Figure 1 Overlapping federal and state oversight of human trafficking laws and massage therapy regulations.
Mica Rosenow, MS, LMT1,*, Niki Munk, PhD, LMT1,2
1Indiana University School of Health & Human Sciences - IUPUI, Indianapolis, IN, USA
2Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney, Sydney, Australia
Human trafficking guised as massage therapy businesses is a highly successful business model that creates independent but related victims beyond the women and girls forced into sex work. Massage clinicians and the massage therapy profession are also negatively impacted by the trafficking massage business model with over 9,000 established illicit massage businesses marketing services alongside professional therapeutic massage businesses. Credential regulation efforts advocated for by various massage-related professional organizations and regulating agencies have fallen short in their purported intentions to protect massage therapists and trafficking victims. Massage industry advocates continue endorsing massage therapy as a branch of health care although health-care workers are not generally considered or treated as sex workers. Sexual harassment research in direct patient care disciplines, such as physical therapy and nursing, points to a high patient initiated incident rate and transdisciplinary, detrimental mental health outcomes for clinicians. Reporting and debriefing instances of sexual harassment inside of health-care organizations, covered by The Civil Rights Act of 1964, promotes a victim-centered perspective to support the well-being of past, current, and pending victims. The massage therapy workforce is comprised of mainly female sole proprietors, creating a double vulnerability in their potential to experience sexual harassment. This threat is compounded by little-to-no protective or supporting systems or networks for massage clinicians. The priorities of professional massage organizations to depend on credentialing and licensing as their primary efforts to fight human trafficking, seems more to perpetuate the current system/expectations, leaving individual massage therapists responsible for fighting or reeducation deviant sexualized behaviors. This critical commentary closes with a call to action aimed at professional massage organizations, regulators, and corporations to protect massage therapists through a unified position, supported in word, policy, and action, against sexual harassment, and unequivocally condemns professional massage devaluation and sexualization in all forms.
KEYWORDS: client-initiated sexual harassment, critical commentary, call to action, sex trafficking, human trafficking, illicit massage businesses, massage therapy
Massage sexualization dates to ancient Rome and remains highly visible in illicit massage businesses as part of human sex trafficking in the United States.(1,2) Illicit massage services are the second most prevalent form of sex trafficking, sandwiched between traditionally defined prostitution activities: escort services and outdoor solicitation. Human trafficking, guised as massage therapy, is a highly successful business model that creates victims beyond the women and girls forced into sex work. The illicit massage business model negatively impacts massage therapists and the massage therapy profession, with over 9,000 established illicit massage businesses marketing services as therapeutic massage businesses.(1)
Massage sexualization and illicit massage businesses have a detrimental impact on the image of the massage profession and the safety of massage therapists across various career trajectories. The nation’s leading organization to combat human trafficking, the Polaris Project, released a comprehensive illicit massage business review in 2018.(1) The review examined recruiting processes, online marketing practices, buyer demographics, and purchasing patterns estimating around 10% of the 32,000 human trafficking reports confirmed illicit massage. The demand for massage prostitution services performed by trafficking victims in the United States is apparent, given about $2.5 billion in annual spending.(1)
The illicit massage business model “takes advantage” of the current nonsystematic approach to massage licensing processes in the United States. The practice of individual states, counties, and cities determining massage professional and business licensing requirements contributes to this issue. In many places, practice regulations (e.g., education hours, business requirements, and inspections) are minimally or loosely enforced. Nationalized education and testing standards do not exist.(3) However, the massage field has demonstrated efforts to standardize education and licensing requirements by creating processes intended to ensure professional competency.
Current coordinated efforts to manage professional legitimacy mainly focus on increasing regulatory oversite of professionals and their businesses.(4) The Federation of State Massage Therapy Boards (FSMTB) was created in 2005 with the mission to “support its Member Boards in their work to ensure that the practice of massage therapy is provided to the public safely and competently.”(5) FSTMB developed the Massage & Bodywork Licensing Examination (MBLEX) to create a centralized documentation process whereby consistent educational standards across states lead to a database of vetted, licensed professionals. The MBLEX was eventually supported by the American Massage Therapy Association (AMTA) and the Association of Bodywork and Massage Professionals (AMBP) in 2009 “as the sole licensing examination for the profession.”(6) Additionally, $8,000,000 was spent on lobbying for state regulations and advocating for more research without acknowledging normalized sexual harassment and the massage sexualization portrayed in the media and pornography industries.(7)
Regulated credentialing efforts have fallen short in their purported intentions to protect massage therapists and trafficking victims. Based on minimal education standards and standardization, the MBLEX does little to protect practicing massage therapists in daily business despite its adoption in 46 states, the District of Columbia, Puerto Rico, US Virgin Islands, and Guam. The centralized documentation process for educational standards via the MBLEX approach also inadvertently places additional 1) expectations about responsibility for massage therapists’ own and others’ victimization(8–10), and 2) requirements to prove professional legitimacy before and after victimization—for example, implied professional responsibility for identifying and reporting illicit massage businesses and filing police reports in the face of systemic stigma, respectively.(1,8,9)
While perhaps with good intention and careful deflection of a need to regulate sexualized behaviors, the increased regulatory oversite of massage professionals and their businesses is circumnavigated by those interested in perpetuating human trafficking guised as massage therapy. Thus, illicit massage businesses appear credentialed and profit from sexualized customer behavior.
Polaris notes that licensure and certification mills present illegitimate credentials to illicit massage business owners and managers as part of organized crime networks in human trafficking.(1) For instance, a Florida massage school employee sold transcripts for $10–15,000 each, and about 200 individuals received approval for state professional licenses without ever enrolling in a course. This example also illustrates a more significant issue understood by those running illicit massage businesses: regulations are in place, but the need to follow them is decidedly superficial and performative.
Sexual solicitation legislation is created and enforced by the states, like massage regulations (Figure 1), and no across-the-board federal sex work policies are in place outside of human trafficking. (National Human Trafficking Hotline, oral communication, April 2021.) All US states still consider sexual solicitation and sexual assault illegal, with penalty severity congruent to behavior severity.(11) Accepting a solicitation (i.e., prostitution) is legal only in Nevada, within regulated businesses, and through stringent worker sexual health screening.(12)
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Figure 1 Overlapping federal and state oversight of human trafficking laws and massage therapy regulations. | ||
Massage therapists field sexual solicitation and other related sexual behaviors in practice, such as exhibitionism, toucherism, and scatologia (sexual pleasure from the obscene language in phone calls), as though they are legal.(2,13) These behaviors toward massage therapists are so minimized by the industry and society that prevalence research within the industry barely exists. The FSTMB is collecting survey data on its website after a Canadian article brought the issue to light in 2020.(2,5)
Sex trafficking is a public health crisis,(14) and perpetrators solicit massage therapists to provide these sexual acts.(15) Authorities and those within the massage field become desensitized to the detrimental effects of solicitation by ignoring, minimizing, and normalizing the inappropriate sexualized behaviors supporting illicit massage business success.(16–18) Subsequently, sexual solicitation within the work environment has forced many licensed massage therapists to defend their education, professionalism, and treatment approaches in the face of socially accepted stigma.(8,9,19,20) Individuals asking massage therapists for sexual services will continue to search until services are provided, often by trafficking victims. Perpetrators will not stop because a single, isolated massage professional turned them down or a business posted a sign.
A systematic reporting approach is needed to identify sexual harassers and penalize sexual predators/those seeking to exploit/utilize trafficked individuals. Licensed massage therapists are not prostitutes; they are not sex workers; they are not police. Massage therapists are health-care specialists who are part of a larger medical profession, whether they work in a medical setting, as an independent, sole proprietor, in a private clinic, or as an employee in a multi-therapist massage environment. Endorsed structures and processes are needed to protect massage professionals from the field’s legitimizing burden of proof. Such a process would/could also ideally provide meaningful support to trafficked individuals by addressing a pivotal root of the problem: the demand.
It is time to call to action professional massage organizations and corporations to lead unified efforts in a systematic and universal process protecting all massage therapists by reporting and documenting individual instances of sexual harassment. Their position must be supportive in both words and action against sexual harassment, and requires unequivocal condemnation of professional massage devaluation and sexualization in all forms. This critical commentary intends to support this action by meeting four key objectives: 1) provide a brief background and related framework for how similar clinical disciplines consider and address inappropriate sexual behaviors in clinical settings; 2) identify issues related to minimizing and normalizing sexually inappropriate behaviors common in massage therapy practice, 3) discuss the implications of victim blaming in current practices; and 4) conclude with a formal call to action.
Sexually explicit behaviors in the workplace are legally defined as sexual harassment (SH) with three classifications: verbal (soliciting sexual favors), non-verbal (suggestive gestures or expressions), and physical (unwanted touching and assault).(18) The Civil Rights Act of 1964 (CRA) provides specific protections from SH in the workplace categorized as sex discrimination, but only applies to organizations with more than 15 employees.(21) Title VII of the CRA created provisions to reduce hazardous work environments due to explicit or implicit SH initiated by co-workers, supervisors, or executives while allowing victim protection from retaliatory harm for reporting. Some states have expanded these protections to smaller organizations and independent contractors.(17) Organization-specific reporting processes that lead to resolutions for SH experiences perpetrated by patrons and all individuals employed or contracted at those companies are in place.(22) Reporting processes can deter instances of SH by prompting those in leadership roles to think carefully about the perceptions of those farther down the organizational hierarchy.(23)
Sexual harassment is often motivated by aggression or power, reinforced by gender dynamics, and more commonly perpetrated against women.(22) Thus, reporting barriers still exist with clearly defined SH reporting processes.(18) Research shows that debriefing in a supportive environment reduces the detrimental effects by validating and processing the victim’s feelings about their experience.(16) Organizations can also offer mental health and legal counsel, if needed. Workplace SH is preventable when reporting structures are approached with attitudes conducive to understanding the victim’s perspective while supporting their well-being.(22)
Extensive research links SH in the patient care environment to detrimental mental health outcomes, including depression, anxiety, and suicidal ideation.(24–28) The need for patient-initiated SH reporting is paramount for the support of health-care workers, as evidenced by one study indicating that 47% of nurses experience SH by the patient and 28% by the patient’s family.(24) Viglianti et al. created a diagrammatic algorithm (Figure 2) in 2018 for physicians to refer to when experiencing patient-initiated SH.(29) Individuals facing safety uncertainty in an interpersonal interaction can benefit from this yes/no decision tree with solutions that include report filing and medical record documentation.(29) Providing health-care workers with a step-by-step process to reason through SH experiences, Viglianti et al. take a victim-centered approach founded on “safe” support from others.(29) These recommendations are appropriate and applicable for health-care workers within organizations where complex medical conditions complicate contextual variables.
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Figure 2 Viglianti, Oliverio & Meeks: Schematic of sexual harassment reporting procedures in a hospital setting.(29) | ||
Teaching reporting processes during formative training is essential because some illnesses create behavioral changes, such as sexual disinhibition, as a symptom of a disease, and differential diagnosis requires clinical judgment.(18,28,30,31) Individuals with complex medical conditions causing sexual disinhibition are less likely to initially present for treatment in a massage therapist’s sole proprietorship, and further discussion on that point is beyond the scope of the current paper. A sexually disinhibited individual presenting for massage therapy requires care outside a massage therapist’s scope of practice. The need to provide appropriate care compounds the need for a reporting process. Ideally, a massage therapist working as part of a multidisciplinary team offers opportunity for communication with other health-care professionals. Other rehabilitation professions within the traditional health-care setting, such as nurse practitioners or physical therapists, are permitted to refer for appropriate care, and document these behaviors in organizational filing systems.(29)
Health-care professionals are not required to defend their professional legitimacy when reporting solicitation or assault as a symptom or as SH within their organizations, despite female health-care sexualization.(28,32) Sex trafficking rarely occurs under the auspices of most health-care service providers, except home health aides,(1) due to professional standards and regulations within those professional fields. However, many utilize massage techniques within their scope of practice. Comparing massage and nursing or other health-related clinicians highlights a double standard for the term professional.(33,34) Credentials create professional health-care workers. Some massage therapists are professionals when they gain credentials and others must prove their legitimacy outside of sex work.
Sexual solicitation and downplayed assault acceptance as a colloquial joke (e.g., “happy endings”) leave massage therapists on the sex trafficking frontline, fielding predatory behavior. Professional massage therapy organizations and schools acknowledge that massage and massage therapist sexualization is a longstanding problem in the field.(2,35–37) However, in 2020, one research paper highlighted client-initiated SH against massage therapists. Richard et al. surveyed 143 Canadian massage therapists (approximately 23% response rate among about 1,000 MTs) and found that close to one-third of responding massage professionals fear experiencing SH while working.(2) Almost 75% of participants indicated experiencing client-initiated SH, with two-thirds experienced three or more incidents across their careers ranging from 1–16+ years. More than one-third of incidents were verbal and physical, and over 50% of those happened within a structured work organization. One-third of participants experienced SH in solo practice within home clinics and during outcalls. All three independent business models lack SH protection and face increasing responsibilities to ensure their safety proactively.
The contextual work environment alone ostracizes massage therapists from clinical health-care providers. With a large majority (88%) of massage professionals identifying as female and sole proprietors (72%),(38) the implications of challenges related to patient/client-instigated workplace SH is profound.(2,23,27,29,32,39,40) Therapeutic massage, definitively separated from sex work, positions the field within the scope of health-care and service, whether working in the hospital or as a sole proprietorship. Because of this and known longstanding massage sexualization, massage therapists are logical collaborators to help guide the department of health (in states that regulate massage therapists) and/or professional organizations in creating future reporting processes to address SH.
Beliefs, values, and stigma drive some massage therapists to minimize and normalize sexualized behaviors, as evident on professional social media forums and additionally reinforced by current practices.(41,42) Many articles in professional publications focus on protecting oneself from being sued for therapist-initiated sexual assault instead of providing a clearly defined and supported reporting process for client-initiated sexualized behaviors.(43–48)
Massage education does not provide formative routine or systematic training for sexually deviant workplace behavior management.
Sexual health-focused curriculum is not formally part of current massage therapy education requirements, although massage therapists are encouraged to use professional judgment when confronted with these situations during treatment.(49) Continuing education courses and industry guidance mention reporting client-initiated sexual behaviors to police for those who do not work in organizations, but not as a primary course of action, nor is such action advocated beyond a few sentences in professional venues. Instead, industry recommendations encourage alternative proactive behaviors like branding to prove legitimacy and pre-screening clients to weed out those seeking sexual gratification.(45,46) Therapists are encouraged to state explicitly, and in all official, written communication, that their practice does not participate in—or tolerate—sexualized behaviors. Advocacy for placing stickers in business windows and zero-tolerance imagery on marketing materials to visually identify “legitimate” businesses is spreading.(50) Additionally, massage therapists are encouraged to identify and remove any business-related verbiage that could be misconstrued as sexual, from the name of their business to the word “release” in marketing materials. These suggestions symbolically remove massage businesses from sexualization without holding potential customers responsible and accountable for illegal behaviors or inappropriate treatment perceptions.
The continued push by professional organizations to participate in “proactive” behaviors to minimize SH could be considered normalizing sexualized assumptions in the massage field. Acquiescent professional massage therapists potentially compromise their professional legitimacy at the beginning of their independent professional development and undermine the power to protect themselves and their businesses from sexualized assumptions. Normalization places responsibility for victim protection on the professional against patrons’ ostensibly acceptable illegal behavior.(42) Massage therapist professionalism is essential; however, considering therapists’ minimal training levels, the current recommendations could be compared to telling women they were inviting sexualized behaviors if, or when, it happens to them. Although that may not be the intent of professional organizations, educators, or peers, those victimized by predators, both massage therapists and trafficking victims, are not protected by the current efforts. Nor is it a massage therapist’s sole responsibility to stop behaviors culturally considered a joke, nuisance, or part of business.
Self-protection continues after establishing a “legitimate” massage business. Pre-screening to identify possible sexualization is purported in continuing education courses to reduce client-initiated SH escalation. Also, pre-screening ultimately isolates illegal conduct to one interaction per therapist without physically meeting. This process inherently occludes how many victims are affected by a single perpetrator.(45) Documenting digital or telephone communications and taking a credit card number for an appointment deposit deter predators. Again, there is little to identify the individual as a serial predator. After these initial efforts, zero-tolerance sexual conduct contracts are encouraged at client intake.(48) While likely providing deterrence as an isolated event, these efforts do not protect any massage therapists or trafficking victims from future sexual predation.
Industry-driven advice includes everything from ignoring or giving a warning while continuing treatment to “escaping” from the treatment room safely and finding support. Then, the victim bears the burden of proof in a non-violent situation with no witnesses and no apparent signs of assault.(19) This burden is very concerning, given the extraordinary harm that can be caused by a single person engaged in SH and by minimizing SH incidents. Several high-profile and related cases exist, with one as recently as March 2021 when 22 massage therapists filed lawsuits (with more expected to report) against NFL quarterback Deshaun Watson for inappropriate sexualized behaviors during treatment.(51) Initially denying accusations, Watson recanted and admitted that there was sexual contact in some treatment sessions but that it was consensual. In April 2021, an emergency motion required Watson’s accusers to release their names publicly to continue prosecution. He faced no criminal charges for alleged sexual misconduct and settled without admitting wrongdoing.(19)
Sexual coercion and assault become civil infractions when proof through evidence does not create probable cause. The extensive sex trafficking investigations required to document evidence treat massage therapists working as sole proprietors, small business owners, and independent contractors as necessary collateral damage. Undercover investigators frequent illicit massage businesses in sting operations, and professional organizations increase regulatory oversight in hopes of taking down global organized crime rings.(52) While these valiant efforts dissect larger crime organizations, this also comes at the expense of individual massage therapists who, when taken collectively, have valuable information to protect colleagues, sex trafficking victims, and sexual violence victims.
The Federation of State Massage Therapy Boards and the Polaris Project suggest that massage therapists independently build working relationships with law enforcement and government agencies to reduce illicit massage businesses and, vicariously, human trafficking.(1,4) Unfortunately, the current advocated approaches do little to protect or support massage therapists from predators and hazardous work environments, evidenced partly by the Watson case. An estimated 400,000 licensed individuals make up the US massage therapy workforce.(38) However, their experiences of workplace SH are not considered a resource. In fact, credibility and professionalism are questioned even when multiple massage therapists come forward in the “right” way, and the perpetrator corroborates.(19,51)
Massage therapists are not sex workers. Soliciting prostitution is currently a criminal and client-initiated activity. Professional massage organizations in the US have no systematic procedures or stances related to providing SH or solicitation protections for massage professionals. Current approaches and recommendations require explicit acknowledgment of refraining from sexual activity during treatment. These approaches and recommendations clearly infer that it is the individual massage therapist’s responsibility to carry the “I’m not a sex worker” burden in real life. That responsibility could be perceived as systemic industry sex discrimination and a civil rights violation on its own.(35–37)
Sexual solicitation is currently normalized as part of massage therapy’s business, making it a function of the massage therapists’ work environment. Sexualized behaviors in clinical work environments are considered SH, currently federally protected as sex discrimination and a civil rights violation. Some states include behaviors deemed obscene, lewd, or lascivious in general harassment laws and may be an avenue for massage therapists to leverage for reporting while waiting for top-down regulations by states and professional organizations to protect them consistently.(53) However, directly reporting solicitation and assault (culturally taboo, illegal, and notorious for victim-blaming(18,20,54)) to the criminal justice system can increase shame and embarrassment, fear of retaliation, as well as complicate complex subjective and contextual variables inherent to the incidents.(9) A defined, systemic, and organized reporting process, supported by professional massage therapy organizations and corporations, to reduce reporting barriers and support debriefing, may allow individual harassment incident documentation of predatory behavior patterns within and across states.
Behavioral repetition is what currently creates a course of conduct history for harassment consideration in some states. However, establishing a pattern of conduct within the professional field is impossible when pre-screening practices and recommendations limit client-initiated SH to one interaction per therapist. Without processes and procedures to establish a record of client-initiated SH in the massage field, predators have little to fear with continued inappropriate behavior, leaving individual massage therapists unprotected and victimized. The current system allows those seeking sexual gratification to continue harassing massage professionals until they ultimately find someone to provide the services they desire, commonly trafficking victims.
It is time for professional massage therapy organizations, regulating bodies, and corporations to directly protect massage therapists and indirectly protect human trafficking victims instead of making massage therapists responsible for their victimization. Creating a centralized and dedicated process for SH reporting, with support staff trained to debrief those reporting predatory behavior, would protect massage therapists that financially invest in those professional massage organizations as required consumers. A key component in protecting massage therapists is a unified position against SH that unequivocally condemns professional massage sexualization by expecting adults to know the legality of asking anyone for sex as a transaction. That position requires organizations to commit in word and action toward the support and benefit of the workforce that assures their existence and pays their salaries.
Coordinated efforts to reduce sexual slavery, represented as massage therapy, have focused on credentialing and regulations despite organized crime networks using fraudulent documentation. Massage therapists are not prostitutes or sex workers; perpetrators engage in illegal, deviant behaviors by soliciting sexual favors in the treatment room. Routinely minimizing and normalizing these behaviors could be considered systemic industry sex discrimination. Established processes and procedures for reporting individual instances of SH, including solicitation and sexual assault, do not currently exist in the massage field but would create a systematic approach to document a predatory course of conduct across multiple therapists. Systematic and organized reporting efforts, championed by professional massage organizations across states, government agencies, and massage therapists, would be a supportive step to protect massage consumers, massage therapists, and sex trafficking victims from the direct effects of sexualized client-initiated behaviors in massage workplaces. Until that becomes a reality, massage therapists will need to know specific harassment or related laws in their states to document and report sexualized behavior in the face of systemic stigma and to collectively advocate for the right to a safe workplace as a civil right.
The authors declare there are no conflicts of interest.
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INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK, VOLUME 16, NUMBER 1, MARCH 2023