The most recent version came from the American Massage Therapy Association (AMTA) in 20251, which announced — with understandable pride — that it is developing national standards of practice for the profession. It’s a worthy goal. It’s also worth pausing to ask a simple question before we celebrate: *Haven’t we done this before?*

AMTA also just announced this at their National Convention happening as I write:

And…what is taking so long. The committee to create the Standards of Practice was created in 20232.

The honest answer is yes. Repeatedly. The history is worth walking through, because it tells us something important about where the profession actually stands — and it lets each of us decide for ourselves what to make of the timing.

First, what a standard of practice actually is…I wrote about it previously this year.

It helps to be precise, because the phrase gets used loosely. A standard of practice is a formal, documented statement of what competent practitioners are expected to know, do, and refrain from doing. It defines scope, sets minimum competencies, and establishes what a competent session requires — assessment, documentation, referral, and the rest.

That is different from a code of ethics. A code of ethics tells you *how to behave* — honesty, confidentiality, avoiding exploitation. A standard of practice tells you *what competent clinical work looks like*. Many professions publish both, and the two get confused constantly. Holding onto that distinction turns out to be the key to reading the history clearly, because much of what our profession has labeled “standards of practice” over the years has actually been conduct and ethics material wearing a clinical name.

With that in mind, here’s the historical record on how long the profession has been talking on standards of practice..

The timeline

2000–2001 — NCBTMB issues its first Standards of Practice.** On October 23, 2000, the National Certification Board for Therapeutic Massage & Bodywork released a document it described as a “consumer bill of rights.” It built on the NCBTMB Code of Ethics and covered six areas: professionalism, legal and ethical requirements, confidentiality, business practices, roles and boundaries, and prevention of sexual misconduct. Every one of those six is a *conduct* domain. The profession’s first national “Standards of Practice,” in other words, was largely an ethics-and-behavior document. That’s not a criticism of its intent — it did real work protecting the public — but it’s worth naming for what it was.
NCBTMB Standards of Practice (2000), reported in *Massage Today*, Jan. 2001. https://web.archive.org/web/20060521162405/http://www.massagetoday.com/archives/2001/01/05.html

2005 — AMTA publishes Practice Standards.** AMTA maintained its own practice standards document, designed to be used alongside its Code of Ethics. (This version is no longer on AMTA’s current website, though it survives on archive.org.) So by the mid-2000s, the two largest national organizations each had a standards document in circulation.

AMTA Practice Standards (2005, archived). https://web.archive.org/web/20051026064110/http://www.amtamassage.org/news/032505.html

2010 — Researchers study whether standards actually affect practice.** Fortune and Gillespie published a pilot study in the *International Journal of Therapeutic Massage & Bodywork* examining how practice standards shaped therapists’ real-world work experience — an early, thoughtful attempt to ask whether these documents changed anything on the table. Fortune, L.D. & Gillespie, E. (2010). *IJTMB* 3(3):5–11. https://doi.org/10.3822/ijtmb.v3i3.73

2013 — ELAP builds the foundation.** The Entry-Level Analysis Project, a 21-month research effort produced through the Coalition of National Massage Therapy Organizations — with AMTA as a participant — defined entry-level competencies for the profession. This was arguably the closest the field has ever come to the foundational competency framework a real national standard needs to be built on. But then it was never adopted. AMTA, which helped create it, later stated it does not support part of it. That single fact is worth sitting with.

While AMTA continues to support the general content of the ELAP report, we have never endorsed or supported the 625-hour recommendation. ( My sources have been deleted but I know they said it.)

Entry-Level Analysis Project (ELAP), 2013. http://www.elapmassage.org/

2017 — NCBTMB revises its Standards of Practice.** The current NCBTMB version, ratified September 15, 2017, updated and expanded the 2000 document. It covers the right ethical territory. It is not, however, a clinical practice standard in the fuller professional sense — it doesn’t define what conditions massage treats, what assessment is required before treatment, or what documentation a clinical session demands. https://ncbtmb.org/standards-of-practice/

2023 — AMTA quietly begins again.

AMTA established its Healthcare Advocacy & Research Committee (HARC) to support government relations in the clinical and integrative care environment. According to the AMTA-Kentucky chapter’s own Government Relations report, the seven-member committee had “only begun the work of reviewing the Standards of Practice for the Massage Therapy profession to determine what, if any, changes may need to be made,” describing it as a slow, deliberate process. So the current effort actually started internally in 2023 — reported at the chapter level in 2024 — well before any national fanfare.

AMTA-KY *In Touch*, Fall 2024, Government Relations Report (Ann Boone, LMT). https://myemail.constantcontact.com/Your-Communicator-2024-IN-TOUCH-AMTA-KY-Fall-Newsletter.html?soid=1101698969607&aid=1PPgAwCKNaw

August 2024 — The VA steps in.** The Department of Veterans Affairs published a Federal Register Notice of Request for Information on developing a national Massage Therapist Standard of Practice — one that carries federal *preemption* authority over conflicting state requirements. A federal agency, in other words, began writing a legally enforceable definition of what a massage therapist is. AMTA and FSMTB both submitted formal responses during the comment period.

VA Notice of Request for Information, Federal Register, 89 FR 62868 (Aug. 1, 2024). https://www.federalregister.gov/documents/2024/08/01/2024-16944/notice-of-request-for-information-on-the-department-of-veterans-affairs-massage-therapist-standard

2025 — AMTA announces its national standards project.** AMTA filed a federal notice that it is developing new national standards of practice, and announced the effort publicly on its website on August 15, 2025.

AMTA RFI response to the VA. https://downloads.regulations.gov/VA-2024-VACO-0001-0560/attachment_1.pdf

2026 — Two processes, running in parallel.** Today, two national standards-of-practice efforts are underway at the same time — one by the VA, one by AMTA — with no public explanation of how they relate. And neither has published the underlying practice framework their standard would be derived from.

What the record shows — and what it doesn’t

Lay the timeline out and a pattern emerges on its own.

The profession has produced documents titled “Standards of Practice” going back to 2000. It has had *two* national organizations maintaining such documents for the better part of two decades. It built a genuine competency foundation in 2013 — and set it down. And now, in 2025, its largest association is announcing the creation of standards of practice as though the ground were fresh.

AMTA claims3:

Throughout this process, we will actively engage with coalition partners, industry leaders, allied organizations, and our members to ensure every perspective is heard and valued. Stay tuned for more information.

Have any other organizations been contacted?

But they are doing that without having a practice framework in place!

Shouldn’t a Practice Framework come first?

Which raises a question the profession rarely asks out loud: shouldn’t a practice framework come first? A framework answers the foundational questions — what is massage therapy’s domain, what problems doest address, what is the clinical process from assessment through outcomes, what are the core values beneath the work?

A strong professional identity is built on a unified vision, shaped by core values and ethical principles that guide practice standards and decision-making responsibilities in client care. A recognized professional identity influences how the massage therapy profession is perceived and how therapists see themselves within it. Establishing a professional identity enhances confidence and deepens the sense of belonging in the massage therapy field.

Professional identity is dependent on two factors:

• A definition of the profession

• A professional practice framework

  Defining Massage Shaping Professional Identity By Sandy Fritz

  Winter 2025

A standard of practice can’t help but answer those same questions; it just answers them implicitly, through whatever assumptions the drafters happen to carry. Build the standard without an explicit, profession-owned framework underneath it, and the standard quietly becomes the framework by default — authored under deadline pressure rather than deliberate consensus, and then everything else in the profession gets aligned to a foundation no one actually chose.

That’s what makes the current moment worth watching closely. Neither the VA nor AMTA has published a practice framework that its forthcoming standard is derived from. AMTA’s own 2023 statement lists “Create Standards of Practice” as a goal, with no mention of the framework that would give those standards their shape. Maybe that framework exists internally and simply hasn’t been shared. Maybe it doesn’t. Either way, it seems fair for working therapists to ask — before the documents are written, rather than after — what foundation they’re being built on.

How has this affected the profession historically?

The historical lack of unified standards within the massage therapy profession created massive hurdles for practitioners, schools, and regulators alike, particularly in the realm of state-level licensing and professional legitimacy.

1. The Patchwork of Local Regulations and the “Adult Entertainment” Stigma

Because there were no statewide or nationwide standards of practice, regulation was left entirely up to individual states, local counties and municipalities. This created a fragmented regulatory patchwork. In regions with no state laws, local municipal leaders frequently governed massage therapists under local ordinances designed to regulate adult entertainment or control illicit activities.

2. Education Gaps and the Scope of Practice Conflict

Up until the 1980s, only nine states regulated massage therapy. Even as state-level licensing began to rise in the 1990s and 2000s, there was no baseline educational standard or defined scope of practice agreed upon by the broader industry.

The AMTA established its own internal educational requirements (eventually a 500-hour minimum) and standards of practice, but these only applied to AMTA members. In 2005, the AMTA Board formally recognized that the wider profession still lacked baseline education standards, an articulated body of knowledge, and a comprehensive scope of practice. Without these, the industry could not even agree on foundational terminology—such as how to define “medical massage” without triggering restrictive, premature regulations by state boards.

3. The Portability Crisis and Competing Exams

The absence of a centralized, uniform standard severely restricted “portability”—the ability of therapists to legally practice when they relocated to another state. Because educational standards and licensing laws varied so wildly from state to state, a therapist licensed in one jurisdiction often faced a mountain of bureaucratic red tape, delays, or was forced to complete entirely new training to practice elsewhere.

Initially, the National Certification Exam (NCE) administered by the NCBTMB (which AMTA originally helped create and seed) was used as a standard for licensing. This was again putting the cart before the horse.

However, the creation of competing exams and the launch of the Massage & Bodywork Licensing Examination (MBLEx) by the FSMTB in 2005 created deep divisions. The AMTA ultimately shifted its support to the MBLEx in 2009 to champion a single, uniform exam that state regulatory boards could accept to facilitate true cross-state portability.

4. Collaborative Initiatives to Unify the Profession

To resolve these deep-seated complications, the industry had to slowly build unified frameworks from scratch:

• The MTBOK Initiative (2008–2011): AMTA, ABMP, FSMTB, MTF, and NCBTMB joined forces to steward the Massage Therapy Body of Knowledge (MTBOK) to map out competencies and establish a unified baseline.

• The Entry Level Analysis Project (ELAP) (2012): A coalition of seven national massage organizations initiated ELAP to map out precise entry-level knowledge and skills, recommending a baseline of 625 hours of education to ensure safe, competent practice nationwide.

We did that, but these projects were left collecting dust…without a practice framework.

The lack of unified standards was never neutral — it shaped the profession in ways still felt today. Because every state wrote its own scope, education hours, and licensing exam, a therapist licensed in one state has long faced real barriers moving to another. The discrepancies among massage laws are precisely why professional mobility stayed so limited. Without an agreed baseline for what a competent graduate must know, schools taught wildly different content at wildly different hour counts, and licensing boards had no shared yardstick for an unfamiliar transcript.

When hospitals and insurers asked the question every payer eventually asks — is there a recognized standard defining what this profession does and how competence is verified? — massage has no single, adopted answer, while nursing, physical therapy, and medicine did. That gap is a large part of why the profession has spent decades knocking on the door of healthcare integration and reimbursement without being fully let in.

Now what?

3

https://www.amtamassage.org/about/news/standards-of-practice/

Your hands are working a knot in his shoulder, and everything is fine — until it isn’t. He shifts. He says something. Maybe it’s a question dressed up as innocent: *”Do you do full body?”* Maybe it’s blunt: *”How much for a little extra?”* Maybe he doesn’t say anything at all — he just moves his body in a way that tells you exactly what he came for.

And in that second, something happens that shouldn’t. **You** feel the flush of shame. **You** feel your heart pound. **You** start wondering if you did something to invite it, whether your website was worded wrong, whether you should have screened differently.

Stop. I want to say this as clearly as I know how:

**He is the one committing a crime. Not you.**

We spend so much time teaching each other how to *manage* these men — how to set the boundary, how to fire the client, how to word the website so the hobbyists stay away. All of that matters, and I’ll get to it. But we almost never talk about the simplest, most powerful fact of all: **what he’s doing is illegal, and you can name it.**

Let’s fix that.

## First, let’s be honest about how big this problem is

If you’ve ever felt like you’re the only one dealing with this, you’re not. Not even close.

The 2026 Human Trafficking report shows the problem is growing across the US. These aren’t massage businesses. They’re sexually oriented businesses (SOBs) hiding behind our name, and many of them are fronts for human trafficking. Trafficking tied to these businesses is one of the most-reported forms of sex trafficking to the National Human Trafficking Hotline.

Here’s why that matters to *you*, even if you’d never set foot in one: those businesses have trained a whole population of men to believe that “massage” and “sex” are the same purchase. So they walk into *your* room — your clean, licensed, therapeutic practice — expecting the same thing. And when they don’t get it, some of them get pushy. Some get angry.

A 2020 study in *The Canadian Journal of Human Sexuality*1 documented what that looks like on the ground: therapists whose clients masturbated on the table, who waited in the parking lot afterward, who “spread their legs extremely wide, pulling at the sheets,” who said things like *”I have money if you’d so-and-so.”* One therapist was followed to her car. In that same study, of the therapists who were harassed, only **one in a hundred** ever told the police.

**One percent.** Read that again. This is happening constantly, and almost none of it gets reported.

That’s not because we’re weak. It’s because no one ever told us we had the right — and the legal footing — to report it.

So is it actually “solicitation”? (The honest answer)

Yes — with one important nuance you should understand.

Most solicitation laws require an *offer or agreement to exchange something of value for a sex act.* That’s the legal heart of it. So it plays out on a spectrum:

**A vague insinuation** — “Do you do extras?” or a loaded question about draping — is often too ambiguous, by itself, to build a criminal charge on. Frustrating, I know. Prosecutors need something concrete.

**A direct request that names an act and money** — “I’ll give you an extra sixty for a hand job” — is much closer to textbook solicitation. And here’s the part that surprises most therapists: in many states, **the offer itself is the completed crime.** He doesn’t have to touch you. No money has to change hands. The moment he offers or agrees to pay for a sex act, the offense is done.

But here is the single most freeing thing I can tell you, and I want you to tattoo it on your brain:

**Your job is not to build the legal case.**

You are not law enforcement. You do not have to determine whether every element of the statute is satisfied. You do not have to get a “better” confession out of him. Trying to do any of that just keeps you in the room longer with someone who has already shown you who he is.

Your job is exactly three things: **stay safe, end it, and write it down.**

What to do in the moment

Keep it flat. Keep it professional. You owe him nothing — not a lecture, not an explanation, not a reaction he can argue with.

- **Stop the massage.** “This is a therapeutic, non-sexual practice. I’m ending the session now.”

- **Get to the door.** Don’t turn your back to fuss with the drape or “finish up.” Leave the room.

- **Don’t negotiate.** Don’t explain twice. Repetition just invites him to keep talking. One clear statement, then you’re done.

- **If you feel unsafe, you don’t have to announce anything.** Your safety beats your script. Get to a public area or an exit.

The research backs this up, by the way: when therapists in that Canadian study discharged these clients, the overwhelming majority just left peacefully. The fear of blowback is almost always bigger than the blowback itself.

What to do after — this is where your power is

This is the part almost everyone skips, and it’s the part that actually protects you and every therapist who comes after you.

**Write it down immediately, while it’s fresh.** Date, time, his exact words, what he looked like, how he booked, how he paid. Contemporaneous notes — notes made right when it happened — carry real weight later. This isn’t busywork. It’s evidence.

**Fire the client and document that you did.** Refuse any rebooking. Note it.

**Report it** if it was a clear solicitation. Use the police non-emergency line. If you work in a spa, tell the owner or manager in writing, not just in passing.

**Flag him in any shared booking or warning system you have access to.** If he did it to you, he’s doing it to others.

And when you make that report, here’s the move that changes everything:

**Name the law.**

Don’t call and say “a client was inappropriate with me.” That gets filed under nuisance and forgotten. Instead say: *”I want to report a solicitation of prostitution,”* and if you can, cite your state’s statute number. In New York, that’s Penal Law § 230.04 — patronizing a person for prostitution. In Washington, it’s RCW 9A.88.110. In Texas, it’s Penal Code § 43.021 — and in Texas, soliciting is a *felony* on the very first offense.

When you name the statute, you’re telling that dispatcher you know this is a chargeable crime, not hurt feelings. You’d be amazed how differently the conversation goes.

Why the reporting matters more than it feels like it does

I know what you’re thinking. *One report, from one therapist, about one creep — what’s the point?*

You may have even done this before and got told that they can’t do anything about this so what is the point?

The point is the pattern.

Right now, there is no organized, profession-wide system for reporting this stuff. The 2023 commentary in the *International Journal of Therapeutic Massage and Bodywork2* said it plainly: established processes for reporting solicitation and assault in our field basically **don’t exist** — and until they do, we each have to know the laws in our own state so we can document and report, “in the face of systemic stigma,” and advocate for a safe workplace as a civil right.

Every report you file becomes a data point. Enough data points become a pattern. A pattern is what a human trafficking task force, a licensing board, or a vice unit can actually *act* on. The man who solicited you might be connected to something much bigger than one bad appointment — and your five minutes of documentation might be the thread someone eventually pulls.

I did actually see a post from someone in a Facebook group who had a situation where they did call to report the person after they left and the police told her to stay inside and lock the door as they would be right over to get the guy who was a known felon.

You’re building the case that our profession has never had.

And please — help us kill the joke

Here’s the cultural piece, and it’s on all of us.

Every time someone makes a “happy ending” joke at a party and we laugh it off to be polite, we feed the exact misconception that puts us in danger.

I created an image for my website www.lookbeforeyoubookamassage.com that calls out the problem. Feel free to use!

Shut down the “happy endings” jokes — online, in the media, in your community. Exploitation and trafficking are not a punchline.

So the next time it comes up, you don’t have to make it awkward. You can just say, evenly: *”You know that’s actually most likely a front for trafficking, right? Real massage therapists deal with harassment because of that stereotype.”* Watch the laughter stop.

That’s advocacy too. It costs nothing and it chips away at the thing that makes our jobs unsafe.

You are not a sex worker. You are a healthcare professional.

Let me end where I started, because I need you to carry this out of here.

That researcher panel said it better than I can: *”Massage therapists are not prostitutes or sex workers. Perpetrators engage in illegal, deviant behaviors by soliciting sexual favors in the treatment room.”* He broke the law in your treatment room. You did nothing but show up to do the work you trained for.

Learn your state’s statute. Say it out loud when you need to. Document everything. Report it and mean it. And stop carrying a weight that was never yours to hold.

The law is on your side. It’s time we started acting like it.

*I’ve built a free 50-state + D.C. reference chart that lays out, for every jurisdiction, the exact statute that makes soliciting you a crime, the penalty the buyer faces, and which states tie special penalties to massage businesses. Print it. Keep it at your desk. Know your number before you need it.* (Let me know if I have anything that is incorrect.)

Laws Against Johns Chart

283KB ∙ PDF file

Download

Download

*This article and download is for education and advocacy — it’s not legal advice, and laws change. Confirm your state’s current statute before you rely on it,
and when in doubt, talk to a local attorney.*

Washington and specifically the insurance commissioner at the time (Deborah Senn) did something that was remarkable for its time.

It told state-regulated health insurers that they could not simply exclude an entire category of licensed health care provider when that provider was legally qualified to provide care for a condition covered by the plan. The whole story is chronicled in a booklet titled From the Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine January 2000. Washington State found on my website.

That included massage therapists.

It became known as Washington’s Every Category of Provider law, RCW 48.43.045.

Thirty years later, Washington’s experience raises a question that deserves far more attention from the massage profession:

The answer is more complicated than I expected.

It Began With Washington’s Attempt to Reform Health Care

The story actually starts before 1996.

In 1993, Washington adopted a sweeping Health Care Reform Act. One of its stated goals was to provide access to essential health and medical services from health care providers licensed by the state.

Much of that larger reform effort was later changed or dismantled.

But one important idea survived.

In 1995, the Legislature enacted what became RCW 48.43.045. Beginning January 1, 1996, health plans subject to the law were required to permit every category of licensed health care provider to provide covered health services when those services fell within that provider’s legal scope of practice.

That distinction is important.

The law did not say that every insurance policy had to cover massage therapy for everything. It essentially said that if a plan covered a health condition or service and a category of licensed provider could appropriately provide that care within its scope of practice, the insurer could not simply eliminate the entire profession from consideration.

Washington’s current regulations still use low back pain as an example. If outpatient treatment for low back pain is covered, a category of licensed provider that can provide cost-effective and clinically efficacious treatment within its scope cannot simply be excluded as a category.

The Washington Office of the Insurance Commissioner still specifically identifies massage therapists as providers protected by the Every Category law.

For massage therapy, this was extraordinary.

The Insurance Industry Fought It

The law did not take effect quietly.

The chronology preserved in Washington’s 2000 Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine tells a remarkable story.

In August 1995, the Insurance Commissioner asked insurers to explain how they intended to develop networks capable of complying with the new law.

By December, the Commissioner had issued an interpretation of the statute.

On January 8, 1996, carriers went to court.

That began several years of litigation over what the Legislature had actually required and whether federal law preempted Washington’s attempt to regulate employer health plans.

The dispute moved through state court, federal court and eventually the Ninth Circuit Court of Appeals.

Initially, insurers won an important federal ruling based on ERISA, the federal law governing many employer benefit plans.

Washington appealed.

In June 1998, the Ninth Circuit reversed the lower court.

The insurers sought rehearing and lost.

They then petitioned the United States Supreme Court.

In January 1999, the Supreme Court declined to hear the case, leaving the Ninth Circuit decision standing.

Washington’s law survived.

The Washington Supreme Court later also addressed the breadth of the statute in Hoffman v. Regence BlueShield. The court noted the statute’s broad language requiring covered plans to permit “every category of health care provider” to provide covered services.

This was not some minor insurance regulation that slipped through unnoticed.

It was contested.

Then Washington Had to Figure Out What the Law Actually Meant

Winning the legal battle did not solve the practical problems.

How do you integrate professions that insurers historically had not included in conventional medical networks?

What standards can an insurer impose?

Can an insurer limit visits?

Can it require referrals?

Does every individual massage therapist have a right to join every network?

Washington eventually developed rules answering many of these questions.

Insurers can use restricted networks. They do not have to contract with every individual provider. They can impose reasonable limits and require providers to meet legitimate standards for clinical effectiveness, utilization review, administration and cost containment.

What they cannot do is decide that an entire licensed profession is inherently incapable of providing any covered, effective service and exclude the profession on that basis.

That is a much more sophisticated policy than simply saying, “Insurance should cover massage.”

It separates three different questions:

Is the condition or service covered?

Is this profession legally qualified to provide that service?

Does this particular practitioner meet the insurer’s network and credentialing requirements?

Those questions are still useful today.

And Then Researchers Got an Opportunity Almost No Other State Could Provide

Washington had inadvertently created a large natural experiment.

What happens when hundreds of thousands of insured people have access to chiropractors, massage therapists, acupuncturists and naturopathic physicians?

Do people suddenly flood these providers?

Do insurance expenditures explode?

Researchers at the University of Washington and elsewhere eventually examined the claims. A 2006 study looked at more than 600,000 privately insured people in western Washington. About 13.7 percent had a claim involving one of the complementary and alternative provider categories studied.

Massage therapy claims were submitted for only about 2.4 percent of enrollees.

More importantly, complementary and alternative provider care accounted for approximately 2.9 percent of total expenditures.

The researchers concluded that utilization was substantial but its effect on total insurance expenditures was modest. They also observed that insurance coverage had not produced the kind of runaway utilization insurers had feared.

That matters.

One of the obvious arguments against expanding provider access is that everyone will start using the newly covered services and costs will soar.

At least in this Washington population, that did not happen.

Later research produced another interesting result.

Researchers compared insured patients with back pain, fibromyalgia or menopausal symptoms who used complementary providers with matched patients who did not.

Average expenditures were actually lower among the CAM users, although they had somewhat higher outpatient expenditures. Lower inpatient and imaging expenditures offset them. The researchers appropriately did not claim that this proved complementary care caused the savings, but the results certainly did not support the idea that access inevitably produced excessive costs.

That distinction is important.

This research does not prove that insurance coverage of massage therapy reduces total health care spending.

It does show that Washington’s experiment did not produce the financial disaster that opponents of broad provider access might have predicted.

So Why Didn’t the Other States Copy Washington?

This is where the story becomes especially interesting.

I have not found evidence of another state adopting the same broad model.

In fact, a 2006 Washington Senate bill report discussing provider contracting stated plainly:

“This is the only state that has an ‘every category of provider’ regulation.”

Other states have adopted laws requiring coverage of particular professions or prohibiting certain forms of provider discrimination. Chiropractic coverage mandates became common. Acupuncture and naturopathic physicians gained coverage in some states. Individual professions have repeatedly fought for their own insurance provisions.

But that is different from Washington’s approach.

Washington created a general principle applying across licensed health professions.

Why didn’t that become the national model?

There probably isn’t one answer.

1. Washington’s Law Came Out of an Unusual Political Moment

The Every Category provision was part of Washington’s much larger early-1990s health reform movement.

The 1993 legislation contemplated restructuring large portions of the state’s health system. Provider access was only one piece of that effort.

When much of the larger reform program disappeared, the provider provision survived.

That combination of circumstances was unusual and difficult to reproduce elsewhere.

2. Insurers Had Strong Reasons to Oppose It

The years of litigation tell us something.

Insurers valued their ability to design networks and determine which categories of practitioners they would include.

Even years later, Washington legislative testimony concerning provider contracting included warnings about interference with insurer contracting and the costs associated with broader provider requirements.

A Washington-style law shifts some power away from insurers.

Instead of asking:

“Does the insurer recognize massage therapists?”

the law begins with:

“Is this a state-licensed health profession legally qualified to provide this covered service?”

That is a very different starting point.

3. ERISA Makes State Health Reform Much Harder Than It Looks

There is also a major limitation that is easy to miss.

States do not control every health plan operating within their borders.

Many large employers operate self-funded health plans governed primarily by federal ERISA law.

Washington’s Office of the Insurance Commissioner still tells consumers that its Every Category protections do not apply to self-funded employer plans and certain other types of coverage.

That creates a strange situation.

Two massage clients can work across the street from one another.

One may have a state-regulated insurance policy subject to Washington’s provider protections.

The other may work for a large employer with a self-funded plan and have completely different rules.

State legislation alone cannot solve that problem.

4. Health Professions Developed Unevenly Across the States

Washington’s model also depends heavily on state licensure and scope of practice.

That creates a particular problem for massage therapy.

Massage licensing developed state by state over many decades. States adopted different education requirements, definitions, scopes of practice, exemptions and regulatory structures.

A law based upon “every category of licensed provider” becomes much easier to implement when everyone has a reasonably clear understanding of what each licensed profession is qualified to do.

Massage therapy has never achieved that degree of national consistency.

That may be one reason the profession has struggled to make a national argument for health care inclusion.

Insurance systems need to know:

What is massage therapy?

What conditions or services fall within its scope?

What level of education supports that scope?

What clinical competencies can reasonably be expected of every entry-level massage therapist?

What distinguishes health care massage therapy from massage provided primarily for wellness or relaxation?

Those questions remain surprisingly unsettled.

5. The Professions Often Fought Separately

This may be the most important lesson.

Washington’s law was not a massage therapy insurance law.

It created a framework for licensed health professions.

That gave massage therapists, chiropractors, acupuncturists, naturopathic physicians and other providers a shared interest.

Across much of the country, however, professions have tended to pursue legislation separately.

Chiropractors advocate for chiropractic benefits.

Acupuncturists advocate for acupuncture.

Naturopathic physicians advocate for naturopathic coverage.

Massage therapists advocate for massage therapy.

That approach can win individual battles.

It rarely changes the structure of the system.

Washington changed the underlying rule.

Didn’t the Affordable Care Act Eventually Do Something Similar?

In 2010, Congress included a provider nondiscrimination provision in the Affordable Care Act. Section 2706 says that health plans and insurers cannot discriminate against a health care provider acting within the scope of the provider’s state license or certification.

At first glance, that sounds remarkably similar to Washington. But there is an important difference.

Federal guidance has emphasized that the provision does not require a plan to contract with every willing provider, and federal agencies have allowed plans considerable latitude in interpreting the requirement.

The federal law therefore never created the straightforward national version of Washington’s Every Category system that some providers hoped it might become.

Washington’s law remains stronger and more explicit about preventing the exclusion of entire licensed provider categories from covered services.

Thirty Years Later, Washington Is Still an Experiment Worth Studying

The Every Category law remains in effect today.

Washington’s regulations still say that insurers cannot exclude an entire category of state-licensed providers when they provide covered services within their scope and meet applicable standards.

Massage therapists are still specifically identified by the Insurance Commissioner as one of the professions covered by the law.

That does not mean Washington massage therapists have perfect insurance coverage.

Far from it.

Plans can impose visit limits. Networks can be restricted. Reimbursement can be poor. Administrative burdens can discourage participation. Referrals or prescriptions may sometimes be required. Self-funded employer plans fall outside much of the state’s authority.

The Washington Apple Health, the state’s Medicaid program, is a separate issue. Massage therapy is currently listed among noncovered services under its general rules.

Private insurance access and Medicaid coverage are not the same policy question.

But Washington nevertheless accomplished something in the 1990s that the massage profession has never replicated nationally.

It established in law that being a licensed health profession should mean something when insurers decide who is allowed to provide covered health care.

In the beginning, plans paid really well but over the years, they continued to reduce their allowable fees and limit the number of sessions. My business was built mainly on insurance work up until about 2010 when the allowable fees dropped so much it was no longer profitable. I went to my AMTA chapter and began asking for help. For 3 years I went to conventions and kept asking what can we do. They said if there was something we could do, we would be doing it. Later I found out that they never asked AMTA National for help on this and were just assuming nothing could be done. Fast forward to 2024 when the AMTA WA Chapter joined forces with 15 other professions and their lobbyists (Chiropractors, Physical Therapist, Speech therapists to name a few) and created a bill asking for fair pay. While the bill did not pass, it was quite revealing to the legislature. As a result, some plans did start increasing their allowable fees. There is more work to be done.

Perhaps We Have Been Asking the Wrong Question

For decades, massage therapists have asked:

Why won’t insurance companies cover massage?

Washington’s history suggests a better question.

If a state licenses massage therapists as health care providers, and their legally defined scope allows them to provide an evidence-supported service for a covered condition, on what basis should an insurance company be allowed to exclude the entire profession?

That changes the conversation.

It also forces massage therapy to confront some difficult issues of its own.

If we want to be treated as health care providers, we need clearly defined professional competencies.

We need defensible scopes of practice.

We need education standards that correspond with those scopes.

We need evidence supporting the services we provide.

We need documentation standards.

We need outcomes research.

We need enough professional consistency that legislators, insurers, other health professions and the public understand what the words massage therapist actually mean.

But do we need all that? Washington opened that door more than thirty years ago without having that in place. Maybe we just need savvy insurance commissioners.

The remarkable part of this history may not be that Washington did it.

The remarkable part may be that almost nobody followed.

And perhaps the question for the massage profession in 2026/2027 should be:

Why aren’t we talking about doing it now?

Once again our national associations have failed us greatly.

In the mid-20th century, the American massage practitioner did not inhabit a clinical office; they occupied a social and legal combat zone. It was an industry under siege, suffocating under a corrosive stigma that refused to distinguish therapeutic touch from the “fronts, dives, and houses of ill fame” that haunted the public imagination. To the average citizen, the terms “masseur” and “masseuse” were often punchlines or police blotter shorthand. This was a “dignity deficit” so profound it threatened to bankrupt the craft’s future before it could even begin.

The birth of the American Association of Masseurs and Masseuses (A.A.M.M.)—the precursor to today’s AMTA—was not a routine business venture; it was a desperate, strategic necessity for survival. As early pioneer George Gammon later observed, the movement was born from a visceral “cry for unity and recognition of our profession.” Without a unified front, the individual practitioner was a ghost in the eyes of the law, defenseless against discriminatory ordinances and the mockery of a skeptical press.

This battle for professional sovereignty found its flashpoint on a humid Monday, August 16, 1943, in a Chicago classroom where twenty-nine individuals decided their hands were worth more than the world’s low opinion.

2. The Chicago Spark (August 16, 1943)

The vanguard of the modern profession emerged not from a corporate boardroom, but from the Post Graduate class of the College of Swedish Massage on East Ohio Street. These students were driven by a jagged dissatisfaction with the status quo. At the time, existing organizations were often little more than “sucker lists” for equipment salesmen—predatory registries designed to harvest names for catalogues rather than protect the rights of the workers.

When the proposal for a member-led association was floated, it was a test of true believers. Out of forty-one students in the room, only twenty-nine had the courage to sign the pledge and put down their money. The buy-in was a mere 50 cents in dues, a sum that was both a symbol of grassroots grit and a reflection of the participants’ meager resources. They elected Charles Williams as their first President, establishing a foundational culture of autonomy. By rejecting the “sucker list” models of the past, these twenty-nine established a precedent: the profession would be governed by its practitioners, not its vendors. This member-led governance remains the bedrock of the association today, born from a 50-cent rebellion against commercial exploitation.

3. Fighting the Shadow: Stereotypes and the Kansas City Crisis (1946)

By 1946, the A.A.M.M. learned that a name on a charter meant nothing without social legitimacy. Their first National Convention in Kansas City was less a celebration and more a trial by fire. Upon trying to book the event, six hotels flatly refused to host the group. The manager of the Convention Bureau, a Mr. Boling, was brutally candid: the name “Masseur and Masseuse” carried no standing, and the hotels were “afraid” of the reputational damage the group might bring.

The standoff only broke when the manager of the Continental Hotel agreed to watch the group for thirty minutes. After observing their proceedings, he admitted they were “sincere and conscientious people” whose aim was to relieve human suffering. It was a small, strategic victory, but it underscored the stakes. Outside the convention hall, the press was less kind. Headlines in the Indianapolis Times sneered, “The Local Rubbers Were in Town,” while the paper’s managing editor, Irving Liebowitz, used his platform at a banquet to talk incessantly about “dives and houses of ill fame.”

This wasn’t just snobbery; it was an existential legal threat. In Spokane, Washington, leaders like Milton Niedfelt and Mrs. Florence Taylor were forced to go to war against a “Spokane Ordinance” that sought to officially brand every “Massage Parlor” as a house of prostitution. By fighting these local skirmishes, the early chapters weren’t just arguing over zoning—they were fighting for the very definition of their craft, struggling to decouple the clinical application of touch from the shadows of vice.

4. The Blueprint for Legitimacy: The 1950 Massage Registration Act

By the 1950 Chicago Convention, the leadership realized that reacting to local fires was a losing strategy. They needed a pre-emptive strike. The association unanimously adopted a model “Massage Registration Act,” a document designed to act as a shield against state medical boards that were increasingly aggressive in classifying therapists as “unlicensed practitioners of medicine.”

This was a defensive masterstroke. By drafting their own legislation, the pioneers ceased being victims of “political football” tossed between indifferent health boards. They established their own educational standards and clinical boundaries before non-practitioner bureaucrats could do it for them. This model act was an assertion of professional adulthood—a declaration that massage therapy was a distinct discipline capable of self-regulation and worthy of statutory protection.

5. The State-by-State Crusades: Administrative Hurdles and Human Sacrifices

The transition from a model act to a signed law was a logistical nightmare fueled by staggering personal sacrifice. The association’s finances were frequently in a state of near-collapse. By 1952, the trust fund meant to support states without chapters held a pathetic balance of just $2.65, sitting against a deficiency of $60.29. National officers often reached into their own pockets to keep the movement alive.

• Oregon (1951): A bill was passed, but it served as a grim warning. The administrative structure was “undesirable,” placing the profession under the Board of Health while excluding massage therapists from the Board of Examiners. It proved that legislative text is worthless without administrative representation—a law without a seat at the table is merely a different form of control.

• Arkansas (1951–1953): A high-stakes battle over government bathhouse employees turned into an administrative trap. The original “Massage Act” passed, but it “failed to name an appropriation in the maximum total dollars and cents.” This oversight meant there was no money to pay inspectors, forcing a grueling multi-year struggle to pass retroactive amendments in 1953 just to make the law functional.

• North Dakota (1953–1959): Samuel Dahlgren, a “new member” inspired at the 1953 Spokane Convention, embarked on a legendary five-year crusade. He spent half a decade organizing practitioners and lobbying a recalcitrant legislature. His persistence finally bore fruit on July 1, 1959, proving that the gap between inspiration and law is paved with years of uncompensated labor.

6. Modern Reflection: The 50-Cent Foundation

The clinical respect and legislative standing enjoyed by the modern massage therapist is a direct “interest payment” on the sacrifices of the 1940s and 50s. The AMTA was built on a “shoestring and a prayer,” sustained by individuals who refused to let their profession be defined by hotel managers or dismissive editors.

We are the beneficiaries of a movement that survived on a $2.65 bank balance and a 50-cent buy-in. The dignity we hold today was bought and paid for by the twenty-nine students who, in the face of public mockery and legal erasure, raised their voices in a “cry for unity” that the world could no longer ignore.

“Thirteen years ago we were a handful of members, today over four hundred... Five years ago the public had no way of knowing for sure who the reputable Masseurs and Masseuses were, today they have a sure means of knowing.” — D.S. Carlson, National President, 1956

History of Massage Licensing in Ohio

Ohio holds a distinctive place in the history of American massage therapy. Unlike any other state, massage in Ohio was — and for most of the twentieth century remained — a legally recognized branch of medicine, practiced under the direct jurisdiction of the Ohio State Medical Board. This gave Ohio massage therapists a form of legitimacy that practitioners in other states did not enjoy, yet now in 2026 they still lack the ability to bill health insurance (like WA State has had since 1996) and they still have to pay sales tax on services except if the client has a prescription for massage.

The 1915 turning point

The story begins in the late 1880s, when Ohio, like most states, attempted to crack down on “quacks and charlatans.” Only medical doctors were licensed to practice medicine, but pressure from other bodyworkers — osteopaths (licensed in 1902), then chiropractors — set off a slow chain of legislative events. Rather than handle each profession separately, Ohio’s legislature crafted a bill (The Platt-Ellis Act of 1915) covering a whole range of practices: chiropractic, massage, naprapathy, neuropathy, magnetic healing, chiropody, and more. These were treated as respected “limited branches” of medicine, each required to seek licensure from the state medical board.

The bill was signed into law in June 1915. Afterward, the Ohio State Medical Board created a Limited Branch Committee to oversee the new branches. In November 1915, the first licensing examinations were administered — Agnes Bridget Forbes of Dayton, Donald B. McDougall of Cincinnati, and others became among the first known state-licensed massage therapists in the entire United States.

In January 1915, the board had defined massage simply as “systematic friction, stroking, slapping, kneading, tapping, or manipulation of the body for therapeutic purposes.” The original scope of practice, effective January 1916, was remarkably broad — it permitted medical gymnastics, vibro-massage, helio-therapy (sun exposure), and thermo-therapy. Medical examinations and diagnoses, however, were forbidden.

The historic first state licensing exam for massage was given along with those for other newly licensed branches of medicine. The exams were administered over three days, from 8 AM to 6 PM, November 16 to 18, 1915. The examiners tested 223 candidates, administering 352 exams, because many candidates applied for multiple limited branch licenses. Only 6 of the 11 persons who were tested in massage passed.

However, the legislation signed by Governor Frank B. Willis on May 1, 1915, had grandfathered into licensing anyone who could qualify without examination based on five years of practice before the licensing date. After submitting an application to support that claim, with a fee of $25 (about $600 in 2016, by some reckoning of monetary inflation), a total of 126 people, either examined or exempted, obtained the first state massage therapy licenses effective January 4, 1916. Licensing continued to be processed for others exempted from examination for some time. By August of 1916, Ohio had issued 156 state certificates to practice massage.
AMTA OH Facebook post

Decades as a limited branch of medicine

For many years, Ohio massage therapists operated as bona fide limited medical practitioners, enjoying privileges unavailable elsewhere. Because massage was a recognized branch of medicine rather than a fringe trade, therapists carried a legitimacy in the eyes of the public and government officials that was hard to find in other states. Massage therapy also became the only limited branch of medicine in Ohio that could be practiced without a physician’s prescription.

Because the field already had legitimacy at the state level, there was little incentive to build a statewide massage association according to an article from 1993 in Massage Therapy Journal (below)1. Practitioners worked largely independently, concentrated in the metropolitan areas of Cleveland, Cincinnati, Columbus, Dayton, Akron-Canton, and Toledo. During this era only two massage schools operated in the state: the Central Ohio School of Massage in Columbus and the Buckeye College of Massotherapy in Akron.

The AMTA arrives and chapters form

The American Massage Therapy Association was founded nationally in 1943, in the middle of World War II. As it began forming chapters across the country, Ohio formed its first chapter in 1955, with Thelma Conley as its first president. That early chapter faded, apparently because Ohio’s therapists already had legitimacy through the medical board and felt the national association offered little they needed.

1975–1982: pressures for change

In 1975 the physicians on the Ohio State Medical Board began having trouble acquiring liability insurance for some procedures. This prompted the board to reexamine the scopes of practice for its limited branches. By this time there was a national trend to eliminate or combine limited branches; in Ohio, only chemotherapy, cosmetic therapy, and massage therapy survived as limited branches. Massage’s scope was narrowed to a single definition: “the treatment of disorders of the human body by systematically applied friction, heat, or by stroking, slapping, kneading, tapping or hand manipulation only.”

During this period, a small faction of therapists in northern Ohio began arguing that massage should actually be withdrawn from the medical board’s jurisdiction and placed under self-governance.

On September 13, 1982, fifteen massage therapists from Dayton, Cincinnati, Columbus, and surrounding areas met in Dayton to re-activate the Ohio Chapter of the AMTA. Ruth Ann Hobbs, an AMTA Eastern District Representative, spoke about the benefits of national membership, including malpractice insurance. Arline Mandas was elected the chapter’s first president. By 1983 the Ohio Chapter was organized and operational, with a treasury of about $1,600 and 40 members.

Around the same time, a competing effort emerged: Morton Bissel and others promoted a State of Ohio Massotherapy Board that would move massage away from the medical board to a private board setting its own educational and testing standards. The AMTA Ohio Chapter opposed this move away from the medical board.

The enduring tension over the word “massage”

Throughout this history runs a persistent concern in Ohio about the word “massage” itself, and the different connotations attached to medical versus non-medical massage. The battle to preserve the professional, positive meaning of the term in the public’s eyes was constant, and AMTA-OH repeatedly sought clarification of the definition from the Ohio State Medical Board.

Ohio’s history is genuinely unique because massage was licensed as a legitimate branch of medicine starting in 1915, Ohio therapists operated under an entirely different form of legitimacy than their counterparts anywhere else in the country — a heritage the author dates back over 78 years from the 1993 writing.

During the 1950s and early 1960s, Ohio occupied a unique and somewhat ambiguous legal position in the national landscape of massage regulation.

1. The Legal and Regulatory Paradox

Unlike states with explicit statutory “Massage Acts,” Ohio had no statutory law specifically regulating the practice of massage on its books. Instead, the Ohio State Medical Board had established rules and regulations governing “limited practitioners” under the State Medical Practice Act for Physical Therapy (under the supervision of the State Board of Medical Education and Licensing).

Under Section 3 of these Medical Board regulations, the state formally listed “Massage and Swedish movements”. To practice legally under these board rules, a practitioner was required to meet the following standards:

• Completion of at least an 8th-grade education.

• Completion of a course of study covering an instruction period of not less than one year.

• Passing a formal licensing examination.

The Enforcement Loophole: Because there was no specific statutory massage law in Ohio, unlicensed practitioners could theoretically face prosecution under the general Medical Practice Act for “practicing medicine without a license”. However, the newsletters noted a major legal gray area: practicing medicine legally implies diagnosing and prescribing treatments—activities that massage technicians did not perform. Consequently, the association pointed out that it was highly unclear how enforcement of these rules could actually be legally sustained, and they had heard of no active prosecutions in the state.

2. Active Association and Chapter Growth

Despite the legal gray areas, Ohio had an active and highly dedicated community of professional practitioners:

• 100% Paid Membership Milestone: For the 1953–1954 association year, Ohio was celebrated as one of the very first states to achieve 100% paid-up membership for all its registered members, demonstrating a highly organized local base.

• The Ohio Chapter of the A.A.M.M.: The Ohio State Chapter held its second official meeting in September 1955. Led by President Conley and Secretary-Treasurer Kinsinger, the chapter deposited its $68.00 charter check from national headquarters into the Huntington National Bank of Columbus, establishing a total chapter treasury of $77.00.

• Cross-Border Networking: In 1959, Blandie Jones of Pennsylvania (one of the association’s most prominent legal advocates) traveled to Columbus, Ohio, to attend the 10th Annual Convention of the National Athletic Trainers Association.

3. Approved Massage Schools in Ohio (1960)

By March 1960, the national association officially recognized and approved two major Class A educational institutions in Ohio for professional training:

• Dayton School of Physical Therapy: Located at 3 N. Williams St., Dayton, Ohio. Directed by Dr. R. H. Pedicord, it offered a 12-month residence course for $300.00.

• Great Lakes College & Clinic (Mechanotherapy & Medical Massage): Located at 1900 Superior Ave., Cleveland, Ohio. This program required 744 hours of study plus 150 practical treatments, with tuition priced at $50.00 per month.

Massage Today in OH.

The very framing that gave Ohio massage its historic legitimacy has, a century later, produced an unintended vulnerability. Because Ohio anchored licensure to massage as the treatment of the body — a limited branch of medicine — anything falling outside "treatment" has always sat outside that jurisdiction by definition. Today the State Medical Board of Ohio confirms that "relaxation massage" is not even a term in Ohio law; it is simply how the public describes non-therapeutic work, which requires no state license at all.

Medical massage, also known as massage therapy, is done for purposes other than relaxation. If you will offer massage therapy, you must be licensed as a massage therapist by the State of Ohio Medical Board. Contact Ohio’s State Medical Board at (614) 466-3934 or http://www.med.ohio.gov/mt_about_massage_therapy.htm. [] Non-medical massage is simply for relaxation. Non-medical massage does not require state licensing. However, it is often regulated locally. Contact your local city or municipal officials. OH checklist

That distinction, a direct inheritance of the 1915 medical model, is now the very gap through which illicit operations move. A University of Dayton human rights report described the problem plainly: Ohio uniquely licenses therapeutic massage through the medical board, yet non-therapeutic "relaxation" massage operates with nearly zero oversight, a loophole that has fueled the spread of illicit massage businesses exploiting primarily foreign workers2.

In other words, the very distinction that secured Ohio massage its medical legitimacy in 1915 — the line between “treatment” and everything outside it — is now the seam through which exploitation enters. The report’s authors call for closing that seam by requiring all who perform massage in Ohio to be licensed, empowering townships to regulate massage establishments, and pairing enforcement with victim-centered services and de-stigmatizing language — reforms aimed at protecting both the vulnerable and the good name of a century-old profession.

The scale is not trivial — that report from 2021 estimated roughly 300 such businesses in Ohio, and state officials, including the Attorney General's human-trafficking task forces that raided four parlors in August 2025, have described these fronts as a growing problem hidden in plain sight among legitimate practices. The tension over the word "massage" that ran through the profession's entire twentieth-century history has thus never been resolved so much as relocated: what was once a battle to distinguish medical dignity from disrepute is now a battle to keep the profession's hard-won name from being used as cover for exploitation.

AMTA OH was working on efforts to end that loophole finally in 2019 but without success3. As of its Spring 2025 update, AMTA-OH reports that the American Massage Therapy Association is not currently pursuing legislative changes in Ohio, having shifted its strategy toward education and awareness. The chapter, working with the national organization, said they would be holding a series of “Legislative Listen and Learn” events at six colleges and universities with massage programs — inviting lawmakers to tour classrooms and simulation labs, meet students and educators, and hear directly from licensed therapists about the rigor of their training. The aim is to build the legislative understanding that earlier bills lacked, laying groundwork for a future push rather than forcing one now.

That makes the present moment a quieter chapter in a century-long story — not a fight on the House floor, but a slower campaign to convince lawmakers, one classroom tour at a time, that licensure is what separates a healing profession from a criminal front. I have not seen any evidence of these events happening in OH.

"Of all the problems facing massage in Ohio — an unclosed loophole, illicit businesses operating in plain sight — the resources spent this year went not toward those, but toward creating a second, competing interstate compact. That choice deserves scrutiny4. Whatever the intent, the effect is a profession split in two. A functioning compact requires seven member states; now there are two compacts, each needing to reach that threshold separately. Rather than one pathway for license portability, therapists face two incompatible ones — and the profession's limited advocacy capital is spent building a parallel structure rather than closing the gaps that endanger the public.

The Facebook posts on the AMTA-OH page and the AMTA National Page show the confusion and lack of transparency around what this really means. The comments were more concerned now about having to take CE classes and most missed the point about how they overrode the Original Compact Bill with inaccurate testimony

This isn’t even about the compact anymore and we can disagree about which version of the compact is better drafted. What is harder to defend is the choice to spend the profession's limited advocacy capital pulling one state out of a national agreement and into a parallel one — while the loophole that lets untrained hands operate in trafficking fronts remains, a decade of newsletters later, exactly where it was.

Update Aug. 19, 2026 — A story on linked caught my attention.

Ohio's newly proposed H.B. 744 (and bill analysis) is intended to combat human trafficking and illicit massage businesses by increasing oversight of massage establishments and tightening requirements concerning who may legally provide and advertise massage services. The goal is understandable, but it raises a larger question: Why does the solution to a sex-work and trafficking problem keep becoming more massage regulation?

Ohio's proposed H.B. 744 may finally address one of the most troubling weaknesses in the state's massage licensing law. By removing the requirement that massage therapy be performed for the "treatment of disorders" and defining it instead by the techniques being performed, the bill could largely close the loophole that has allowed unlicensed people to offer what they call "relaxation massage." It even specifically addresses advertising for "relaxation massage" and other massage methods. That is an important step toward making a massage license actually mean something. But the bill also preserves an old and questionable system in which townships can impose another layer of regulation on massage therapists who are already licensed by the State Medical Board, including local licensing, fees, police investigations, fingerprints, and even physical examinations for communicable diseases. If Ohio is going to modernize a massage law rooted in 1915, this is an opportunity to do more than close the relaxation-massage loophole. It is an opportunity to ask why legitimate massage therapists should continue to carry regulatory burdens created largely because massage therapy has been used as a cover for commercial sex and illicit businesses.

Don’t you think?

1

Massage Therapy Journal, Fall 1993 AMTA- OH and Ohio’s Historical Legitimacy

Amtaohandohhistoricallegitamacy

46.4MB ∙ PDF file

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4

FSMTB’s Statement: https://fsmtb.org/2026/07/08/ohio-no-longer-connected-to-the-impact/

OH Bill tracker - https://www.legislature.ohio.gov/legislation/133/sb105

https://www.legislature.ohio.gov/legislation/136/sb276/committee
AMTA’s testimony on the bill from Jada Thompson and testimony from NCBTMB president Christopher Deery claiming that there are NOT two compacts when indeed there are two compacts.

AMTA also wishes to clarify that there are not “two competing versions” of the compact. Rather, there is a single interstate compact undergoing appropriate legislative refinement—a standard and necessary part of the legislative process. Interstate compacts are statutory instruments, and legislatures retain full authority to amend and improve the language before a compact commission is formally established. These revisions are consistent with how professional practice acts are routinely updated to improve clarity, strengthen oversight, and address unintended consequences.

AMTA states clearly on their website that there are two compacts.

Deep tissue?

Trigger point therapy?

Myofascial release?

Neuromuscular therapy?

None of those.

The answer surprised them.

Presence.

Not because presence replaces good assessment, anatomy, or clinical skills. It doesn’t. But without presence, even excellent technique can become mechanical. With presence, every technique becomes more responsive, more intentional, and often more effective.

Yet presence is one of the least discussed skills in massage education.

What does it mean to be present?

Presence is often misunderstood.

It is not meditation.

It is not spirituality.

It is not emptying your mind.

It is something much simpler.

Presence means giving your full attention to what is happening right now.

That includes what you are feeling through your hands.

What you are observing in the client’s breathing.

How the tissue responds.

What your own body is doing.

Whether you are rushing.

Whether your mind has wandered to grocery shopping, your next client, or tonight’s dinner.

Many massage sessions happen on autopilot.

The therapist follows a familiar routine.

The client drifts somewhere between sleep and daydreaming.

The massage may still feel good, but there is very little real interaction taking place.

Presence changes that.

Working with someone instead of working on someone

Jack Blackburn and Cynthia Price in their paper Implications of Presence in Manual Therapy 1 described presence as a central element in body-centered therapies. They contrasted a routine massage session with one in which both therapist and client actively participate in the client’s awareness of their own body.

That distinction reminds me of something massage therapists have debated for years.

Are we simply applying techniques to tissue?

Or are we helping another human being become more aware of their own body?

Those are very different experiences.

The goal is not to become a psychotherapist.

It is not to analyze someone’s emotions.

It is simply to create the conditions where the client can notice what is happening inside themselves while you do your work.

Presence begins with the therapist

Clients can usually tell within seconds whether you are actually with them. Although many may not know the difference if they have never experienced it themself.

Your hands reveal it.

When your attention drifts, your touch often becomes predictable and repetitive.

You stop responding.

You start performing.

Presence starts before the first stroke.

Before entering the treatment room, take a slow breath.

Notice your own posture.

Relax unnecessary tension.

Feel your feet on the floor.

Ask yourself one question:

Am I actually here?

That small pause can change the quality of the entire session.

Your hands become better listeners

Many therapists think of their hands as tools.

Presence turns them into instruments of observation.

Instead of asking:

“Where is the knot?”

You begin asking:

“How is this tissue responding?”

“What changes when the client exhales?”

“Am I using more effort than necessary?”

“Is this area becoming softer, warmer, or more mobile?”

Blackburn and Price describe this as continually monitoring your own experience while simultaneously paying attention to the client’s responses. Rather than performing a memorized sequence, the therapist continually adjusts based on what is actually happening.

Clients can learn presence too

Many people arrive for massage disconnected from their bodies.

They know they hurt.

They know they are stressed.

But they have very little awareness of what their body is actually experiencing.

Simple questions can gently invite awareness.

“What do you notice under my hand?”

“Does the sensation change when you breathe?”

“What happens if you let your shoulders soften a little?”

These are not psychological questions.

They are awareness questions.

Sometimes the answer is simply:

“It feels warmer.”

Or:

“I didn’t realize I was holding my breath.”

That awareness alone can change the session.

Presence is different from distraction

This conversation has become especially relevant recently.

Many massage therapists now wear earbuds during sessions while listening to podcasts, audiobooks, or music that only they can hear.

Some therapists report that it helps them focus.

Others believe it divides attention.

The important question is not whether earbuds are inherently good or bad.

The question is this:

Can we honestly say we are fully present with another human being if part of our attention is following an unrelated conversation or story?

Presence asks us to examine where our attention actually is.

Because clients deserve more than our hands.

They deserve our attention.

Now the people with the earbuds listening to podcasts/audio books etc. will say that doing that helps them focus and I have to wonder if that is true or not as many who are neuro-divergent also exclaimed that they used learning massage how to train their thoughts more and stay focused. (Are our students getting the help and support they need to learn to do that?)

Presence creates trust

Clients rarely remember every technique you used.

They remember how they felt.

They remember whether they felt safe.

Whether they felt heard.

Whether you seemed rushed.

Whether your touch felt connected.

Presence communicates something that no advanced technique can.

“I am here with you.”

That may be one of the most therapeutic experiences we can offer.

Presence is a professional skill

Massage therapists spend hundreds of hours learning anatomy, pathology, assessment, contraindications, and manual techniques.

Those things matter.

But perhaps we should spend more time teaching therapists how to cultivate attention.

How to recognize when they have slipped into autopilot.

How to notice their own body mechanics.

How to truly observe instead of simply perform.

Presence is not mystical.

It is trainable.

Like palpation, it improves with deliberate practice.

A question for the profession

We spend enormous amounts of time debating techniques.

Which method is better.

Which certificate is worth earning.

Which continuing education class to take next.

Maybe we should spend more time asking a simpler question.

How often are we truly present with the person on our table?

Because in the end, presence may be the one skill that quietly improves every other skill we already have.

Why professions have associations in the first place

Before we talk about AMTA and ABMP, it’s worth asking a more basic question: why do professions form associations at all?

A profession is more than a collection of people who do the same kind of work. What separates a profession from a job is a set of shared commitments — an agreed-upon body of knowledge, standards for entry, a code of ethics, and some mechanism for holding practitioners accountable to the public. None of that maintains itself. Someone has to define the standards, defend them, and speak for the field when outsiders — legislators, insurers, regulators, the press — come asking “who are you people and can we trust you?”

That’s the work associations exist to do. Historically, professional associations serve a handful of overlapping functions:

• A collective voice. When a legislature drafts a licensing bill or an insurer decides whether to reimburse, they need one credible party to negotiate with. An association gives the profession a seat at that table.

• Standard-setting. Associations define what competent, ethical practice looks like — through education requirements, scopes of practice, and codes of conduct.

• Identity and boundaries. They answer the question “what is this profession, and what isn’t it?” — which is really a question about who belongs.

• Member services and belonging. Insurance, continuing education, publications, community, discounts. The practical glue that makes membership worth paying for.

• Public trust. By vouching for their members, associations signal to the public that a practitioner meets a standard.

Here’s the tension baked into that list: the first three functions serve the profession as a whole, while the last two serve members as customers. An association can lean toward being a movement that advances a field, or a service organization that sells benefits to individuals. Most do some of both. But which way an organization leans shapes everything about how it behaves — and it turns out this distinction sits at the very heart of the massage profession’s divide.

AMTA: the profession-building instinct

The American Massage Therapy Association traces its roots to 1943, making it the elder by more than four decades. Its history reads like a case study in the profession-building functions above.1 It is a non-profit 501c6 membership association meaning it has obligations to members.

AMTA didn’t just serve members — it tried to build the scaffolding of a profession. It authorized and funded national certification, loaning $150,000 in 1988 to create the NCBTMB. It created the Commission on Massage Therapy Accreditation (COMTA) to accredit schools, and the Massage Therapy Foundation in 1990 to fund research.

AMTA started out as the American Association of Masseuses and Masseurs (AAMM) and changed it to American Massage & Therapy Association in 19582. They later dropped the “&” from its name in 1983 to become simply the American Massage Therapy Association, it was making a statement: the term therapy defined the field as a health profession, and the title “massage therapist” gave it legitimacy in the public eye. massagetherapynexus

But that whole project was and continues to be an problem for the massage profession. AMTA created it (along with 5 other orgs), supported it, didn’t support it, supported the MBLEx and now is keeping it alive by funding it since about 2018. See the history of NCBTMB here.

That’s the instinct of an organization trying to elevate a craft into a profession — build the exams. They also now are involved in our associations that accredit the schools, fund the research and define the identity. Should one association have that much control and influence over the profession?

But that same history shows the strain that comes with it. AMTA’s structure has grown more centralized over time. Between 2017 and 2018, the member-elected House of Delegates, which had power to pass binding resolutions, was replaced by an Assembly of Delegates relegated to a purely advisory role, with final authority resting with the National Board. In the 2025 board election, of roughly 93,000 eligible voters, only about 3.5% voted — and 94.5% approved the board’s slate. That’s the profile of an organization that has drifted from a member-driven movement toward a staff-run service provider — the very tension I flagged above. The American Massage Therapy Association (AMTA) utilizes a representative governance structure rather than a direct democracy, meaning members exert their control by voting for leaders rather than directly voting on industry policies or strategic directions. Ironically, the slate removes the members choices. massagetherapynexus.com

ABMP: the service-organization instinct

Associated Bodywork & Massage Professionals came from the opposite direction. It was founded in the mid-1980s (ABMP dates itself to 1987; its predecessor APMT to 1986) explicitly as an alternative to AMTA — and its origin story is telling.

Not all bodyworkers wanted to join AMTA. Some saw it as “the Swedish massage organization” and considered their own disciplines distinct from old-school massage. Others were libertarian heirs of the counterculture who distrusted “the establishment” and couldn’t stomach the hierarchy and politics of professional associations. AMTA, advocating for a unified profession since 1943, became a symbol of everything they rejected — and that opening created room for a new organization. massagetherapynexus.com

ABMP was built as a “big tent” for all modalities, and — crucially — as a for-profit member-services organization. It offered liability insurance, discounts, a newsletter, directory listings, and certificates. It deliberately rejected state chapters and meetings to avoid “petty bureaucracy,” favoring fast, centralized decisions. massagetherapynexus.com

And here’s where the philosophical divide becomes concrete: through the 1990s, ABMP actively opposed the AMTA-backed national certification and state licensing efforts, framing massage as an “industry” rather than a profession. massagetherapynexus

Industry versus profession. That single word choice captures the whole fault line. One organization was trying to build a profession’s regulatory scaffolding; the other saw that scaffolding as bureaucracy that got between practitioners and their livelihoods. Today ABMP is involved in advocacy and watching regulations and they do support projects like the IMpact (Interstate Massage Compact) where AMTA felt the need to create their own compact thereby creating a larger divide and more controversy. They continue to hide this from their members and give questionable testimony to the legislature to get their version passed. (See what happened in Ohio recently. AMTA claimed it was a landmark event. If you look at the comments on their Facebook post, most people are concerned about adding CE and don’t have a clue what happened.)

So — is the two-association structure part of the problem?

Plenty of professions have more than one association without being fractured. Medicine, law, and accounting all have multiple bodies that coexist and often collaborate. Competition between associations can even be healthy — it keeps them responsive to members and prevents any one body from growing complacent.

When a legislator or an insurer asks “who speaks for massage therapy?” there is no single answer. There are two — and historically they’ve often given different answers. That’s the actual cost of the divide: not duplication, but the absence of a unified position at the exact moments the profession most needs one.

There are a few genuine moments of cooperation worth acknowledging — in 2017 the two issued a rare joint statement rejecting the FSMTB’s human trafficking report, and ABMP eventually joined AMTA’s Body of Knowledge effort in 2008. They also worked together with the Coalition of Massage Associations back in 2012 to create the Entry Level Analysis Project. AMTA never supported that afterwards. But these are the exceptions that prove the rule. They’re notable because they’re rare. But neither organization worked to implement and preserve these valuable projects. massagetherapynexus.com

The deeper question

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I have seen many threads on this over the years and I saw one that morning so I posted this. It is my own personal preference - neuro-divergent or not, that if you are wearing earbuds/an ear bud while giving a massage, I (and many others!) don’t want you as my therapist. Plain and simple. So that means, you need to disclose that you are using them. For me it’s about - I don’t trust that your attention will be on me. For many others in the discussion thread it was about being present in the massage session.

For others it is also the other risks that come with wearing one and not being up front about it with clients. If they find out later they may think you were recording them or that you were not giving your best attention. Whatever the case, trust is lost.

If you are going to wear them for your ADHD, because you are bored, because you dislike spa music…whatever you want to say. Tell them.

The fact that many did not want to share that information is telling in itself.

At first I just wanted to gather all of the comments and see what people were saying so I put it into Claude.ai to do that for me as of 9:30 Monday Morning 07/27/2026. More comments continued to be added after that. Here is the official result created by Claude.ai

Earbud Debate Qca Report (1)

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Now what?

I have gone through many versions of this writing this article…point by point explaining all of those things in the last image: full attention, respect for autonomy, informed consent, professionalism, client centered care, transparency, trust and fiduciary responsibility.

Were people in massage school being taught presence - can that even be taught or is it something that only comes with experience?

Is it true that Neurodivergent people focus better listening to podcasts/other music etc?

It isn’t about the Earbud(s).

It was the fact that many did not want to disclose the use of the earbud. That’s different.

It made me wonder what is being taught in ethics classes in massage school and in CE classes.

But was I crazy for bringing it up?

The main comment that got my attention was the one announcing that Ontario, Canada had already put their attention to this matter.

Here is what their website says about it:

“But I am present.”

I already know the strongest objection to everything I’ve written, because I heard it all through the thread, and it comes from people I take seriously. A neurodivergent therapist will read this and say: I’m not divided. The audio is what lets me focus. I am more present with it than without it. My attention is on my client.

I believe you.

And here’s the thing — that objection, as true as it is, doesn’t actually touch what I’m asking for. Because my point was never that you aren’t present. I can’t know that from the outside, and neither can your client. That’s exactly the problem.

Presence isn’t only something you have. It’s something the person on your table has to be able to trust. And trust doesn’t run on what’s happening inside your head — it runs on what the client knows. When someone is undressed, face-down, eyes closed, and can’t see your face, they’re reading every available signal to reassure themselves that your attention is theirs. An earbud they didn’t know about, discovered halfway through, reads as a signal in the wrong direction — not because you were absent, but because they were never given the chance to understand why it was there.

So this was never a referendum on whether neurodivergent therapists can be present. Of course they can, and many are extraordinary at this work. It’s about who gets to decide whether that presence is trusted. Right now, when the earbud stays hidden, the therapist decides for the client. Disclosure hands that decision back to the person it belongs to.

That’s the whole ask, and it costs you almost nothing. “I keep something playing quietly in one ear because it helps me focus on you — is that alright?” If you’re as present as you say — and I believe you are — that sentence loses you nothing and protects everything. The client either says “of course” and now trusts you more, or they say “I’d rather you didn’t,” and you’ve learned something about them before it became a wound. Either way, the trust stays intact, because you never asked them to take your presence on faith they didn’t agree to give.

Being present is your work. Being trusted to be present is theirs to grant. Disclosure is simply how you ask.

It is about time the US caught up researched this and created a policy.

We know many therapists feel podcasts help them focus. What we don’t know is whether spoken audio changes a therapist’s ability to notice subtle client cues, make clinical decisions, or respond to changing conditions during treatment. We also don’t know whether other accommodations might provide the same benefit without introducing those questions. Those are exactly the kinds of issues a profession should study rather than settle through opinion alone.

A clear Practice Framework would have ended that three-day argument before it started, the way Ontario’s guidance does. We should have one.

But I want to be careful here, because a rule can only reach the behavior, not the understanding beneath it. You can require a therapist to disclose the earbud. You cannot require them to feel that the person on their table is owed the truth — and that feeling is the whole thing. A therapist who needs a standard to tell them not to hide something from a vulnerable client is already missing what matters most, and no standard can hand it back. It has to be formed in them, in training, before they ever walk into a room.

That’s what worries me about reaching only for rules. It’s the easy answer — write the policy, tick the box, declare the problem solved — while the real gap goes untouched, because “teach presence and the meaning of trust” is far harder to legislate than “disclose your devices.” A framework built on that formation, like Ontario’s, works. A framework used as a substitute for it just produces compliance without conscience. And I’ve come to think compliance without conscience is exactly how a profession loses its soul while congratulating itself on its standards.

Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention Francesco Cerritelli ^1,2,3, Piero Chiacchiaretta ^1,2,*, Francesco Gambi ^1,2, Antonio Ferretti ^1,2

Would love to hear your comments!

For years, I thought the biggest problems facing massage therapy were things like insurance reimbursement, public perception, inconsistent laws, continuing education, and organizations that didn’t seem to work together.

The more I researched our history, the more I realized those weren’t separate problems. They were symptoms of something much bigger.

I kept asking myself one question:

**Why do other professions seem to move forward together while massage therapy often feels like it’s pulling in different directions?**

That question led me down a rabbit hole through old journals, meeting minutes, legislative records, and forgotten white papers.

One of the most important things I found was a paper Rick Rosen wrote in 2008 about what it actually takes to build a profession. It wasn’t about techniques or modalities. It was about the structure behind the profession itself. I wrote about it a few days ago here: On Becoming a Profession

Reading it changed the way I look at almost everything happening in massage therapy today.

Now, when I see debates over education, licensing, specialties, research, portability, or professional organizations, I don’t see isolated issues anymore. I see pieces of a much larger puzzle.

That’s why I’ve spent so much time studying our history. I don’t believe we can build the future of massage therapy unless we understand how we got here, what previous leaders were trying to accomplish, and where the work stopped.

History isn’t just interesting.

It’s a roadmap.

And I think more massage therapists deserve to know it’s there.

Six Components of a Profession

Rosen followed up with an article titled “The Structure of a Profession”:

While each mature profession has its own developmental history, culture, and methods of operation, there are six basic components that are common to all.

These are:

1) Membership Association;

2) Independent Organization of Colleges or Schools;

3) Accrediting Commission;

4) Federation of State Licensing Boards;

5) Specialty Certification Boards; and

6) Research Center.

To visualize this model, it is helpful to view these components as a set of interlocking hexagons that fit together in an interactive matrix. As you can see, this creates a geometric structure that is inherently strong, and that has a well-defined center.

Each component organization functions independently, according to its own bylaws and strategic plans. At the same time, each is part of a unified whole where individual actions directly influence the entire profession.

The health of a given profession depends upon the ethical and efficient operation of each entity, as well as its relationships with the others. To address the collective needs and challenges of the profession, there must be ongoing dialogue, planning and cooperation among the leaders of these organizations. This provides a crucial integrating function.”

~Rick Rosen, 2009 The Structure of a Profession

Rosen Structure Of Profession

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My efforts to get this out on Facebook led to Rick Rosen commenting himself on where we are today!

The Structure of the Massage Profession Today (2026)

“16 years after I wrote this article for Massage Today entitled, “The Structure of a Profession”, here’s my perspective on the status quo of our field. I’ll use the numbering system in the post above:

1) Membership Association: Our field has two major national trade associations in AMTA and ABMP, along with a number of unrelated state associations (such as the Florida State Massage Therapy Association). This division makes it challenging for the field to speak with a single voice, or to exert influence when the various groups do not agree on a given issue or challenge.

2) Independent Organization of Colleges of Schools: Our field has the Alliance for Massage Therapy Education (of which I was a co-founder and the first Executive Director). However, AMTA and ABMP both have school member categories, so this arrangement splits the landscape, and has kept AFMTE from becoming the singular representative for the massage education community.

3) Accrediting Commission. This component is literally all over the map in our field. To begin with, accreditation is generally not a requirement of massage schools. For those that choose to become accredited (primarily to gain USDE eligibility for Federal Student Aid grant and loan programs), there are seven different agencies that accredit massage schools and programs. That means there are no consistent standards for entry-level education.

4) Federation of State Licensing Boards. This is the one big success story in our field. The Federation of State Massage Therapy Boards (of which I was also a co-founder and the first Executive Director) marked its 20th anniversary last year, and it administers the sole national examination for licensing. New York and Hawaii are the only remaining states that administer their own exams. The MBLEx supplanted the National Certification Exam administered by NCBTMB, which was adopted by a number of states that gained license laws before the MBLEx came into existence. FSMTB also provides an important forum for state board members and administrators to meet and exchange best practices in regulation.

5) Specialty Certification Boards. This is still an undeveloped area in our field. The “Board Certification” exam offered by NCBTMB is for a generalist credential, and does not test or assure competency in any specific area of massage therapy or bodywork practice. As an example, look at the American Nurses Credentialing Center (part of the American Nurses Association): they offer certifications in 30 defined areas of clinical practice or skills.

6) Research Center. Our field has the Massage Therapy Foundation, which is underwritten and supported by AMTA. It has funded a number of studies, provides training in research literacy for massage students and practitioners, and hosts educational conferences. There are some overarching limitations to the effectiveness and impact of research in our field: a) Few of the studies conducted have been replicated, and most have small sample sizes. These factors can limit the acceptance of data in the larger health care arena. (b) And even if studies show positive effects of the application of massage therapy for various conditions or populations, the reality is that without consistent entry-level education and universal standards of practice in our field, there is no assurance that the average massage therapy practitioner could deliver treatment that matches what was performed in these various studies. So this “research” remains largely theoretical -- a kind of Holy Grail in our field.

Our field has not yet achieved the kind of coherence and common structure that has been the hallmark of mature professions. Look at professions like physical therapy, nursing, occupational therapy, acupuncture, naturopathy, pharmacy -- and you’ll see what I’m talking about. The lack of standards, the patchwork quilt of state regulations, the uneven training students get in schools, the absence of teacher training requirements for instructors -- all are pieces of the puzzle that must get put into place if massage therapy and bodywork is to become a true profession. I’ve been a part of this field for nearly 50 years, and I don’t see the puzzle getting solved anytime soon.

- Rick Rosen, MA, LMT”

The Puzzle Isn’t Unsolved. It’s Occupied.

Rosen ends with a puzzle metaphor — pieces that must get put into place. After nearly fifty years in the field, he doesn’t see it happening. I’ve come to think the metaphor is too gentle. The pieces aren’t scattered on the table waiting for someone patient enough to assemble them. They’re already picked up. Someone is holding each one, and has a reason not to let go.

Consider what it would actually cost to fix each component. (My perspective!)

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In 2008, Rick Rosen published an article that should have changed the course of the massage therapy profession.1

Many therapists have never read it. Many have never even heard of it.

That is unfortunate because Rosen did something remarkably simple. Instead of arguing about techniques, continuing education, or licensing hours, he stepped back and asked a much bigger question.

**What does a real profession actually look like?**

Then he compared massage therapy to that model.

The result was uncomfortable.

### A profession is more than people doing the work

We often say, “massage therapy is a profession.”

But saying something does not make it true.

Medicine isn’t a profession simply because doctors exist.

Law isn’t a profession simply because attorneys have licenses.

Every mature profession has an infrastructure that supports it.

Profession Infrastructure

Each has a different job.

Each operates independently.

Each depends on the others.

If you remove one piece, the whole structure weakens.

If one organization tries to dominate the others, the system becomes unstable.

That observation is just as important today as it was in 2009.

The profession actually started moving in that direction

Around the time Rosen wrote his article, many important pieces were falling into place.

FSMTB had recently been created in 2005 to coordinate state licensing boards.

The Alliance for Massage Therapy Education had just formed to represent schools independently.

COMTA already existed as a massage-specific accrediting agency.

The Massage Therapy Foundation was building research capacity.

Perhaps most exciting of all, six organizations came together to launch the Massage Therapy Body of Knowledge Project in 2010.

For the first time, the profession was attempting to answer fundamental questions.

What is massage therapy?

What knowledge should every entry-level therapist possess?

What belongs within our scope of practice?

Those are the kinds of questions mature professions answer before they debate everything else.

Then something happened

Looking back from 2026, it is difficult not to ask an uncomfortable question.

**How much of this vision did we actually complete?**

Some progress has certainly been made.

Licensure is now nearly universal but licensing laws vary greatly.

The MBLEx became the primary licensing examination.

Board Certification exists.

Research has expanded dramatically.

But many of the foundational issues Rosen identified remain unresolved.

We still argue over what massage actually is.

State scopes of practice vary widely.

Educational standards remain inconsistent.

Specialization is still NOT defined. We lack specialty Certifications after attempting to create specialty “certificates”.

Continuing education requirements differ from state to state and there is no data to show what is needed for continuing competence after basic massage licensing.

Professional organizations often pursue separate agendas rather than shared ones.

Instead of building one coordinated profession, we sometimes seem to be maintaining several parallel systems.

The missing center

One idea from Rosen’s article stands out more than any other.

He warned that when organizations stop functioning as parts of a unified system, they naturally begin focusing inward.

Each protects its own interests.

Each develops its own priorities.

Each speaks for itself rather than for the profession.

Eventually, there is no true center holding everything together.

If you’ve watched debates over education, certification, continuing education, portability, interstate licensure, or the current compact controversy, that observation probably sounds familiar.

Building a profession never ends

Professions are not created by passing a licensing law.

They are built over decades.

Sometimes over generations.

Every generation inherits unfinished work.

Rick Rosen gave massage therapy a blueprint.

Not a perfect one.

Not the final answer.

But a thoughtful framework for understanding how professions mature.

Whether we agree with every recommendation is less important than recognizing the value of the question he asked.

Are we making decisions that strengthen the profession as a whole, or are we strengthening individual organizations while the overall structure remains incomplete?**

That may be one of the most important questions massage therapists can ask today.

Because before we can decide where the profession should go next, we need to understand the foundation that was laid long before many of us entered practice.

Join me as I provide a deep dive on the history of the massage industry like you have never seen or heard before…

Every week on Massage Therapy Nexus, I dig into the history, politics, research, and decisions that have shaped our profession, using original documents and primary sources you won’t find anywhere else.

Subscribe free to follow the conversation. Become a paid member if you want to help build what’s next.

Because the future of massage therapy won’t be written by accident. It will be written by those who show up.

~Julie Onofrio, LMT (About me!)

Rosen On Becoming A Profession

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I was a member I think for a few years when I started but mainly because they were the only one in business. I quickly changed when ABMP came into being.

In 2011 or so I went to my AMTA-WA Chapter to get help with the problem of insurance carriers reducing our allowable fees quite significantly. I asked for three years and finally got the answer — if there was something we could do, we would be doing it. So a group of us left AMTA and started the WA State Massage Therapy Association (www.mywsmta.org) to try to work on the issues that we had with the insurance carriers.

In about 2018 I left that group and had also worked with a few groups trying to start a medical massage therapy association that never came into being. The issues kept increasing. Covid Happened. The problem of illicit businesses got my attention and I bought the website www.lookbeforeyoubookamassage.com to work on the issues.

In 2023 I decided to give AMTA one more chance. I was attending the AMTA WA Convention where a new president was elected and at the luncheon she was asking for volunteers. For some crazy reason, I stepped up and worked on their website and then ran for a Board Position that I held for 2 years and then became the GR chair for the chapter. If you know how AMTA works, the chapters are the heart and sole of this organization, working for free to monitor and create legislation, give input to the Board of Massage and many other things.

I apparently asked too many questions — asked for help with ordinances, asked for what they stand for to give input to the Board of Massage on education'/CE, asked for them to track and preserve history more carefully, asked them to start a human trafficking committee or task force to study the problem and provide best practices in dealing with this problem.

I got the letter. You are doing something wrong, but we won’t tell you what so pleas stop or you will be removed. Huh? Yes indeed. It is very common. After a few of my friends got that letter before me, I actually requested a bylaws change to correct that and was told it was a legal thing and couldn’t be changed. Here is the story on all that.

When Asking Questions Becomes a Problem

For years, I have dedicated thousands of hours to researching the massage therapy profession. I’ve read legislation, compared state laws, analyzed organizational documents, followed regulatory meetings, interviewed people, and tried to make complicated issues understandable for massage therapists.

I don’t claim to know everything. I don’t claim to be right about everything.

What I do claim is this: I care deeply about getting the facts right.

Whenever I write, I work from publicly available documents whenever possible. I cite legislation. I compare original source materials. I distinguish between facts, interpretations, and my own opinions. And when I discover that I have made a factual mistake, I correct it.

Yesterday, however, I received a letter from an attorney representing AMTA accusing me of spreading “false statements,” “lies,” and “misinformation.” It was also cc’d to the other CEO and GR Chair for AMTA National. (Stegink, Flom, Specker)

What struck me most wasn’t the accusation itself.

It was what was missing.

The letter did not identify which specific statements were supposedly false.

As someone committed to accuracy, I welcome correction. If I have published an incorrect factual statement, I want to know exactly what it is. Tell me where I got it wrong. Show me the evidence. I’ll review it carefully and correct any verified error.

That’s how honest discussion works.

But disagreement is not the same as misinformation.

People can look at the same legislation, the same meeting minutes, the same public statements, and reach different conclusions. That is especially true when discussing public policy, organizational governance, legislative strategy, and the future of a profession.

Healthy professions should encourage those conversations—not discourage them.

Throughout my work, I have asked massage therapists to do something very simple:

Don’t believe me. Don’t believe AMTA. Don’t believe anyone without looking at the evidence.

Read the legislation.

Read the meeting minutes.

Read the position statements.

Read the original documents.

Then decide for yourself.

That has always been the purpose of Massage Therapy Nexus.

I have no interest in attacking individuals. My goal has never been to create division for the sake of division. My goal is to encourage transparency, accountability, and informed discussion about issues that affect every massage therapist.

The massage profession deserves organizations that welcome thoughtful questions, explain their decisions openly, and engage respectfully with members who hold different views.

We should never confuse criticism with disloyalty.

Nor should we confuse disagreement with misinformation.

Progress depends on our willingness to ask difficult questions, examine the evidence honestly, and continue learning—even when the answers make us uncomfortable.

That is the standard I intend to continue following. I will be continuing to ask the questions. I hope you will too.

Sincerely, Julie Onofrio, LMT

A Note About My Writing

The views expressed on this website and my social media platforms are my own. My commentary is intended to encourage discussion about issues affecting the massage therapy profession and is based on publicly available documents, legislative records, organizational publications, and other source materials.

When I express an opinion, it is my opinion. When I state factual information, I strive to ensure it is accurate and supported by reliable sources. If I become aware of a factual error, I will promptly review the evidence and make any appropriate corrections.

I welcome respectful dialogue and evidence-based discussion. If you believe I have made a factual error, please contact me with the specific information and supporting documentation so I can review it. Thanks for your continuing support! Julie Onofrio LMT

I graduated from massage school in 1987 with 250 hours of education. That was the requirement at the time. I opened a practice in a Seattle gym with a friend from school, and I had no idea what I was doing on the business side. Nobody did. There was nothing to read.

In 1996, Washington passed a law requiring health plans to cover massage therapy called the Every Category Law and overnight, a door opened that had been shut for the entire history of our profession.

Back then there were a few manuals on billing insurance. The way we learned was by helping each other. Back then there was no internet, email or anything so it was just information sharing the old fashioned way - talking to each other.

I wrote the first edition of my billing manual in 2005 specifically so nobody else would have to learn it that way. The manuals that were out there were not updated. I kept mine updated.

The door is open wider than it has ever been

Here’s what’s true in 2026, and what most massage therapists still don’t know:

The VA is the single biggest opportunity in our profession’s history. In 2017, the VA added massage under its Complementary & Integrative Health umbrella through VHA Directive 1137. Veterans can receive clinical massage as part of their treatment. You get an authorization before you treat, you bill the codes you were authorized for, and the VA pays the full cost. No co-pays. No chasing patients for money.

Over 250 Medicare Advantage plans now include massage therapy benefits. Original Medicare still doesn’t cover massage performed independently by an LMT — that hasn’t changed. But Medicare Advantage is a different animal, privately administered, and it has quietly become one of the fastest-growing sectors for our profession. Most of these plans target exactly what we’re good at: chronic musculoskeletal pain.

Workers’ compensation has been paying for decades. Musculoskeletal injuries are the number one workers’ comp claim in the country. That is not a niche. That is the center of the map.

Auto injury (PIP and MedPay) pays without co-pays. It’s documentation-heavy and attorneys are often involved, which scares people off. But the coverage is real.

Six sectors, actually. Add commercial insurance and employer self-funded ERISA plans, and you have six distinct systems that will pay a licensed massage therapist.

Six sectors. Six completely different sets of rules.

And that last sentence is the whole problem.

The barrier isn’t complexity. It’s not knowing where to begin.

Many claim it isn’t worth it. But there is another factor that does make it worth it. It is about being at the table and showing the carriers through charting how and why massage therapy works.

It is also about the dwindling pay rates of some health insurance carriers too. There is an answer to that too. In WA State we recently teamed up with 15 other professions and created a bill for fair pay. While it didn’t pass it was revealing. The insurance carrier lobbyists were caught lying for years saying that they would always negotiate a contract with massage therapists but it finally came out that indeed they don’t! After that some of the carriers started increasing their allowable fees.

So the problem is that no one has been advocating for us in the health insurance arena or health care integration. Learning to bill and just starting with a few cases will show you how it is all working and not working so we can also work to get to the table with insurance carriers and organizations like the VA and Workers comp.

Which brings me to the part that actually matters

I’ve spent nearly forty years in this profession. I’m was the AMTA-WA government relations chair. I helped found the Washington State Massage Therapy Association. I have spent an enormous amount of my life on advocacy. I have come to believe that the most powerful advocacy tool most therapists have isn’t a letter to a legislator.

It’s a clean claim.

Every properly billed, well-documented claim you submit is a data point. It says: massage therapy exists in a real clinical context, addressing a real health problem, with a measurable outcome. It builds the evidentiary record that policy is eventually written from.

Every therapist who gives up before starting is a data point too — an absence, a silence, a hole in the record where our profession should be.

Coverage and allowable fees do not expand because insurers wake up one morning persuaded of our value. It expands because therapists understand the rules well enough to insist on fair treatment inside them.

If you are not at the table, you are on the menu. That’s not a slogan. It’s a description of what happens when a profession declines to participate in the systems that determine its future. Allowable fees get set without our data. Rules get written about our scope without our input. And we find out afterward.

So here’s the guide

I put together a free Insurance Billing Field Guide — fourteen pages, no cost — because I got tired of watching people quit at step one. It is an introduction to the six sectors where massage therapists can bill and how each one actually works. Getting your NPI and CAQH set up. CPT and ICD-10 codes explained plainly, including the 8-minute rule and the pairings that trigger audits. Functional SOAP notes that get approved. The CMS-1500 form, box by box. HIPAA and the fraud statutes you need to know about. And the prescription rule, in detail, so you never take a phone rep’s word for it again.

It’s the overview I wish someone had handed me in 1996.

Download the free Field Guide →

If you want the complete version — the templates, the exact workflows, the appeal strategies, the legal detail — that’s my full manual, Modern Insurance Billing for the Massage Professional, now in its fourth edition. But start with the guide. Start with the NPI. Start this week.

When you have questions, bring them to the Massage Insurance Billing group. Insurance billing is isolating by design — carriers don’t publish what they pay, denials feel personal, and most of us are working alone. Comparing notes with other therapists is how we find out what’s actually true.

The door is open. It has never been open this wide.

Walk through it.

Julie Onofrio, LMT has been a massage therapist since 1987 and has billed insurance for most of that career — workers’ comp, motor vehicle collisions, and health insurance. She wrote the first edition of her insurance billing manual in 2005. See the full table of contents and details of the Massage Insurance Billing Manual.

This isn’t incompetence. It’s structural and until we understand the structure, we can’t fix it.

Let me explain the two legal systems that are supposed to be protecting the massage therapy profession — and why they keep failing us.

Two systems. Two completely different jobs.

Civil law — sometimes called administrative law — is where licensing lives. Your massage license is a civil instrument. Your state board is a civil agency. When the board fines someone, suspends a license, or denies an application, that’s civil law doing its job. Civil law is about regulation, compliance, and professional standards.

Criminal law is where trafficking, prostitution, and organized crime live. When law enforcement makes an arrest, charges someone with a crime, and sends a case to the district attorney, that’s criminal law doing its job. Criminal law is about punishing conduct that harms people and society.

Here’s the problem: these are two separate systems, with two separate agencies, two separate courts, two separate standards of proof, and almost no coordination between them. We keep trying to solve a criminal problem with civil tools.

What a licensing board can and cannot do

Your state board can inspect premises. It can review license applications. It can fine licensees, suspend licenses, and revoke them. It can deny renewal. In some states it can assess civil penalties.

What it cannot do: make an arrest. Kick down a door. Charge someone with a crime. Subpoena records from a criminal enterprise. Freeze assets. Compel testimony under oath in a criminal proceeding.

So when a board inspector walks into a business and finds unlicensed workers, they can write a civil fine. That fine goes to the owner of record — who may be a shell company, a fake name, or someone who has already moved on to open another location two miles away. The business keeps operating. The fine is a cost of doing business. The workers, many of whom are trafficking victims with no control over what happens to them, face the consequences.

You cannot regulate a criminal problem with an administrative solution. It has to go through the criminal justice system.

That is not a criticism of state boards. It is a description of reality. Boards were built to regulate professionals. They were not built to investigate criminal enterprises.

Four Things That Would Actually Change This — And How to Make Each One Happen

We have been having the same conversation for decades. How do we get rid of the sexually oriented businesses disguised as massage that are destroying our profession’s reputation, trapping women in exploitation, and making it impossible for licensed therapists to be taken seriously?

We keep getting the same answers: more ordinances, more establishment licensing, more paperwork, more compliance burdens on the people who already followed all the rules.

None of it is working. The number of these businesses has nearly doubled since 2018.

I want to talk about what would actually work. Not more laws layered on top of broken enforcement. Not more requirements for licensed therapists to prove they’re not criminals. What would actually change this.

There are four things and for each one I have some ideas on exactly how to push for it.

The Fix Is Simpler Than You Think

We keep making this complicated. It isn’t.

Four things would change this situation. Here they are, plain and direct.

1. Give law enforcement the authority to act.

Right now a police officer can walk into a massage business, find workers without licenses, and do almost nothing about it — because in most states, licensing violations go to the board, not to law enforcement. The board can write fines. It can’t make arrests.

We need law enforcement to be able to write a citation on the spot, the same way a cop writes a traffic ticket. No board referral. No complaint form. No waiting. An unlicensed worker in your business? The officer cites the owner. That day.

To make this happen, ask your state legislators one question: does a police officer in this state have the authority to cite a massage business owner for employing unlicensed workers? In most states, the answer is no. That is your opening.

2. Stop treating our profession as the problem.

Every law that piles new requirements specifically onto massage businesses — requirements that don’t apply to physical therapists, chiropractors, or acupuncturists — treats massage therapy as inherently suspect. We are not the problem. We are a healthcare profession that criminals are using as a cover. Those are not the same thing.

We regulate doctors. We prosecute drug dealers. We do not make every physician’s office prove it isn’t a pharmacy front. We should be demanding the same standard for ourselves.

When a new licensing bill comes up in your state, ask this: does this apply to physical therapy offices? If the answer is no, push back. Ask why massage is being treated differently. Put that question on the record every single time.

3. Make it a crime to OWN/ RUN an unlicensed operation — and aim at the owner.

A civil fine doesn’t stop an organized criminal operation. It’s a business expense. What stops it is a misdemeanor charge on the first offense and a felony on the second — aimed at the owner who is running the business, not the workers who may have no say in what happens inside it.

Add one more thing: a prohibition on reopening. An operator who has been convicted cannot open another massage business in this state (or any state - not sure how to make that happen). Period. That closes the revolving door where someone gets caught, closes the location, and reopens two blocks away under a different name three weeks later.

Talk to your state legislators about criminal penalties aimed at owners. Tell them the owner bears the responsibility, the owner faces the charge.

4. Stop trying to build the perfect case. Just make it uncomfortable to operate.

Human trafficking prosecutions are hard. They require enormous resources, terrified witnesses who may not be able to testify, and months or years of investigation. Most districts cannot build them. While everyone waits for the case that never comes, the business keeps running. Just make it harder to do business with stricter fines like felonies and high monetary penalties.

The Missouri Attorney General’s Hope Initiative produced a 45% statewide reduction in these businesses in nine months. Not through trafficking convictions. Through letters to landlords.

That is the model. Make it expensive. Make it visible. Make it a problem every single day. Ongoing unannounced inspections. License verification every time. Landlord letters. Business license denial for operators with a history of violations. Bad actor registries. None of these require a trafficking case. All of them make the business model harder to sustain.

The people running these operations are counting on us to stay confused, stay fragmented, and keep trying to solve a criminal problem through licensing paperwork while they operate in plain sight.

We can do better.

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That’s not an opinion. That’s the gap this work is trying to close.

Today I’m releasing a resource I’ve been building for the Massage Therapy Nexus HUB: a state-by-state analysis of every establishment licensing law currently on the books in the United States. Twenty-three states. Five questions answered for each one and a clear-eyed look at what we actually know — and what we urgently need to find out. ( I did this all myself - yes with the help of AI but I am checking everything so let me know of any errors or misinformation.)

Why this matters

The only published academic research on this question — a peer-reviewed study comparing Texas and Oklahoma1 during the period when Texas implemented licensing — found no evidence that massage therapist licensing reduced crime rates. That study had real limitations, and the authors acknowledged them. But its core finding was damning: we passed these laws, we told the profession it would help, and we never measured whether it did.

The FSMTB’s establishment licensing toolkit argues these laws are valuable tools. The profession’s two largest associations, ABMP and AMTA, have pushed back, arguing that establishment licensing treats massage therapy differently from every other healthcare profession and puts the burden of a criminal problem on civil licensing2. They’re both right about something. They’re both missing data.

The argument that has never been settled — because nobody has done the work to settle it — is this:

Does establishment licensing actually reduce the presence and operation of sexually oriented businesses disguised as massage, or does it simply create a compliance burden for licensed therapists while bad actors adapt and reopen somewhere else?

The scoping document in my research files puts it plainly: “Legislative whack-a-mole. Traffickers adapt and more and tougher establishment licensing laws are not the answer.” That might be true. But it also might not be. We don’t know.

The full guide — all 23 states, all five questions, every verify flag and research gap — is available as a downloadable PDF through the link. This is the foundation document for the research that needs to happen next.

The survey. No one has asked licensed massage therapists in establishment licensing states how the law has affected their practices. I built one.

Take the survey today.

Now I need more help.

I am asking for help in submitting public records requests to state boards for establishment license counts, denial rates, and enforcement actions. I am asking for your help first - ask your state board for the information. I have the full instructions here.

Twenty-three states have some form of establishment licensing. Every single one of them passed that law without a benchmark, without a measurement plan, and without asking the people most affected — licensed massage therapists — whether it helped.

That’s not good enough. The profession deserves to know whether the laws being passed in its name are actually working. The victims in these businesses deserve better policy, not more paperwork. And the licensed therapists who carry the compliance burden every single day deserve someone asking whether it was worth it.

Here’s where I need your help.

I need people who are willing to help me request public records from state boards. Enforcement data, establishment license counts, denial rates — this information is public record. It just takes someone willing to submit the requests and wait for the responses. Sign up here to let me know you are working on your state.

Download the form letter to request public records. https://docs.google.com/document/d/1vEAdFykthdY9r6VJcqMNzz4OR_btf_OFtLC6OC_ihdU/edit?usp=sharing

I need LMTs in states that are currently debating establishment licensing to let me know what’s happening in your legislature. These debates are happening right now, with the same recycled arguments on both sides and no new data. We can change that.

For 128 years this profession has been fighting to separate itself from businesses that have nothing to do with massage therapy. We’ve tried associations, certifications, individual licensing, and now establishment licensing. Each tool has been adopted with confidence and evaluated with almost no rigor.

It’s time to actually look.

If you’re in state with establishment licensing, sign up to investigate your state! Let’s find out together what’s working, what isn’t, and what we should be asking for instead.

— Julie Onofrio, LMT
www.lookbeforeyoubookamassage.com
www.massagetherapynexus.com
Tired of waiting for our associations to do something. I am not even sure if this will work or provide us with the information we need to help create better laws. I won’t be stopping until we figure it out!

2

https://www.abmp.com/updates/news/abmp-and-amta-joint-response-fsmtb-human-trafficking-report

Some massage therapists think primarily in terms of anatomy, physiology, and biomechanics. Others focus on the nervous system. Some work from Traditional Chinese Medicine or Ayurvedic principles. Others incorporate Reiki, Healing Touch, Therapeutic Touch, or other forms of energy work into their practice.

The diversity of these approaches has helped the profession reach many different people. It has also created a problem that we rarely discuss openly.

We often use the same words to mean completely different things.

No word illustrates this better than energy.

What does “energy” actually mean?

If you ask a physicist what energy is, the answer is surprisingly straightforward.

Energy is the capacity to do work.

It exists in forms that can be measured, including heat, light, electricity, chemical energy, kinetic energy, and gravitational energy. Scientists can calculate it, measure it, and describe how it changes from one form to another.

Our bodies certainly contain energy in this scientific sense.

Our nerves conduct electrical signals.

Our muscles convert chemical energy into movement.

Our hearts and brains generate tiny electrical and magnetic fields.

Our cells constantly transform energy through metabolism.

None of this is controversial. It is basic biology and physics.

The other meaning of energy

Many traditional healing systems use the word energy very differently.

Traditional Chinese Medicine describes qi.

Ayurveda describes prana.

Reiki practitioners speak of universal life energy.

Healing Touch and Therapeutic Touch describe balancing or influencing the body’s energy field.

These ideas are meaningful to many practitioners and clients. They are part of long-standing healing traditions that deserve to be understood within their own historical and cultural contexts.

The difficulty arises when we begin using scientific language to describe concepts that science has not established.

When we say we are balancing electromagnetic fields, changing frequencies, or altering vibrations in a scientific sense, we are making claims that require scientific evidence.

At present, that evidence does not exist in the way many people assume it does.

Experience is not the same as explanation

This distinction is important because it is often misunderstood.

Suppose a client receives an energy-based treatment and leaves feeling calmer, sleeping better, and reporting less pain.

Those experiences are real.

The question is not whether the client improved.

The question is how we explain the improvement.

Many factors could contribute.

• The therapeutic relationship.

• Focused attention.

• Relaxation.

• Reduced stress.

• Changes in autonomic nervous system activity.

• Expectation.

• Meaning.

• Gentle touch.

• Time away from daily pressures.

• The body’s own capacity to recover.

These explanations are supported by growing scientific evidence.

None of them require an invisible life force to exist.

That does not prove traditional energy concepts are false.

It simply means we do not have scientific evidence demonstrating them as measurable physical phenomena.

There is an important difference between saying, “We do not know,” and saying, “Science has proven this.”

Why language matters

Some people will ask why this distinction is so important.

After all, if clients benefit, does the explanation really matter?

I believe it does.

Massage therapy increasingly presents itself as a healthcare profession.

We seek greater integration into hospitals, rehabilitation settings, multidisciplinary clinics, insurance systems, and public health.

Healthcare depends on clear communication.

When we use scientific words in ways that scientists do not recognize, we create confusion instead of clarity.

This has consequences.

It makes research more difficult.

It weakens our credibility with physicians and other healthcare professionals.

It gives critics an easy opportunity to dismiss legitimate benefits because our language appears to overstate what is known.

We don’t have to choose sides

This conversation is often framed as a battle.

Either you believe in energy work or you believe in science.

I do not think the profession benefits from that false choice.

Traditional healing systems deserve respect as historical and cultural models of understanding health.

Scientific medicine deserves respect for developing methods that allow ideas to be tested objectively.

Those two things can coexist. What we should avoid is presenting traditional beliefs as though they have already been confirmed by modern physics. Likewise, we should avoid dismissing every client experience simply because we cannot yet explain it.

Humility belongs on both sides.

A better way forward

Perhaps massage therapy should become more intentional about distinguishing among three different kinds of statements.

Traditional belief

“This healing system teaches that balancing qi supports health.”

Clinical observation

“Many clients report feeling calmer and more relaxed after this treatment.”

Scientific evidence

“Research has demonstrated measurable changes in these physiological processes.”

These are not competing ideas.

They simply answer different questions.

One describes a philosophy.

One describes experience.

One describes evidence.

Confusing them helps no one.

The future of massage therapy

As our profession continues to evolve, I believe our language will matter as much as our techniques.

We do not strengthen massage therapy by borrowing scientific terminology that has different meanings within science.

We strengthen it by being honest about what we know, careful about what we claim, and curious about what remains to be discovered.

Massage therapy has always lived at the intersection of art, tradition, and science.

We do not have to abandon any of those.

But if we hope to become a more respected healthcare profession, we should learn to recognize which one we are speaking from at any given moment.

That kind of clarity is not a weakness.

It is the foundation of credibility.

This article was created as a result of a discussion on Facebook about the ABMP article Energy Medicine in Bodywork Expand the Lens of Your Practice By Lynn Teachworth Summer 2026

Also read this article Science and Energy from Keith Grant, a physicist and massage instructor on his website Ramblemuse.

See also the video below: Does Reiki Work?

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**250 Years After America’s Declaration of Independence**

When, in the course of professional history, it becomes necessary for a profession to reclaim its purpose, restore its voice, and secure its future, respect for those we serve requires that we declare the principles upon which that future shall be built.

We hold these truths to be self-evident:

That every person deserves safe, ethical, competent massage care.

That therapeutic touch has value beyond relaxation alone, improving health, easing suffering, supporting recovery, and strengthening human connection.

That massage therapists are healthcare professionals, educators, business owners, researchers, and compassionate caregivers whose work deserves understanding and respect.

That a profession belongs to its practitioners, not to institutions or associations.

Whenever organizations lose sight of those they represent, whenever transparency gives way to secrecy, whenever politics replaces service, whenever division replaces collaboration, it is the right and the responsibility of professionals to seek a better path.

Therefore, we declare our independence from:

* confusion over who we are and what we do.

* outdated definitions that fail to describe modern massage practice.

* fear-based advocacy that defines us by what we are not.

* unnecessary division among therapists, schools, educators, researchers, businesses, and professional organizations.

* silence in the face of problems that affect both practitioners and the public.

* the belief that individual therapists have no voice in shaping their profession.

Instead, we declare our commitment to:

* evidence where evidence exists, and honest inquiry where it does not.

* ethical practice rooted in compassion and accountability.

* education that prepares therapists for the future, not merely for licensure.

* member-driven leadership that earns trust through openness and transparency.

* protecting the public while supporting ethical practitioners.

* confronting human trafficking and illicit businesses without allowing them to define massage therapy.

* advancing massage as an essential part of health and well-being.

* preserving the uniquely human value of therapeutic touch in an age increasingly shaped by machines and artificial intelligence.

We believe that disagreement need not become division.

We believe that progress requires conversation.

We believe that history should inform the future, not imprison it.

And we believe that the next generation of massage therapists deserves a profession stronger than the one we inherited.

Therefore, with respect for those who built this profession before us, and confidence in those who will carry it forward, we pledge ourselves to the work ahead.

Not for one association.

Not for one school.

Not for one philosophy.

But for the profession itself.

Because the future of massage therapy will not be written by a few.

**It will be written by all of us.

**The profession does not belong to any association, certifying body, regulator, or corporation. It belongs to every ethical massage therapist who serves with knowledge, skill, integrity, and compassion.**

The short answer: there was no massage therapist waiting to see you. That profession didn’t exist yet — not in America, not anywhere. But therapeutic touch was everywhere, tucked inside older, stranger systems of belief. Understanding it tells you a lot about the country that was just being born.

So no — there was no occupation called “massage” in Philadelphia or Boston in 1776. The word itself didn’t exist in English yet. The systematic techniques we now think of as “Swedish massage” were developed by a Swedish gymnast named Pehr Henrik Ling — who, in a small coincidence, was born in 1776, the same year as the Declaration. His movement cure wouldn’t take shape for another three decades, and it wouldn’t cross the ocean to America until the 1850s. The word “masseuse” didn’t enter common use until the 1880s. “Massage therapist” as a job title is practically modern — it dates to the mid-20th century.

So what actually happened when your body hurt?

Manual healing existed in 1776 America — just not as its own profession. It was folded into everything else: home remedies, midwifery, bonesetting, and the healing traditions that Native Americans and enslaved Africans carried and preserved, often against enormous pressure to abandon them.

The caregiver archetype is the root of all others in the history of massage therapy in North America. The domestic caregiver of colonial times tended to the needs of the sick and injured using simple medicines and herbal remedies, and provided comfort and healing for those under her care. She used basic manual techniques of friction and rubbing for various purposes in the execution of her duties. The caregiver accumulated practical knowledge and benefited from experience that was passed down from generation to generation in folk remedies and home care practices. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

At home, mostly by women. With trained physicians scarce outside the biggest cities, most healthcare in Revolutionary America happened in the kitchen, not the clinic. Families relied on household remedy books, inherited knowledge, and the hands of mothers, aunts, and neighbors. The era’s bestselling home medical guide, a Scottish physician’s manual called Domestic Medicine, sold tens of thousands of copies on both sides of the Atlantic and recommended rubbing, friction with oils or spirits, and warm compresses for everything from sprains to nervous complaints. This wasn’t considered a specialized skill — it was just what a capable household did.

When someone was sick or injured in the colonies, the first line of treatment was in the home, and was routinely provided by women.7 Folk healing, called “domestic medicine” by some anthropologists, was the primary line of care in the remote communities of the early colonies. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Midwives, who did far more than deliver babies. The best window we have into this world comes from the diary of Martha Ballard, a Maine midwife who delivered over 800 babies between 1785 and 1812 while also functioning as her town’s de facto doctor, nurse, and pharmacist. Her hands did the work that would later be split across a dozen professions — hers included the kind of manual, physical care we’d now recognize as bodywork, though nobody at the time would have called it that.

Bonesetters — the closest thing to a specialist. A handful of families made a name for manual manipulation specifically. The most famous were the Sweets of Rhode Island, whose bonesetting skill was passed down for generations. One of them, Job Sweet, was called on during the Revolution to treat wounded French officers, and after the war Aaron Burr reportedly summoned him to reset his own daughter’s dislocated hip. This was hands-on, technical, valued work — but it was about bones and joints, closer to what we’d now call orthopedics than to relaxation massage.

In colonial North America, when a disease or injury was beyond the expertise of those at home, folk healers or doctors were called upon for help. Among the most respected lay medical practitioners available at the time were the midwife and the bonesetter. The midwife and bonesetter archetypes are notable in the history of massage for a number of reasons. The midwife, who cared for the special needs of women, and the bonesetter, who treated musculoskeletal problems, demonstrate the importance of lay healers in colonial times. Especially in the early days, they would not have been considered alternatives to regular medicine – they often were the only health care providers in the area.

Midwives and bonesetters were highly skilled hands-on specialists sought out for their ability to heal – relying almost exclusively on their own experience and on traditions passed down from generation to generation without the benefit of schools and textbooks. Although their work was not defined entirely by soft tissue techniques, rubbing and friction were important tools in their skill sets. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Native healing traditions that predated the colonies entirely. Indigenous nations had their own long-standing systems combining herbal medicine, sweat lodges, prayer, and manual techniques like rubbing for pain and swelling. These traditions operated on their own terms, largely outside colonial society, and in some cases later influenced American manual medicine in ways history rarely credits properly.

In 1774, signer of the Declaration of Independence and prominent physician Benjamin Rush (1746-1813) presented a paper to an early medical society, the American Philosophical Society, titled An Inquiry into the Natural History of Medicine among the Indians. Among other things, Rush noted that the “Indians” around Philadelphia maintained good health by anointing their bodies with oil and by taking cold baths every day. He concluded, however, “We have no discoveries in the materia medica to hope for from the Indians of North America.” Apparently caregivers in the settlements thought otherwise. ~Patricia Benjamin, PhD. The Emergence of the Massage Therapy Profession in North America. A History in Archetypes

Healing carried by enslaved Africans, often in secret. Enslaved communities maintained their own medical knowledge alongside — and often instead of — whatever care enslavers provided, including herbalism, spiritual healing, and hands-on treatment passed down from African traditions. This knowledge was so threatening to the social order that Virginia and South Carolina made it a capital crime for enslaved people to teach or practice herbal medicine. That a colony would criminalize healing knowledge tells you something about how much power was recognized in those hands, even as it was suppressed.
Article, "'I have been obliged to Send Nassaw': an enslaved healer's medical labour and skill in eighteenth-century Virginia," Medical History, 2021.

Why this matters on the 250th

There’s something worth sitting with here. The founding generation didn’t have massage therapists, chiropractors, or physical therapists. What they had was a patchwork — home remedies rooted in old European humoral theory, hereditary bonesetting families, midwives who were really community health workers, and Indigenous and African healing traditions that persisted despite everything working against them.

None of it looked like a spa. All of it was someone’s hands, doing their best, for another person’s body. Two hundred fifty years later, we’ve turned that instinct into a licensed profession with its own vocabulary and credentials — but the underlying impulse, that touch itself can heal, hasn’t really changed at all. It just used to run in the family, or live in the kitchen, or hide in plain sight.

So this Fourth of July, somewhere between the fireworks and the flag-waving, it’s worth remembering: the country’s founders had no massage therapists. But they had healers all the same — they just called them mothers, midwives, and neighbors.

Starting a state-focused massage therapy association has been both exciting and humbling. It began with the question: What does our profession need right here, in this state, at this time? For the Illinois Massage Therapy Professional Association, or IMTPA, the answer was clear.

Illinois massage therapists needed an organization focused specifically on Illinois law, Illinois advocacy, Illinois licensure issues, Illinois public safety concerns, and Illinois opportunities for healthcare integration. National organizations serve an important role, but they cannot always respond to every state and local issue with the speed or specificity those issues require. Massage therapy laws, local ordinances, regulatory decisions, legislative relationships, insurance coverage, healthcare integration, and public safety concerns often unfold in real time within each state. A state-focused association can help ensure therapists have a voice where those decisions are being made.

IMTPA is still in its early stages. We have not reached every milestone we hope to reach, and we are still learning as we build. Many of the ideas in this article are not presented as finished accomplishments, but as lessons, priorities, and goals that have guided the formation of IMTPA and may help others who are considering a similar effort in their own state.

Start With a Clear Purpose

Before forming an association, it is important to define why the organization needs to exist. For IMTPA, the purpose was not to duplicate what already existed. The goal was to create an Illinois-focused, profession-driven, member-centered organization that could respond to the specific needs of Illinois licensed massage therapists.

That meant asking:

• What are therapists in our state struggling with?]

• What laws or regulations affect daily practice?

• Are local ordinances treating legitimate massage therapy fairly?

• Are massage therapists included in healthcare conversations?

• Do therapists understand legislative changes that may affect their license?

A state association needs a clear mission from the beginning. Without that, it is easy to become reactive, scattered, or overly dependent on one issue. A strong mission helps guide decisions, explain the organization to others, and keep the work focused when things become busy.

For IMTPA, that mission continues to serve as a guide. We are still developing the organization, but having a clear purpose has helped us decide what issues deserve attention and what kind of association we want to become.

Build the Foundation Before You Build the Public Presence

It is tempting to launch quickly, especially when there is momentum or urgency around a legislative issue. But an association needs a solid foundation before it can effectively represent the profession.

Be sure to research your state’s laws and procedures for forming a professional association or nonprofit entity. Once the organization is properly established at the state level, consideration can then be given to the appropriate federal tax status. Understanding tax rules, reporting requirements, and financial responsibilities is extremely important. These details are what help keep the association legitimate, accountable, and able to serve the profession with credibility.

Some of the early steps aside from forming a legal entity include writing bylaws, creating basic policies, identifying board roles, setting membership categories, opening a bank account, and deciding how decisions will be made.

A professional association needs structure, transparency, and accountability. Members need to know who is leading the organization, how decisions are made, how money is handled, and how they can participate.

For IMTPA, governance documents, board policies, meeting procedures, membership structure, and internal systems have been important early priorities. Some of these pieces have been started, while others continue to be refined as the organization grows. Building this foundation has helped us better explain who we are, what we are working toward, and how therapists may eventually participate more fully.

Keep the Mission Bigger Than One Person

Many state-level efforts begin because a few people see a need and are willing to work. That is often how grassroots advocacy starts. Over time, the goal is to turn that early energy into a shared structure that others can participate in and help carry forward.

From the beginning, think about sustainability.

Create systems. Use shared documents. Keep meeting minutes. Track decisions. Write down processes. Create templates. Build committees when possible. Invite members to help with specific projects.

IMTPA is still working towards this. Like many new organizations, much of the early work has required a small group of people to carry several responsibilities at once. That is common in the beginning, but it should not be the long-term goal. A healthy association needs shared responsibility, clear roles, and room for others to step into the work. Not every volunteer needs to serve on the board. Some people may be willing to make phone calls, review local ordinances, write educational content, share social media posts, help with outreach, or attend a legislative meeting. A strong association creates many ways for people to participate.

Understand the State’s Legislative and Regulatory Landscape

A state-focused massage therapy association needs to understand how laws, rules, and regulations affect the profession. That does not mean every board member needs to be a legal expert or lobbyist. It does mean the association should learn how to track bills, read legislative language, understand committee assignments, monitor licensing board activity, and communicate clearly with members about what is happening.

For massage therapists, legislative updates can feel confusing or overwhelming. One of the most valuable services a state association can provide is translating complex policy activity into plain language.

For example:

• What does this bill do?

• Does it affect massage therapy?

• Is it moving forward or stalled?

• Who should therapists contact?

• What should they say?

• What happens next?

This is an area where IMTPA hopes to continue growing. Legislative tracking, compact discussions, licensing issues, and regulatory updates are all part of the work we believe a state association should be paying attention to. We are still developing our systems for communication and member updates, but the goal is to help Illinois therapists better understand what is happening before decisions are made without their input.

State associations can also help build relationships with legislators and regulators before there is a crisis. Advocacy is not only about opposing or supporting bills. It is also about education, trust, and being available as a professional resource.

Pay Attention to Local Ordinances

One of the biggest lessons from Illinois is that local ordinances matter. Massage therapists are often affected not only by state licensing law, but also by city and village rules. These ordinances may address zoning, business licensing, inspections, signage, hours of operation, room requirements, employee records, or anti-trafficking provisions.

Public safety is important. Communities have a legitimate interest in preventing illicit businesses and human trafficking. At the same time, ordinances should not unnecessarily burden licensed massage therapists who are practicing legally and professionally.

IMTPA has begun paying close attention to local ordinance activity because we believe licensed massage therapists should be included when local rules are being discussed. A state association can help by reviewing proposed ordinances, educating local officials about the impact on licensed therapists, encouraging stakeholder input, and referring municipalities to appropriate professional and public safety resources, such as FSMTB and The Network, when more specialized guidance is needed.

Focus on Member Value Early

When starting an association, people will ask: Why should I join?

That is a fair question.

Members need more than a mission statement. They need to see practical value. For a state massage therapy association, value may include legislative updates, compliance resources, local ordinance alerts, templates, professional guidance, networking, healthcare integration tools, employer resources, continuing education updates, and opportunities to participate in advocacy.

For IMTPA, these are goals we are working toward. Some resources may be created early, while others will take more time, more volunteers, more funding, and more member input. It is important not to promise more than a new association can realistically deliver right away.

Early member resources do not have to be perfect or expensive. They should be useful.

Examples of possible resources include:

• A state practice compliance guide

• A legislative update page

• A local ordinance checklist

• A provider outreach letter

• A documentation template

• A member survey

• A volunteer interest form

• A plain-language explanation of current bills

• A sample letter to local officials

• A guide to contacting legislators

As IMTPA grows, resources like these can help turn the mission into practical support for members.

Communicate Often and Clearly

Clear communication is one of the most important parts of building trust.

Massage therapists are busy. Many are solo practitioners. Many do not have time to follow legislative calendars, board meetings, municipal agendas, or policy changes. A state association can help by providing short, timely, accurate updates.

Communication should be professional, but it should also be understandable. Avoid unnecessary jargon. Explain what is known, what is not known, and what members can do. This is especially important for a new association. In the early stages, not everything will be fully developed. Not every question will have an immediate answer. Not every project will be finished. Being honest about that matters.

It is also important to be honest when something is still developing. Not every bill will pass. Not every local ordinance will change. Not every effort of advocacy will produce an immediate result. But members should be able to trust that the association is watching, communicating, and representing the profession in good faith.

Build Relationships, Not Just Campaigns

Advocacy works best when relationships are built over time.

State legislators, municipal officials, licensing board members, regulators, healthcare partners, schools, employers, and public safety organizations may all affect the future of massage therapy. A state association should think beyond one bill or one issue.

Relationship-building may include introducing the association, offering to be a resource, attending public meetings, requesting stakeholder input, thanking officials for their time, and following up respectfully.

For IMTPA, relationship-building is a long-term goal. The profession benefits when massage therapists are known as informed, professional, and constructive participants in state and local conversations.

Be Willing to Learn as You Go

No one starts an association knowing everything.

There will be questions about nonprofit structure, tax status, governance, insurance, banking, membership systems, websites, committees, volunteers, legislative tracking, public messaging, and board development. That is normal.

The key is to keep learning, ask good questions, document decisions, consult qualified professionals as needed, such as an attorney or CPA, and stay aligned with the mission. Starting a state association requires patience. It also requires humility. Some things will need to be revised. Some plans will change. Some volunteers will step back. New people will step forward. The work evolves.

Protect the Profession While Welcoming the Profession

A state massage therapy association should represent the profession with seriousness and care.

That includes supporting licensed practice, ethical standards, public safety, and professional accountability.

At the same time, the association should be inclusive. Therapists come from different work settings, educational backgrounds, career stages, and professional interests. Some are clinical. Some are spa-based. Some work with veterans. Some are employers. Some are sole proprietors. Some are new graduates. Some have been practicing for decades.

A strong state association does not require everyone to think exactly alike. It creates a place where therapists can work together on shared priorities. For IMTPA, this is a guiding principle. We are still building the structure to support broad participation, but the goal is to create an association where Illinois massage therapists can be informed, involved, and respected.

Practical Steps for Therapists Considering a State Association

For anyone considering starting a state-focused massage therapy association, I would suggest thinking about the process in stages.

Early Exploration

1. Identify the need in your state.

2. Learn your state’s massage therapy law and regulatory structure.

3. Understand the current legislative, regulatory, and local ordinance issues affecting massage therapists.

4. Gather a small group of committed professionals who are willing to explore whether a state association is needed.

5. Discuss whether existing organizations are meeting the specific needs of therapists in your state.

Formation and Foundation

6. Write a clear mission statement.

7. Research your state’s requirements for forming a professional association and nonprofit entity.

8. Create basic governance documents, including bylaws, board roles, decision-making procedures, and recordkeeping practices.

9. Decide on membership categories, dues, voting rights, and basic member expectations.

10. Consider the appropriate federal tax status and consult qualified professionals as needed, such as an attorney or CPA.

Building the Association

11. Build simple systems for communication, recordkeeping, member updates, and financial tracking.

12. Begin tracking legislation, regulatory activity, and local ordinance issues in a consistent way.

13. Create practical member resources gradually, based on the needs of therapists in your state.

14. Build relationships with legislators, regulators, local officials, schools, employers, public safety organizations, healthcare partners, and other professional resources.

15. Invite participation and stay transparent about what is established, what is still being developed, and where help is needed.

Final Thoughts

Starting a state-focused massage therapy association is a significant undertaking, but it is meaningful work when it is grounded in service, transparency, and a clear purpose. For IMTPA, the goal remains to support Illinois massage therapists, strengthen the profession, and help therapists become more informed and involved in the decisions that affect their work.

To anyone considering starting a state-focused massage therapy association in your own state, I hope you find success in the work ahead. Take your time, ask good questions, seek guidance when needed, and stay focused on serving your members and strengthening the profession.

About the Author: Colleen graduated from Illinois Valley Community College with an associate degree in massage therapy and later became an adjunct instructor there. She volunteered with AMTA-IL for 9 years — serving on the government relations committee, as membership chair, and as chapter president. She currently practices in her private practice in Ottawa and is a Community Care Partner with the VA.

Local governments are writing — or rewriting — ordinances that regulate massage businesses. Some of these ordinances are good. Some are well-intentioned but flawed. Some of them treat you, a licensed healthcare professional, like a suspect. It is clear that the leaders in our communities are not informed about what happens in a massage business which leads them to create ordinances that add burdens to massage therapists while ignoring the real problem in our communities - the fact that the men who frequent these places are doing so for various reasons.

The stakes are real. The wrong ordinance can require you to submit to a second criminal background check your state already required. It can let inspectors walk into your treatment room unannounced while a client is on your table. It can mandate unlocked doors putting you and your business at risk. It can force you to keep your hours to a schedule that makes no sense for your clients’ lives.

The right ordinance, on the other hand, can do something genuinely important: make it harder for sexually oriented businesses (SOBs) disguised as massage to operate in your community — and easier for clients to find you, a real massage therapist.

We need to understand the difference. Because if we’re not at the table when these rules get written, we become the target instead of the protected.

I will actually take it a step further and say if only our laws were able to make unlicensed massage a felony with stricter penalties and law enforcement would do their job of going after these ‘bad actors’, we would not need ordinances.

Why Ordinances Exist at All

Let’s be direct about what’s happening. SOBs disguised as massage businesses are operating in every state in the country. They use the cover of massage therapy — the signage, the terminology, the storefronts — to sell commercial sex. Many of the people working in these operations are trafficking victims, controlled through debt bondage, document confiscation, and physical coercion. The victims often don’t even understand that they are victims.

This is not a massage therapy problem. It is a crime problem that is using our profession as a disguise.

Because these operations look like massage businesses on the outside, local governments have tried to regulate them through massage ordinances. When the ordinance isn’t written carefully, the burden falls on licensed massage therapists rather than on the operators of illicit sex businesses.

We can fix that. But first we need to understand what’s actually in these ordinances and what the research says works.

What the Research Shows Actually Works

The Network Team, an anti-trafficking research organization, analyzed massage ordinances from cities across the country and interviewed law enforcement, city councils, and code enforcement officials in places that had measurably reduced the presence of SOBs disguised as massage. Successful Massage Ordinance Factors September 2021 provides insights into various ordinances and provides suggestions for successful ordinances.

The cities that succeeded didn’t just write a list of rules. They focused on two things simultaneously: preventing illicit businesses from opening in the first place, and having real teeth when violations occurred.

Aurora, Colorado implemented an ordinance in 2018 that required a thorough application process and gave the city authority to close businesses immediately for certain violations. Within a year, Aurora had closed 18 illicit businesses. By 2021, its closure rate was at least 93%.

Cedar Rapids, Iowa saw a nearly 60% drop in illicit businesses within a year of passing its ordinance in November 2018.

Johnston, Iowa implemented an ordinance requiring detailed credential verification for all employees — not just the owner of record — plus an in-person interview as part of the application process. The Network could find no illicit businesses listed on sex buyer review sites in Johnston since 2016.

What made the difference? Not unlocked doors or health certificates. The things that actually worked were:

• Unannounced inspection authority. Pre-scheduling inspections lets operators hide evidence and rotate workers. Unannounced inspections — the same standard we apply to restaurant health codes — don’t.

• Rigorous application processes that verify credentials for all employees and check criminal backgrounds, not just for the owner.

• Authority to close businesses immediately when unlicensed workers are caught giving massages, when sexual activity is found, or when evidence shows women are living on the premises.

• Prompt notification of personnel changes, because trafficking operations rotate victims frequently. Requiring a business to notify the city whenever a new worker starts — with that worker’s license information — closes a major loophole.

• Regional coordination. When Aurora drove illicit businesses out, they simply moved to Denver and neighboring suburbs. When those cities passed similar ordinances the following year, the regional net became much harder to escape.

What Burdens Legitimate Massage Therapists — And Doesn’t Work

Here’s where we have to be honest about the friction between two legitimate concerns: protecting trafficking victims and protecting licensed massage therapists.

Some ordinance provisions that get proposed — sometimes with good intentions — fall harder on licensed therapists than on the illicit businesses they’re trying to address.

Unlocked door requirements are a clear example. The idea is that inspectors can verify what’s happening inside a treatment room. But a client receiving a massage has a reasonable expectation that no one will walk in unannounced mid-session. The American Massage Therapy Association explicitly opposes this provision, and they’re right to. A legitimate massage therapist shouldn’t have to choose between client privacy and legal compliance. Alternatives — like door viewing panels or mandatory response to a knock — can serve the same purpose without stripping away professional standards.

Duplicate criminal background checks add cost and delay for licensed therapists when the state practice act already required one. If your state board ran a background check before issuing your license, a second local check provides no additional public protection.

Doctor’s examinations and health certificates have no parallel in any other healthcare profession. Requiring them implies that massage therapists are presumptively a public health risk. No other licensed health professional is treated this way.

Hour restrictions so narrow they don’t match other healthcare settings penalize the many legitimate therapists who see clients in the evenings and on weekends. Reasonable late-night restrictions — say, no operation after 10 p.m. — have real enforcement value, because that’s when illicit businesses do most of their business. Restrictions tighter than that hurt legitimate therapists without added benefit. (Most massage therapists have already limited their hours because of the high risk of getting those bad actors as clients at that hour. This is problematic for many workers like airline pilots/stewardesses, doctors, factory shift workers and others.)

Ordinance provisions that apply equally to solo practitioners miss the mark entirely. A solo massage therapist working out of a single room does not present the same risk profile as a multi-practitioner establishment with rotating staff. Exemptions for sole practitioners aren’t a loophole — they’re recognition of reality.

State Establishment Licensing vs. Local Ordinances: Which Is Better?

This is the question I get asked most. The honest answer: state establishment licensing is the stronger, more durable solution — but local ordinances fill critical gaps.

As of June 2026, 24 states have some form of state-level massage establishment regulation. If your state isn’t one of them, a local ordinance may be the only tool available.

But here’s why state-level licensing is generally superior:

It creates a uniform floor. A business can’t hop from city to city to escape stricter rules when the state standard applies everywhere. This is the Aurora problem made structural — when Aurora drove illicit businesses out, they moved. A state framework eliminates that game.

It puts oversight with people who understand massage. Your state massage board knows the difference between a legitimate therapeutic business and an illicit sex operation. Local code enforcement officials often don’t. The Federation of State Massage Therapy Boards (FSMTB) has developed a full model establishment licensing framework — complete with a model application, inspection checklist, and citation form — specifically designed to be adopted by states and adapted to local needs.

Fsmtbestablishmentlicensing

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It protects sole practitioners by design. The FSMTB model explicitly exempts sole practitioners, out-call therapists, and healthcare facilities from establishment licensing requirements. That’s not an oversight — it’s intentional recognition that a single therapist working independently is a different category than a multi-practitioner business.

It bars illicit businesses from the start. The FSMTB model includes explicit language prohibiting sexually oriented businesses from obtaining a massage establishment license. They can’t even apply.

It ties violations to the disciplinary system that licensed therapists already live within. An establishment that violates standards can lose its license through the same board that licenses individual therapists — with the same due process protections.

Local ordinances still matter, though, for one crucial reason: they can move faster than state legislation, and they have an enforcement tool state boards typically lack. A city inspector can post a “closed for violations” sign the same day a violation is found. State board disciplinary processes take months.

The ideal arrangement — and what the FSMTB model explicitly builds in — is state establishment licensing that sets the floor, with local authority to enforce and add location-specific requirements that don’t conflict with state law.

What a Good Ordinance Actually Looks Like

Based on everything the research shows, here’s what we should be pushing for — and what we should be pushing back on.

Every ordinance should require:

• Verification of valid state massage therapy licenses for all practitioners — employees and independent contractors, not just the owner on record

• Criminal background checks on owners and responsible managers (not individual therapists when the state already required one)

• Explicit prohibition on SOBs disguised as massage obtaining any establishment license or permit

• Public display of all licenses

• No living on premises

• No sexual conduct on premises

• Inspection authority

• Non-transferable permits — when ownership changes, the new owner must apply from scratch

Strong ordinances also include:

• In-person application interviews

• Pre-licensing inspections before a business can open

• Hours restrictions (no operation after 10 p.m.)

• Human trafficking awareness poster requirements in multiple languages

• License numbers required in all advertisements

• Landlord notification when illicit activity is found on the property

Ordinances should never include:

• Doctor’s examinations or health certificates

• Therapist dress or hygiene language beyond what state rules already require

• Unlocked door requirements (consider alternatives instead)

• Duplicate background checks when the state already requires them

• Requirements that apply equally to solo practitioners without exemption

What You Can Do Right Now

Your city council may be writing these rules right now. Your state legislature may be considering establishment licensing. You may not know about it until it’s already law.

Here’s how to get ahead of it.

Find out what’s already on the books in your city and state. Look up your local business ordinances and your state massage practice act. What do they say about establishment licensing? Inspections? Hours?

Get connected with your state massage therapy association. They track legislative activity and often need voices like yours when ordinances are being drafted. (AMTA has already said that they are not able to help with local ordinances so consider creating a coalition in your state that will work to address the problem locally)

Learn the FSMTB model. The Federation of State Massage Therapy Boards has published a full Massage Establishment Regulatory Toolkit — including model law, a model application, inspection checklist, and citation form. It’s publicly available at fsmtb.org. If your state or city is working on establishment regulation, this is the framework you want them to start from.

Show up. City council meetings are public. Public comment periods exist. When an ordinance is being drafted that affects your profession, you have a right to be in that room. Bring your perspective. Bring the research. Bring colleagues.

Correct the language. When your local news outlet calls an illicit sex business a “massage parlor,” write to the editor. When a council member talks about “cracking down on massages,” gently redirect: this is about sexually oriented businesses disguised as massage, not about massage therapy. Words matter, and the wrong language shapes the wrong policy.

The Bottom Line

The communities that have successfully reduced the presence of SOBs disguised as massage didn’t do it by treating massage therapists as suspects. They did it by making it very hard for illicit businesses to open, and by making it fast and decisive to close them down when they did.

That’s a framework we can support. That’s a framework that protects victims, protects our profession, and protects the public.

But we have to be in the room when it’s written.

A true continuing competence system — separate from professional development — would require every state to do four things differently (or our professional associations can do this together like they worked on the Entry Level Analysis Project together):

1. Research first, requirements second. Before any state mandates competency maintenance, it needs to identify: What specific knowledge gaps correlate with disciplinary actions or client harm in massage therapy? No state currently has this data. Building it is step one.

2. Assess competence, don’t just count hours. The current system counts seat time. A competency-based system would require practitioners to demonstrate knowledge — through pass/fail assessments with identity verification — in the specific areas tied to public safety.

3. Separate regulatory from developmental requirements. State boards handle public safety. Professional associations handle career growth. Never the same bucket.

4. Publish what works. Every state would be required to publish effectiveness data: Are disciplinary actions declining? Are client complaints decreasing? If the requirements aren’t producing measurable results, they get revised. (The main problem that most boards deal with are ethical issues and usually not injuries to clients.)

What the Competency Assessment Would Cover (All States, Core Module)

Every licensed massage therapist, in every state, would demonstrate current competency in:

Ethics & Professional Boundaries

• Scope of practice for their state

• Informed consent and draping standards

• Mandatory reporting requirements

• Recognizing and responding to boundary violations

Contraindications & Client Safety

• Current evidence on contraindications (updated, not based on 1990s textbooks)

• Red flags that require medical referral

• Communicating limitations and scope to clients

• Adapted techniques for special populations

Hygiene & Infection Control

• Current public health standards

• Bloodborne pathogen protocols

• Sanitation requirements specific to their state

Legal & Regulatory Updates

• Any changes to state law since last renewal

• Human trafficking awareness and reporting (now required in many states)

• Trauma-informed practice basics

Assessment format: Online, proctored, 50–75 questions, minimum passing score. Not a no-fail survey — an actual test. Multiple approved providers compete on quality and price.

Frequency: Every 2–4 years at license renewal (aligned with current renewal cycles). Cost cap: No more than the equivalent of 2–3 hours of work at the state’s median massage therapy hourly rate.

(After a certain number of years and with no violations, the CC requirement would most likely be reduced to zero. )

State-Level Variations (Flexibility Within the Framework)

While the core module is universal, states would be permitted to add one additional competency module based on documented local need:

These modules would be based on documented harm patterns in that state — not added arbitrarily.

What Would NOT Be Required (By Any State)

Under a true continuing competence model, the following would not count toward licensure renewal:

• Technique workshops (hot stone, Thai, bamboo, etc.) — these are professional development, not competency maintenance

• Modality certifications or specialty courses — same reason

• Business development courses — professional development

• Any course not directly tied to the entry-level safety competency framework

• Courses from providers who cannot demonstrate evidence-based content

These aren’t bad courses. They just belong in a different system — the voluntary professional development system run by professional associations.

What Professional Associations Would Build Instead

With regulatory CE requirements stripped down to what actually serves public safety, professional associations (AMTA, ABMP, specialty bodies) would build the professional development infrastructure the profession actually needs:

Specialty Certification Tracks (voluntary, recognized by employers and insurers)

• Clinical/Orthopedic Massage

• Oncology Massage

• Sports Massage

• Prenatal & Perinatal Massage

• Hospital-Based Massage

• Pediatric Massage

• Geriatric Massage

Formal Mentorship Programs

• New Graduate Mentorship (first 1–2 years of practice)

• Specialty Apprenticeships

• Business Mentorship for Solo Practitioners

• Master Practitioner / Mentor Designation

Research Literacy

• Science literacy courses

• Evidence-based practice integration

• Journal clubs and peer learning circles

Business & Career Development

• Solo practice development

• Employment navigation and workers’ rights

• Leadership and advocacy training

The Timeline: What Implementation Could Look Like

Year 1–2: Research Phase

• Commission research on what knowledge deficits correlate with harm in massage therapy

• Survey disciplinary records across all state boards

• Identify the specific competency gaps that regulations should address

Year 3–4: Pilot Phase

• 3–5 states pilot the competency assessment model at renewal

• Multiple providers compete to develop assessment tools

• Costs, pass rates, and practitioner feedback documented

Year 5+: Nationwide Rollout

• Remaining states adopt model based on pilot results

• Professional associations launch formal development frameworks

• Effectiveness data published annually and used to refine the system

Why This Hasn’t Happened Yet

The honest answer: MONEY and inertia.

The CE approval and delivery industry generates significant revenue. Organizations like NCBTMB and FSMTB have built infrastructure around the current system. Professional associations use CE as a membership benefit. State boards have invested in approval processes.

Changing the system means disrupting established revenue streams — even when the evidence (or lack of it) clearly supports change.

That’s why this conversation has to happen at the practitioner level first. When enough therapists understand what the system is supposed to do — and how far the current system falls short — the pressure for reform becomes impossible to ignore.

That’s what this series is about.

Understanding Continuing Competence in the Massage Therapy Profession An examination of the evolution, controversies, and future directions of professional development requirements for massage therapists

The Massage Profession’s $252 Million Mistake: Why We’ve Been Confusing Competence with Development for 30 Years

How fixing this one confusion could transform the entire profession.
A New Model for Maintenance of Competence Evidence-Based, Practitioner-Centered, and Focused on Actual Public Safety