How Therapists Can Protect Themselves from Sexual Assault

• Article By the Massage Ethics Council

In the summer of 2023, the Massage Ethics Council was founded to offer guidance in establishing clear, ethical standards of care for the massage industry. The Council members are Laura Allen, Ben Benjamin, Beverley Giroud, Nathan Nordstrom, and Cherie Sohnen-Moe.  They have more than 150 years of combined experience in teaching, writing, and consulting on ethical issues in the massage field. They are currently in the process of publishing guidelines on The Prevention of Sexual Misconduct and Assault in Massage Therapy. These guidelines are for massage therapists and for anyone who employs them. 

This article is the beginning of a detailed series of articles on what you can do to adhere to the safest standards of care in massage therapy. Whether you are a day spa, a massage clinic, a small or large franchisee, a franchisor, or a massage therapist in private practice, these articles and templates will help you provide a safe, professional environment.

Predatory sexual behavior by the client is a serious issue and not something a therapist should ignore or try to manage on their own. This can occur with male and female therapists. Therapists are entitled to work in an environment free of sexual abuse, whether a therapist is in private practice or an employee. If violations happen, they have the right to make themselves safe, remove themselves from the situation, and take all available steps to have the abuser reported and held responsible for their actions. Therapists need to know they are not alone and not powerless.

Unfortunately, formal reporting remains rare. Therapists stay silent because they fear not being believed, worry about retaliation from employers who prioritize client retention over staff safety, or simply don’t know that reporting is an option. Therapists need to know they are not alone and not powerless. 

There are instances where a client might not be a predator, yet could cross sexual boundaries due to poor impulse control, ignorance of proper boundaries, or because they are in a vulnerable personal situation. The therapist needs to be able to protect themselves in dealing with all situations.

Here are examples of inappropriate client behavior collected by surveying dozens of currently practicing massage therapists: 

Client…

• not following the therapist’s instructions about draping.

• telling sexually inappropriate jokes, stories, or making inappropriate comments.

• making romantic or sexual advances.

• pushing the boundaries of what is appropriate as outlined by the therapist.

• touching or grabbing the therapist.

• trying to kiss the therapist.

• greeting the therapist at the door naked or in suggestive attire.

• asking for genitals to be massaged or a “happy ending,” often for extra pay.

• arousing themselves on the massage table and/or ejaculating.

While good intentions and many years of practice might seem to guarantee safety, a client may still cross boundaries. The ethically safe touch experience doesn’t just happen; it must be created, structured, and sustained. This means consistently demonstrating absolute professionalism in all aspects of practice, particularly in matters of sexuality and touch. There are actions therapists can take to help mitigate clients’ inappropriate behavior and boundary crossings. 

Maintain a Professional Appearance and Demeanor 

The therapist’s appearance reflects their professional standards. Make sure that the therapist’s image projects competence and doesn’t sexualize them: 

• Dress appropriately for the work environment. A therapist’s attire isn’t meant to be a distraction or a loud message.
• Avoid provocative, tight-fitting, or revealing attire, such as tank tops, short shorts, shirts that show cleavage or nipples, shirts that expose the midriff, and shirts with questionable statements or provocative images. 
• Maintain good hygiene.
• Be fragrance-free.
• Keep jewelry to a minimum.

Ensure That the Physical Environment is Professional 

The physical environment differs depending on whether the therapist is in a professional office, a home office, or doing outcalls.

Professional Office:

Be aware that sight, sound, smell, and touch all have the potential to create emotional or sexual responses. Practitioners may aim to create a very relaxing environment with a darkened room, candles, and soft music. These can send confusing messages—particularly to new clients or to people in vulnerable situations regarding their romantic relationships. Ideally, start with the room well-lit and ask clients whether they want the light dimmed or an eye pillow. Choose soothing music that isn’t sensual or romantic. Use quality equipment and supplies. Consider hanging pertinent anatomical charts and other health-related posters. Limit displays of personal photos and keepsakes.

Home Office

If the practitioner works in a home office, follow the above guidelines and comply with local ordinances (if applicable). Keep the treatment room separate from the living space (if possible) and decorate it to make it feel professional. Minimize clutter in the waiting area. Be sure the treatment room windows are covered. If possible, have a separate bathroom that’s free of personal belongings.

Outcalls

Set up a space that feels like an office when doing home or hotel visits. Avoid working in a bedroom unless there is no other option, such as a hotel room, or if the client is severely injured or ill. Professionally display your supplies and equipment. Consider investing in a hard case on rollers that holds your supplies. Those items can be displayed on top of the case; this helps make the space look more office-like. 

Business Practices

Policies

In general, it’s important to have clear written policies that address the types of services offered, hours of operation, cancellation and lateness, fees, communication guidelines, what to expect during treatment, draping, hygiene, sanitation, confidentiality, and which body parts are off-limits. It’s also wise to include a statement such as: “Main Street Massage has a zero-tolerance policy for sexual comments or behavior. If this occurs, the massage will be ended immediately, and payment in full is expected.”

Policies are designed to prevent boundary crossings, but when prevention fails, the therapist must address the issue immediately as it arises. If the therapist doesn’t do this, they have just given the client permission to carry on with the problem behavior, whether it’s making a sexual joke or asking for something inappropriate.

Marketing Materials

Any form of advertising, whether online or in print, opens your business to the public at large. Ensure a professional image in all materials:

• Choose an appropriate business name. 
• Set up separate business and personal email accounts. Make sure the business email address is professional.
• Ensure that no photos are sexually provocative.
• Use appropriate language and terminology. Avoid phrases like “full-body massage.”
• Routinely verify that your website links point to the intended destinations.
• Regularly search for your business to verify that your business isn’t linked to inappropriate sites.
• Most towns have free local publications that cover local events and feature advertising. Before agreeing to run an ad, check where it would be placed. You don’t want it next to an advertisement such as “Buffy’s Massage & Pleasure Spa.”

Social Media

Most people spend a significant amount of time on social media. Here are some things to consider:

• Create separate personal and business pages/accounts on all platforms.
• Only allow friends and family to access the therapist’s personal pages/accounts.
• Ensure that content and photos are appropriate.
• Remember, once something is on social media, it’s there forever.

Client Interactions
Keep communication professional and not personal. Limit self-disclosure, as this can blur boundaries. Avoid careless comments that could be misconstrued as flirting or sexual innuendo. In most massage sessions, there is minimal conversation. Also, never discuss charged topics, even if the client brings them up, such as politics, money, sex, or religion.

It’s essential to establish clear boundaries. If a client touches the therapist, makes a sexual comment or joke, or asks for something sexual, then the therapist must pause to firmly establish the boundary. If the client’s behavior doesn’t change, then it’s appropriate to end the session. Keep in mind that not everything is as serious as a sexual assault, but it could be dismissal-worthy.

Dual relationships should be avoided. A dual relationship occurs when a therapist has a second, distinct relationship with a client, such as a friend, employee, business partner, or romantic relationship, in addition to the primary professional one. These relationships are generally not advisable because they could impair the professional’s judgment or increase the risk of harm or exploitation of the client. 

Dual relationships may be unavoidable and require careful management to protect the client’s interests, especially in small communities or during specialized training. Failure to navigate the risks involved in a dual relationship can result in personal or professional harm. Dual relationships can be a gateway to inappropriate behavior and embolden a predator. Conscious consideration of the potential risks is essential before engaging in a relationship of this nature; if so, clinical supervision is strongly recommended.

Professional Documentation

In addition to standard treatment notes, if a client is sexually inappropriate, document it immediately. Speak to a manager/supervisor (if you have one) or a trusted colleague. This type of documentation is particularly important in the event of a criminal or civil complaint.

Steps to Take with New Clients
Proper screening should be conducted before the client arrives. Always call new clients, even if they book online, to verify they are a legitimate client, clarify what they’re looking for (they might want a technique you don’t offer), and briefly review key policies. Once a client arrives, do the following:

• Review policies.
• Provide an orientation.
• Complete and review the Health History.
• Create a treatment plan depending on the client’s goals.
• Have clients sign an Informed Consent document.
• Describe the disrobing and draping protocols.
• Instruct the client on how to lie on the table (prone or supine), the anticipated sequence of the work, and any other pertinent details.

Tips to Reduce Sexual Boundary Crossings by Clients

Sexuality is a natural part of the human experience. By recognizing this fact, therapists can consciously choose to create a professional treatment space, to maintain clear boundaries, and to deal ethically and compassionately with unintended sexual responses. They can also protect themselves and their clients from sexually inappropriate behavior. By understanding the physical, social, and cultural dynamics and applying behavioral strategies, therapists can enhance their effectiveness as a safe, healing presence in the treatment setting.

• Conduct a thorough client intake interview: ask what sort of work they are looking for, what their problem is, and how they heard about the practice. 
• If a therapist doesn’t feel safe, take whatever steps are necessary to protect themselves: it’s best to err on the side of caution. 
• Ensure all intake forms and establishment websites clearly state that sexual inappropriateness results in immediate termination of service and full payment for time. 
• Confirm that the client has read, signed, and agrees to the policies. 
• As part of a client information document, include statements that address what areas of the body are never massaged.
• Don’t allow any sexual conversation. 
• Limit personal self-disclosure. 
• Don’t seek emotional support from clients.
• Don’t ask clients for favors. 
• Avoid seeing clients after regular hours.
• Be cautious when accepting gifts.
• Be mindful of body contact during the session.
• Always use proper draping techniques. Draping is intended to protect the client’s safety, modesty, and comfort. It is also a way for the therapist to protect themselves from misunderstandings.
• Be mindful when discussing a client’s body. Anatomical terms are far less suggestive and less offensive than layperson’s terms or slang words. 
• Don’t engage in any romantic relationships with clients.
• Be aware of transference and countertransference.
• Be careful when working in sensitive areas, such as near the breasts, groin, upper thigh, and gluteal region.
• Immediately address any sexual overture from a client. 
• Always address the client’s sexual arousal and erections; don’t ignore them.
• Put up a visible camera system in the reception area. 
• If you work alone, carry mace or other personal protection equipment, and keep your phone (volume off) and keys on your person.
• Establish a procedure to alert colleagues or staff to a potential problem. For instance, if doing outcalls, phone a colleague or friend (in front of the client). Tell them the location, estimated finish time, and that they will receive a call when the session is over.

Responding to Inappropriate Client Behavior

How should a practitioner respond when a client has an erection during the session? It depends on the situation, the client, and your comfort level. Some practitioners wrongly believe that if a person is having an erection, the practitioner must immediately end the massage. There is the misconception that for a man to get an erection, he must be deliberately sexualizing the massage and either be mentally or physically stimulating himself. Erections may occur as a natural physiological response to being touched. When an erection occurs, it can make both client and practitioner feel vulnerable. If you respond with unnecessary disapproval and fear, you’re doing an already embarrassed client a disservice. Instead say, “I notice you have an erection. Tell me what you’re experiencing.” or “I notice you are sexually aroused. Tell me what’s happening.” If there is no sexual intent, you would go on to explain that this is a natural physiological response. Yet, you have to be on guard against the threat of a disrespectful, abusive client. It’s a tricky situation that requires tactful nuance.

If a client makes an inappropriate sexual suggestion during the session, respond to it immediately. Hesitating will give the client the impression that you are open to the idea. It is up to you to address it in the moment; otherwise, you have given them the impression that you condone the behavior and reinforced the idea that it is okay to try something with you or the next unsuspecting therapist they work with. 

If the client is being obviously aggressive—physically stimulating themselves, grinding on the table, or trying to grab you- end the session immediately. You can say, “I’m not comfortable working with you anymore. This session is over. I’ll wait outside while you get dressed.”

In rare cases, a client might falsely accuse a therapist of sexual misconduct. 

How to Prevent False Accusations

This information focuses specifically on ethical issues related to false sexual complaints lodged against therapists. Any practitioner can be accused of sexually violating a client. Sexual abuse and violation issues are about power, and they cross all lines of gender and sexual orientation. Most complaints are made by female clients against male practitioners. So, men, on the whole, are more at risk of accusations. All who touch people need to be cautious about sexual boundaries, and practitioners in those groups should be especially mindful.

Examples of Actual False Accusations

• A female client thought a male therapist had an erection because he was wearing a lotion holder, and it kept touching her hand while she was on the table with her eyes closed. 
• A client made suggestive comments and physical advances toward a therapist. The therapist refused their advances. The client was offended and filed a claim that the therapist sexually harassed them.
• A therapist had a client with whom they had been romantically involved many years ago. The therapist saw the client for several sessions, and the interactions were professional. The client’s current partner filed a claim with the massage board, accusing the therapist of sexual misconduct (falsely), stating they were currently having sex.
• A client was upset with the spa and took out their anger by accusing the therapist of sexual misconduct.

Steps to Take to Minimize Risks of False Accusations

• Describe the treatment using terminology that best reflects the therapeutic aspect of the work. Realize that what is said might be interpreted differently from what is meant, and avoid language that can be sexualized. 
• Get Specific Informed Consent when working in a potentially sensitive area.
• Avoid comments that could be misconstrued as flirting or sexual innuendo.
• Always use proper draping techniques.
• Be mindful of unintentional body contact during the session and avoid straying strokes or movements.
• Make sure that no clothing, hair, jewelry, or equipment (such as a massage lotion holster) touches the client’s body.
• Beware of sexually provocative and emotionally disturbed clients.
• Be cautious regarding dual or sequential relationships, even if they were in the distant past. 
• If a problem occurs during a session (whether initiated by the client or the therapist), immediately discuss it with the client and document it in the session notes – even if it is resolved.
• Here’s a protocol developed by Daphne Chellos¹ for when a client makes sexual comments or gestures:
  • Pause the session and describe the client’s behavior.
  • Clarify the client’s intent.
  • Restate the purpose of the session.
  • Based on the client’s response and intention, continue or discontinue the session.
  • Be sure to document what occurred and report it to your supervisor (if you have one).
• Engage in supervision. Get a reality check with a consultation from a trained mental health professional who can help you understand the dynamics of the situation.  

Stay tuned for our next article, adapted from the Prevention of Sexual Misconduct and Assault in Massage Therapy by the Massage Ethics Council.

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