The city’s response? New rules for massage therapists.

I want to be fair. Some of what Federal Way passed is genuinely good — prohibiting internal warning systems designed to alert operators when law enforcement is nearby, banning late-night operations, requiring card-only payments to create a financial paper trail. These provisions target real operational signatures of criminal businesses.

The other requirements - not so much.

But here is what I can’t stop thinking about.

Licensed massage therapists in Washington State are already required by law to display their license and carry valid ID. That law exists right now. Any investigator could walk into any business claiming to offer massage and verify licensure on the Washington Department of Health website in under sixty seconds.

That tool is already in hand.

It is not being used.

So before we talk about what Federal Way got wrong — and before we talk about what actually works — we need to talk about the question nobody in that council chamber asked out loud:

Why aren’t we enforcing what we already have?

The Problem Nobody Owns

The answer is a coordination failure so complete it’s almost architectural.

Unlicensed massage practice is a civil matter — it belongs to the Washington Department of Health. Prostitution belongs to law enforcement. Business licensing belongs to the city. Human trafficking belongs to a task force that may or may not exist, may or may not be funded, and may or may not include any of the above.

Everyone has a piece of this problem. Nobody owns it.

The Department of Health is complaint-driven. They don’t have investigators walking into businesses. They respond when someone files a complaint. Trafficking victims can’t file complaints. Buyers won’t. Neighbors don’t know what they’re looking at. So the complaints don’t come, and the businesses keep operating.

Law enforcement is focused on prostitution charges — which require proving a sex act occurred, often dependent on victim testimony from women who are traumatized, linguistically isolated, and afraid of deportation. Those cases are hard. So they don’t get made.

The city can revoke a business license — but only if someone tells them to and so these businesses thrive. Not because the laws don’t exist. Because the laws exist in separate silos, each silo waiting for someone else to act first.

Federal Way’s ordinance is a local workaround for a state enforcement failure. That’s what it is. Until we name that clearly, we’ll keep passing ordinances that burden the compliant and ignore the criminal.

What Doesn’t Work

More regulations on licensed massage therapists will not close a single SOB disguised as massage.

Not. One.

These criminal networks are sophisticated, well-funded, and highly adaptive. They comply with nothing. They move when pressured. They reopen under new names. When Kent, Washington cracked down and shut down 18 suspected businesses, authorities immediately noted that operators simply moved to neighboring cities.

This is called the whack-a-mole effect and it’s the predictable result of every single-jurisdiction crackdown that doesn’t coordinate with its neighbors.

The businesses that comply with new display requirements, new ID requirements, new hours restrictions — those are the legitimate massage therapy businesses. The ones that were never the problem. They now carry more paperwork, more inspection risk, more regulatory burden and the criminal operations continue operating until law enforcement decides to act.

We are regulating the compliant and ignoring the criminal.

Establishment licensing — requiring the business itself, not just individual therapists, to obtain a special license — is frequently proposed as a solution. There are arguments for it, the evidence that it actually reduces trafficking or shuts down SOBs is thin. The ABMP and AMTA have both opposed it for years, for a simple reason: it treats massage therapy differently from every other licensed healthcare profession and implies that licensed therapists are part of the problem rather than victims of it. (AMTA now apparently is for it as seen in many states proposing establishment licensing.)

We are not the problem. We have never been the problem.

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What Actually Works

The cities that have actually moved the needle — not just passed ordinances, but sustained real reductions in SOBs disguised as massage — did five things that most cities, including Federal Way, are not doing.

1. Prosecute operators as criminal enterprises, not businesses.

These are not massage businesses that went bad. They are organized crime operations using the word “massage” as a cover. Treat them accordingly.

The charges that actually dismantle these networks are not prostitution charges. They are RICO charges. Money laundering. Tax evasion. Labor law violations — failing to file I-9s, misclassifying employees, not carrying workers’ compensation insurance. Consumer fraud. Unlicensed practice of a health profession.

These charges are built on financial and paper trails, not victim testimony. They don’t require a traumatized trafficking survivor to relive her abuse in open court. Denver’s “Bad Apple” RICO case. Ohio prosecutions using corruption and money laundering charges. Multi-state federal cases involving the IRS and DOJ. These are what actually take networks down.

The cash is there. Seizures in the tens and hundreds of thousands of dollars have been reported in successful operations. Asset forfeiture funds the investigation and cripples the network simultaneously.

2. Assign someone to own the problem across every agency.

This is the simplest and most important structural fix. A designated cross-agency coordinator — someone whose actual job is to connect the DOH civil violation to the law enforcement investigation to the city license revocation — changes everything. Where this coordination exists, results follow. Where it doesn’t, the problem persists regardless of how many ordinances get passed.

No new laws required. Just someone whose job it is to make the existing systems talk to each other.

3. Use nuisance abatement.

This is the most underused and most effective tool cities have right now, and almost none of them are using it.

Nuisance abatement uses building codes, fire codes, zoning ordinances, and health codes to shut down a property — without ever proving prostitution or trafficking. A coordinated inspection by health inspectors, fire inspectors, code enforcement officers, and police, all entering simultaneously and looking for code violations, sanitation failures, zoning violations, and signs of people living on premises — can shut a building down legally, quickly, and without a single victim having to testify.

Bellevue WA used this approach awhile ago.

4. Go after the demand.

Surveillance near suspected locations. Traffic stops. Buyer arrests and public identification. Every buyer who faces consequences reduces the flow of money into these operations. These businesses run on demand. Interrupt the demand and the business model collapses.

This is politically uncomfortable. It is resource-intensive. It requires cooperation from prosecutors who may not prioritize it. But it works. And it is the only intervention that attacks the criminal network at its revenue source.

5. Hold landlords accountable.

The landlord knows.

In most cases, the landlord is collecting cash rent, seeing the late-night traffic, noticing the covered windows and the buzzer system, and looking the other way. Some landlords are profiting directly. Some are simply afraid. All of them are enablers.

Washington State’s Attorney General has attended convenings by the Network Team who promote a Landlord Engagement Program specifically designed for this. ( I actually spoke with someone in the AG office back in 2023 who was working on this…of course it never came to fruition and the person has left. When I most recently contacted the AG office, they would not speak to me on the issue.) Some jurisdictions now allow landlords to break leases and evict tenants when human trafficking or prostitution is suspected — and are exploring penalties for landlords who refuse to act when presented with evidence.

When the building is unavailable, the business cannot operate. Target the real estate and you target the infrastructure.

Stop with the Ordinances. Demanding

We are licensed massage therapists. We are healthcare providers. We have completed state-approved education, passed licensing examinations, and submitted to background checks. We work in pain clinics, rehabilitation facilities, hospitals, and hospice. We help people recover from injury, manage chronic conditions, and reduce the stress that underlies so much disease. In WA State we are providers with health insurance companies providing relief from pain and injuries.

We are not the problem.

We have watched our profession be hijacked by criminal networks for over a hundred years. We have watched media call them “massage parlors.” We have watched ordinance after ordinance add burden to our practices while doing nothing to dismantle the organizations exploiting our name.

Here is what we are demanding — from every city council, every law enforcement agency, every state legislator who wants to address this problem:

Enforce what exists before you create more. Washington State law already gives you the tools to walk into any business using the word massage and verify licensure in sixty seconds. Use it.

Coordinate your agencies. Assign someone to own this problem across DOH, law enforcement, and city licensing. Right now nobody does.

Prosecute operators as criminals. RICO. Money laundering. Tax evasion. Labor violations. Build financial cases that don’t depend on victim testimony.

Use nuisance abatement. You don’t need to prove trafficking to close a building that’s failing health codes and housing workers against their will.

Engage the landlords. Make harboring these operations legally and financially costly.

Stop adding regulatory burden to licensed massage therapists who were never the problem, who are already complying with every existing law, and who are absorbing the stigma and cost of criminal enterprises they have nothing to do with.

The whack-a-mole stops when the entire environment becomes inhospitable — through coordinated multi-agency enforcement, financial prosecution, landlord accountability, and demand suppression, all happening simultaneously across jurisdictions.

That takes political will. It takes resources. It takes agencies working together instead of protecting their turf.

What it does not take is more paperwork for licensed massage therapists.

Julie Onofrio, LMT, is the author of The Massage Therapists Toolkit and the creator of www.lookbeforeyoubookamassage.com*, a national resource for the public, law enforcement, and legislators. She has been a licensed massage therapist for [X] years and has spent [X] years documenting the impact of sexually oriented businesses disguised as massage on the profession.*

If you are a massage therapist, share this article with your local network, your city council member, and your state representative. If you are a legislator or law enforcement officer, reach out. We are ready to work with you.

Meanwhile, down the street, a business with no licensed massage therapist in sight put the word “massage” on their sign, opened their doors, and started operating. In most states, nothing happened to them.

That’s title protection in action — or rather, title protection failing in action. If we want to change what’s happening to this profession, we have to start here: understanding what title protection is, what it was designed to do, and why the gap between the law on paper and the law in practice is costing us everything.

Also looking at the history of our licensing laws is needed to see how we got into this entanglement. AMTA has been the force behind licensing laws since the early 1950s and continue to have their head in the sand on this issue. (I have written AOD proposals on the topic that were rejected and one AOD proposal that got passed a few years ago on the issue has no report on the progress. I also volunteered with my local chapter in WA State as GR for a few years asking AMTA for help on these city ordinances that were popping up all over and no response.)

What Title Protection Is Supposed to Do

Title protection laws exist to do one simple thing: reserve the use of professional titles for the people who have earned them. When a state passes a massage therapy licensing law, it is saying that only a licensed massage therapist — someone who has met specific education, examination, and background requirements — can call themselves a massage therapist or advertise massage therapy services.

Think of it like medicine or law. You can’t hang a shingle that says “Dr.” or “Attorney at Law” unless you’ve gone through the required training and passed the required tests. Title protection for massage therapy is the same concept. The word “massage” belongs to us — the licensed professionals who earned it.

Most states now have these laws. In most states, a licensed massage therapist is the only person legally authorized to use the term massage or massage therapy to advertise or perform services. The laws typically require that your license number appear on your advertising, that your license hang on the wall of your office, and that you carry photo ID that matches that license.

What the Laws Actually Look Like

The strength and specificity of title protection laws varies enormously from state to state. Some are strong. Some are full of holes and a few states still don’t have licensing at all — which means title protection there is essentially nonexistent.

In the states that do have licensing, most also have laws against unlicensed practice. The penalties for practicing massage without a license are supposed to create a deterrent. But here’s what those penalties often look like in practice: civil fines. Misdemeanors. Minimal consequences for operators who are often running profitable businesses and simply write the fines off as a cost of doing business.

A small number of states have elevated unlicensed massage to a felony or made it a felony to knowingly aid and abet unlicensed practice. NY and OR are two that I know of that make it so unlicensed massage is a felony. Yet NY has one of the highest numbers of illicit massage. So is making it a felony the answer?

The Loopholes That Swallow the Law

Even in states with strong title protection laws, there are gaps and sexually oriented businesses disguised as massage (SOBs) are very, very good at finding them.

The reflexology exemption. Some states exempt reflexology — foot and hand massage — from massage licensing requirements. That sounds reasonable on the surface. In practice, it means that an Sexually Oriented Business (SOB) can open a “foot massage” business, avoid the licensing requirement entirely, and use that loophole to operate without background checks, without a licensed therapist in sight, and with near-total impunity.

The “relaxation massage” loophole. Some states (OH) allow something called “relaxation massage” to be performed without a license. The same problem applies. The loophole becomes the front door.

The “Asian massage” problem. There are often no specific laws against using the term “Asian Massage” even though it carries no licensing requirement and is routinely used as a cover by illicit sex businesses. Legitimate Asian bodywork practitioners use specific titles for their work — acupressure, shiatsu, tuina, and others — not the vague marketing term “Asian massage.” The loophole is being exploited at our expense and at the expense of Asian communities.

Diploma mills and fake credentials. This one is particularly painful. Some SOBs don’t avoid the licensing system — they game it. Fake massage schools have issued fraudulent credentials. Some businesses obtained one legitimate license and displayed it on the wall while every worker in the building claimed it was theirs, because no one was required to carry photo ID. It took years for states to add the photo ID requirement specifically because of this tactic.

The Enforcement Gap: Where the System Really Breaks Down

Even where the laws are good, enforcement is inconsistent at best and nearly nonexistent at worst. Law enforcement does not understand that it is a crime and when it is only a civil offense or misdemeanor it is not high on their list of priorities.

State massage boards primarily exist to regulate licensed massage therapists. They handle complaints about licensed practitioners — discipline, license suspension, revocation. When an unlicensed business shows up on their radar, they typically refer the case to law enforcement. Then what happens? Often, very little.

Law enforcement agencies are stretched thin. They are dealing with violent crime, property crime, drug offenses — and then there’s this referral about a business using the word “massage” without a license. The business may simply close and reopen somewhere else. Traffickers are highly adaptive. They move, reopen, and adjust faster than enforcement systems can follow.

The result is a significant enforcement gap — the law says these businesses are illegal, but the law isn’t being applied consistently enough to stop them. This isn’t just a missed opportunity. It’s an open door that criminal networks walk right through.

When “Protecting the Public” Ends Up Targeting Us

Because state and local governments struggle to enforce title protection and unlicensed practice laws against SOBs, many have turned to a different approach: regulating massage businesses harder. Establishment licensing laws — now on the books in states including Alabama, Alaska, Colorado, Florida, Texas, Oregon, and many others — impose additional licensing requirements on massage businesses. Inspections. Operating hour restrictions. More paperwork. (State Establishment licensing is being worked on now across the US mainly because the individual cities are creating a mish-mash of ordinances to try to deal with the problem and they usually start out with unfair rules like a massage business must be a cash business only or be open only certain hours of the day restricting business.)

There is no conclusive research showing these establishment licensing requirements actually separate legitimate massage from SOBs. Traffickers adapt. They find new loopholes. Meanwhile, legitimate massage therapists bear the cost and burden of complying with yet another layer of regulation designed to fix a problem we didn’t create.

Cities and counties are passing ordinances that restrict massage businesses in ways that make it sound like we are the problem. We are not the problem. We never were. We are licensed healthcare providers who are being regulated as if we are the criminal element — while the actual criminal element continues to operate with minimal consequences.

The responsibility for this problem has been placed squarely on our shoulders. That is wrong, and we need to say so loudly.

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What Good Enforcement Actually Looks Like

Title protection only works when it is enforced. That means:

We need Laws with real penalties — not just civil fines and misdemeanors, but felony-level consequences for operators who knowingly run unlicensed businesses and for those who aid and abet unlicensed practice.

We need enforcement agencies that are trained and empowered to act on unlicensed practice referrals — not just licensed-therapist complaints need training on how to handle the women who work at these places as they are usually the victims of human trafficking or indentured servitude.

We need to close the loopholes. Reflexology exemptions need to be tightened or eliminated. Relaxation massage carve-outs need to go. Laws still using the terms “massage parlor” or “masseuse” need to be updated — those words now signal sexually oriented businesses, not legitimate massage therapy. We need to do away with them and explain it or fight for them like we do the words massage with “Hands Off Our Name”

Photo ID requirements enforced. License verification systems made publicly accessible and promoted to the public.

More critically: law enforcement, city councils, and legislators need to understand the difference between the massage therapy profession and sexually oriented businesses disguised as massage. Right now, many do not.

That education gap is part of our work. (Because no one else is doing it. Our professional associations could be doing this but they won’t.)

Why This Matters to You Right Now

You might be thinking — I follow the law. I have my license. I’m doing everything right. Why is this my problem to solve?

Because when title protection fails, it’s your reputation that suffers. Your clients who don’t know the difference. Your community that sees “massage” and thinks of something shameful. Your profession that gets lumped in with criminal operations. Your income that gets undercut by businesses charging $30 for “massage” because they have no overhead — no school, no exam, no license, no legitimate employees.

This is your problem because it is our profession and the only way to fix the laws is for us — the licensed professionals, the people who know this issue from the inside — to show up and demand it. (Got a better idea? Let me know.)

Action Box

• Know your state’s laws. Look up your state’s title protection and unlicensed practice laws. (Check on www.lookbeforeyoubookamassage.com or your state board website.) Know exactly what the penalties are in your state and whether unlicensed practice is a civil matter, misdemeanor, or felony.

• Report unlicensed businesses. When you see a business using the term “massage” without visible licensing, report it to your state massage board. Document everything. Also use www.simplyreport.com to report suspicious businesses.

• Contact your state legislators. Push for stronger unlicensed practice penalties, closure of loopholes like reflexology exemptions, and removal of outdated language (”massage parlor,” “masseuse”) from your state statutes or officially reclaim them.

• Educate your clients. Tell them how to verify a massage therapist’s license. Direct them to your state’s license verification system. An informed public is one of our strongest tools.

• Connect with your professional associations. Push them to take a unified, vocal stance on this issue. They work for us.

• Work with your City Council to educate them in your communities about the issue and work with law enforcement and fire departments to help shut these places down. Have them contact the Network Team to get a list of suspected businesses to look at. Make sure law enforcement is trained in how to handle these cases. Make sure there is a community support system for the women who are victims of these places.

But ask most working massage therapists what a standard of practice actually is — what it does, what it requires, what happens when one exists versus when one doesn’t — and you will typically get a vague answer about ethics and professionalism.

That vagueness is expensive. Because standards of practice are not primarily about ethics. They are primarily about power — specifically, about which institution gets to define what your profession is, what it does, and who is qualified to do it. When a profession has strong, well-adopted standards, the profession holds that power. When it doesn’t, everyone else does.

Here is what you actually need to know.

What a standard of practice is

A standard of practice is a formal, documented statement of what competent practitioners in a given field are expected to know, do, and refrain from doing. It defines the scope of professional activity — what is within the field’s boundaries and what is outside them. It establishes minimum competencies — what someone must be able to do before they are considered qualified to practice. It sets documentation and conduct expectations — what a competent practitioner records, how they communicate, how they handle specific clinical situations.

Standards of practice are distinct from codes of ethics, though many professions publish both and they are often confused. A code of ethics governs professional conduct and moral obligations — honesty, confidentiality, respecting autonomy, avoiding exploitation. A standard of practice governs clinical and professional performance — what constitutes competent work, what a practitioner must assess before treating, what documentation a session requires, what conditions require referral.

A code of ethics tells you how to behave. A standard of practice tells you what competent practice looks like. Both are important. They are not the same thing.

Standards of practice are also distinct from scope of practice, which is a legal concept defined by state licensing law. Your scope of practice is what you are legally permitted to do in your state. Your standard of practice is what you are professionally expected to do within that legal permission. The law sets the outer boundary. The standard describes what competent work looks like inside it.

Refer a friend

What standards of practice actually do in the real world

Understanding what standards accomplish requires looking at what they do across multiple domains simultaneously, because their effects are not limited to the clinical encounter.

In clinical practice, standards give practitioners a clear framework for decision-making. What do you assess before beginning treatment? How do you document it? What findings require you to modify or decline treatment? What constitutes adequate follow-up? Without a standard, each practitioner answers these questions differently, based on their training, their school’s emphasis, their personal judgment, and whatever their state licensing board happens to require. The result is enormous variation in practice quality, even among well-intentioned, well-trained therapists.

In regulation, standards give licensing boards a basis for enforcement. When a board receives a complaint against a practitioner, the question is whether the practitioner deviated from the standard of care. Without a documented standard, that determination is made based on expert testimony, which is expensive, inconsistent, and often contradictory. With a documented standard, the board has a reference point. The practitioner either met the standard or did not.

In education, standards define what schools must teach and what graduates must demonstrate. Without a national standard of practice, massage therapy schools teach wildly different things. One program emphasizes clinical assessment. Another emphasizes relaxation techniques. Another covers energy work. All produce graduates who receive the same license in states that don’t distinguish between them. This is not a problem the schools created — it is a problem that the absence of a standard creates, and that schools fill with their own judgments.

In credentialing and insurance coverage, standards are what insurers and health systems use to make contracting decisions. When a hospital credentialing committee decides whether to contract with a massage therapist, or when an insurance carrier decides whether to credential an LMT as an in-network provider, they are asking a specific question: is there a recognized standard that defines what this person is trained to do, how they document it, and how their competency is verified? For medicine, nursing, physical therapy, and chiropractic, the answer is yes and the infrastructure exists to verify it. For massage therapy, the honest answer in most states is no, and that answer costs the profession billions of dollars in unreimbursed care every year.

In legal proceedings, standards of practice define the standard of care against which a practitioner’s conduct is measured. When a client is harmed and litigation follows, the question is whether the practitioner deviated from what a competent practitioner would have done in the same circumstances. A well-documented standard of practice protects practitioners who meet it and provides accountability for those who do not.

When professions develop standards of practice, and why the timing matters

Professions do not typically develop standards of practice voluntarily, from a position of organizational health and professional unity. They typically develop them under pressure — from regulators, from the legal system, from payers, or from public harm events that demand accountability.

Nursing developed formal standards of practice in the 1950s and 1960s as the profession sought recognition as a clinical discipline distinct from medicine. The standards were a tool for claiming professional identity and autonomy. They were not created because nurses thought it would be a good idea in the abstract. They were created because without them, physicians and hospital administrators controlled every decision about what nurses could do and how they would be compensated.

Physical therapy developed and standardized its clinical practice guidelines over decades, accelerating significantly in the 1970s and 1980s as the profession sought direct access — the ability to treat patients without physician referral. The standards were the argument. They demonstrated that physical therapists were competent to assess and treat independently. Without documented standards showing what competent PT practice looked like, the direct access argument had no foundation.

Chiropractic developed standards in the context of its long fight for insurance coverage and legitimacy. The standards were not perfect when they emerged and they remain contested in some areas. But they gave insurers and regulators a framework to work from, and that framework made coverage conversations possible in a way they had not been before.

The pattern across professions is consistent: standards of practice are developed when a profession needs to demonstrate to an external audience — regulators, payers, health systems, courts — that it has a defined, consistent, verifiable body of competence. They are not primarily internal documents. They are external credentials presented to the world.

The worst time to develop standards is under crisis, when outside institutions are already defining you and the profession is scrambling to reclaim authority it should never have ceded. The best time is before the external pressure arrives, so that the profession’s own definition is already in place when regulators and payers come looking for one.

Massage therapy missed the best time by about twenty years. The question now is whether it is going to use the crisis productively or repeat the familiar pattern of producing a document that doesn’t get adopted.

And that is exactly what AMTA is now doing… the VA started working on Standards of practice in 2024… then AMTA filed a federal notice in 2025 they were working on some and announced it on their website too. August 15, 2025

AMTA did create The Healthcare Advocacy & Research Committee (HARC) was established in 2023 to support the ongoing AMTA Government Relations as it relates to the clinical and integrative care environment as mentioned in the AMTA-KY newsletter…but what is taking so long and why the secrecy?

What makes a standard of practice actually work

Not all standards of practice accomplish what they are intended to accomplish. The difference between a standard that transforms a profession’s standing and one that sits in a binder on a shelf comes down to a few specific characteristics.

Adoption is the first and most important. A standard only matters if it is actually used. Adoption means state licensing boards incorporate the standard into their regulatory framework. It means schools align their curricula to it. It means credentialing bodies use it as a reference. It means courts treat it as evidence of the standard of care. A voluntary standard that has no mechanism for adoption — no connection to licensing, no regulatory backing, no credentialing infrastructure built around it — is aspirational, not operational.

Scope is the second characteristic. A standard that covers professional conduct without addressing clinical practice is a partial standard. For massage therapy’s current strategic needs, a standard that does not include clinical definitions of what conditions massage therapy treats, what assessment is required before treatment, what documentation a clinical session requires, and what competencies distinguish entry-level from advanced practice is a standard that will not move the insurance coverage needle. It may be valuable for other reasons. It will not open the credentialing door.

Breadth of application is the third characteristic. A standard that applies only to members of a voluntary association or holders of a voluntary credential reaches a fraction of the profession. Approximately 350,000 -450,000 massage therapists are practicing in the United States. NCBTMB has a few thousand certificants. AMTA has approximately 108,000 members. Any standard that applies only to those populations leaves the majority of the profession outside its scope and gives insurers and regulators a reason to treat it as a membership benefit rather than a professional standard.

External legitimacy is the fourth characteristic. A standard developed exclusively by and for massage therapists, without input from the health systems, insurers, regulators, and health professions that the standard needs to influence, will reflect what massage therapists believe about their profession. That is not nothing. But it is different from a standard developed with meaningful participation from the institutions that will be asked to recognize it. The most durable standards in health care are developed through processes that include payers, regulators, and allied professions, precisely because those standards then have built-in recognition from the institutions that matter most.

Enforcement is the fifth characteristic. A standard without an enforcement mechanism is a suggestion. Enforcement does not require litigation. It can mean credentialing consequences, licensing implications, or simply the professional expectation that practitioners can account for their adherence to the standard when asked. But something must make compliance meaningful, or the standard gradually ceases to function as a standard and becomes a statement of aspiration.

The specific problem for massage therapy right now

The massage therapy profession is currently at a juncture where two national standards processes are underway simultaneously — one by a federal agency with preemption authority, one by the profession’s largest association — with no public explanation of how they relate to each other, and no clear commitment from either that the resulting standard will address the clinical and credentialing dimensions that matter most for insurance coverage.

The NCBTMB standards from 2017 cover the right ethical territory. They do not constitute a clinical practice standard adequate for the profession’s current needs.

The Entry Level Analysis Project from 2013 produced exactly the kind of foundational competency framework a national standard needs to build on. It was never adopted. The organization that should have championed it said it doesn’t support it.

The VA is writing a definition of massage therapy that will have federal force. The profession had a comment window to shape that definition. Whether the organized profession engaged substantively is unclear.

AMTA is building a new standard. The public announcement describes outcomes that are real and worth pursuing. It does not describe a standard designed to get massage therapy covered by health insurance. It describes a standard designed to improve professional consistency and public trust — which are different goals, producing a different document.

All of this is happening at the same time. None of it has been explained to working therapists in a way that connects the governance questions to the clinical ones to the payment ones.

A standard of practice is not a bureaucratic formality. It is the document that answers the question every insurer, regulator, hospital, and court will eventually ask: what is this profession, what does it do, and how do we know when someone is doing it competently?

The profession has been asked that question for thirty years. The answer has been fragmented, inconsistent, and institution-dependent. That is what is being decided right now. Whether the profession gets to answer the question for itself, or finds out what the answer is after the VA and AMTA have already written it, depends on whether working massage therapists understand what is at stake and show up to say so.

These two processes are happening simultaneously, the profession's largest association just formalized control of the credentialing body it created, and neither organization has published a practice framework that their standards are derived from. What does that mean for your profession and your livelihood? That's what the rest of this article addresses.

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The evidence has been there for decades. The Joint Commission recommended massage for pain management in 2000. The CDC named it as a cost-effective alternative to opioids in 2016. The American College of Physicians recommended it for low back pain in 2017. The National Association of Insurance Commissioners asked insurers to cover it as an opioid alternative that same year. Federal pain task forces named it. Medicare Advantage plans started covering it. The VA finally classified massage therapists as health technicians after fifteen years of advocacy.

Outside institutions keep opening doors and the profession keeps not walking through them.

This isn’t bad luck. It’s a structural problem that has repeated itself so consistently over twenty-five years that it can only be described as a feature, not a bug. The massage therapy profession has never been able to build a durable advocacy institution with the authority to act — because it has never been able to agree on whether it wants to be in the health care system at all.

The 2010 moment that defined everything

When the Affordable Care Act passed, it contained something remarkable: Section 2706, a federal nondiscrimination clause that prohibited health plans from discriminating against licensed providers acting within their scope of practice. It was written specifically to protect providers like massage therapists, acupuncturists, and chiropractors from being locked out of coverage by insurers who would only pay for the same services when performed by a physician or physical therapist.

Advocates outside the massage profession celebrated it. The Integrative Healthcare Policy Consortium launched a state-by-state implementation campaign. Former Washington State Insurance Commissioner Deborah Senn — the architect of Washington’s Every Category of Provider law — came out of retirement to lead that campaign. This was arguably the most significant federal policy opening massage therapy had ever seen.

AMTA’s response was that 51 percent of their members didn’t want massage therapy covered by health insurance.

So they waited.

ABMP wrote a position paper. Individual leaders pushed hard. Diana Thompson, one of the most respected voices in the profession, wrote a letter to AMTA requesting support and got a vague, noncommittal reply. An AMTA representative showed up to a major ACA hearing and, according to a report from Diana Thompson herself, was visibly out of step with every other clinical speaker in the room.

Three years after the ACA passed, AMTA’s official position was still that the law “continues to be debated, analyzed and scrutinized” and that implementation “will continue to evolve.” That was their public statement in August 2013. The law had been in effect for three years. The window for organized advocacy around implementation was closing. And the profession’s largest association was still doing a risk assessment.

What AMTA’s problem actually is

It would be easy to frame this as a leadership failure, and there have certainly been leadership failures. But the deeper problem is structural, and it’s important to name it precisely.

When 51 percent of your members don’t want insurance coverage, and your governance model requires you to represent all members equally, you cannot be an effective insurance advocacy organization. That’s not a flaw in any individual leader. That’s math. An association that must achieve broad member consensus before taking a policy position will always be slower, more cautious, and more hedged than the moment requires — especially on a question where the membership is genuinely split.

The massage profession has always contained two distinct populations with genuinely different interests. One group wants to be in the health care system — credentialed, billing insurance, working alongside physicians, treating diagnosed conditions, building careers in clinical settings. The other group wants none of that. They want to provide therapeutic work on their own terms, outside the insurance system’s administrative apparatus, without anyone 20 miles away deciding how many sessions their client can have. Both positions are legitimate. They represent real values and real tradeoffs.

The problem is that AMTA has been trying to represent both populations simultaneously on a question that requires choosing. You cannot be the professional home for people who want insurance coverage and for people who actively oppose it and also be an effective insurance advocacy organization. The attempt to do both produces exactly what the timeline documents: years of studied neutrality, carefully worded statements, letters co-signed with other organizations, conference attendance with no public follow-through, and a perpetual sense that something important is about to happen but never quite does.

And who really knows what they do now…random news blurbs talk of small actions but their lack of training in State Chapter volunteers in advocacy and their flip-flopping stance on whether or not to make massage covered by health insurance in every state continues on. (See the new Illinois Massage Association that is being created because the AMTA chapter was not able to work on it.)

The pattern of almost winning

Once you see the structural problem, the timeline reads differently. It stops looking like a series of missed opportunities and starts looking like a system working exactly as designed.

An external opportunity opens. Outside allies — physicians, federal agencies, pain management organizations, insurance commissioners — create the policy hook. The profession shows up to claim it, often late and divided. A small win is achieved. And then there is no institutional infrastructure to defend it, expand it, or use it as the foundation for the next step.

The VA classified massage therapists as health technicians in 2019. The timeline notes it took over fifteen years to make that happen and today it is a covered benefit under the Community Care Networks.

270 Medicare Advantage plans added massage therapy coverage in 2019. That is a significant foothold. Medicare Advantage is one of the fastest-growing segments of health insurance in the United States. A coordinated effort to credential LMTs into those plans, track outcomes, and use the utilization data to argue for expansion could have been transformative. There is no entry in the timeline about that coordinated effort, because it didn’t exist. Today there are not as many advantage plans in general.

The NOPAIN Act got 8,000 letters from the profession, 62 House co-sponsors, and 24 Senate co-sponsors. That is real bipartisan political traction for a bill that would expand patient access to massage therapy under Medicare. The timeline ends without noting whether it passed. It didn’t. There was no sustained pressure infrastructure to push it through, and when Congress moved on, so did the moment.

The definition problem underneath everything

There is one more structural failure the timeline illuminates indirectly, and it may be the deepest one.

The VA had to create its own definition of massage therapy when it classified massage therapists as health technicians, because the profession hadn’t provided one.

There is also a 2024 Federal Register notice that the VA is now developing national standards of practice for massage therapists specifically, building on the 2019 qualification standard. That's here: https://www.federalregister.gov/documents/2024/08/01/2024-16944/notice-of-request-for-information-on-the-department-of-veterans-affairs-massage-therapist-standard

CMS wrote its own massage therapy coverage language for Medicare Advantage. The CDC included massage in its opioid prescribing guidelines without the profession having supplied a clinical framework for policymakers to work from. The Joint Commission named massage therapy as a nonpharmacological pain management strategy using its own language, not language the profession had developed and advocated for.

When outside bodies define you, they define you in service of their own administrative needs. They define you narrowly. They attach conditions — physician oversight required, prior authorization required, visit limits, bundled into other therapy categories — because no one showed up with a clear, profession-authored definition of what massage therapy is, what it treats, and what standards govern its clinical delivery.

The profession has been letting other institutions write its clinical identity because it has never written one itself. The 50 different scope of practice definitions across 50 states is not just a regulatory inconvenience. It is a signal to every insurer, regulator, and policymaker that the profession does not have a shared understanding of what it is. And into that vacuum, insurers have written their own definitions — ones that almost always restrict coverage, require physician intermediaries, and limit which practitioners qualify.

What actually worked, and why

The one clear success story in this entire timeline is Washington State and the reason it worked is worth sitting with.

It didn’t work because AMTA organized a membership campaign. It worked because Deborah Senn had an office, a budget, regulatory authority, and a clear mandate — and she didn’t need anyone’s permission to use them. She also happened to believe in the power of massage therapy and had a savvy assistant, Lori (Belinski) Grassi, who was also a massage therapist but is now the lobbyist for the WA State Chiropractic Association.) She wasn’t running a consensus process. She was a regulator who believed licensed providers deserved coverage parity, and she used the tools her office gave her to make it happen. She then tried to replicate that in other states before her death in 2016, working with the Integrative Healthcare Policy Consortium on the Section 2706 campaign. (Interesting enough - her office was a block away from mine and I ran into her a few times at my favorite lunch spot and got to talk to her. She also was a presenter at a local event called the Future of Massage and Bodywork which was held by Brian Utting and Jack Blackburn. Invitation and Outline.)

That effort largely ended when she died. Not because the legal arguments were wrong — they were sound. Not because the political will evaporated — the opioid crisis was creating new will every year. It ended because the effort was housed in a coalition of organizations without a single institution that had the authority, the funding, and the durability to carry it forward without her.

The profession has been here before. It will be here again. External allies create openings. Commissioners, physicians, federal agencies, bipartisan coalitions in Congress. The openings are real. The legal tools are real. The evidence is real.

What’s missing is the institution.

The honest question

If you have been in this profession for any length of time and you have watched this pattern, the honest question is not why the insurers won. Insurers always resist. That is expected and manageable.

The honest question is why the profession keeps showing up to these fights without the infrastructure to win them.

The answer the timeline suggests is uncomfortable but clear. A significant portion of the profession — historically around half — doesn’t want to win this particular fight. They don’t want insurance coverage. They have real reasons: the administrative burden, the loss of autonomy, the fear of being defined by diagnosis codes and prior authorizations and visit limits set by someone who has never given a massage. Those concerns are legitimate.

What the last twenty-five years of almost winning actually tells us is this: the profession needs a dedicated advocacy institution — not a committee inside AMTA, not a task force, not a working group — whose sole mandate is insurance coverage and clinical integration, funded by the practitioners who want that outcome, and accountable only to that goal.

Deborah Senn built it inside a regulatory office and nearly pulled it off. The profession needs to build the equivalent from the outside in — and stop waiting for another Deborah Senn to appear inside an office somewhere and do it for them.

The door has been opened more than once. The profession has to decide whether it wants to walk through. I would like to see us walk through it and have been working to create a plan to do this… But now I need YOU! What do you want? How do WE want to do this?

I will be revealing my plan in my Paid Subscribers Section over the next few months as well as my plan to reduce and even shut down the problem of illicit businesses. Will you join me?

You’ve seen it. The neon sign. The locked door with the buzzer. The drawn blinds at two in the afternoon. The hand-lettered sign that says “Asian Massage” or “Foot Spa.” The price list in the window: $40 for an hour.

You’ve probably wondered.

You’re right to wonder.

These are not massage businesses. They are illicit businesses — fronts for prostitution and human trafficking, run by sophisticated organized crime networks that have systematically stolen the name of a legitimate healthcare profession to hide their operations in plain sight. The 2026 Human Trafficking Report Estimates put the number of these businesses at over 17,000 across the United States as recently as 2020, generating billions of dollars annually. The women inside are frequently trafficking victims and in most communities across this country, almost nothing effective is being done to stop them.

That’s not because the problem is unsolvable but it sure is complicated.

The First Thing We’re Getting Wrong: The Language

When you read a news story about one of these businesses getting raided, what words does the reporter use?

Almost certainly: “illicit massage business.” Maybe “massage parlor.”

Both of these terms are wrong, and the wrongness isn’t just semantic — it’s operationally damaging. These phrases imply that the problem originates within the massage therapy profession. It doesn’t. Licensed massage therapists attend hundreds of hours of approved training, pass state licensing exams, and submit to background checks. They are victims of this confusion, not contributors to it. The conflation causes real harm: legitimate therapists are regularly sexually harassed by clients who confuse their practices with these criminal operations. Many have left the profession entirely.

Call these businesses what they are: Illicit Businesses, Brothels Disguised as Massage Businesses. Sexually Oriented Businesses. Human Trafficking Operations.

The North American Industry Classification System already made this correction — the “Massage Parlor” category has been eliminated at the federal level. The media still refers to these places as massage parlors I think because they don’t know what to call them. Using the term massage makes the public think that it is a licensed massage therapist doing bad things but the reality is if they would call them what they are, the message would be different. Everyone else needs to catch up.

What’s Actually Been Tried — And Why It Keeps Failing

The standard response has been a combination of occasional police stings and piecemeal local ordinances. None of it has worked. The numbers keep growing.

The reason is simple: these are networked criminal enterprises. Close one location and the operators move across the city line within days. Arrest the women working inside — who are frequently trafficking victims, not willing participants — and you’ve punished the victims while the network rebuilds elsewhere. Pass a local ordinance in one city and the problem migrates to the next suburb over.

You cannot fight a network with isolated, uncoordinated actions. As retired four-star General Stanley McChrystal wrote about fighting networked enemies: “To defeat a networked enemy we had to become a network ourselves.”

What Actually Works: An Eight-Part Plan with the first five parts here:

1. State Establishment Licensing. Not local ordinances — state law. The Federation of State Massage Therapy Boards has developed a model law that requires criminal background checks on all business owners, full disclosure of ownership (no anonymous shell companies), rosters of all workers with verified license numbers, a prohibition on anyone living on the premises, license non-transferability, and immediate revocation authority for violations. Twenty-one states have some version of this. Every other state needs it.

2. The Landlord Engagement Program. You cannot run a brothel without a location. A nonprofit called The Network Team, working with state Attorney General offices across the country, has developed a systematic program for engaging commercial landlords — educating them about what is happening in their buildings, explaining their legal exposure for inaction, and getting them to evict these operations. I have heard of this program now for a few years and even got to talk one on one with the WA State Attorney General Lawyer back in 2023 that was working on this —but nothing has ever come of it.

3. Strengthened Business Licensing. City and county business licensing offices are an underused chokepoint. With the right requirements — verified licenses for all workers, ownership transparency, cross-jurisdictional databases of denied and revoked licenses — they become a powerful screening mechanism that prevents operators from simply reopening under a new name down the street.

4. Smarter Law Enforcement and Prosecution. Massage licensing laws have penalties for unlicensed practice but most of these laws make it only a civil offense. That isn’t enough to make law enforcement want to work on this crime.

These are organized crime enterprises and should be prosecuted as such — with RICO charges, money laundering, tax evasion, labor law violations, and conspiracy charges that result in asset seizures and real consequences. This requires specialized training and genuine coordination between local police, state AG offices, federal prosecutors, and the IRS. It also requires — non-negotiably — treating the women inside as victims who need support, not criminals who need arrest.

5. Survivor Support and Demand Reduction. Enforcement without survivor support just re-traumatizes victims. And all of the above is treating symptoms rather than the disease if we never address demand — the men who pay for these services. Both pieces are essential to any strategy that aims to actually end this, rather than just move it around.

The other parts of this are working to change the language in the media and with legislators as well as shutting down the diploma mills handing out fake diplomas and stealing test questions so that untrained people can pass the test. Then of course there is the issue of Demand — that is a major societal issue.

Why This Matters to Everyone

This is not a niche issue for the massage therapy profession or anti-trafficking advocates. These businesses are operating in nearly every community in America. They are hiding in plain sight in your strip malls, your commercial corridors, your neighborhoods.

The women inside are not there by choice (or they are there by choice but have no idea that it is illegal as I have recently found out by hearing of a woman coerced into working at a massage business) and the reason the operations continue is not that they are impossible to stop — it’s that stopping them requires the kind of coordinated, sustained, multi-stakeholder effort that is hard to build and easy to avoid.

The full plan — the model legislation, the landlord engagement program mechanics, the prosecution strategy, the survivor support framework, and exactly what each stakeholder needs to do — is in the paid section of this newsletter.

The tools exist. The knowledge exists. What’s been missing is the will to coordinate them.

It’s time to build the network. Are you in?
I have a plan…or at least some ideas for a plan and now I need YOU! In the next few weeks I will be revealing the 8 step plan and working to gather massage therapists in every state to start working on the problem.

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The Four Interlocking Questions

Rosen framed his challenge as a prerequisite for both the National Certification Board (NCBTMB) and the Federation of State Massage Therapy Boards (FSMTB) to move forward:

“Before NCB and FSMTB continue any further down their respective pathways, we must address and get frank answers to these interlocking questions:”

1. Should continuing education be mandatory for renewal of state licensure—and is it essential for the ongoing protection of the public?

2. Given the reported inconsistencies in the instructional design and delivery of CE courses, is it even possible for an approval process to provide quality assurance?

3. Does the cost of compliance for CE providers (both in terms of time and money) bring an equal or greater benefit to the massage therapy field, and to the public at large?

4. What kind of regulatory process—if any—is needed; and which organizational entity is best suited to perform this function?

These questions are described as “interlocking” for good reason—they cannot be answered in isolation. Each depends on the others, creating a web of policy considerations that the profession has largely avoided confronting directly.

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