Body Shaming

Where Pathology and Ethics Collide

By Ruth Werner
[Pathology Perspectives]

Why do some people avoid massage? Maybe it's because they don’t have the time, or they have a financial barrier, or because it simply doesn’t appeal to them. But often, the story of why someone doesn’t get massage looks more like this:
“I am super self-conscious. The thought of being naked on a massage table just makes me shake. Finally, I resolved to make an investment in my health and well-being, because, well, maybe I really am worth the trouble.  
“So I went online to see what kind of massage therapist I should look for. And what did I find? MTs making fun of clients with hairy backs and complaining about smelly feet. I saw mean comments about overweight clients, clients with acne, and clients with body odor.
“I never want to be that kind of target. Forget it. Massage might be OK for some people, but it’s definitely not for me.”
We will never know how often this happens.
We will never see the clients who reject massage therapy out of a fear of being judged or laughed at—only to have those very fears validated when they stumble on a just-for-fun post or hear insensitive words from a would-be therapist.
Sometimes that laughter and judgment is on public display, like in open Facebook groups. Sometimes communication of judgment is far subtler. Either way, the end result is the same: a potential client who might derive wonderful benefit from massage therapy feels excluded, unworthy, and possibly rightfully angry, especially when the reasons behind the problems are common situations that could affect anyone.
“I have psoriasis. My skin is discolored and flaky and itchy, especially on my back.”
“I have hypothyroidism. No matter how hard I try, I will never be thin.”
“I used to be anorexic. Now, I work hard to eat right, but having someone comment on how thin I am is a real trigger for me.”
“I am a smoker. I have tried to quit, I know the risks, and I’ve heard all the lectures. Right now, I just have to admit that I am not strong enough to change this part of my life, but maybe I can change some other things.”

What is the Source of Your Discomfort?
Feeling uncomfortable because a client has a physical flaw does not make you a bad person. It does suggest, however, that it would serve you well to ask why that person or situation is difficult for you. Try to narrow down where your discomfort comes from; this will give you much better tools to deal with it.

What Not to Do: A Short List
Share Thoughtless Comments in Public Places
Sometimes it makes sense to vent our strong feelings. This allows us to discharge them so that we can be more effective and less distracted in our work. However, complaining about our clients is never appropriate in any setting that may get back to them. And online posts and tweets, no matter how “private” they may be, are not safe from that danger: the only thing between you and the client you mocked is one screen capture. Further, even when clients are not identified by name, anyone who connects the timing of your posts to the entries in your appointment book could make an argument that you are in both ethical and legal breach of confidentiality laws.
Be aware that Facebook and Twitter are not the only places thoughtless jokes or comments can become public. I have wandered into a fair number of clinic break rooms with comics on the bulletin board that would appall a self-conscious client. Not only do these postings endanger our clients’ sense of safety and well-being, they also create a culture where this kind of mockery is institutionalized and made acceptable. It is not.

Make Unasked-For Comments About Your Client’s Body
Watch what comes out of your mouth. Thoughtfully consider every word you might say, and listen to those words from your client’s ears. Your polite, un-charged “wow, your shoulders are tight” can sound like the end of the world to someone who is wound up and self-conscious. Even a comment meant to be positive and supportive like, “Have you been losing weight? You look great!” can be perceived as judgmental if the client is sensitive about his size.
Be aware that this caution refers to unasked-for commentary. When we have been invited to be a part of someone’s health journey, for instance when they share their bodybuilding goals and massage is part of their strategy, then the rules are different.

Unconditional Positive Regard
Most of us enter this profession with a desire to serve, to be a conduit for healing, and to be a positive influence. We all want to make the world a better place one massage at a time. Unconditional positive regard for each and every client is the baseline attitude with which we must begin each session. This applies to rich clients and the struggling ones; those who smell like a rose, and those who definitely do not; those who respond quickly and satisfyingly to our work, and those who need us to keep trying something else.
Working in the sacred bubble of the massage space limits our ability to share our experiences with our peers—both our triumphs and our challenges. I believe this is a contributor to the occasional embarrassing body-shaming memes that appear on Facebook and elsewhere. All these feelings accumulate, and then they are expressed in inappropriate ways.
People have flaws. We do, they do, everyone does. In our job, we will deal with cellulite, bad breath, sweaty feet, and flatulence. Hopefully, anyone who can’t handle that reality has already left the profession.

Steps for Better Connection
Feelings are important, but they are feelings, which are not the same as reality. We have the capacity to make choices that override our first feeling-based reactions, and, in time, those initial reactions can dissipate and disappear.

Analyze Your Discomfort
The first step after recognizing we have some level of discomfort is to try to figure out where it comes from, and, in that process, to determine whether the issue is a problem or not. Often the first place to look is within, since so much of what bothers us about others is a reflection of some quality of our own that we aren’t happy about. And when we make peace with ourselves for our imperfections, it becomes much easier to be at ease with others who share them.

Practice Makes Comfortable
Are you nervous about working with a client who has a lot of body hair? It’s probably because you want to give him a great massage, and you’re not sure you can—that’s a good kind of nervousness. The first few times it will be a little difficult. Then, you’ll figure it out, and it will be just another great day at your office. You can expedite the process by seeking out extra practice: see if one of your hirsute colleagues will let you experiment with lotions, oils, and techniques to find your best strategies. The same principle applies to situations like working with clients who are overweight, or those who are super-muscular, or those who are smaller and thinner than the average person. Look for opportunities to work with the situations that flummox you, and you will cease to be flummoxed.

Enlist Your Client as Your Partner
Does flaky, itchy skin make you shiver? In a situation where a person presents with psoriasis or eczema, we can quickly remind ourselves that the condition isn’t contagious and it doesn’t spread. The worst thing we could do—besides making our client feel bad—is to irritate the client’s skin or create a risk of infection if a lesion has cracked and bled. Both of these are easy to avoid with a little sensitivity. And if you’re brave enough, you can enlist your client on your team: “I’ve never worked with someone who has psoriasis on their back before. Let’s figure out a way to give you the best massage ever.” You become the local psoriasis authority, and people will go out of their way to see you because you really understand what they’re going through.
Does your client have a thick layer of fat and fascia between you and her neck—where she really needs some great massage? Enlist her help in exploring new ways to work with her, maybe from a different angle, or with a different kind of traction. You aren’t limited to the strokes you learned in massage school; you can use your imagination and compassion to create an experience that is customized to each client.

Consider Forming a Peer Supervision Group
New massage therapists may not face the reality of people’s physical flaws and challenges until they’re well into student exchanges or school clinics. If they’re lucky during this time, they have some safe, private outlets for processing surprises or discomforts. But without this option, these feelings can interfere with their ability to do great work.
I am always pleased to hear about schools that build in time for debriefing in relation to clinic sessions; it provides a model for appropriate peer supervision that students can use for the rest of their careers. This can easily be carried into professional practice; peer supervision groups are considered a best practice in many helping professions.     
For massage therapists, they can be an appropriate place to express discomfort or embarrassment—as long as this has the intention of seeking a solution instead of simply complaining. And if a group gets stuck, they can combine resources to bring in an outside consultant to help process difficult situations. We ordinarily work in isolation; a place to appropriately share our struggles and triumphs adds enormous richness to our professional lives.

Go Back and Try Again
We all make mistakes. To paraphrase Salvador Dali, we needn’t fear perfection, because we will certainly never achieve it. Bad days will happen, and poor communication will muddy relationships. But we always have the chance to try again. We can build our compassion and unconditional positive regard again. The world needs our best; let’s give it. And then, let’s give it again.

When Our Buttons are Pushed
Every single one of us will be faced at some point with a client who has a condition or a physical characteristic that pushes some kind of emotional button in us.
Here’s mine: a client bought a gift certificate for her husband. His skin was sticky, and tiny pimples covered areas of his arms and legs. His heels were deeply cracked and discolored. His sweat smelled like ammonia. All of these were signs that his ability to manage waste products was compromised.
Rather than give him the safest and most caring massage in my power, I gave him the worst massage I could manage in the hope that he would never come back. Indeed, he didn’t. But this is a bad way to manage the problem.
It would have been a courageous and much more ethical choice to conclude his appointment with a conversation in which I urged him to see his doctor for a general checkup because I observed some things that made me generally concerned for his health.

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at