Sperm counts are down, infertility is up and impotence problems are on the rise, causing many sex experts to believe sex is dead or dying. In fact, according to the Medical Journal of Australia, sexual problems are the third most common reason for failed relationships.
But for many of today's dedicated sexual therapists, all is far from lost - even for singles or those without a willing sexual partner.
The controversial solution? Sexual surrogates. Not to be confused with surrogate mothers, sexual surrogates work in conjunction with sex therapists to treat sexual disorders of all kinds - from impotence to premature ejaculation to vaginismus (fear of penetration associated with painful spasms of the vagina).
In a triangular therapeutic approach, patients and surrogates meet as a couple and then weekly with the sex therapist individually in order to track their progress. The express goal of the surrogate is to educate the patient about sexuality under the guidance of a trained, experienced therapist.
First developed by the well-known gynecologist William Masters and psychologist Virginia Johnson in the late 1950s, the practice of using sexual surrogates for treatment has been a hotbed of controversy and suspicion since its inception.
Rooted in behavioral therapy, the theory is that people cannot be cured of certain ailments until they confront them in reality. In other words, learn and then practice. But for people either without partners or with unwilling partners, Masters and Johnson soon realized there was no one with whom some patients could practice their "homework." Hence, the idea of using a surrogate was born.
For Dr. Ilan Biran, a sexual therapist in Tel Aviv, the use of surrogates is the most obvious of possibilities.
One sultry afternoon, as the sunlight dances across a tiled floor and over a coarse, fold-out sofa in Biran's sexual therapy clinic, the explanations begin.
"The goal of a sexual surrogate is to learn how to make love and have a relationship with a partner," he says, slowly stroking his white beard like a puzzled sage. "The surrogate is just a way for singles to practice what they will then be able to emulate in reality."
According to Biran, sexual intercourse with a surrogate has little or nothing to do with actual physical attraction. But this might be more believable if the first surrogate I meet, "Tamar," doesn't waylay my stereotypical perception of the average surrogate quite so well. I imagined frumpy or chunky, not lithe and elegant.
Tall and busty with long, dark hair, Tamar enters Biran's sexual therapy clinic like a star. With her silken locks, smooth olive skin, doe eyes and stunning figure, the 20-something bombshell looks much like a cover model for Elle.
According to statistics from a New York University study, the average sexual surrogate is middle-aged, highly educated, single and usually has children.
"You see, not everything fits the stereotypes," says Biran, leaning forward and giving me a piercing glance with his bright blue eyes. As polite introductions are made, I try to get my chin back into position. Apparently, sexual surrogates, just like their patients, come in all shapes and sizes.
And despite Tamar's striking appearance and coy demeanor, Biran firmly maintains that sexual therapy with a surrogate (defined as a member of a sex therapy team who has sexual interactions with a patient for therapeutic purposes) is not about physical attraction. He adds that rarely do patients and surrogates refuse to proceed based on looks, and says that if this is the case, then the patient has not understood what the therapy involves.
SO WHO are the surrogates?
"Surrogates are not therapists. They are as close to average people as possible, with nurturing personalities," says Dr. Ronit Aloni, the head of a sex therapy clinic in Tel Aviv since 1987. Aloni, who studied the sexual surrogate population in the United States for her master's degree at New York University, first introduced the idea of using surrogates in Israel with the disabled population on a kibbutz.
"We consulted the kibbutz rabbinate, and they agreed to this therapy as long as the surrogate women were not married," says Aloni. "After a while, we noticed that more than half of our applicants were people without disabilities, so I decided to open a private clinic to meet those demands."
Today, one of the most prominent arguments against the use of sexual surrogates is that it amounts to nothing more than legalized prostitution. In fact, all of the surrogates interviewed by The Jerusalem Post say they maintain strict anonymity about their profession because most people confuse it with prostitution.
Tamar, an undergraduate student in psychology, became a sexual surrogate after she read an article on the Internet about the subject. But she says sharing the true nature of her work with others is rare because of the stigma associated with it.
"I have taught a lot, but I have also learned a lot," Tamar says of the experience. "It has helped me in my own private life, and I only choose to keep my profession to myself because most people don't understand."
Biran, whose sexual therapy clinic in Tel Aviv has been running for 11 years, claims that as sexual surrogate therapy becomes more and more mainstream, the majority of people who object to it do so out of ignorance.
"People tend to make a simplistic connection between paying for sex and prostitution, but sex therapy with a surrogate has nothing to do with prostitution," says Biran.
The process starts with a meeting between the patient and surrogate in a caf on a "blind date." After the quasi-date, the pair decides whether or not they will continue in a clinical setting. Treatment usually lasts about 12 weeks.
"Patients are not looking for their future partners in a surrogate, but they are trying to find a good match that will simulate reality," says Biran.
This simulation of reality seems to contradict the earlier argument that physical attraction has little to do with surrogate therapy, but so far, no one could offer a good explanation about the difference.
Biran explains that unlike prostitution, the actual act of sex has little to do with surrogate therapy. In fact, according to the practitioners, sexual intercourse usually marks the end of a successful treatment cycle, and only occurs once or twice. Most of the sessions between patients and sexual surrogates focus on talking, touching, hugging and hand-holding. Although little research has been done on the subject, a study conducted in the early '80s at New York University by Raymond Noonan found that surrogates engaged in sexual activities only 10 percent of the time.
"The other major difference is that a prostitute makes a deal with a client for the use of his/her body, but nobody is learning anything, especially if the prostitute fakes pleasure," says Biran. "The surrogate is there to heal and to teach, not to do what the patient demands, and the therapist guides and directs the surrogate throughout the treatment."
AN ADDITIONAL problem noted by adversaries is the inability of sexual surrogates to lead normal lives while treating patients.
"Noa," a sexual surrogate who sees up to five different patients a week, admits that it is difficult for her not to share what she does and that it makes leading a normal life and forming relationships of her own much harder. She also says that while some patients do fall in love, it is not the express goal of the therapy and rarely poses any long-term problems for either the surrogate or the patient.
Noa says the many positive outcomes of the surrogacy relationship - patients deciding upon sexual orientation, having fulfilling relationships and healthy sex lives - make it all worthwhile.
Critics point to the fact that sexual surrogates enter the profession for the money - between NIS 250 and 400 per session - but for Noa, a single mother who has worked as a sexual surrogate for four years, nothing could be further from the truth.
"I became a surrogate to help people, not for the money," she says. "I have a background in counseling, and I thought this was something I could do well. I wanted to use my ability to give."
Beyond the emotional difficulties and financial criticisms associated with such delicate work are the health risks, which remain a major concern for surrogates and patients alike. According to Aloni, scrupulous physical exams testing for HIV, AIDS and STDs are required before therapy begins, and patients must agree not to have sexual relations with anyone other than their surrogate during the treatment period.
In order to be a surrogate, applicants have to pass a strict screening exam and meet certain criteria.
"We have found that the best surrogates are above the age of 30 and have had relationships in the past. They need to have mature perspectives on life experiences," says Aloni.
These specifications line up with the American profile of typical surrogates: middle-aged mothers with high levels of education. However, Israeli sexual therapists often hire surrogates outside these norms and follow different training procedures, which leads to one of the problems critics cite: the lack of a standard procedure and the ability of just about anyone to hang up a shingle and start treating the public.
Although no laws against either prostitution or sexual surrogacy exist in Israel today, neither does any form of governmental regulation. And like any therapeutic field, abuse does occur. Perhaps the most severe consequence of abuse in this fragile system is that victims rarely come forward with formal complaints for fear of being publicly exposed and embarrassed by their reasons for seeking therapy.
In one case last January, Dr. Yosef Zaider, a sex therapist, was convicted on three counts of sexual assault after luring young men into his office for purported "surrogacy training sessions."
According to Dr. Danny Derby, a clinical psychologist who sometimes works with surrogates and teaches at Bar-Ilan University, the laws in Israel pose a huge problem because they allow the practice but do not regulate it.
"Any person with no training whatsoever can say they are a sexologist," says Derby. To further exacerbate the problem, Derby says that even being a member of an association, such as the Israeli Society for Sex Therapists (ISST), does not necessarily mean much since just about anyone can start an association.
Aloni, who is a member of the ISST, disagrees that the associations are unimportant when considering consulting a sex therapist.
"Sex therapists who are not members of the ISST do not meet the requirements because they lack formal training, yet they are legally allowed to treat people, too," says Aloni. "You even see that people who once owned a sex shop or were writing about sex therapy have now opened clinics. If the sex therapist is not a member of the ISST, people should reconsider."
So, membership of ISST aside, how does one know who is legitimate when you can't exactly ask friends for recommendations?
Derby advises people to thoroughly check the training and experience of the sex therapist.
"Look at the credentials of the sexologist, find out where they studied. Institutionalized training, such as Bar-Ilan or Tel Aviv University, usually means higher quality," says Derby. "And remember that just because they may be in the media or the newspaper does not necessarily mean they are legitimate."
Even among the sexual therapists like Aloni and Biran, both of whom are respected by other members of the Israeli sexual therapists' community, problems arise.
"Biran was my administrator until 1999, but he does not have the prerequisites or the training to be treating patients today," claims Aloni.
IN MORE religious circles, using a sexual surrogate is considered unscrupulous and counter-productive.
"I strongly frown upon the use of sexual surrogates and find it unacceptable," says Rabbi Shmuley Boteach in a telephone interview. Boteach is a well-known radio and television personality in America, a columnist for The Jerusalem Post and the author of more than 10 books, including Kosher Sex: A Recipe for Passion and Intimacy.
Boteach maintains that most sexual dysfunctions occur as a direct result of sexuality being placed out of context, and advises people without a partner to talk to a sex therapist but not to have sex with a surrogate in what he describes as a cold, detached, clinical environment.
"Engaging in sex with a surrogate is not going to treat the underlying emotional problems," Boteach says. "It is impossible to divorce sexual issues from the emotional context within which they arise."
Furthermore, he says the claim that behavioral therapy needs actual practice in order to work effectively poses another problem. Boteach retorts that no responsible counselor would claim one must experience a condition in order to transcend it.
"What if someone is afraid of death? Should we kill him?" he asks.
According to Boteach, polling data shows that one out of three young married couples today admit they are not having sex at all. Nonetheless, he says the lack of morality behind sexual surrogacy renders it both ineffective and damaging.
Rabbi P. Waldman, the editor of Aish.com, agrees.
"Counseling brides and bridegrooms or therapy for married couples is allowed. Even diagrams may be used. However, to involve strangers with intimate relations, caressing, kissing, touching, etc., is disallowed," writes Waldman in response to an e-mail query by The Jerusalem Post. He cites the Code of Jewish Law, E.H. 21:1, 5-7 as his source.
But despite the disapproval of most rabbis, Aloni says she does treat some religious patients.
"Most of my religious patients are homosexual and want to have sex with women. I try to help them solve the problem," she says.
And objections and risks aside, for some former patients who have been cured through therapy, sex with a surrogate was the only option.
"Ayelet," a former patient of Aloni who was treated for vaginismus, says she could not have overcome her fear through any other means. When she tried to attend therapy with a boyfriend, he broke up with her before the sessions could begin.
"First, let me tell you that I am a very attractive woman and sexual surrogacy treatment was a last resort," says Ayelet in a phone interview. "Sexual disorders have nothing to do with being ugly, and this treatment changed my life. It enabled me to move on, get pregnant and have a baby."
One of the first women in Israel to be treated by the controversial therapy, Ayelet says that almost 10% of women suffer in silence, and it is important that the message about other options be shared. Only able to surmount her fear of penetration by having intercourse, Ayelet was cured through sexual relations with a surrogate.
"It may not cure everyone, but I would not be a mother today without it," she says. "Once I had sex, I realized it doesn't hurt and my fear disappeared. Today, I lead a normal life. That would not have been possible without a sexual surrogate."
How long, how much
So how long does the treatment last and how much does it cost? On average, therapy with a surrogate lasts between three and four months, but patients are often encouraged to continue treatment with the sex therapist after sessions with the surrogate end. Fifteen weeks, with two sessions a week, cost about NIS 35,000 - and surrogate treatment is not covered by national insurance.
In Dr. Ronit Aloni's clinic, males make up about 60 percent of the patients while around 40% are female, much more balanced percentages than in the past thanks to education and greater awareness of sexual dysfunctions.
"In recent years, a great effort has been made to open therapy for women and more and more women are seeking help," says Aloni.
One sex therapist, who prefers to remain anonymous, says working with surrogates is difficult since many of the people attracted to the field come from abusive or damaged backgrounds and want to heal themselves through their work.
This begs a big question: How is it possible to heal someone else while you are hurting yourself?
Dr. Ilan Biran, who agrees that most therapists come to specific areas because of their own weaknesses, says helping others with things you have suffered from yourself is not intrinsically bad, provided that the healing process has ended for the therapist.
"Therapists need to have emotional stability. They need to be sensitive and react, but not be too affected by the situation," says Biran. "This is not a simple balance to achieve."
For surrogate "Noa," the theoretical arguments for and against sexual surrogates are all meaningless compared to the reality of helping people.
"I have been working for four years as a sexual surrogate, and I consider it holy work," she says.
"Sex is a must in leading a healthy life, and so many people give up on it who shouldn't," says Noa. "It's important for them to know that they can get treatment, even without a partner."