MASSAGE THERAPY AS HEALTH CARE SERVICE. (a) Massage therapy constitutes a health care service if the massage therapy is for therapeutic purposes. Massage therapy does not constitute the practice of chiropractic ...therapy or therapeutic procedures do not include the diagnosis or treatment of illness or disease—Texas State Occupations Code Section 455.002

Whether you are a professional massage therapist or someone who just likes to give occasional shoulder rubs to friends or co-workers, touch comes with its own set of ethical concerns. Attention to these can prevent misunderstandings and even legal problems.

First, Do No Harm*

Massage, even when practiced by someone who is relatively untrained, not only feels wonderful, but can be wonderfully healthful. Massage improves the circulation, stretches out tissues, improves the lubrication of joints and is often effective at relieving headaches, insomnia, hyperactivity, nausea and a host of other maladies.

Like almost anything that can be helpful, massage, if practiced incorrectly, can also be harmful. Too much pressure or traction (pulling against joints) can injure organs and connective tissue and can actually even break bones in some cases. It is important to know if the person you are working on has any medical conditions—blood clots, osteoporosis, cancer or diabetes, for example. In these cases, care must be taken not to worsen the condition or do injury to the person. It is the responsibility of anyone who is performing massage to know how to protect their client.

Let's NOT Play Doctor

Massage is great, but it is not a substitute for the care of a qualified physician, nurse, chiropractor or physical therapist. Under the right circumstances, massage (especially the deep tissue and friction varieties) can bring about results that may almost seem miraculous. This can have the unfortunate effect of giving a massage therapist a feeling that is disconcertingly close to omnipotence. You want to climb to a high place, shake your fists and shout "I am a healer!!" This fact, combined with a few irresponsible therapists and massage teachers, has made for an unfortunate (but fortunately small) number of therapists who like to sell massage therapy as a substitute for medical or chiropractic attention. It should probably go without saying that you should avoid any such behavior (although if you want to do the fist-shaking thing, I won't tell!).

That said, anyone giving a massage should do as much as possible for the client. Massage is a first line of defense for some clients and frequent massages may be sufficient to keep them from having to visit a chiropractor, physical therapist or doctor (or, if they do go, to improve these professionals' results). Doctors and chiropractors will usually consult with a therapist (or even an interested friend) regarding what sort of massage would be most effective. Use every resource at your disposal to make your client feel better—it is good massage karma.

The Sexy Stuff (NOT!)

There is a time for flirting, sexy jokes, innuendo and the like—massage time is not it. This is as true for an amateur giving a quick hand rub to a friend as it is for a professional giving a full-body massage to a paying client. In my own opinion, this even goes for couples or friends who are on intimate terms with each other—make massage time into a special, soothing time without the added complications of sexuality.

Observing good etiquette in massage includes almost every facet of what the massage therapist says and does. It is extremely important to have extra care in three areas when you are giving a massage: what you say, what you touch and (if the person is undressed) what you uncover.

When massaging an unclothed person, only uncover and massage parts that you have express permission to be working on. When working on new clients, I will often avoid contact with the buttocks unless my client specifically says it is okay to do so. This goes double for a woman's breasts! Breast massage (legal in most places, but often requiring signed permission) is a great comfort to many women, but it should never be attempted without permission. Genitals and their immediate environs are right out. Any touching of the naughty bits pretty much falls under a different writeup entirely and in most cases can get you into big trouble.**

Any comment that could be considered off-color, sexual or flirtatious should be off-limits. That which may seem innocent by daylight could be unaccountably lewd when one is naked in a darkened room with a relative stranger.

It is also important to avoid making accidental inappropriate contact, especially if the client is new or not at ease with you. Most clients don't care if your forearm brushes their rear end or breast, but if you are repeatedly touching genitals or resting a hand between their buttocks, you may not have a repeat customer (in some cases you might, but that is covered in the next section). It is also very likely that if you accidentally bump a male client in the crotch with an elbow, you won't likely have a very relaxed guy on the massage table.

In the course of a normal massage, client, therapist or both may find the experience a little bit arousing. This can be pretty embarrassing, especially (for obvious mechanical reasons) for male clients, undressed on a table. Whatever the case, embarrassment can be avoided (or lessened) by simply not making a big deal of it (that pun was probably inevitable).

Even if you are giving a massage to the sexiest client in the world, having a care about your words and actions can keep the experience positive and pleasant for you both.

The Not-So-Sexy Stuff II: It's Not THAT Kind of Massage

Massage and prostitution have been mixed up (unfortunately) throughout much of history and some clients still get confused. If a client makes an inappropriate remark or asks for 'extras' with the massage, it is possible to politely tell them that this is not that kind of massage, or 'I can not do that.' Usually, that will be the end of the matter, most clients will drop it right there, and may even be embarrassed. If the client persists, you may have to terminate the massage right there, especially if this is a good client. Simply explain that there has been a misunderstanding, firmly tell the client that the session is over and step out of the massage room.

Do not—under any circumstances—accept one of these offers! Once you cross that line, you are almost certain to be breaking the law and also compromising your professional integrity. It is a therapist's responsibility to delineate clear boundaries—the person giving the massage must be very careful to make clear what is acceptable behavior and what is not.

What The Books Won't Tell You

It is common wisdom among practitioners of massage that fraternizing with clients is inappropriate—many feel that it compromises the boundary between therapist and client. Nearly all therapists feel that dating a client is not appropriate but some even extend this to going out to lunch, or, in some cases, even joking around during a massage session. The locations of these boundaries must be up to the individual therapist. If you ever perform massages as a professional, and you ever admit to joking with clients (or, heavens forbid, going out to dinner with them), you might well expect to have some other therapists sniff at you and cluck their tongues.

Many of the same massage mavens will insist that it is not appropriate for a professional (or semi-professional) massage therapist to give out free work to friends—some will even say that working on friends at all is inappropriate, as there tends not to be the level of professionalism that there would be with paying clients.

My own feeling is that much of this debate is absurd. I take all my cues from my clients and I will talk if they are talkative, joke if they are jocular and I will (horrors!) even laugh if they make a dirty joke. I have been to lunch and even dinner with clients, exchanged presents on holidays and even been to their homes without losing their respect. I also give out lots of free neck, hand and foot rubs–usually leading to increased business and happy friends.

These etiquette points all have grounding in good sense. It is best to be careful not to overstep your authority, not to try to cure clients or put on airs about what you can do. It makes sense not to flirt with clients or touch them in ways that could be construed as licentious. Like any rules, however, if they are followed dogmatically, they become a straitjacket which may ultimately cause more problems then they prevent or solve. Use a drop of common sense and respect the bodies of those people you massage and etiquette is really quite easy.

*It's not in the Hippocratic Oath, but the sentiment is there...
**There are a few legitimate, more or less, massage techniques that work very close to the goodies, but unless you are specifically licensed to practice 'em, it's probably a good idea to steer clear!

Bruder, Leslie, "Massage and Sexuality; Let's Talk About it" Massage magazine, May/June 2005.
"First, Do No Harm" Is Not in the Hippocratic Oath, online at
Texas Occupational Code: Online at
Benjamin, Ben E and Sohnen-Moe, Cherie, "the Ethics of Touch" (Lippincott Williams & Wilkins, 2004).

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