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Artists expressing their work through tattoos and piercing

All authors equally contributed to this paper with regard to conception and determination of scope, literature review and analysis, drafting and critical revision and editing, and final approval of the final version. Published by Baishideng Publishing Group Inc. This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers.

Abstract Tattooing the skin as a means of personal expression is a ritualized practice that has been around for centuries across many different cultures. Accordingly, the symbolic meaning of tattoos has evolved over time and is highly individualized, from both the internal perspective of the wearer and the external perspective of an observer.

Within modern Western societies through the 1970s, tattoos represented a cultural taboo, typically associated with those outside of the mainstream such as soldiers, incarcerated criminals, gang members, and others belonging to marginalized and counter-cultural groups. This paper aims to review the more recent epidemiology of tattoos in Western culture in order to establish that tattooing has become a mainstream phenomenon.

We then review artists expressing their work through tattoos and piercing and psychiatric aspects of tattoos, with a goal of revising outmoded stigmas about tattooing and helping clinicians working with tattooed patients to facilitate an exploration of the personal meaning of skin art and self-identity. We suggest that as a kind of augmentation of the physical exam, looking at and talking to patients about their tattoos can provide a valuable window into the psyche, informing clinical practice.

Although traditionally associated with deviance and psychopathology in modern Western culture, tattoos have evolved into a mainstream phenomenon, especially among younger adults. While there are myriad motivations for obtaining a tattoo, most individuals seek tattoos as a means of personal expression that provides a potential window into the psyche that can be used to facilitate psychiatric treatment.

By reviewing the literature on psychological and psychiatric aspects of tattooing, we suggest that tattoos should be viewed not as signs of pathology, but as opportunities to explore core aspects of self-identity that can be valuable in clinical work. He is a divorced father of two, currently in law school, with overall high functioning despite significant life challenges.

A tumultuous childhood, including neglect and trauma at the hands of his mother and within the foster care system, led to several suicide attempts as a pre-teen and one psychiatric hospitalization where he was diagnosed with intermittent explosive disorder, bipolar disorder, and obsessive compulsive disorder.

While medication titration was attempted during that hospitalization, he was never followed consistently by mental health as a child or adolescent, nor did he take psychiatric medication.

Despite these developmental barriers, Mr. A was considered a gifted child with an intellectual capacity well beyond his years and background.

At the age of 31, he presented for treatment of PTSD with bilateral full arm tattoos along with visible tattoos on his hands, knuckles, and the back of his neck. Artists expressing their work through tattoos and piercing, he revealed that most of his body was covered with tattoos.

Discussions in psychotherapy revealed that he started getting tattooed at the age of 11, when his father forced him to learn how to fight, subjecting him to physical beatings in order to prepare him for the violent realities of his neighborhood. His first tattoos declared affiliation with his ethnic background, depicting themes of racial affiliation and violence that reflected long-time engagement with racially-based groups for the purpose of enhancing survival on the dangerous streets of his childhood home and within the juvenile corrections system.

One tattoo referenced the names of fellow soldiers who were killed in action during the wars in Iraq and Afghanistan. Although he claimed to have thrived within military culture, he often clashed with superiors when he felt disrespected. During deployments, he accumulated extensive combat experience where he expected to die. However, he ultimately completed his military service and after an initial period of instability that included intoxicated fighting and divorce, he obtained sobriety and decided to go to law school.

At the time of enrolling in treatment, he was living with a long-time girlfriend while maintaining partial custody of two children from his previous marriage. Criteria for inclusion were original research involving human subjects, meta-analyses, reviews, published in the English language between January 1, 1990 and February 1, 2016 with the exception of reference 7 which was included for historical purposes.

The bibliographies of articles identified through electronic search were also reviewed for additional relevant publications including online resources such as the Harris Poll and military service regulations.

Over the past two decades however, epidemiologic studies have demonstrated that tattooing has become more of a mainstream phenomenon, with decreasing associations with stigma. No tattooed respondents ever had a tattoo removed.

  1. Depending on the type of procedure and where it is located, healing time varies.
  2. Accordingly, historical biases and pathological implications about tattoos warrant revision for present-day tattoo wearers. A tumultuous childhood, including neglect and trauma at the hands of his mother and within the foster care system, led to several suicide attempts as a pre-teen and one psychiatric hospitalization where he was diagnosed with intermittent explosive disorder, bipolar disorder, and obsessive compulsive disorder.
  3. Here are specific words related to piercings.
  4. She says her mother, who works in public health, worried that her daughter would never find a job—that is, until she started noticing the number of physicians and nurses with tattoos.
  5. There is a lot of admiration for these personalities.

Very few tattooed respondents reported being treated differently in work or social settings due to tattoos, suggesting that stigma surrounding tattoos has faded along with increasing popularity. Based on limited sample sizes from these two surveys, it therefore appears that tattooing has become much more common in the United States, particularly among young adults where rates may approach 1 in 2. Although tattoos have been traditionally more common among men, gender divides have lessened to the degree of extinction in recent decades in some countries, with tattooing now more common in women overall compared to men in the United States and more common among women 20-29 years old in Australia.

In addition to general prevalence data, Kruger noted that tattoos remain common in groups most traditionally associated with tattooing[ 5 ]. Differences in rates may reflect variations in sanctioning within separate settings, with peer group pressure playing a significant role.

In Brazil for example, tattooing was not introduced until 1959 and the practice is illegal for minors in some states[ 6 ].

  • The field experiment measured how long it took for anonymous men to approach them[ 38 ];
  • They act as mentors that guide millions of people especially the youth who want to be like them;
  • Establishing guidelines for body art in the workplace will be increasingly important as the millennial generation floods into the workplace;
  • There are special courses that train people to engage in tattooing in order to create jobs for millions of youth who are jobless;
  • Their own overall physical appearance, anxiety about 16 different body sites, measures related to a positive body image, self-attributed need for uniqueness, social physique anxiety, self-esteem, desire to stand out with appearance, reasons for obtaining the tattoo, schematic outlines of the front and back of their bodies to ascertain tattoo visibility and percentage of body covered by the new tattoo, satisfaction with the tattoo, and likelihood of obtaining future tattoos.

Tattoos in the incarcerated population serve to align the wearer with a specific group, as a remembrance, as a sign of strength or aggressiveness, or to simply help to pass the time.

Due to the makeshift nature of prison tattooing, inmates are at high risk for obtaining blood borne illnesses such as hepatitis C and human immunodeficiency virus HIV.

Evolutionary and historical perspectives Tattooing has been a human practice for more than 5000 years, leading Carmen et al[ 2 ] to examine tattoos through an evolutionary lens. They hypothesized that, regardless of the proximal motivations for getting a tattoo e. In tracing the evolution of tattooing across history starting from its ritualistic tribal origins, the authors note that the modern rise in the popularity of tattoos within Western culture emerged from individual niches such as military culture during World Wars I and II, the subsequent countercultural movements of the 1960s and 1970s, and the current cultural mainstream as a status quo.

Psychoanalytic perspectives Like Carmen et al[ 2 ], Grumet[ 7 ] tracked the development of tattoos throughout artists expressing their work through tattoos and piercing, but did so through a lens of psychodynamic psychiatry as opposed to evolution. Motivations for tattooing In keeping with the view that tattoos should not be solely regarded as reflections of psychopathology, Wohlrab et al[ 1 ] reviewed studies exploring the myriad motivations for obtaining tattoos.

This motivation may be especially age-relevant and helps to explain the desire to obtain a tattoo during adolescence and young adulthood.

Tattoos as a window to the psyche: How talking about skin art can inform psychiatric practice

In addition to the more identity-based, personal narrative, and group-oriented motivations for getting tattoos, some studies suggest that tattoos can also be viewed as a means to embellish the body as a fashion accessory or piece of art to wear on the body.

Others have noted that tattooing can serve as a kind of badge that reflects pain tolerance and physical endurance, as a means of emphasizing sexuality, and as an affiliation with a religious or spiritual tradition, while tattoos are also sometimes obtained impulsively for no specific reason.

Based on a literature review, Dickson et al[ 9 ] likewise enumerated a variety of motivations for getting tattoos, including body adornment and personal decoration, expressions of individualism and markers of identity, and overcoming difficult emotions as a means of affect management. Motivations for tattooing vary between genders, with women more likely to seek tattoos for personal decoration and to feel more independent, and men more likely to use them as symbols of group identity.

Contrary to traditional stereotypes, most adults with tattoos do not associate them with rebelliousness or cultural alienation, do not usually obtain them impulsively or while intoxicated, and do not regret getting them afterwards.

About Body Art & Piercing

Respondents tended to view their tattoos as a means of self-distinction, rating them as having significant personal meaning as opposed to symbols of rebelliousness. This suggests that the process of obtaining multiple tattoos reflects a self-concept that continually evolves with time.

For the majority of survey respondents who didn't have tattoos, reasons cited to forgo tattooing included not liking tattoos, concerns about permanency, anticipated disapproval from family, fear of pain, and not knowing what kind of tattoo to get. Psychopathology and personality traits in tattooed individuals Although several studies have indicated a greater prevalence of tattoos among psychiatric samples compared to the general population, the data to support this conclusion are largely drawn from older studies based on comparisons of cross-sectional measures of psychopathology among tattooed individuals in either non-psychiatric settings or psychiatric settings with inadequate controls between samples[ 10 ].

For example, Birmingham et al[ 11 ] reported an association between tattoos and a diagnosis of schizophrenia, but their study was based on a limited sample of male prisoners with visible tattoos. Two studies have reported an association between tattoos and a history of abuse, but both included individuals with body piercings[ 1213 ] and one was based on responses to a survey published in a German body modification magazine[ 12 ].

Studies of such specialty populations may have limited generalizability due to other confounds that might better explain associations with psychopathology. Similarly, reported associations between tattoos and risk-taking behaviors such as drug use, early sexual activity, gang affiliation, and violent behavior have typically been drawn from small studies of adolescents, with methodological problems related to sample population and size, survey techniques, and the potential for type I error[ 514 ].

Taken in aggregate, now that tattooing has become more common and is well-represented amongst adults, any associations with psychopathology are much less clear.

  • Among current drinkers, those with tattoos drank significantly more alcohol, although only a small minority of those tattooed had ever obtained their tattoos while intoxicated;
  • The toolbox contains all the defined tools with each tool programmed to create a certain effect on the illustration Hand and Middleditch, 147;
  • Within-study controls suggest that tattoos in young women have the potential to be interpreted as a signal of sexual availability to young men, but across studies, and in reality, visible tattoos are only one of many aspects that might influence female attractiveness;
  • Addition features of these processions include direction of flow and a roaming aspect with a certain outline that are in line with the theme of the artwork, be it religious, political and technology among others Lazzari, 126 In a regular artwork, there is use of predefined pages that have common features that have to be embedded in all artworks;
  • An art has special background styles and fill in effects that are meant to capture the attention of the viewer and loudly display the idea, feeling.

The percentage of tattooed respondents was lower among those who had never consumed alcohol. Among current drinkers, those with tattoos drank significantly more alcohol, although only a small minority of those tattooed had ever obtained their tattoos while intoxicated. Beyond the United States however, Kluger[ 5 ] noted that an association between tattoos and alcohol usage has not been detected in surveys from other countries and is therefore not well established.

On the other hand, associations between tattoos and both cigarette smoking and recreational drug use especially cannabis may be more consistent. A number of studies have used psychological rating scales to explore potential personality differences between tattooed and non-tattooed individuals, with mixed results[ 15 ].

Swami et al[ 15 ] administered a battery of inventories measuring various personality traits to a sample of 540 subjects from the southern German-speaking region of central Europe and found that those with tattoos only scored higher on measures of extraversion, experience seeking, and need for uniqueness. Although effect sizes were small to moderate, these results highlight that, if personality differences do exist among those with tattoos compared to the general population, they may not necessarily be dysfunctional or pathological.

This conclusion is in keeping with recent findings from the United States in which the Community Body Modification Checklist was given to 213 adult subjects with and without tattoos or non-ear body piercings[ 16 ]. Defying hypothesized expectations, Giles-Gorniak et al[ 16 ] reported that the only significant difference in mental health history and behavioral choices between the two groups was that those with body modifications were more likely to engage in social and healthy behaviors.

In contrast to these studies involving adults across the lifespan, much of the work to date on personality differences between tattooed and non-tattooed individuals has been performed in samples of college students, with limited generalizability.

In order to avoid the methodological limitations of earlier studies, Tate and Shelton measured personality traits with validated scales that assessed for the Big Five Factors of personality neuroticism, extraversion, openness to experience, agreeableness, conscientiousnessthe need for uniqueness, and the desire to be perceived favorably by others[ 14 ].

Tattooed participants, as compared to their non-tattooed counterparts, scored significantly lower on agreeableness and conscientiousness and higher on need for uniqueness.

However, while these differences were statistically significant, effect sizes were small and personality scores found among tattooed individuals were, with a single exception among women, within published norms. Suicide, self-injury, and tattoos Tattooing is an inherently painful ritual that is usually voluntary, with a history of other acts of self-injury and of suicidal ideation sometimes noted anecdotally by recipients. Comparing those with and without a history of self-cutting, self-cutters had the same average number of tattoos, but significantly more piercings.

However, the inclusion of those with body piercings and the lack of a control group without body modification limits the generalizability of this conclusion to those with tattoos. A possible association between eating disorders, self-injury, and tattoos was explored in a study of 65 female patients referred to a specialized unit for the treatment of anorexia, bulimia, and binge eating disorder[ 19 ].

Therefore, tattoos may sometimes represent positive modifications of body image as opposed to markers of self-injurious behavior. An association between tattoos and suicide was suggested in a study of 134 completed suicides over a 3-year period in Mobile County, Alabama[ 20 ]. Having a tattoo was associated with a significantly younger age at death and greater risk of death by an unnatural manner e.

Taken together, these small, regional studies offer conflicting evidence for artists expressing their work through tattoos and piercing being associated with suicide. Both studies did speculate that tattoos might be a potential marker of risk-taking behaviors and substance use that could in turn be associated with early mortality, but larger, epidemiologic studies are needed to more clearly elucidate associations between tattoos, self-injury, and early death.

However, the effect of the tattoo could depend on motivations for tattooing and the type and meaning of the tattooed image. A 2015 Harris Poll found that although most respondents did not feel that tattoos made them feel more sexy, attractive, rebellious, or spiritual, having a tattoo also did not make them feel less intelligent, respected, employable, or healthy[ 4 ]. In an attempt to examine effects of tattoos on self-perception, Swami conducted a prospective study of adults from London who were planning to get their first tattoo by recruiting them in a tattoo shop[ 22 ].

Their own overall physical appearance, anxiety about 16 different body sites, measures related to a positive body image, self-attributed need for uniqueness, social physique anxiety, self-esteem, desire to stand out with appearance, reasons for obtaining the tattoo, schematic outlines of the front and back of their bodies to ascertain tattoo visibility and percentage of body covered by the new tattoo, satisfaction with the tattoo, and likelihood of obtaining future tattoos.

Assessments were conducted immediately before and after obtaining the tattoo, and then again after 3 wk. Immediately after getting the tattoo, both men and women reported reduced anxiety and less dissatisfaction around their appearance, effects that were sustained at 3-wk follow up. On 3-wk follow up, both genders also reported an overall increase in self-esteem.

However, while men demonstrated a sustained decrease in social physique anxiety after obtaining a tattoo, female participants had higher social physique anxiety after 3 wk. The reason for this gender difference is unclear, but may be related to more negative perceptions artists expressing their work through tattoos and piercing women with tattoos in society. Collectively however these findings suggest that at least in the short-term, tattoos have the power to improve self-esteem and satisfaction, with their appearance providing fertile ground for exploration in the therapeutic setting.

Armstrong et al[ 23 ] surveyed a sample of 196 subjects who sought tattoo removal from 4 clinics across the United States and found that the average person waited 10 years to do so. Issues surrounding stigma were especially prevalent among women see below for additional discussion. However, tattoo removal does not necessarily reflect an overall dissatisfaction with tattoos.

In the study by Armstrong et al[ 23 ], a third of subjects seeking removal were interested in getting more tattoos in the future, suggesting that for some the desire of ablation is more about specific tattoos rather than tattoos in general.

In addition, while tattoos have become a more mainstream phenomenon among adults, considerable stigma remains with tattooing as an adolescent[ 25 ]. Significant research has been devoted to the study of tattoos in adolescents, highlighting negative associations with risk-taking behaviors such as substance abuse, smoking, sexual activity, violent behavior, and problems in school[ 5 ].

  • Back to Top Are there any issues involved with removing a piercing?
  • This suggests that tattooing may indeed be a signal of risk among minors, but those risks should not necessarily be extended to those obtaining tattoos as adults[ 25 ];
  • Due to the makeshift nature of prison tattooing, inmates are at high risk for obtaining blood borne illnesses such as hepatitis C and human immunodeficiency virus HIV;
  • Tattoos among military personnel and veterans seeking psychiatric treatment might therefore offer especially valuable avenues to gain access to self-identities transformed by war and personal loss.

This suggests that tattooing may indeed be a signal of risk among minors, but those risks should not necessarily be extended to those obtaining tattoos as adults[ 25 ]. With these demographic differences in mind, a prospective, longitudinal study followed a national sample of 13101 United States 7th-12th graders over 12 to 18 mo, looking at predictors of getting a tattoo[ 25 ]. The study also found that adolescents who used alcohol or marijuana and engaged in violent behavior were more likely to be tattooed at follow up.