Editor's Note

We believe one of the best ways to curb sexual abuse in massage therapy is to sear the problem with bright light and constructive conversation throughout our community. This feature by industry expert Ben E. Benjamin, PhD, flows from his decades as a therapist and educator, and is punctuated by more than 12 years as an expert witness in sexual assault lawsuits. It underscores the importance of anyone vested in massage therapy careers working together to uphold the profession’s reputation. We appreciate his willingness to have this tough discussion and his determination to move forward with solid advice about how to avoid blurring the lines.

Leslie A. Young, Editor-in-Chief

Having worked in the industry, and served as an expert witness on cases of sexual misconduct by massage therapists and bodyworkers for more than 12 years, I feel compelled to write this article. As I’ve raised this topic with clients, students, and friends over the years, I’ve found that many of us have a story of inappropriate behavior in a therapeutic session—affecting either ourselves or someone we know. And, overwhelmingly, these violations were never reported. (Since sexual abuse in general is significantly underreported, this isn’t surprising.1) As I see some massage therapy schools reducing the ethics, sexuality, and communication content in their curricula, as well as employers sometimes hiring new therapists without proper employment vetting, I fear that the incidence of these violations will only increase.
We must protect ourselves, our clients, and our profession, which means we all need to be part of the solution. The best protection for clients’ safety, health, and dignity is broad-based education of management, staff, and clients themselves about the dangers and warning signs of predatory therapists, as well as maintaining our own best practices. This information is essential for both current and future clients, as well as for everyone who practices, teaches, or hires employees in hands-on modalities.  

There is no doubt that the vast majority of massage therapists and bodyworkers are honest, hardworking professionals who would never engage in sexual misconduct of any kind. Unfortunately, some individuals who enter our profession lack the integrity, psychological boundaries, or mental and emotional stability to practice ethically. It is a few predatory therapists who cause profound damage to the clients on their tables, as well as the profession as a whole. Knowing what to look for will only help us be better at policing the profession from within.

Cultural Context
Certainly, sexual abuse and harassment are not unique to the massage therapy profession. However, the physical intimacy involved in hands-on bodywork heightens the level of vulnerability for a client. Think about what happens in these therapeutic relationships: a client makes an appointment with someone they’ve never met; enters a dimly lit, private room with this person; removes most, or all, of their clothing; and lies passively while being touched—usually skin to skin—for an hour or so. The client is highly vulnerable, both physically and psychologically.
Add to that the fact that many of your clients come to you with a variety of experiences, including some having been sexually abused. Research estimates that approximately 1 in 53 boys and 1 in 9 girls experience sexual abuse at the hands of an adult before the age of 18—often in trusted environments such as homes, schools, and places of worship.2 This means that although they may never tell us directly, some of our clients are survivors of abuse and are likely to be highly sensitive to any physical boundary crossing (even an accidental one) and can be easily retraumatized. Because we don’t always know, we must treat every individual with the care, respect, and clearly defined boundaries we would offer to someone with a known history of sexual trauma. Guidelines for ethical practice must always err on the side of caution and client safety.

Maintaining Sexual Ethics Within a Session
Clear guidelines for therapeutic practice are essential to protect the public, practitioners, employers, and the profession as a whole. The sections that follow describe parts of a typical massage therapy session, including necessary precautions and areas where therapists with difficulty maintaining boundaries may run into trouble. All of the basic warning signs and guidelines outlined here apply equally to any therapeutic interaction, regardless of the genders of the client or the therapist.

Disrobing
There is no rule that clients have to be nude to have a massage. If the client is perfectly comfortable being naked, that is fine. But if the client is more comfortable leaving on undergarments for the massage, that is fine as well.
A practitioner should never pressure a client into getting naked for a therapy session. Clients faced with that pressure should consider it a warning sign and probably terminate the session. However, the client is not in the best position to know this and may believe that getting fully nude is required and/or at least expected. It is both a spa’s and practitioner’s responsibility to always inform the client that they may undress to their comfort level. The spa/practice should have procedures and safeguards in place to ensure that all practitioners follow these guidelines—for example, providing a written statement for clients to read.
Therapists should always give clear and specific directions about what the client should do (e.g., disrobe to your comfort level, lie face down/face up under the sheet), and ask if they have any questions, before leaving the room while the client undresses in preparation for the massage.

Draping
Some bodywork is done with the body fully clothed so no drape is used, but when clothing is removed, drapes must be used appropriately. Proper draping techniques are not difficult to teach, to learn, or to perform, and should be taught well in all massage schools. Prior to hiring, a massage therapist should be evaluated on proper draping techniques by a knowledgeable supervisor.
Many clients, especially new ones, are not clear about what constitutes appropriate draping. It is the practitioner’s responsibility to use proper draping to ensure their clients feel secure and unexposed. And it is a spa’s responsibility to ensure their practitioners are appropriately draping their clients.
As for draping protocols, the genital regions (and female breasts) should always be covered (Image 1). The drape may be lowered to the base of the sacrum (Image 2) when the client is prone. The buttocks may be undraped only with explicit permission from the client, and usually only one side at a time (Image 3). When putting the drape in place, the therapist may lift each leg slightly to bring the drape securely under the thigh. While the client is disrobed, their legs should never be spread wide apart to secure the drape.
The primary fact to remember is that the drape is there to define the area of the body to be worked on. The therapist’s hands should never go under the drape.

Attention to Sensitive Regions of the Body
The Female Breasts: Female breasts should always be fully draped. When the client is supine, the drape generally covers the body up to the upper axilla (Image 4). Sometimes the drape is lowered to right above the top breast line to work on the upper pectoral muscles, but only when the client gives permission. In some areas of the United States, direct treatment of the breast is prohibited either by law or by professional ethical guidelines. In certain parts of Canada, Europe, and the United States, breast massage is considered appropriate when indicated by a particular client condition and with specific consent. For instance, massage can be useful for nursing mothers, especially when there is a clogged milk duct, or for women with painful postmastectomy scars.
Another potentially legitimate reason for working near the breast is the treatment of injuries to the intercostal muscles and when working with other types of tissue damage in close proximity to the breast (Image 5). Intercostal massage is appropriate only when performed by a therapist who is trained in working with these particular types of injuries, following the specific request of a client seeking help for this issue. Typically, that would occur in a private massage therapy practice or a chiropractor’s office.
The Upper Inner Thighs: It is essential to maintain good physical boundaries during massage of the thighs. In most people, the upper inner thigh is a very private, sexually sensitive area. The drape should always cover the upper 3–4 inches of the inner thigh, whether the client is lying prone or supine (Image 6, page 60).
In most massage therapy sessions, the therapist should never make contact with the upper inner thigh. Careless technique is no excuse for the fingers to move under the drape near the genital region. This should never happen. The only exceptions to these guidelines occur when the client specifically requests therapeutic work on an injury in this region. For example, a client may seek treatment for a strained adductor muscle-tendon unit from a therapist who is trained in working with those particular injuries. Even in these cases, the genital area should always remain covered and never be grazed or touched. The drape is secured at the very top of the thigh at the lateral aspect of the pubic bone, delineating a boundary that must never be crossed.
The Lower Abdomen: Abdominal massage can be very therapeutic for certain conditions. However, the abdomen—especially the lower abdomen—is a very sensual area of the body for most clients.
If the therapist has a good therapeutic reason to perform abdominal massage, they should explain that and receive the client’s permission before the treatment begins. As a general rule, the therapist’s hands should remain at least 2 inches above the client’s pubic bone. (Depending on the client’s build, this boundary will lie roughly 2–3 inches below the navel.) There may be some exceptions to this guideline—always with client consent—such as treatment of Caesarean section or similar surgical scars by a qualified therapist.
The Genital Region: The genital region should never be touched in a massage or bodywork session under any circumstance, even by accident. Any client, and especially one who has a sexual-abuse history, may freeze at that moment and be unable to move or say anything. At this point, they are experiencing sexual trauma and often go into shock. A predator therapist may mistakenly interpret this reaction as agreement with what is being done, when actually the client is frozen in fear. After experiencing such abuse, these clients may suffer from extreme emotional distress. Any touching of a client’s genital region during a massage, even by accident, is grounds for the client to immediately terminate the massage.   
Sometimes, legitimate accidents occur. One example, cited in a book I co-authored with Cherie Sohnen-Moe, The Ethics of Touch (Sohnen-Moe Associates, 2013), occurred when a chiropractor found himself in an unfortunate situation that was quickly and easily dealt with through honest and direct communication:

A male chiropractor was beginning to work on a prone female client who was wearing a gown opened in the back. He placed one of his hands on her lower legs and the other hand on her upper back. All of a sudden, with a cry of shock, the client said, “Doctor, what’s going on?” The chiropractor looked down and saw that his tie had fallen between the client’s thighs. In an even and professional voice, he said, “I’m sorry; my tie slipped and is touching you. Let me keep my hands where they are while you turn your head to see for yourself.” The client saw that the chiropractor was telling the truth; because of his clear and honest communication, she relaxed and continued the treatment.3

In the case of honest error, as this example illustrates, the therapist immediately stops, apologizes, and provides a direct, straightforward explanation of what has happened. If anything sexually inappropriate occurs more than once by a practitioner, however, it is likely to be intentional sexual misconduct, and the practitioner should no longer see clients. It is not only the practitioner’s, but also a spa’s or clinic’s, responsibility to ensure that clients are protected from any inappropriate sexual contact.   

Placement of the Client’s Hands
Another type of sexual violation can occur when a female client is lying prone with her hands on the table and her palms facing up toward the ceiling (Image 7). This positioning requires male therapists to be very careful. I know of multiple incidents where a therapist’s penis and testicles have ended up in the hand of a client—some by accident and others on purpose. When I owned a school, this happened to a young male massage student by accident—just once, for a moment—but it was still profoundly disturbing to the client. The student was totally unaware that it had happened until the client reported the incident to his supervisor. In a special meeting facilitated by the school, the soon-to-be-therapist apologized profusely to the client.
In order to prevent accidental contact with the therapist’s genitals, a client who is lying prone can drop her arms over the side of the table or place them under her hips while the practitioner works on her back (Image 8).

Light Touch
Light touch is also something to be aware of. The following story explains the problematic path to which it can lead. About 40 years ago, in the early years of owning a massage school, I began encountering students whose male clients at the practice clinic repeatedly got erections. The students were disturbed that this kept happening—they had no sexual intent—and they reached out for help.4 I was called in by the clinic supervisor to figure out what was going on with these particular students.  
The common denominator, we discovered, was light touch. Many massage techniques have two parts: the primary movement, where the greatest pressure is applied, and then the firm but lighter drag back to the starting position. Each of these students was working too lightly, especially on the return part of the technique. The issue was not just a matter of pressure—it’s OK to use a small amount of force—but the particular quality of the contact. This type of touch felt like a light grazing or brushing against the skin, causing a sensation verging on tickling (Image 9). Even without sexual intent, this type of touch can feel sexual to a client. Once this faulty aspect of the students’ technique was recognized, they received more explicit training and their technique was corrected. None had any further issues with client sexual arousal.
With good training, massage therapy students learn the difference between therapeutic touch and light, potentially sexual touch, and therefore avoid these issues altogether. However, a therapist with sexual intent uses light touch deliberately—often with the palms lifted off the body and/or with the fingertips barely grazing the skin. Most of us can sense that something is off when we experience touch that is more sexual than therapeutic, even if we can’t pinpoint exactly what’s going on.  

Guidelines for Schools, Spas, Therapists, and Clients
School Owners and Administrators  
If you are a school owner, be sure you have processes in place to (1) screen out inappropriate employment candidates, (2) effectively train students in ethical touch and communication, and (3) detect warning signs that a student or staff member may be acting inappropriately. Be alert for any evidence of poor physical, emotional, or verbal boundaries. If guidelines for sexual ethics are clearly and explicitly taught, other students will help keep their peers accountable. Encourage all students to come forward and safely speak to a faculty or staff member if they feel violated or intimidated in any way, and thoroughly investigate any complaints. If you don’t take these responsibilities seriously, you run the risk of putting clients, students, and other therapists in danger, sullying our profession, and destroying the reputation of your school.

Spa Owners  
If you are a spa owner, manager, or supervisor, please carefully consider all the risks outlined in this article. Help prevent abuses in your spa by adhering to the following guidelines:
• Run a Criminal Offender Record Information (CORI) check on your prospective employee, if your local or state agency has not done so recently. Relying on a background check performed in the course of licensing makes sense for a practitioner who was licensed a few months ago, but is inadequate for someone who has been practicing for several years.
 • Screen your therapists carefully before you hire them, including a thorough check of their references, a Google search, and a social media search. In several legal cases that I’ve worked on, a simple Google search on the defendant revealed incidences of criminal sexual misconduct that happened out of state or in another country.
• Before hiring a new massage therapist, have them interview both with an administrator and with an experienced therapist. A supervisory-level staff massage therapist should receive a therapeutic session from this person. It’s fine for an administrator to receive a session as well, but highly skilled therapists are much more likely to detect inappropriate actions.
• Periodically send in a “mystery shopper” to ensure your therapists are behaving appropriately.5
• Take all client complaints seriously, and meet personally or by phone with any client who lodges a complaint of a sexual nature. (Some clients understandably do not feel comfortable returning to the facility where the incident occurred and instead prefer to talk by phone.) Be aware that clients are usually in shock right after an abusive experience and may not be able to give you a full and accurate account of what occurred right away. Give clients the benefit of the doubt whenever they lodge a complaint, especially a complaint of a sexual nature. It is often difficult and uncomfortable for clients to speak about sexually inappropriate contact. Complaints of clear sexual misconduct (e.g., touching the breasts or genitals, making sexual comments) call for immediate suspension and investigation, followed—if the allegations prove to be true—by termination of employment and a report of the incident to the police and state massage board. More ambiguous complaints (e.g., a vague sense of discomfort with a therapist’s draping or quality of touch) may be investigated using a mystery shopper or anonymous surveys, and may warrant conversations with and/or training of the therapist. If your spa receives more than one such complaint about a therapist, consider it a pattern. Do not delay in investigating and taking appropriate action.
• Provide professional supervision by a qualified supervisor and ongoing training in ethics and boundaries.6    
Following these guidelines can prevent a great deal of pain and suffering. Only by being proactive and establishing clear boundaries can you fulfill your ethical, moral, and legal obligations to your clients.

Therapists
If you are a therapist, then this article has hopefully reinforced what you already know about safe and ethical practice. All of us in this profession have a responsibility not just to avoid intentional misconduct, but to take care to avoid even accidental boundary violations. We are also responsible for addressing any violations that come to our attention. If we see, hear, or experience troubling behavior from other therapists we encounter in our work or training, we need to speak up. Depending on the situation, it may be appropriate to check in directly with the person you’re concerned about, or to speak to the leaders of the school, spa, or other environment where the incident occurred. In regulated jurisdictions, you may also have an obligation to report what you know to the regulatory body.

Clients
Client education is an important tool to putting a stop to sexual abuse and impropriety in the massage treatment room. Carefully and slowly explain directions about disrobing (especially for clients new to you and new to massage), make sure to check in with clients throughout your session, and ask if they have any questions before or after the massage. Consider posting “A Pledge to Clients” (found in the September/October 2017 digital edition of Massage & Bodywork) on your website to further reassure your clients of your ethical fortitude, and reiterate your professionalism at all turns.

On the Side of Caution
Every time I hear of new cases of sexual abuse involving a massage therapist, I feel angry and deeply saddened, both for the clients and for the therapists; these perpetrators are unhealthy and disturbed individuals. I’m also frustrated to see many missed opportunities for prevention. Quite a few court cases I’ve been a part of have involved clear management negligence, where owners, managers, or supervisors failed to do simple background checks or to take complaints seriously and investigate them.
To some of you working in the field, the precautions I advocate might sound a bit extreme. I assure you they are not. Erring on the side of caution protects not only our clients, but also the reputation of our profession as a whole. Massage therapy has been shown to have tremendous value in promoting health and well-being. Everyone has a right to enjoy these benefits without fear of sexual, physical, or emotional harm.

Do You Know the Definitions?
Sexual Abuse
In a therapeutic relationship, the practitioner develops a power advantage over the client (power differential) and is considered a legal caregiver. For this reason, any sexual misconduct (regardless of whether the client consents), is considered sexual abuse. The practitioner is responsible and liable for sexual abuse, even if the client initiates sexual behavior. Sexual abuse is a crime.

Sexual Assault
According to the Rape, Abuse & Incest National Network (RAINN), sexual assault refers to sexual contact or behavior that occurs without explicit consent of the victim. This term is often interchangeable with the term sexual abuse. Sexual assault is a crime.

Sexual Harassment
Uninvited or unwelcome verbal or physical behavior of a sexual nature, especially by a person in an authority position (e.g., a practitioner with a client). Sexual harassment is a crime.

Sexual Impropriety
A failure to observe professional standards or show due modesty in the massage environment, including poor draping practices, telling sexual jokes, making gender-based comments, requesting or accepting a date, or emailing or calling clients for reasons unrelated to the massage session. Sexual impropriety can lead to sexual harrassment charges.

Notes
1. US Department of Justice National Sex Offender Public Website, “Facts and Statistics,” accessed July 2017, www.nsopw.gov/en-US/Education/FactsStatistics.
2. David Finkelhor, et al., “The Lifetime Prevalence of Child Sexual Abuse and Sexual Assault Assessed in Late Adolescence,” Journal of Adolescent Health 329 (2014): 329–333.
3. Cherie Sohnen-Moe and Ben E. Benjamin, The Ethics of Touch, 2nd ed. (Tucson, AZ: Sohnen-Moe Associates, 2014): 94.
4. Ibid, 151–53.
5. You can contact a mystery shopper service to hire a person to visit your facility, receive a session with one or more of your therapists, and report back to you about the quality of their work, their level of professionalism, and any boundary violations that occurred. Alternatively, you can independently hire a person who has been in the field for a long time—especially as an instructor of massage, communication skills, or ethics at a local massage therapy school—to perform this service.  
6. For details on important qualifications for supervisors, see Cherie Sohnen-Moe and Ben E. Benjamin, The Ethics of Touch, 2nd ed. (Tucson, AZ: Sohnen-Moe Associates, 2014): 290–91.

Since 2004, Ben E. Benjamin, PhD, has worked as an expert witness in cases involving sexual abuse by massage therapists. He has authored many articles on professional ethics and coauthored The Ethics of Touch (Sohnen-Moe Associates, 2013). Benjamin has taught courses in ethics, boundaries, and communication to somatic therapists for more than 25 years. He can be contacted at drben@benbenjamin.com or
www.benbenjamin.com.