One of the most revelatory moments of Carlene Ostedgaard's career was the time she got an orgasm from having her shoulder touched.

It happened a few years ago, when Ostedgaard, 35, began training to become a surrogate partner. Typically treating sexual anxiety or trauma, surrogate partners work in collaboration with licensed therapists to teach their clients relaxation tools, hands-on intimacy exercises and social skills—eventually leading to unstructured, penetrative sex.

Part of Ostedgaard's training included a two-week program in Los Angeles, in which trainees paired up for a series of exercises that slowly became more intimate, from holding hands to footbaths. One exercise involved "erotic body mapping," in which Ostedgaard and her partner took turns touching, licking and sucking spots on each other's bodies and rating the sensation. When Ostedgaard's partner got to her scapula, she began to feel a current running down her spine.

"It was super cool," she says. "I thought I knew all these wonderful things about my body, and that was a totally new experience."

Orgasms, though, are rare in surrogate therapy, and somewhat beside the point. Instead, the focus is on understanding why and when relaxation becomes difficult. Touch, erotic or not, can communicate painful memories, insecurities and vulnerabilities that are hard to verbalize.

"You can decide what you tell your therapist and what you don't tell your therapist," says Ostedgaard. "The body is not very good at lying."

Ostedgaard has been working in Portland as a surrogate partner for three years. The practice exists under the broader category of "touch therapy." In almost every case, hands-on coaches tend to work with clients whose symptoms—whether it's erectile dysfunction or pelvic pain—stem from shame, anxiety or sexual trauma, and the treatment can encompass a range of physical contact. Somatica, for instance, focuses on breathing exercises and nonerotic touch, while sexological bodywork often involves genital touch but not necessarily penetrative sex.

Surrogate therapy, however, almost always involves sexual intercourse. But Ostedgaard stresses that it is only a small part of the overall treatment. Most of the time is spent working on communication skills and relaxation techniques.

"Ninety-five percent of what we do has nothing to do with sex," says Ostedgaard. "It's getting someone to that place where they're relaxed enough to be present in their bodies so they can enjoy sex. It's learning to communicate about sex."

Even in the realm of sex therapy and coaching, touch-based work is a niche practice—Ostedgaard says she is among only a few dozen nonmedical sexual health practitioners in Portland who use physical contact as part of their treatment.

Because it involves sex, the legality of the profession is complicated. Few states have directly addressed surrogate therapy. While serving as deputy district attorney in Alameda County, Calif., Kamala Harris said of the practice, "If it's between consensual adults and referred by licensed therapists and doesn't involve minors, then it's not illegal."

In Oregon, commercial sexual solicitation is broadly defined as paying for any kind of "sexual conduct or sexual contact." But according to certain experts, the therapeutic purpose of surrogate partner therapy could dissuade prosecution.

"It's not the actual sex that's criminalized, it's the business aspect," says Lake Perriguey, a Portland lawyer who has represented defendants facing sex crimes charges. "If the agreement is more broadly stated as a joint effort to overcome an impotence through therapy, that may not run afoul of the criminal statue. If there is an agreement, written or oral, that includes the words 'You're going to pay me to eat you out and then your sexual blockage will be cleared,' that would be illegal."

In other words, it's mostly legal in the sense that it's not explicitly illegal. Still, according to Ostedgaard, no surrogate partner has been prosecuted in the 50 years the treatment has existed.

"I'm a little bit tired of having the conversation,"she says, "because it's never happened, no one's gotten in trouble, and it's such good therapy. That's why people leave us alone."

The American Psychological Association's code of ethics prohibits any kind of sexual intimacy between patients and therapists. Hands-on workers are not recognized as therapists, and refer to those they treat as "clients" rather than patients. But surrogate partners are unique in that they work in conjunction with a licensed therapist. Clients see a therapist throughout the duration of their surrogacy treatment, and sign disclosure agreements so the two professionals can share notes.

Some therapists can be skeptical about the collaboration. It's usually the client, rather than the surrogate, who does the convincing.

"When someone comes to this stage in therapy, they've tried everything else," says Ostedgaard. "If someone needs this therapy, in my mind, it's unethical to deny them when it is so effective."

Of the various disciplines of hands-on sex therapy, surrogate therapy is perhaps the most regimented. At the beginning of each session, the surrogate checks in with the client to see if he or she is ready to proceed with the plan for the day. Sometimes, that means repeating hand caress exercises for a session before moving on to touching one another's faces. Just before surrogates and clients have sex, there's usually a session that involves "quiet penetration," sometimes colloquially referred to as "stuffing," which is essentially just penetration without the intent of having an orgasm, and with little movement (the vast majority of clients who seek surrogate therapy are cisgender men).

"We just hang out there for like five minutes," she says. "What we're really doing is normalizing that sensation, whether that's bringing them to the point of ejaculation and teaching them like, you can control this, or normalizing the feeling of a vagina, because for a lot of these folks, that's why they're prematurely ejaculating, it's because they're excited or they're fearful."

Treatment typically takes one to two years of weekly sessions. Emotional involvement is inherently part of the treatment—the closing sessions are somewhere between an exit interview and a breakup. The surrogate recaps the skills the client has built, and the pair say goodbye.

"The client knows from the beginning that the relationship is going to end," says Ostedgaard. "We frame it a lot from the perspective of, 'Look at all these beautiful new skills you have. You deserve to go spread that to the world. Why on earth would you choose to share with only me?'"

After treatment is over, clients continue to see their therapist, but cannot contact the surrogate for at least three months. "It's painful and there's crying and you're going to miss them and they're going to miss you," says Ostedgaard. "Then they come back and they tell you like, they've gotten married, they've had a baby—really wonderful things like that."

Sex coaches and surrogate partners often speak about their work as a way of not only healing individual clients, but also recoding cultural attitudes about sex and pleasure.

Few believe a mass shift is going to happen anytime soon. Though the practice is gaining in recognition—this weekend in New Orleans, the American Association of Sexuality Educators, Counselors and Educators will hold its first conference for certified members who use hands-on touch—Ostedgaard says legalizing sex work, regardless of a worker's philosophical leanings, would be a big step.

"It would change attitudes so much if it wasn't in the shadows," she says. "It would change to the idea that pleasure and sex are a birthright."