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When someone thinks of going for a massage therapy treatment, do they, consciously or unconsciously, consider whether the therapist will be a male or female? If they do, are decisions surrounding the therapist’s gender based on past experiences, word of mouth, personal preferences or some combination of the three?  

Respect, professionalism and clear communication is required from the regulatory body, and it is the responsibility of the therapist to consider each and every client, and their diversity in culture, comfort level, past experience and religion.

If someone is in pain and seeking treatment, you would think they would welcome help to relieve the discomfort as soon as possible regardless of the health professional’s gender. But therapists are taught – and it is reinforced in their regulations – that the gender of a therapist can influence a patient’s comfort level and even choice of therapist. Gender does not need to figure into this in a negative way. There are ways in which therapists, and the profession, can approach the gender issue in a positive and constructive manner. I would like to discuss this a bit further in this article. Much of the article will be based on my own experiences as a male therapist with a client base that is by and large female and involves work of a very sensitive nature.

I will discuss some of the rules and regulations we have as therapists, in this area, and what the literature says about the topic, to demonstrate that it is within your scope and abilities as therapists to make patients feel at ease, regardless of our gender.

REGULATED SCOPE OF PRACTICE
As massage therapists, we have rules and regulations with regard to conduct. These rules are in place and enforced by the governing bodies. The rules may differ, slightly, in the various countries, and jurisdictions within countries, but overall they have many similarities and are in place to protect the public and to assure that the client is informed about all aspects of their treatment. 

Becoming a registered massaged therapist (RMT) is not an easy task and in order to gain licensure in Canada with the College of Massage Therapists of Ontario (CMTO), you must complete a training program from an approved school or equivalent (generally averaging 2,000 hours of academic and clinical training) followed by successful completion of both the written multiple choice questionnaire (MCQ) and the Objectively Structured Clinical Examinations (OSCE) set by the CMTO. Once registered with the CMTO, you are able to practise as a massage therapist.

Every school is different, which is why there is a huge emphasis on getting schooling consistent across the province and then across the country. All schools must adhere to standards and the “Massage Therapy Competency Standards” set out but the CMTO. The content of this document must be taught so that the student RMT can pass OSCE and MCQ, but the course titles and methods of teaching are autonomist to the educational institution.

I studied in Ontario, where consent for treatment is always required when a client requests treatment from an RMT. The CMTO standards of practice require consent for treatment from each and every client. Therapists are reminded that “full body” treatment may mean different things to different clients. Therefore, it is recommended that all body areas be discussed for inclusion in or exclusion from a given session, but, as well, special consent is required for sensitive areas such as the inner chest wall, inner thighs, buttocks and breast areas. It should also be noted that consent can be modified or revoked at any time, including during the treatment, by the client for any reason.

BOUNDARIES AND COMMUNICATION
Membership in a professional regulatory body does not ensure that all therapists will act in the same professional manner.

Professional consideration is a part of our massage therapy education and clinical experience. Each registered/licensed massage therapist will develop their own manner and method of interacting with the clients, but all will follow the policies and procedures of their specific regulatory body.

When I was in school studying to become a massage therapist, it was brought to my attention that people sometimes request one gender over another. This message did not resonate with me personally until we were learning about draping and treating sensitive areas such as the breast tissue. The majority of my classmates did not have a gender preference; however, some students wanted to be treated only by a therapist of their own gender. This experience reinforced the importance of making each and every client, regardless of gender, feel comfortable, safe and empowered.

I think that if a person is feeling vulnerable, especially a woman, they may seek out a same-gender therapist unless the male therapist comes with a personal recommendation.   For example, Lynn, a client of mine from across the ocean, says that before coming to me for treatment she read I was presenting a lecture on post-surgical mastectomy treatment, and then she read my article on the subject. This combination of her findings made her feel “in safe hands,” although we had never spoken or met prior to us meeting in London, England. Looking for a treatment post-mastectomy, she put aside her vulnerability and decided to see a male therapist. She said, “to allow a man to see me in such a vulnerable way after breast surgery took a lot of courage. I was glad I did it!”

If a male client is needing a treatment, there are also concerns that influence gender choice. Some men have admitted that they prefer male therapists for fear of having an erection during the treatment and having the female therapist mistake this for arousal.  Conversely, there are some male therapists who will not massage female clients without having another person present, for fear of being accused of inappropriate touch.
 
I believe that massage therapy necessitates touch and, if boundaries are established right from the beginning, this sets the stage for empowering the client and building the client-therapist relationship. 

Regardless of the client’s selection, I was taught, and strongly believe, that two-way communication through the exchange of information and consent is the best way to keep the client abreast of all actions planned, present and future. The interest of the client should be at the forefront of every treatment, regardless of the length of time you have known the client.

My experience as a male therapist includes working on patients who have various issues and treating sensitive situations such as pregnancy, mastectomy, augmentation, hip/knee replacements, temporal mandibular joint dysfunction, sacroiliac joint dysfunction, abdominal/constipation issues, etc. I have not come across any roadblocks, or been cited for behaviour contrary to the rules of conduct, in any anatomical location I have treated to date. I have found that clear client-therapist communication is the best policy. Prior to the patient/client receiving any hands-on treatment, I find it best to make sure they understand, and agree to, the proposed treatment plan. As I was taught to do, I inform the patient of what the treatment procedures are, areas to be treated, whether or not they may experience discomfort, how they are to be draped and covered, etc., right down to the type of lotion I plan on using. This helps to ensure there is no misunderstanding and to build open communication between the client and therapist. This approach to treating has allowed me to treat patients around the world in an atmosphere of clear expectations and mutual understanding.

CULTURAL CONSIDERATIONS
Draping and the approach to treatment may differ from country to country. I have presented workshops in Canada, the United States, Europe and Japan. Just as there are cultural differences in other areas of life and work, so there are cultural differences in the realm of massage therapy. What is acceptable in one country may be bordering on unacceptable in another. For example, some countries use towels to cover only sensitive areas, whereas, in Canada, sheets are used to drape the client, while the area that is to be worked on is undraped and then recovered when moving to other areas of the body.  

I believe the combination of following the policies and procedures of one’s regulatory body and understanding how to maintain boundaries that I described above will help to universally align our thinking and bring clarity to grey areas. But boundaries, we, as therapists, must keep in mind, will vary from one individual to the next and will differ, from one cultural and social situation to the next. As we approach each individual, it may help to understand the cultural context – especially as it relates to the local policies and regulations – surrounding our client base.

ETHICAL ISSUES IN CLINICAL PRACTICE
Ethics are taught as part of the study of massage therapy across Canada. “Therapeutic relations” was the name of the course where I went to school. This course was valuable in helping me to understand client-therapist relationships and in preparing me to address various real-life sensitive situations. It introduced me to the notion that health-care professionals are perceived as having power in the client-therapist relationship; this power is derived from having knowledge, authority and privileged information. The course also listed the possible influences we, as professionals, have on a client, which reinforced the need for maintaining clear boundaries.   

The course focused on ethics, but included other topics, such as ways of interacting with colleagues and clients on a professional level. There were classroom lectures. In addition to these lectures, I remember gathering together in a comfortable, cushion-and-couch-filled room with other classmates to voice our opinions and concerns to a therapist, and to each other, about anything we wanted to discuss. This activity allowed us to discuss and view how we related to one another, as well as how – verbally or nonverbally – we responded and why. We soon learned that our actions, whether verbal or nonverbal, may have a positive, negative or neutral effect on the receiver – and that, by extension, this could have an impact on client responses.

As a student, I was often asked, “How does this subject relate back to massage therapy?”

As I reflect, I realize that we were taught a lot of material that has become more and more useful to me as I gain clinical experience. One particular lesson stood out for me. That lesson was about responding to something in a way that seems harmless, but could have quite an impact on the listener.

For example, your client comes to see you and completes her health-history form. On the form, she notes she is pregnant. Your first instinct may be to say, “Congratulations!” In this course, however, we were taught to ask, “How do you feel?” The client may have come in because of  stress, and the pregnancy may be unexpected or not seen positively by the client. That one word, “congratulations,” may increase the stress level of the client or create an uncomfortable situation from the start.
We were taught not to ask leading questions but rather to be neutral and caring while allowing conversation and discussion to continue.

I believe that the client’s experiences play an important role in future decisions about where they seek help. Respect, professionalism and clear communication is required from the regulatory body, and it is the responsibility of the therapist to find the method that not only works for their personality, but to consider each and every client, and their diversity in culture, comfort level, past experience and religion.

We are entrusted with clients’ vulnerabilities and they expect unequivocal treatment regardless of age or gender. We don’t get to go out and select our clients, but clients, on the other hand, select therapists based on word of mouth, personal preferences or recommendations. Therapists, although they are in their individual practices and jurisdictions, are seen by the public as belonging to the same college. Our behaviour – especially as male therapists – is under the public microscope. The behaviour of one reflects on the group as a whole. To help dispel any stereotypes held by clients or by the general public, to promote a profession free of public discrimination, and to ensure that gender will become less of a barrier to patients and therapists working together, we must treat every client to the best of our abilities and with respect. Maintaining boundaries and clear communication is a good place to start.    

Sources used to prepare this article

Post-Mastectomy Pain Syndrome 

http://www.livestrong.com/article/76270mastectomy-complications/

Complementary & Natural Healthcare Council http://www.cnhc.org.uk/assets/1033.pdf

Preventing Sexual Abuse http://www.cmto.com/cmtowordpress/assets/bulletin_02.pdf

College of Massage Therapists of Ontario http://www.cmto.com/member/CEUNewGuide.htm

National Certification Board for Therapeutic Massage & Bodywork http://www.ncbtmb.org/about_code_of_ethics.php

The Federation of Holistic Therapists (FHT)  http://www.fht.org.uk/home/

Paul Lewis is an international presenter, massage therapist, and certified yoga and fitness instructor who travels and treats patients around the world. For more information, visit www.paullewis.ca.