When “Public Protection” Backfires: How State Licensing Hurts the Massage Therapy Profession

For decades, state licensing has been promoted as the solution that would legitimize massage therapy and protect the public. We were told it would raise standards, improve safety, and elevate the profession.

Instead, the opposite happened.

The very system designed to protect the public has contributed to lower quality care, wage stagnation, increased harm, and a damaged professional reputation—all while burdening ethical, experienced therapists with rising costs and little meaningful support.

I’ve considered writing this article for many years, but an investigative piece titled Discord on the Massage Board finally convinced me it was time to speak plainly.

Recent reporting on the North Carolina Board of Massage and Bodywork Therapy highlights a deeper problem with state-based regulation: when licensing boards operate with little oversight, they become disconnected from both the practitioners they regulate and the public they are meant to protect. Licensing fees are supposed to fund public safety, not systems that therapists pay into but cannot meaningfully question or influence.

This is not unique to North Carolina. It’s what happens when licensing boards lack transparency, accountability, and measurable outcomes. When a system becomes more focused on sustaining itself than on whether it is actually working, everyone loses.

So it’s fair to ask:
Where are the measurable outcomes of state regulation in North Carolina and elsewhere?

What’s currently being measured is rule enforcement, license compliance, and administrative activity. 

Those are process metrics, not proof of public protection.

I have questions. What harm was the public being protected from in the first place? Has that harm been reduced? And how exactly are licensing and renewal fees being used to ensure real safety?

Massage Therapy Was Already Regulated 

Before state licensing, massage therapy was not the “wild west” it’s often portrayed as.

In my years practicing before licensure, no reputable spa, practice, or resort hired therapists without a massage school diploma. Professional liability insurance was standard, and most therapists belonged to AMTA or ABMP, agreed to the Code of Ethics, and maintained continuing education as required by their professional organizations. 

Schools acted as true gatekeepers, with elevated entry standards, interviews, and an admissions process that considered the whole person applying, not just whether they finished high school. 

Before state licensing, there were already multiple layers of accountability:

• Schools — admission standards and out-of-pocket tuition
• Employers — owners knew one another and communicated
• Insurance companies — coverage requires proper education
• Professional organizations — ethics, CE, and standards
• Community reputation — word traveled quickly when there were fewer schools and therapists

That is an industry regulating itself: decentralized, relational, and it was effective.

State licensing didn’t introduce standards. It centralized them, and in doing so, weakened many of these safeguards.

Hiring shifted from community-based vetting to credential-based verification. Where massage businesses were once run by massage therapists who relied on reputation and referrals, many employers now verify a license number. The informal systems that once helped keep unethical practitioners out were lost.

Liability Insurance Tells a Story Regulators Ignore

Insurance companies don’t operate on sentiment. They operate on data.

If massage therapy had posed a widespread public risk before licensing:

• Liability insurance would have been expensive or unavailable
• Claims would have driven premiums sharply upward
• Employers and therapists would have struggled to obtain coverage

None of that happened. Insurance was accessible and affordable, which strongly suggests that massage therapy was not causing widespread public harm. 

That raises a reasonable question:
What problem was state licensing actually meant to solve?

Licensing Lowered the Bar

Once massage therapy became state-licensed, schools gained access to federal student aid. That changed everything.

Federal student aid, including loans, incentivized rapid program expansion, high enrollment over high standards, and minimal screening for suitability, boundaries, or motivation

Community colleges and federally funded programs are required to prioritize access. They are not designed and are often not permitted to screen students for suitability for intimate, hands-on work. Denying entry beyond basic academic requirements can trigger legal or funding consequences.

As a result, massage education shifted to open enrollment, pushing responsibility for public protection downstream to licensing boards, and after harm has already occurred.

Today, many programs require little more than a high school diploma. Graduation and exam passage matter more than forming professionals with the maturity, boundaries, and commitment required for therapeutic work. The incentive to get therapists test-ready regardless of suitability or hands-on skill is purely financial; the more graduates, the more federal funds flowing into the schools. 

This is in stark contrast to the therapist-run “mom and pop” schools that existed before state licensing. In those programs, students could be accepted, denied, or dismissed based on factors such as professionalism, ethical behavior, respect for boundaries, interpersonal skills, and readiness for intimate, client-facing work. Schools were accountable not just to regulators, but to their local professional communities and their own reputations.

Licensing created a system where almost anyone can become licensed, regardless of readiness or ethical fitness.

That is not public protection.

Scaling Fueled Wage Stagnation

Licensing dramatically increased the number of massage therapists, enabling large chain models to thrive.

Businesses like Massage Envy rely on an oversupply of new graduates (therapists carrying student debt are often not in a position to fund a business start-up), high turnover, and interchangeable labor.

State licensing made this scale possible. Without a constant pipeline of new licensees, these models would not be sustainable.

The result has been stagnant wages, reduced bargaining power and fewer viable career paths outside self-employment. 

In 1998, I earned $28.50 per hour at a day spa while paying $350 per month in rent. Today, many spas pay $20–$35 per hour, while comparable housing exceeds $2,000.

That is not the progress we were promised!

Licensing Doesn’t Prevent Abuse

Almost weekly, another massage therapist employed by a large chain is arrested for sexual assault.

Licensing did not create predators. It failed to stop them.

Licensing created a false sense of safety for the public, rather than actually raising professional standards. Replace relational accountability through existing self-regulating systems with bureaucratic approval. And, removed upstream screening in favor of downstream punishment.

Predators are now removed after harm occurs, not before. The informal safeguards that once limited who could enter the profession were weakened by the same system that claimed to protect the public.

The public’s confusion about massage therapy is not rooted in outdated stereotypes. Our reputation is suffering because real sexual predators are operating within licensed systems.

More than 180 women have alleged sexual misconduct by Massage Envy therapists, according to national reporting. Utah regulators have found that massage therapy generates the highest volume of sexual misconduct complaints among licensed professions. In Georgia, nearly all such complaints resulted in little or no action.

These patterns reveal a deeper problem.

State licensing helped create a system where predators can enter easily and are difficult to remove. Employers often quietly terminate offending therapists, allowing them to resurface elsewhere. Victims frequently drop complaints to avoid months or years of retraumatizing proceedings. And the private nature of massage makes misconduct difficult to prove.

Enforcement after harm occurs is not enough. A system that relies on complaints places the burden on victims instead of preventing abuse.

We Were Promised Legitimacy and Higher Standards. We Got Bureaucracy and Fees.

If licensing truly protected the public, we should see precise results: better care/skills, fewer cases of abuse, greater trust, higher wages, and ethical, transparent regulation.

Instead, we see the opposite.

In North Carolina, roughly 65% of licensing and renewal fees go to a single private law firm—the same firm that helped draft the governing laws. This began as a practical solution when the board had no funding or infrastructure. But twenty-five years later, the structure remains essentially unchanged.

What began as a temporary workaround became permanent. Regardless of intent, this raises legitimate questions about incentives, oversight, and priorities in a system funded entirely by licensees.

The contrast with cosmetology regulation makes this even clearer. Cosmetologists pay under $30 per year and receive regular inspections. Massage therapists pay far more and receive none, despite inspections being one of the most effective tools for protecting client safety, sanitation, professionalism, and identifying potential human trafficking.

Fees are collected. Oversight is not delivered.

Final Thoughts: A Hard Truth 

The system designed to protect the public did the opposite, damaging the profession in the process.

Massage therapy didn’t need legitimization. It needed leadership, protection, and a recommitment to the ethical, mentorship-based systems that sustained the profession long before licensing. The state can issue licenses, but it cannot build culture. That responsibility belongs to us.

Protecting the public must start before someone ever enters massage school, not after harm has already occurred.

Licensing efforts were launched with good intentions. But twenty-five years in, it’s time for an honest reckoning with the outcomes and unintended consequences. We must push for standards that truly elevate the profession and protect the public without losing the heart of massage therapy.

Caring, compassionate touch, and human connection are essential, and it's difficult to regulate something that every one of us possesses, hands and heart. While regulation can set minimum standards, it cannot create ethics, presence, or genuine care. When a profession relies too heavily on paperwork, fees, and rules, it risks losing the very qualities that make massage, well, massage.