An ethically safe massage environment provides much more than the assurance that a massage therapist will not flirt with, fondle, attempt to date, or seek to sleep with a client, and vice versa. If the massage therapist and the client are to be completely safe in all regards, these professionals must ensure that the massage experience is not sexualized. If, despite all cautions and proper behavior in the massage room, the therapist and the client fall in love and move into a romantic relationship, then their professional roles as therapist and client must cease. Then who massages whom becomes a private matter apart from the massage room. Dr. Pat Feinstein, psychiatrist and avid proponent of massage therapy, introduced the concept of desexualizing the massage experience in her interview on breast massage for the Massage Therapy Journal article, Why DonÕt They Do Breast Massage? (MTJ, Winter 1998). She said both the client and the therapist must be capable of desexualizing the massage experience. This can be a challenging task indeed. The factors that contribute to this challenge are numerous and deserve individual attention.

Typically, the sexual nature of the client or therapist is not regarded unless something sexually inappropriate happens that requires ethical intervention. This reactive stance does not work. To be diligent in their ethical efforts, massage therapists must proactively consider human sexuality, both their own and that of their clients. To do this, they must always appreciate the impact that massage can have on the sexual response, take full responsibility for how they are affected when they perform massage, and remain keenly aware of the potential effects of massage on their clients.

Sexuality, a much more complex issue, is about our nature, character, and makeup as sexual beings. It encompasses all of who we are as men and women. The Sexual Health Network says, Sexuality spans the biological, psychological, social, emotional and spiritual dimensions of their lives. [It] begins with us and our relationship with ourselves and extends to our relationships with others. Our relationship with ourselves includes how we feel about ourselves as a person, as sexual beings, as men and women, and how we feel about our body and how we feel about sexual activities and behaviors.1

The ways in which we channel and express our sexual nature are as different as the number of human beings on this planet, since we express each and every aspect of our nature uniquely. How we integrate our sexual nature into our personality is greatly influenced by genetics, upbringing, health status, and cultural, social, and religious influences, and while we do not have control over having a sexual nature, we do have control over when and how we express it. The term desexualize is best defined by examining its opposite, sexualize. Sexualizing means making an event, procedure, conversation or experience that is not implicitly sexual into something that is sexual or could be interpreted as sexual.2

Desexualizing, then, means ensuring that massage is not sexualized; that it is not in any way turned into a sexual experience, either overtly or covertly, for either the therapist or the client. While the terms sex and sexuality commingle and share aspects of their meanings, their differences can be significant in the massage setting.

You don't have to look far to see the truth in this statement; even animated characters in children's movies have sex appeal. Current views on sexuality, so skewed, tend to perpetuate the association of sex and massage in the minds of the consumer, despite current appreciation for the holistic health benefits of massage. So, despite the respect and acceptance massage has gained in recent years, the word massage still summons erotic thoughts in the minds of many. The corporate workplace has, in recent years, found the need to prohibit the deleterious expressions of sexuality among its personnel. The creation of laws regarding sexual misconduct and harassment now prohibit what was, in the past, regarded a benign interaction (See Ethically Speaking, page 136). Like the corporate workplace, so must the massage workplace be desexualized. Therapists may be na•ve in thinking that if they have the correct intentions and act professionally enough, inappropriate expression of sexuality will be kept out of treatment sessions.

Massage to certain areas of the body can further complicate the matter, since they may actually induce a sexual response. Tactile stimulation of sensory nerve pathways in the area of the abdomen, lower extremities, and buttocks are carried over the same two nerve plexuses as the genitalsthe lumbar and sacral plexuses. Stimulation of these nerve plexuses, as would occur in massage to the abdominals, gluteals or thighs, would not be not confined to local perception, but instead would be diffused throughout the area and the nerve signals of the genitals would be affected.4

The parasympathetic nervous system provides the second vital link between massage and the sexual response. This aspect of the autonomic nervous system is responsible for the bodyÕs regulation of the rest and digest, the restorative responses, and counterbalances the effects of the sympathetic division, which regulates the fight or flight dynamic. Furthermore, parasympathetic influences regulate both the relaxation response induced by massage and the physiological changes that occur during sexual arousal. When massage methods such as slow, rhythmic, repetitive stroking; passive movement; slow, broad compressions; reflexology; and acupressure are used, the relaxation response, under parasympathetic control, is induced. The parasympathetic nervous system also controls the primary and secondary bodily responses that occur during sexual arousal. The common characteristics are vasocongestion, or the increase of blood supply to the genitals, and myotonia, which is the increase in muscle tension that is the result of sexual stimulation.5

Fritz tells us that, Therefore, each time a client relaxes out of the fight or flight responses of the sympathetic autonomic nervous system into a more relaxed response, the predisposing factors are present for sexual arousal. The reaction is not only possible for the client, but also for the practitioner as he or she begins to relax and flow with the massage.6

The third link is the limbic system, a group of structures that form a curved border around the brain's core. This complex aspect of the brain controls emotional and sexual experiences.7

Stimulation of the body by massage influences the limbic response. This not only serves to be another physiological connection between sex and massage, but may also explain why emotional responses occur in the client during or after massage therapy. These physiological influences, touch, the parasympathetic nervous system, and the limbic system, mandate the deliberate consideration of, and accountability for, human sexuality in the massage setting. Under most circumstances, a sexual response can be completely bypassed. Or, if a sexual response does occur, and the erotic energy is not directed, it is short-lived, and the massage can continue within ethical bounds. If sexual arousal does occur, however, on the part either of therapist or client, and regardless of the situation or circumstances, it is always the responsibility of the therapist to establish and maintain appropriate boundaries (see below). Sexual talk, sexual relations, sexual acts and activities, sexual pleasures, sexual intercourse, sexual touching, or being any way involved in a sexual manner is always unethical and must never occur in the professional massage setting.

     1) Observe and know yourself. Be aware of your own tendencies toward flirtation, and notice the times and places when and where you sexualize an event or conversation. Consider how you may come across and the messages you may be transmitting to others, especially to your clients. Take time to think about your work environment and your approach with clients. Ask yourself, Is there anything about me or my workspace or what I say or do, that is likely to be sexualized? Ernie Ezersky, licensed massage therapist, teacher and student-clinic supervisor in Massachusetts, instructs students, In this business, you must be squeaky clean. Remember that your good intentions are not enough; you are also responsible for how you may be perceived.

     2) Be clear about your intentions toward your clients. Clients are not candidates for romantic interest or sexual pursuits. Every therapist must be steadfast in this rule. It is never appropriate to date and/or sleep with a client. To date a client, even when the feeling is mutual, is a very precarious situation. Do so and you invite potential problems into your practice. The very least of these is unethical patterns in your client interactions. Always seek guidance for these issues with a mentor, supervisor or professional consultant, so that you can make decisions responsibly and fully cognizant of possible ramifications. Never be in the position of being a client's massage therapist and suitor. Being clear about, and adhering to, your own boundaries in this regard will set limits for your clients and will help to diffuse aroused erotic energy.

     3) Establish ethical safety at the initial contact. Do not wait until the new client arrives for her appointment to discern whether or not your communications are ethically appropriate. In other words, whether interviewing on the phone or in person, determine your intentions and goals for the massage when you first talk with the client to set up the appointment. Assess her demeanor, language and approach as to whether or not she is seeking nonsexual massage. Ask questions such as, Why are you seeking massage at this time? and What are your goals for this session? If she remains vague and obscure, inform her directly that the massage you offer is therapeutic and nonsexual. This is especially important when doing out-call or residential massage for a new, unknown client, either at hotel or client's home. Beyond determining that he is not seeking sexual massage, it may be wise to ensure your own ethical and physical safety by developing a policy where you require that another adult be at home at the same time. Also, if possible, avoid setting up your massage table in a bedroom. These actions may be easier to accomplish at a client's residence than at a hotel. In discussing what you will need when arranging the appointment, inform the client that you prefer that someone else is home and that the table be set up in a space other than a bedroom.

     4) Maintain a professional appearance and demeanor. Dress appropriately when you massage, avoiding provocative or revealing attire. Realize that when and where you represent yourself as a massage therapist, you represent the entire profession. For example, do not hand out your massage therapy business cards when you are out dancing, or while you are working as a waitress or bartender at a part-time job.

     5) Establish a professional, healing space. Sight, sound, smell, touch and imagination all have the potential to arouse. Desexualize the workspace by providing a professional atmosphere that communicates clear boundaries in all regards. If the area you use to massage happens to be in a spare bedroom in your home, remove the furniture that makes it a bedroom. Declare your massage table a sacred healing space and do not pursue sexual interests with anyone, even your mate, on your table. Being clear about your role during a massage, regardless of who is the recipient of your work, allows you to secure your professional boundaries, making you less likely to give mixed signals to clients. This also fosters trust, as well as appreciation of the professional nature of your work, by your mate.

     6) Provide informed consent. Before the massage begins, always inform the client about what you intend to do for the treatment protocol, so he knows what to expect. Take him into the treatment space and run through the session scenario verbally. Explain whether you will begin with him in the prone or supine position, the anticipated sequence of where you will work, how he will be draped, and any other pertinent details. For instance, if the client is to receive a full-hour relaxation massage, inquire before the massage begins as to whether or not he wants his abdomen massaged. If it is a female client in this case, describe how you will employ the breast-draping linen.

     7) Allow privacy. Regardless of how well you know the person to be massaged, always allow her complete privacy while she undresses and redresses. Some clients will begin undressing before you have a chance to leave the room. In these instances, ask them to wait, then leave promptly. Remember, the client is not the one responsible for setting professional boundaries. You are.

     8) Choose appropriate music. If the client wants music, offer the soothing but not the sensual or romantic kind. Songs containing lyrics about lovemaking or instrumental music that sounds seductive will give mixed messages about the intention of your massage session, and about massage, in general.

     9) Speak clean language. Strive for more professional ways to communicate about massage. Be aware that what you say may be interpreted differently from what you mean. Avoid language that might be sexualized. Instead of using misleading and suggestive terms such as full-body massage, describe it as a full-hour relaxation treatment, or use other terminology which accurately and neutrally explains what you do. Consider using the phrase residential massage when referring to house calls. When referring to certain anatomical parts, be careful to use terms that are not suggestive. More obvious examples are terms such as gluteal area versus butt, and inguinal area or groin instead of crotch. Less obvious, though, are phrases that can be suggestive. For example, direct clients to move your feet apart, versus move your legs apart, or open your legs. When making comments to the client about the body, avoid statements that refer to anything other than what is related to the massage. While it is essential to report objective findings that are related to her physical well-being, refrain from commenting about matters such as weight gain or loss, attractiveness, beauty, and other appearance issues, especially when the client is on the table. For one thing, when you make such comments, it fosters the notion that you are observing his body in a judgmental way. This can make a client feel like a bug under a microscope. Secondly, comments that sound like compliments may be interpreted as flirtation. If a client thinks you may be flirting with him, he may become sexually aroused during the treatment. Confused about the intentions of the therapist, he may be inclined to pursue his sexual interest.

     10) Always use proper draping techniques. While the client has a clear choice about many aspects of the massage, such as what to wear under the draping linen, proper draping should not be optional. Modest draping is recommended. A sheet or large bath towel is used to cover the body areas that are not being massaged. If a client insists on forgoing the draping linen, explain that you are more comfortable when modest draping is used, that, in the interest of your professionalism, modest draping techniques are used with all clients. Offer to adjust the room temperature, turn on a fan, or uncover her feet if she claims to be too warm. If and when the client does wear underwear during the massage, recognize it as a boundary and do not move the underwear to apply massage techniques to that area. Massage therapists need to remember that effective techniques, such as compression, can be applied to clothed or draped areas, in the event that the client feels uncomfortable disrobing. Ensure that all draping is secure and does not allow drafts or partial exposure of areas intended to be draped.

     11) Be mindful of body contact during the massage. Beyond using proper body mechanics, be attentive to how you brace, support and lean. Mind where your body may contact the clientÕs body during your strokes, stretches and techniques, and avoid contacting the client with body areas other than your extremities. Maintain a professional posture and stance throughout the session.

     12) Prevent straying strokes. When working areas such as the medial thigh, gluteal tuberosity, the sacrum, or the subclavicular area, strokes must not stray, even accidentally. The slightest slip in these areas would be invasive and inappropriate, and they could give the client the wrong message about your intentions.

     13) Be prepared. When working with a male client who has never received massage in the past, or is a new client, request that he keep his undershorts on during the massage. Make it a matter-of-fact direction when you are explaining the procedure, as in, Disrobe, keeping your undershorts on, then lie on this table under the draping linen. In some instances, beginning the massage on the dorsal body, with the male client lying prone, may allow him to become accustomed to touch and the parasympathetic response before being massaged supine, which hazards higher-risk areas for arousal. The arousal response for a male is less likely to occur as he becomes more accustomed to the massage experience, so this may not be a necessary step for the client who receives massage more often.

     14) Diffuse any hints or signs of sexual arousal immediately. You should know what to do if you find yourself, as the therapist administering the massage, becoming sexually stimulated when a client is on your table. Charles Wiltsie IIIÕs article, Uniquely Male, summarizes this issue. It quotes William Frick, a New York-licensed massage therapist: Dealing with erotic energy is one of the most challenging issues that face massage therapists. Erotic, sexual feelings periodically occur in the massage experience. These feelings cannot be eradicated by working only on members of the same sex, since homoerotic feelings may come up É What is one to do with erotic feelings? At least three possibilities exist: acting them out, repression and conscious sacrifice of the impulse to act out such feelings.8 Of course, the ethical massage therapist will choose not acting on the impulse. However, this must not be the result of repression. A stereotypical response is to ignore such feelings. But that will not make them go away. It will only remove the feelings from rational thought, which may actually increase the risk of unethical actions.9 Conscious sacrifice of the impulse to act out is necessary.

The arousal response of a client may or may not have any connection to an interest in having sex. As explained above, various aspects of the nervous system can generate this response automatically. Of course, there is a major difference between the sexes responses to being aroused. The female can largely keep her feelings to herself. Unless her nipples are erect and noticed, the therapist would never know of the client's arousal. The male also may keep his feelings to himself but his erection is a prominent sign that arousal has occurred. In either case, male or female, if behavior suggests that sexual arousal is occurring, the situation requires immediate intervention.

There is no cookbook method for dealing with the sexual arousal of a client. Intervention may mean different things, depending on the client and circumstances. In any situation where a client indicates, either overtly or covertly, that arousal has occurred, the therapist must determine, at that moment, the best way to handle the situation before it becomes an incident. When first aware of the situation, the therapist must change what he or she is doing. The antidote to the parasympathetic response is activation of the sympathetic response. Changing the tempo of the massage to a quicker pace and increasing the pressure and depth of the work will encourage sympathetic nervous system involvement. Moving to a less risky area of the body, such as the upper extremity or the face and head, helps, too. As long as the client does not in other ways indicate sexual interest, give the client a minute or two to pass through this phase, since it will likely subside. Then massage may be able to continue without further arousal. It is often appropriate to not discuss the situation at the time it occurs. Whether or not the therapist should discuss it after the session depends on the situation and a sense of whether or not it is fitting and necessary. Discussing it may simply mean informing the client that arousal can be a short-lived physiological response that may occur, and that while it would never be acceptable to act on it, the incident was not interpreted by you as improper or unethical.

A situation in which the client expresses sexual interest, whether or not actually in an aroused state, requires a clear, unequivocal response that this is an inappropriate interest. A statement an be used such as, This is inappropriate and unethical and it cannot continue. If the client persists past this set limit, it may be necessary to terminate the session by simply stating, Please get dressed; the session is over, and walk out of the room. Do not engage in discussion about the subject. Instead, state your directions simply and clearly. Regardless of the cause or intent, sexual arousal should not be allowed to continue under any circumstances. Even if the client does nothing else to follow it up, it is inappropriate to allow the client to remain aroused. Some therapists opt to pretend to ignore the signs of sexual arousal if the client does not act otherwise inappropriately. This is an incorrect stance. Remember, both the client and the therapist must be capable of desexualizing the massage experience if it is to be ethically safe and sound.

Dianne Polseno, former chair of the National Ethics subcommittee, is a practicing massage therapist, practical nurse, author and publisher of Comprehensive Review Manual For Massage Therapists. A teacher at Bancroft School of Massage Therapy, she receives mail at dipol@aol.com or 1 Raymond St., North Smithfield, RI 20896-8215.

References

1. Fritz, Sandy, Mosby's Fundamentals of Therapeutic Massage, St. Louis: Mosby-Year Book, Inc., 1995, p. 33.

2. Redleaf, Angelica, with Susan A.Baird, Behind Closed Doors: Gender, Sexuality and Touch in the Doctor-Patient Relationship, Westport, CT: Auburn House/Greenwood, 1998, p. 119.

3. Sexual Health Magazine, p. 1. [www.sexualhealth.com].

4. Ibid.

5 . Gotwald, William H. Jr., and Gale Holtz Golden, Sexuality: The Human Experience. New York: Macmillan Publishing Co., Inc., 1981, p. 295.

6. op cit., Fritz, p. 33.

7. op cit., Gotwald and Golden, p. 297-298.

8. Wiltsie, Charles III, Uniquely Male. Massage & Bodywork Magazine, April/May 1999, p. 47.

9. op cit., Redleaf, p. 171.