Gender effects in massage therapy

Abstract

Massage therapy is a widely used alternative therapy whose outcomes and mediating processes are under-researched. Objective: To examine the possible role client and therapist gender played in the outcomes of massage therapy. Study group: Gender effects on massage therapy were examined in this study of 45 male and 125 female clients treated by 51 male and 119 female massage therapists. Methods: The clients provided ratings of pain and range of movement before and after a 60 minute session of massage therapy. Results: Clients had significant pain relief and improved range of motion after treatment and that these effects were not mediated by gender. Improvements were experienced equally among the male and female clients, and obtained equally from the male and female massage therapists. Conclusions: The beneficial effects of massage therapy appear to transcend gender factors, which argues for the robustness of their positive impact.

Full text

J Altern Med Res 2012; 4(2):201-206 ISSN: 1939-5868
© Nova Science Publishers, Inc.
Gender effects in massage therapy
Thomas Edward Smith, PhD,
Pamela Valentine, PhD, and
Bruce A Thyer, PhD
Southeastern Research Institute, Tallahassee, Florida and
College of Social Work, Florida State University,
Tallahassee, Florida, United States of America
 Correspondence: Thomas E. Smith, PhD, Southeastern
Research Institute, 1328 Avondale Way, Tallahassee, FL
32317 United States. E-mail:
thomassmith558@gmail.com.
Abstract
Massage therapy is a widely used alternative therapy whose
outcomes and mediating processes are under-researched.
Objective: To examine the possible role client and therapist
gender played in the outcomes of massage therapy. Study
group: Gender effects on massage therapy were examined
in this study of 45 male and 125 female clients treated by
51 male and 119 female massage therapists. Methods: The
clients provided ratings of pain and range of movement
before and after a 60 minute session of massage therapy.
Results: Clients had significant pain relief and improved
range of motion after treatment and that these effects were
not mediated by gender. Improvements were experienced
equally among the male and female clients, and obtained
equally from the male and female massage therapists.
Conclusions: The beneficial effects of massage therapy
appear to transcend gender factors, which argues for the
robustness of their positive impact.
Keywords: Massage therapy, gender effects, client-
therapist matching, wellness, pain.
Introduction
Within our culture, society, and inherent nature,
gender provides a predisposition upon which we act
and how others react to us. Because gender roles
affect us in everyday life, it is not surprising that the
same effects are reproduced in therapy. Gender often
moderates the treatment effects of therapeutic
relationships and interventions (1). In the
psychotherapeutic process, clients learn ways to
perceive and understand their behaviors, beliefs, and
thoughts in the context of their environment. (2).
Because of ubiquitous effects of gender in many
aspects of life, this study examined whether the
effects of massage therapy are mediated by the gender
of the client, of the therapist, or by the interaction of
the two factors. Studies point towards sex-dependent
reactions to situations that are closely linked to
therapeutic processes. Baumeister and Sommer (3)

Thomas Edward Smith, Pamela Valentine, and Bruce A Thyer
202
reported that women generally oriented themselves to
close dyadic relationships, whereas men direct
themselves to larger groups. In a meta-analysis,
Feingold (4) found that men are more assertive and
have higher self-esteem than women who are more
extroverted, anxious, and nurturing. These gender
roles are also often present during the therapeutic
encounters. Because of their socialization, men are
less likely to seek out therapy and, if they do so, are
less likely to disclose personal details than are women
(5). Heatherington and Allen (6) found that
communication patterns involving male clients,
regardless of the therapist’s gender tended to be short,
abrupt, and quick. The exchanges in answers and
questions were rapid and labeled as though the male
clients were trying to gain some edge or control
during the session. This style of communication was
explained by inferring that male clients were trying to
protect or reduce a perceived threat to their self-
esteem. Carli (7) also found that men are more
assertive toward other men and women, and that
women tend to be more assertive with other women,
but tentative with men.
Kirshner, Genack, and Hauser (8) focused on
gender interactions in therapy outcomes and
demonstrated that selected areas of the therapeutic
outcome were dependent on gender. Female clients
improved more than male clients in attitudes toward
careers, academic motivation, academic performance,
and relationships with family members. More so than
male therapists, their female counterparts reported
having their clients improve more with major
problems, self-esteem, and overall greater satisfaction
with therapy. Jones and Zoppel (9) found that the
clients of female therapists rated their therapy as more
successful than clients of male therapists. This study
found that these same clients of female therapists
perceived that them as more effective, attentive,
accepting, and as having formed a stronger
therapeutic relationship than male therapists. Finally,
Cottone, Drucker, and Javier (10) conducted a large
study to assess gender effects in psychotherapeutic
dyads involving 163 clients (43 men and 120 women)
and 113 therapists (49 men and 64 women). With
gender distribution equivalent to normal intake
percentages and involving an ethnically diverse
sample, possible gender effects were evaluated on the
dimensions of treatment length, depression and
anxiety. It was found that female clients were more
likely to advance in treatment and complete treatment,
relative to male clients. More male clients reported
having lower anxiety scores with female therapists
than the female-female dyads or the female client to
male therapist dyad. Female therapist dyads showed
lower anxiety scores overall, while male clients with
the female therapists improved the most. While there
were no male-male dyad interactions reported, this
may have been caused by small sample size for this
dyad.
Massage therapy
Massage therapy is an ancient form of medical
treatment that can be seen in such texts as the Ayur-
Veda from India around 1800 B.C. that lists massage
therapy as necessary for health along with proper diet
and exercise (11). Today, massage therapy is being
used to treat a number of maladies including dropsy,
mental illness, torpor, spasm, stomach pain, heart
disease, muscular and skeletal disorders and diabetes
(12).
In an address to the Massage Research Agenda
Workgroup, Kahn (13) expressed the need for
massage therapy to define its own techniques, to study
what comprises best practices for specific problems,
and then compare optimal massage therapies to other
fields and forms of treatment. She went on to exhort
practitioners to study both the process and outcome of
massage therapy. One key recommendation was to
manualize massage therapy because of the
inconsistency in treatment protocols. With
manualized, replicable treatments, massage therapy
will be more amenable to systematic outcomes
research and process studies. Not surprisingly, she
called for better collaboration between researchers
and practitioners. More recently, Moyer (14) urged
massage therapy practitioners and researchers to
conduct research on this healing practice under
clinically representative conditions, so that the
external validity of findings may be enhanced.
Marjorie (15) published a case study of a client
who suffered from atrial fibrillation. During an
episode of acute arrhythmia, hypertension, and erratic
pulse rate, Marjorie massaged the client along the
spine, neck, and rib cage. The heart rate and blood

Gender effects in massage therapy
203
pressure were lowered and most importantly the client
relaxed and the arrhythmia subsided. While
informative, this case study, it could be definitively
shown that massage therapy per se produced these
improvements. Beeken et al (16) conducted a study
with 5 individuals who suffer from chronic
obstructive lung disease (COLD), where the goal was
to improve lung function. Beeken et al (16) employed
neuromuscular release massage therapy (NRMT) in
which pressure is applied to muscle groups to increase
blood flow, to release fluid and accumulated wastes,
and to support healing. The four male clients and one
female client received 24 weeks of NRMT and were
tested and evaluated on measures that assessed
respiratory functioning. Beeken et al. concluded that
this form of massage therapy was effective in
increasing respiratory functioning. Once again, the
results showed improvement but could not clearly
isolate what was responsible for the positive results.
Soft tissue manipulation, the psychosocial support, a
mixture of the two interventions, the passage of time,
simple physical contact, placebo influences are all
plausible explanations for client improvements?
Hammer (17) studied the treatment of chronic hip
and shoulder bursitis by using transverse friction
massage. This case study involved a 55 year-old
female with hip bursitis and a 40 year-old man with
shoulder bursitis. In utilizing this massage treatment,
both were relieved from joint inflammation of the
bursae in their respective joints. Bursae are closed
sacs composed of connective tissue inside the joint.
Transverse friction massage also helped to remove
scar tissue and essentially helped the healing process.
Hammer (17) suggested that this mode of treatment
be studied in controlled clinical setting along with a
larger randomized sample. Although the need for well
controlled trials is persuasive, it may not be clear
what about the intervention was responsible for
change. An example of a methodologically rigorous
study involved massage therapy focused on the area
of tension headaches. Puustjavir, Airaksinen and
Potinen (18) studied 21 female patients with chronic
tension headaches. Upper body massages which
manipulated deep tissue were used during 10 sessions
over two and a half weeks. Evaluation of the massage
therapy included measures on range of motion, an
EMG muscular test, and self reports of pain intensity.
Puustjavir et al (18) found that this massage therapy
increased range of motion, decreased muscular
tightness and shortening, lessened perceived pain, and
improved the subjects’ mental state. Still not certain is
the therapeutic mechanism underlying the
effectiveness of the massage therapy.
Other studies have also reported positive results
of case studies of massage therapy applied to different
presenting problems, and in general the evidentiary
foundations of the positive effects of massage therapy
are modest but growing (19). One important step in
defining a treatment model is to determine what
moderates its effects. Massage therapists have many
characteristics found in psychotherapists such as the
use of highly honed skills to assist clients resolve
pain, ability to create trusting and professional
relationship, and a commitment to provide the best
practices of their profession. Although massage
therapists focus on kneading muscles, there is also a
distinct emotional component to doing so. One well
documented moderator of psychotherapy is gender.
Given the similarities between psychotherapy and
massage therapy, an intuitively reasonable speculation
is that may be distinct gender effects in both
modalities. In this study, we examined the potential
effects of client/therapist gender on massage therapy
outcomes. In a factorial design, we studied four
pairings: male therapist/female client, male
therapist/male client, female therapist/female client,
and female therapist/male client.
Method
Clients were recruited from three clinics located in
massage therapy training institutes in the state of
Florida. After giving informed consent to receive
massage therapy and to participate in the study,
clients completed a demographic data sheet, health
history questionnaire, and pain and wellness
checklists. The intake procedure was designed to
establish rapport, trust, and comfort. The health
history questionnaire was administered to rule out
contraindications and to facilitate the design of the
massage treatment.
A licensed massage therapy instructor screened
clients for the study and excluded those who had
medical and health concerns.

Thomas Edward Smith, Pamela Valentine, and Bruce A Thyer
204
Only experienced massage therapy trainees were
recruited to participate in the study. After being
identified by clinic administrators, trainees were
asked whether they wished to participate in the study.
All trainees were supervised by a licensed massage
therapy instructor.
After receiving the massage, clients completed
post-treatment pain and range of motion. The
supervisor reviewed the massage procedures checklist
to ensure that comparable massages had been given.
The conduct of this study adhered to the principles of
the Declaration of Helsinki.
Two methods of administration of the massage
were given using similar techniques, consisting of a
60 minute table massage protocol and a 15 minute
chair massage. The table massage protocol included
manipulation on the face and neck, the hands and
arms, anterior legs and feet, the abdomen (as
requested), the posterior legs and feet, and the back.
The chair massage protocol focuses on the upper back
and shoulders, the neck, scalp, arms and hands, and
the upper and lower back.
The techniques that are included in the sequence
include effeurage, petrissage, friction, myofascial
spreading, and trigger-point therapy. Although each
treatment was structured, the goal was to replicate
what actually occurs in the clinical practice of
massage therapy. For the purpose of generalizability,
the therapists were instructed to design the treatment
as if it were “real world” situation.
Client needs, desires, indications, and
contraindications were used by each therapist in the
design of the treatment session. The focus of the
clinic treatments was “relaxation,” and the clients
were informed that the type of massage was a
relaxation massage.
The post-treatment feedback session had two
phases. First, clients provided their massage therapist
with feedback about their administrative and technical
proficiency. Second, participants completed post-
treatment measures to describe treatment effects.
Results
A pretest/posttest design was used to measure the
possible impact of massage therapy on clients.
Clients’ experience of 1) pain 2) well-being, and 3)
head and neck range of motion before and after
massage was analyzed using paired t-tests.
After a Chi-square test was used to assess the
effects of gender distribution of therapists across the
gender of clients, analyses of covariance (ANCOVAs)
were employed to determine the possible effects of
client and therapist gender on the change in the
pretest-posttest scores made by the clients.
The final sample consisted of 51 female and 119 male
therapists and 125 female and 51 male clients. Chi-
square analyses showed that the distribution of gender
in both clients and therapists were not significantly
different (X2 = 32.45; p < .57). See table 1 for the
distribution of gender in therapists and clients.
The first analysis consisted of paired t-tests that
measured gains on client-rated perceived pain,
perceived wellbeing, and perceived range of motion
of the head and neck, collapsed across gender, from
pretest to posttest.
The results demonstrated that clients experience
relief from their presenting concerns following
massage therapy. Clients (collapsed across gender)
reported a significantly pain as a result of massage
therapy (t = 15.75; p < .01, df = 190). On perceived
well-being (t = 14.42; p < .01, df = 194), clients
showed a significant improvement. On the third
outcome measure, perceived range of motion, clients
also showed significant improvement (t = 16.41; p <
.01, df = 194).
Table 1. Therapist by client counts
Therapist Gender Total
Male Female
Client
Gender
Male 15 30 45
Female 36 89 125
Total 51 119 170

Gender effects in massage therapy
205
Table 2. Effects of Massage Therapy by Client Gender
Female (n=125) Male (n=51)
Means Standard
Deviations
t-test
(df)
Means Standard
Deviations
t-test
(df)
Perceived
Pain
Pretest 5.36 2.049 13.39
(124)**
5.51 2.361 7.14
(50)**
Posttest 7.76 1.789 7.66 2.219
Perceived
Well-Being
Pretest 6.07 2.135 11.82
(126)**
6.76 2.016 7.17
(51)**
Posttest 8.01 1.793 8.45 1.747
Perceived
Range of
Motion
Pretest 5.50 1.816 14.34
(126)**
5.80 2.324 7.65
(51)**
Posttest 7.61 1.619 7.96 1.788
*p<.05.
**p<.01.
Separate paired t-tests were conducted for each
gender across the three outcome variables. They also
revealed significant differences from before to after
treatment. Table 2 provides a breakdown of analyses
by gender. Although gains from pretest to posttest
were significant for both genders across the three
outcome variables, an ANOVA showed that there was
no interaction effect of gender (e.g., male
therapist/female client; female therapist/female
client).
Discussion
The results showed that clients experienced a
significant relief from pain and significantly increased
their range of movement. These results were not
unexpected. When done properly, immediate relief of
muscular pain is a common benefit from massage
therapy. More important than the outcomes on pain
relief and enhanced range of motion was the lack of
gender effects. This finding was unexpected. All four
permutations of the therapist-client failed to show
statistical significance. The practical implication is
that gender makes no difference in massage therapy
and that its beneficial effects transcend client or
therapist gender. Because gender is a critical variable
in psychotherapy and nearly every other aspect of life,
this finding was not anticipate.
One possible reason for the lack of gender
differences is that relaxation engendered positive
attitudes regardless of the therapist, with gender
influences being overshadowed by symptomatic
relief, at least in the short run. Another possibility is
that once a massage session has begun, clients
typically close their eyes and become deeply relaxed,
and in doing so become relatively oblivious to the
gender of their therapist, indeed often oblivious to
their surroundings as whole. Massage therapists
themselves are taught to treat all clients similarly and
in a respectful and non-sexual manner. This
professional pattern of studied neutrality, similar to
that taught within the practice of psychoanalysis, may
also attenuate the influence of the therapists gender
with the client.
Our concluding that the effects of massage
therapy are not mediated by client/therapist gender
must be tempered by the recognition that this was not
a truly experimental study, with clients and therapists
randomly assigned to the various combinations of
gender. We used a quasi-experimental method, with
client/therapist matching being dictated more by the
convenience of the clinical setting. A true experiment
would be needed to see if our quasi-experimental
results regarding an apparent lack of gender effects in
massage therapy practice can be replicated and
corroborated.
We did not examine the related factors of race or
of the physical attractiveness of clients and therapists.
These would be other variables useful to examine in
future studies of the processes and outcomes of
massage therapy. To our knowledge this is the first
large scale study of the possible role of gender in
mediating the effects of massage therapy. Our failure
to find any unilateral or factorial effects of
client/therapist gender may be seen as a positive
feature of massage therapy, indicating the robustness
of its therapeutic benefits which appear to transcend
nonspecific influences in treatment. This study could

Thomas Edward Smith, Pamela Valentine, and Bruce A Thyer
206
be consisted analogous to a Phase One clinical trial,
an open-label, uncontrolled evaluation of the possible
benefits of a treatment (20), involving subgroup
analyses. Experimental replications involving the
random assignment of clients and therapists to gender
dyads would be a logical next step in investigating the
possible mediating role of gender influencing the
outcomes of therapeutic massage.
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Submitted: October 26, 2011. Revised: November 26,
2011. Accepted: December 09, 2011.