Tattooing through history

Body marking has been present continuously since the history of mankind, playing diverse roles at various times (Reference Ferguson-Rayport, Griffith and StrausFerguson-Rayport 1955). Evidence from archaeological evacuations date some forms of body marking to as far back as 12 000 bc. Among early nomadic tribes, the tattoo was used as a mark of identity or belonging to a group and the tattooed marks, such as tigers, monkeys and birds, were usually totemic in nature (Reference PalermoPalermo 2004). Tattoos are reported to have been present in the ancient cultures of Egypt, China, Japan and India (Reference PalermoPalermo 2004).

Knowledge of the early history of European tattooing is sketchy. Evidence from caves in Portugal and France suggests that tattooing was being performed as early as 6000 bc (Reference Levy, Sewell and GoldsteinLevy 1979). The practice of tattooing declined to the point of disappearance in the Dark and Middle Ages in Europe, although it flourished among people who lived outside the law (Reference PalermoPalermo 2004). Captain Cook introduced the word ‘tattoo’ from Polynesia to the Western world on his return from the South Pacific in the late 18th century (Reference PostPost 1968; Reference Raspa and CusackRaspa 1990; Reference PalermoPalermo 2004). There has been a resurgence of tattooing in modern Western culture in the past three decades, with prevalence rates as high as 24% recorded among the general population (Reference Laumann and DerrickLaumann 2006).

Motivations behind tattooing

Compared with other body modifications such as body piercing, tattoos are unique because they are permanent. Motivations for acquiring a tattoo found in the literature are summarised in Box 1.

Common motivations include fashion, to prove masculinity and toughness, or as means of asserting independence, but whatever the motivation, some form of non-verbal communication appears to be central to tattooing. The nature of the communication varies and is dependent on the inner world of the individual.

Human skin interacts with the surrounding environment. It has a protective function but it is also the conduit of positive and negative sensations to the nervous system. Reference PalermoPalermo (2004) postulated that skin plays an important role in defining the ‘self’. Its modification, for example by tattooing, is a form of non-verbal communication of inner ideas or conflict within oneself or with the outside world. Tattoos may therefore represent a person's attempt at self-expression and defining their individuality. Psychological aspects of a person such as sexual immaturity, rebellion and problems with identity (Reference TaylorTaylor 1968) have been associated with acquiring tattoos. Low self-esteem has also been noted (Reference Raspa and CusackRaspa 1990), leading some to conclude that tattoos are a defence mechanism against negative emotions.

Some authors have suggested that tattoos may be a form of ‘exoskeletal’ self-defence (Reference Manuel and RetzlaffManuel 2002), signifying aggression and strength in the bearer. They are often seen in prison populations and include tattoos relating to the individual's aggressive violent past and gang affiliation, possibly acquired to ward off unwanted attention or assaults in prison.

At times people acquire tattoos in the belief that they beautify the body and make it more attractive. This is pertinent to an increase in the prevalence of tattoos as a fashion statement in recent decades. A study exploring motivations for women acquiring tattoos (Reference AtkinsonAtkinson 2002) reported that they obtained tattoos to enhance the feminine image or as a form of social resistance. In the former case, the tattoos were generally subtle and hidden, whereas they were generally bold and on exposed parts of the body in the latter.

Throughout history, tattoos have been acquired for religious, magical, social and communal reasons (Reference ScheinfeldScheinfeld 2007). Even today, in some parts of the world strong religious and superstitious significance is found in certain body markings. Muslim women in Yugoslavia mark their forehead with a cross to ward off evil. People in seafaring circles have a tattoo of a rooster and pig on either foot to protect against death (Reference PostPost 1968), and in some cultures, such as Cambodia and Burma, tattoos are acquired to protect the bearer in a fight or a war (Reference ScheinfeldScheinfeld 2007).

No significant differences have been reported in motivations for getting tattooed between psychiatric and non-psychiatric populations (Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969, Reference Gittleson and Wallen1973; Reference Buhrich and MorrisBuhrich 1982), although psychiatric patients with tattoos are more likely to be emotionally immature and have psychosexual disturbances (De los Santos Sanchez-Barudo 1985, cited in Reference PalermoPalermo 2004). Tattoos are obtained at a young age in both groups. In a minority of cases, psychotic experiences (for example, auditory hallucinations and passivity phenomena) have led individuals to seek a tattoos (Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969). Acquisition of tattoos following a traumatic event such as rape or by patients with post-traumatic stress disorder has been observed (Reference AtkinsonAtkinson 2002; Reference Manuel and RetzlaffManuel 2002).

Whatever the motivation, it seems that in the majority of cases, tattoos are obtained on impulse at a young age (Reference Varma and LaniganVarma 1999), and studies on adolescents show an association between tattoos and risk-taking behaviour and impulsivity (Reference Brooks, Woods and KnightBrooks 2003).

Tattoos and psychiatry

Evidence of a relationship between tattoos and psychiatric disorders comes from studies of psychiatric pathology in tattooed individuals in non-psychiatric settings (Reference Lander and KohnLander 1943; Reference MeaseyMeasey 1972) and of tattooed psychiatric populations (Reference Ferguson-Rayport, Griffith and StrausFerguson-Rayport 1955; Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969; Reference Raspa and CusackRaspa 1990; Reference Inch and HuwsInch 1993; Reference WilliamsWilliams 1998). Both types of study report higher rates of alcoholism, drug misuse, impulsivity, risk-taking behaviour and personality disorders in both men and women (Reference Lander and KohnLander 1943; Reference PostPost 1968; Reference MeaseyMeasey 1972; Reference Buhrich and MorrisBuhrich 1982; Reference Raspa and CusackRaspa 1990; Reference Inch and HuwsInch 1993). These individuals are also more likely to have a history of self-harm, possibly as a result of a disordered personality and increased impulsivity (Reference GoldsteinGoldstein 1979; Reference Buhrich and MorrisBuhrich 1982).

Tattoos and criminal behaviour

Lombroso, an Italian psychiatrist and a criminal anthropologist of the late 19th century, considered tattoos to be a clear sign of intrinsic atavism, a tendency to conform to wild and primitive behaviour in the ‘born delinquent’ (Reference FerracutiFerracuti 1996). Tattoos are common among both adult and adolescent prisoners (Reference PostPost 1968; Reference NewmanNewman 1982; Reference Birmingham, Mason and GrubinBirmingham 1999; Reference Strang, Heuston and WhiteleyStrang 2000; Reference Hellard, Aitken and HockingHellard 2007). Prevalence rates ranging from three to five times those in the general population have been reported (Reference Strang, Heuston and WhiteleyStrang 2000; Reference Hellard, Aitken and HockingHellard 2007). The prevalence is even higher among adult and adolescent prisoners who have used intravenous drugs (Reference PutninsPutnins 2002). Tattooed individuals, with or without a mental disorder, are more likely to have previous convictions than non-tattooed controls (Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969, Reference Gittleson and Wallen1973; Reference Buhrich and MorrisBuhrich 1982).

Are tattooed individuals more likely to offend or is tattooing part of a criminal subculture? The answer is probably yes to both the questions. There are abundant examples of criminal gangs using tattoos, often on exposed areas of the body (Reference Mallon and RussellMallon 1999), as a marker of affiliation and membership. It is therefore possible that tattoos reinforce criminal behaviour by allowing individuals to affiliate with criminal elements in gangs. On the other hand, it seems that individuals with certain psychological makeup who are more likely to engage in criminal behaviour are also more likely to acquire a tattoo, owing to shared risk factors. Prisoners with antisocial and sadistic personality types, as measured by the Millons Clinical Multiaxial Inventory, are more likely to obtain tattoos while in prison (Reference Manuel and RetzlaffManuel 2002). In incarcerated adolescents, having a tattoo is associated with engaging in hostile and aggressive behaviour and risk of violent recidivism (Reference PutninsPutnins 2002). Rates of alcoholism, drug misuse (Reference Buhrich and MorrisBuhrich 1982; Reference Raspa and CusackRaspa 1990; Reference WilliamsWilliams 1998; Reference Brooks, Woods and KnightBrooks 2003), impulsivity, risk-taking behaviour (Reference Brooks, Woods and KnightBrooks 2003) and personality disorders (Reference Ferguson-Rayport, Griffith and StrausFerguson-Rayport 1955; Reference Yamamoto, Seeman and LesterYamamoto 1963; Reference PostPost 1968; Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969; Reference WilliamsWilliams 1998) are high in both men and women bearing tattoos, and all these are risk factors for criminal behaviour.

There are other reasons why tattoos are so common among prisoners. They may represent a form of visual communication and a form of defence. They may indicate gang membership and criminal past, symbolise aggression and toughness or a form of exoskeletal defence (Reference Manuel and RetzlaffManuel 2002). They may also be obtained to rebel against the authorities, deal with boredom or express one's creative side (Reference Mallon and RussellMallon 1999).

Tattooing among prisoners is a public health problem, with 20–30% of tattooed prisoners, both male and female, acquiring their tattoo in prison. Not surprisingly, the techniques and materials used are crude and such individuals are at high risk of acquiring blood-borne viruses such as hepatitis C (Reference Strang, Heuston and WhiteleyStrang 2000; Reference Hellard, Aitken and HockingHellard 2007).

Health, safety and legal issues relating to permanent tattooing

Tattoo removal

Tattoo removal may be requested for personal reasons such as regret after having acquired a tattoo, to improve self-esteem, appear more professional or increase credibility (Reference Varma and LaniganVarma 1999). Removal is sometimes required because of medical complications such as allergic or granulomatous-type reactions (Reference Burris and KimBurris 2007). Removal methods (Box 3) are expensive and can lead to incomplete removal and scarification.

Reference Gittleson and WallenGittleson (1973) described tattooing as a ‘group activity of youth and regretted in maturity’. Up to 50% of those who acquire tattoos subsequently regret it, with duration of regret varying from 2 months to 48 years before requesting removal (Reference Varma and LaniganVarma 1999). This is not surprising considering that the majority of tattoos are obtained impulsively at a young age (Reference Varma and LaniganVarma 1999). A majority of adolescents report feeling positive about their body modification(s) (Reference Brooks, Woods and KnightBrooks 2003), but a substantial proportion regret the decision with age. Reference Gittleson and WallenGittleson & Wallen (1973) reported that 24% of men (mean age 52.4 years) wanted their tattoo(s) removed and 69% regretted acquiring a tattoo. This applies to both psychiatric and non-psychiatric populations (Reference Gittleson, Wallen and Dawson-ButterworthGittleson 1969).

Tattoo removal, despite the difficulties, can be beneficial. Negative attitudes to a permanent body modification, especially if on an exposed part of the body, can be intense and cause social and psychological difficulties (Reference Varma and LaniganVarma 1999) that can be alleviated by removal. Many people have a negative perception of individuals bearing tattoos, particularly visible ones, and therefore removal can help the individual in obtaining employment and gaining the social acceptance of others. In some cases, removal might indicate a profound positive change in the person, for example removal of a gang-related tattoo indicating an end to such associations (Reference Mallon and RussellMallon 1999).

There are mechanical, chemical and thermal methods (Reference Burris and KimBurris 2007) for removing tattoos (Box 3). In some cases, tattoos can be camouflaged by injecting skin-tone pigments or by acquiring a new pattern on an existing tattoo.

In England and Wales, primary care trusts have commissioning policies for aesthetic treatments under which tattoo removal falls. Tattoo removal only for cosmetic purposes is not available on the National Health Service (NHS) unless the tattoo is the result of trauma (Box 3). It is considered a low-priority treatment, but some trusts may offer treatment on the basis of significant psychological distress and dysfunction likely to improve with treatment, or if the individual was a minor lacking ‘Gillick competence’ (of insufficient understanding and intelligence to be capable of making a reasonable decision) at the time of tattooing. Such treatments are approved on a case-by-case basis.

Implications for clinical practice

The relevance of tattoos needs to be seen in the context of the prevailing culture. With increasing popularity of the practice and increasing prevalence, a large proportion of individuals with tattoos will be of little significance to a psychiatrist. However, tattoos are overrepresented in marginal groups in society, which often come in contact with the psychiatric profession, whether in the community, in-patient or prison setting, and can provide clinically useful information. Their presence and type can give clues to the existence of particular psychiatric conditions and to the inner world of patients. Tattoos are sometimes acquired for a variety of complex psychological reasons, exploration of which in a therapeutic setting can prove useful. If seen as a form of non-verbal communication, they give clues to important personality traits (such as impulsiveness and risk-taking) that can be relevant to general lifestyle and clinical treatment. We recommend that tattoos are noted during the psychiatric examination and a record is made of their characteristics (location, size and content). The reasons and motivation for acquiring the tattoo(s) should be explored. Another benefit of recording tattoos is that they can be used for person identification.

Psychiatrists need to be aware of the medical complications surrounding the procedure of tattooing and be able to give appropriate advice to their patients if they wish to acquire a tattoo. The issue of capacity must be considered in a patient seeking advice on obtaining a tattoo. For example, a patient's wish to obtain a tattoo may be related to their disturbed mental state. In such circumstances, there is a potential risk that a patient will subsequently bring legal action against the doctor, if they were allowed to obtain a tattoo while in an altered mental state. The assessment of capacity is particularly relevant to clinicians working with adolescents, the most common age group for acquiring tattoos. Owing to the high proportion of adults subsequently regretting their tattoos and the associated psychological and social distress, clinicians should be aware of the methods of tattoo removal.

MCQs

Select the single best option for each question stem

1. 1 The term ‘tattoo’ was introduced to the Western world from Polynesia by:

   1. a Captain Scott

   2. b Captain Cook

   3. c Pope Hadrian 1

   4. d Nero

   5. e Emperor Constantine.

2. 2 Individuals with tattoo(s) do not have higher reported rates of:

   1. a drug misuse

   2. b obsessive–compulsive disorder

   3. c personality disorder

   4. d impulsivity

   5. e alcohol misuse.

3. 3 Tattoo artists working legally in the UK must be registered with the:

   1. a local council

   2. b local government

   3. c health and safety executive

   4. d tattoos association

   5. e local environmental health department.

4. 4 Which of the following is not a relative contraindication for tattooing:

   1. a previous tattoos

   2. b chronic skin conditions

   3. c haemophilia

   4. d diabetes

   5. e high/low blood pressure.

5. 5 Which of the following is true:

   1. a tattoos are usually obtained in late adulthood

   2. b only a minority of individuals regret acquiring a tattoo

   3. c tattoos can be easily removed

   4. d tattoo removal for cosmetic purposes is widely available on the NHS

   5. e tattoo removal may be requested to improve self-esteem.

MCQ answers

1

b

2

b

3

e

4

a

5

e