (Forgeard et al., 2011; Seligman, 2011) as a

theoretical construct for research was confirmed in this study. As discussed earlier, PERMA

provided a theoretical understanding of surrogate partners as people who gained a sense of

accomplishment through forming authentic connections that holds a purposeful existence. An

172
application of this theoretical understanding can be demonstrated by linking the coding and

themes associated to the model: surrogate partners are altruistically motivated by a sense of inner

fulfillment by sharing real intimate connections with clients that helps to provide healing to

negative social, interpersonal, and cognitive effects. As demonstrated, the PERMA framework

can be used as scaffolding to explore new meanings and describe the relationship between data.

The research study findings of PERMA described the interaction between relationships,

meaning, and achievement was likely impacted by the nature of the interview being a topic about

working in a specific area. Furthermore, the controversy (i.e., a comparison to prostitution)

(Freckelton, 2013) facing surrogate partners had likely served to prepared them to validate what

they do (e.g., many of the surrogate partners made reference to the incorrect public assumptions

of SPT), which could have added to the category of relationship, meaning, and achievement.

A unique feature of this research study was the inclusion of subjective sources to inform

the researcher (see Chapter 2: Critique of Previous Research Methods). A review of the

subjective sources was apprehensively considered due to no other reasonable option being

available. However, subjective sources did provide a useful context that was found to correctly

describe surrogate partners being used in the treatment of severe issues (Dennett, 2017; IPSA,

2013) and a lot of anxiety (Savage, 2018; Tobin, 2017). This research confirmed surrogate

partner descriptions as well intentioned, compassionate, instructive, in a professional context

working with a clinician (Garelick, 2015), and using educative interventions (Roberts, 2018).

The findings also reflected a wide variety of training from unique life experiences (Shapiro,

2017), or formal education like masters (Chao, 2019) or doctorate degrees (Reilly, 2019). These

descriptions helped to inform the researcher of how to design the research study in a way that

reflected current views on surrogate partners and SPT. A significant challenge to designing the

173
research methodology was the lack of theoretical frameworks applied in prior SPT research, so a

comparison to other forms of work were considered. In order to validate the use of

methodological assumptions from positive psychology’s PERMA model (Forgeard et al., 2011;

Seligman, 2011), an initial comparative review was made from information directly attributable

to surrogate partners belonging to a professional association within subjective sources (i.e.,

media, articles, self-authored writings, websites). The general ideas gained from a preliminary

review of surrogate partners in subjective sources assisted research understandings for

methodological design (i.e., interview question areas, language, and terminology used), but was

not believed to significantly bias the data results but rather improved the focus on relevant areas

by avoiding contentious ideas (e.g., sexual explicitness found in popular media interviews,

arguments between prostitution versus therapeutic benefit). This research supported a strategy of

being guided by the best available information, which required consideration of information

from subjective sources.

Limitations

This research study had design limitations and areas that were intentionally not

investigated. Design limitations were heavily influenced by the methodology that defined the

sample as needing to work with a qualified clinician in a triadic relationship and the use of

referral sampling. The sampling procedures resulted in only attaining people who were members

of a professional association for surrogate partners, therefore this study did not address the

experience of surrogate partners who worked independent of an association or in a different

collective group. Furthermore, the referral sampling method resulted in participants only being

gained from surrogate partners within the same professional association who referred each other;

meaning that the sample group had the potential of collusion without researcher knowledge. The

174
use of a third-party field expert (e.g., researcher known in the field of SPT, a clinician who

works in the SPT model) could have been used to validate the data findings but was beyond the

scope of resources available to a student funded dissertation. The types of information presented

by participants contained the bias of using the PERMA model (Forgeard et al., 2011; Seligman,

2011) as an underlying theory that guided questions and informed parts of the data analysis. The

researcher as a research instrument collecting and analyzing data was also limited to the abilities

of a human being as doctoral researcher. The results of the research study were believed to be

sufficiently protected from the bias inherent to qualitative research (Creswell, 2013) through

member checking and third-party reviews. The limitations of this study were not believed to

interfere with the results or validity of the findings.

Delimitators to this research study are the areas that were intentionally not investigated.

The literature review presented other services used for sexual improvement like sex coaching

(Goddard, 2013), body workshops (Dodson Foundation, 2019), or the area of sexual access for

persons of debility (e.g., Mintz, 2014; Shaprio, 2002) as being separate from SPT and therefore

were not investigated; notwithstanding that some participants also described such areas as being

different from SPT. Among the population sampled, the area of client interventions (including

sexual contact) was not intentionally investigated because the purpose of this research was

focused on the experience of surrogate partners. Although intervention types were discussed and

categorically found in the analysis of data (e.g., Treatment not provided by clinicians, Use of

professional association treatment protocol & client specific interventions), the range of

interventions were not sufficiently explored. Sexual contact and sexual experiences between a

surrogate and client were not investigated; meaning that the descriptions provided were surficial

(e.g., Use of therapeutically indicted interactions, Direct touch) and are incomplete. Including

175
these areas could have broadened the scope of the research, but were not within the limited

resource ability of this research study. However, the limitations and delimitations were

important to improving this research by providing a narrow focus where results could have more

meaningful findings.

Implications of the Study

This research study provided implications for psychological theory and knowledge bases,

and the practice of SPT. The psychological knowledge base on SPT has been improved by the

descriptions provided by this research study on surrogate partners. The understandings provided

are the first research findings specific to surrogate partners in the United States that belong to a

professional association; which can serve to assist future researchers in understanding the

neglected area of SPT. The findings of this study were unique by being the first presentation of

surrogate partner perspectives on the experience of SPT as culminated from multiple participants

and independently researched. Research on the people directly involved with SPT within the

United States had been absent for many years (see Chapter 2: Review of the Literature), and this

research updates that knowledge base by describing the experience of people working as

surrogate partners within a professional association.

The findings of this research had practical implications for the practice of SPT.

Understanding surrogate partners within a professional association in the United States as

uniquely different is an important distinction to make due to the influence of publications on

surrogate partners that are based on Aloni’s clinic in Israel (Aloni et al. 1994; Aloni et al., 2007;

Aloni & Heruti, 2009; Ben-Zion et al., 2007). The unregulated nature of the title used for

surrogate partners and SPT means that anyone can advertise themselves as providing the service

without qualification. A clinician and client should not mistakenly assume that SPT literature

176
universally applies to all persons describing themselves as surrogate partners, but that reasonable

judgement is required in decision making for the appropriateness of referral.

A final implication of this research applies to the clients of SPT. Undergoing treatment

within the SPT model requires a client to make significant investment of personal and financial

resources. From a psychological ethics perspective, client vulnerability requires protection

(APA, 2010; CPA, 2017); therefore, elements are recommended as based on a review of

literature and the results of this research. Surrogate partners should be considered based on

achievement of client goals through their training or expertise and the potential therapeutic

benefits should exceed the risks inherent to the intervention. Engagement of SPT services

should also consider how the surrogate partner and those making arrangements are held

accountable for providing ethical and therapeutic benefit: are they part of a professional

association with a formalized complaint process, who else do they work in collaboration with,

what are their credentials, and are they endorsed by the governance of a state or country.

Recommendations for Further Research

Recommendations for future research have been formulated from the research data

collected, methodological delimitations, and topics emerged while investigating SPT. The data

collection and analysis provided significant support for interventions used, indicating this as an

area of future interest to further understand the types of therapeutic actions performed. Client

concerns were also not investigated and therefore only provided surficial findings (e.g., Client

concerns have clinical impact), which also provides future researchers with an opportunity to

inquire about the range of client concerns treated by SPT. Explicit sexual components of SPT

were delimitated, but the importance of treatment methods and client concerns to research

participants indicated that future research should consider including those therapeutic areas.

177
 While reviewing the literature and while in discussions with participants, other topic

areas were brought up. This research focused on SPT as defined by surrogate partners working

in a triad with licensed clinicians while excluding other things people access to improve their

well-being. Future researchers may consider an investigation of sexual help areas that this

research intentionally delimited: sex coaching (Goddard, 2013; Stein, Britton, Gunsaullus, &

Dunlap, 2017), bodysex workshops (Dodson Foundation, 2019), sexual function improvement

(Hutchins, 2011), and debility sexual access (Mintz, 2014; Perlin & Lynch, 2014; 2016;

Timmins, 2017). Understanding what people do to improve their sexual functioning (implicit to

well-being) could culminate the breadth of resources available and may impact current clinical

understandings of social behavior (e.g., prostitution or bodywork as potentially providing

education or therapeutic benefit).

Conclusion

This research study investigated the experience of surrogate partners working with sex

therapy clients in a qualitative embedded multiple-case study design (Yin, 2014) from a positive

psychology PERMA model theoretical orientation (Forgeard et al., 2011; Seligman, 2011).

Research on SPT has been sparse since its inception over half a century earlier (see Chapter 2:

Review of the Literature). This is the first research that exclusively investigated surrogate

partners within a professional association in the United States. The results of this study found

that surrogate partners experience their work as a calling, taken with the seriousness of a helping

professional who has therapeutically bonded authentic relationships as part of a complex and

dynamic intervention involving touch.

The overall conclusions of this research study were that surrogate partners within a

professional association were clinically and academically unknown; ICASA (1998) and The Dr.

178
Ronit Aloni Clinic (Aloni, 2020) are outside of the United States and provide a similar but

different service. Clinicians and clients should prudently consider the qualifications and

oversight provided when selecting a surrogate partner therapist. The use of a surrogate partner

who is part of a professional association is expected to provide clients with a real relationship

with a trained professional who is therapeutically bonded to fulfill agreed upon triad goals

(clinician, surrogate partner, client) using methods that a referring clinician cannot (e.g.,

mutuality, touch). Although the client population is reported by participants as being small, the

reported benefits indicate SPT is an important therapeutic tool.

179
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