Howard Fischer
Uppsala, Sweden

“It was in 1972 and you didn’t really go around showing tattoos or talking about them…
And now all of a sudden it has become the thing to do.”¹
– Cher, American singer, actor

Placing dyes or pigments into the dermis to form a design dates back at least 12,000 years. Tattooing was seen in all parts of the world. The ancient Egyptians tattooed royalty. The Romans tattooed slaves and gladiators.²

The generation of physicians who studied medicine fifty years ago were taught that the presence of a tattoo indicated that a person was either a former serviceman (“Tattooing has…withdrawn to the vicinity of naval dockyards and other sailors’ haunts.”³), a former prisoner, or was suffering from psychosis. In addition, there was the category of sideshow “freaks” such as the tattooed lady. Tattooed women were sufficiently rare that a song was written about one of them (“On her back was the battle of Waterloo / Beside it the wreck of the Hesperus too / and proudly above waves the red, white, and blue / you can learn a lot from Lydia.”⁴).

In modern times, tattoos are used for decoration (artistic tattoos), to affirm religious beliefs (or non-beliefs), to show sentiments, or to serve a medical function. Medical tattoos can be used to “color-in” areas of vitiligo, to produce an areola after breast surgery, or to indicate the target area for repeated sessions of radiotherapy. Prisoners in the Auschwitz concentration camp were tattooed with an “identity number” by their Nazi captors.⁵

During World War Two, the Selective Service Board in the U.S. rejected tattooed men for military service at a rate 50% greater than non-tattooed men. Most of the rejected tattooed men were rejected because of a “neuropsychiatric disability.” Ex-military men who had the tattoo “Death Before Dishonor” had invariably received dishonorable discharges.

A 1959 U.S. Navy study of 648 men suggested that tattooed men had higher levels of “personal maladjustment.” Tattooing, the author noted, was “a subcultural practice…rather than an established trait uniformly characteristic of a whole society.” Prostitutes were frequently tattooed with designs to “sexually stimulate certain clients.” There was also an elevated percentage of “sexual abnormality” in people with tattoos. The article ends with an absolute statement: “The appearance of multiple tattoo marks which differ greatly in motivation, which have no symmetry…and no apparent connection …is always [emphasis mine] diagnostic of severe psychoneurosis.”⁶

This is what we physicians learned in our training in the 1970s. Then things changed. Somewhere in the ‘70s tattoos became a “mainstream part of Western fashion,” and for people of all economic classes. A survey done by the American Academy of Dermatology in 2008 found that 36% of Americans between the ages of 18 and 25 had a tattoo, as well as 40% of those aged 26–40 years, and 10% of those between 41–64 years. In 2008, it was estimated that 14% of all U.S. adults were tattooed.⁷ A study of 643 high school students in Texas showed that most of the tattooed adolescents were high achievers in school. Thirty-one percent of gay, lesbian, and bisexual individuals had tattoos, as compared to 16% of heterosexual men and women.⁸

Another study from 2008 with prisoners in a forensic psychiatric unit indicated that more prisoners with antisocial personality disorder had tattoos than those without tattoos. The prisoners with tattoos had more frequent histories of being sexually abused, of substance abuse, and of suicide attempts.⁹

An Australian telephone survey from 2012 of nearly 9000 men and women between 16–64 years old indicated that 14.5% of that population had tattoos. Twenty-nine percent of women in their 20s were tattooed. Most of the tattooed men and women aged 20–39 years had lower educational attainments, more tobacco smoking, more marijuana use (women), and more histories of depression (men). The authors concluded that tattoos are “still a marker for risk-taking behavior in adults.”¹⁰ There was no specific mention of criminal or antisocial behavior. It has been stated that 47% of people living in Stockholm are tattooed.¹¹

In all fifty states in the U.S. and the District of Columbia, a person must be eighteen years old in order to get a tattoo. A few states will allow younger persons to be tattooed with clearly documented parental consent. Tattooers may refuse to inscribe what they consider offensive designs and may refuse to tattoo certain areas of the body. In some states it is illegal to tattoo intoxicated persons.¹² In most European countries, the legal age for obtaining a tattoo is eighteen. Some countries have no legislation concerning the minimum age for getting tattooed.¹³ The U.S. Army will accept recruits with hand and back-of-neck tattoos, but no face tattoos. The Army has estimated that 41% of 16–34-year-olds have at least one tattoo.¹⁴

Tattooing, especially done by unregulated, unlicensed tattooers, may have serious medical consequences. Chief among these is infection. Documented viral infections^15,16 resulting from tattooing include hepatitis B virus, hepatitis C virus, herpes simplex virus, human immunodeficiency virus (HIV), and human papilloma virus. Bacterial infections with common pathogens like Staphylococcus aureus and Streptococcus pyogenes produce impetigo and furunculosis.¹⁷ There are documented infections with Mycobacterium tuberculosis,¹⁸ nontuberculous mycobacteria,¹⁹ and Mycobacterium leprae,²⁰ the causative agent of leprosy. Complications of bacterial infections produced by tattooing include bacteremia, endocarditis, necrotizing fasciitis, toxic shock syndrome, and pyelonephritis caused by methicillin-resistant staph aureus.^21,22,23 Infection with the fungus Aspergillus fumigatus has occurred.²⁴

There have been cases of anaphylactic reactions to the tattoo dye,²⁵ various forms of contact dermatitis, and morphea (scleroderma)-like lesions.²⁶ Occasionally, red dye has produced reactions so severe that an extremity amputation was required.²⁷ Skin cancers (squamous cell, basal cell, and melanoma) have arisen in tattoos. The incidence is low and the “association has to be considered thus far as coincidental.”²⁸ The presence and color of tattoos may interfere with the diagnosis of melanoma. The iron-containing black dye also is a problem when an individual has an examination with magnetic resonance imaging (MRI), as the iron in the dye heats up and may cause burns. Individuals who get a tattoo may not donate blood for twelve months unless the tattoo was made in a licensed studio.²⁹

A frightening variant of tattooing has come about in the last dozen years: eyeball or scleral tattooing. Dye is injected between the clear conjunctival membrane which covers the eye, and the white scleral membrane (the “white of the eye”) to give the appearance of a colored sclera. Multiple injections are needed to achieve the desired effect. Complications are abundant—scleritis, episcleral nodules, orbital cellulitis, uveitis (inflammation of the iris), retinal detachment, and perforation of the eye.^30,31 Oklahoma outlawed the procedure in 2009, Ontario in 2017, and Saskatchewan in 2020.

Two methodologically different studies to test patients’ reactions to a visible tattoo on a physician were recently reported. One study³² used actual contact with a physician with a tattoo and a physician without a tattoo. Patients saw no difference in the (high) levels of physician competence, professionalism, caring, approachability, trustworthiness, and reliability in the tattooed and untattooed physician. The second study³³ used photographs of the same physician with and without tattoos and found a perception of less confidence in the adorned physician. A resident physician with his forearm covered by a tattoo (a “sleeve” tattoo) writes³⁴ that he had no problems with his colleagues or his younger patients. He thought that “more conservative patients” may be uncomfortable with a tattooed doctor. As a wise man once said, “The times, they are a-changin.’”

References

1. Jennifer Flanagan and Vance Lewis. “Marked inside and out: an exploration of perceived stigma of the tattooed in the workplace,” Equality, Diversity, and Inclusion: An International Journal, 38(5), 2019.
2. “Tattoo.” Wikipedia.
3. Desmond Morris. Manwatching, New York: Harry N. Abrams. 1977.
4. E.Y. Harburg and Harold Arlen. “Lydia the Tattooed Lady.”
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6. Richard Post. “The relationship of tattoos to personality disorders,” The Journal of Criminal Law, Criminology and Police Science, 59(4), 1968.
7. “Tattoo.” Wikipedia.
8. Miliann King and Katherine Jones. “Why do people get tattoos?” Context, 6(1) 2007.
9. William Cardasis et al. “Tattoos and antisocial personality disorder,” Personality and Mental Health, 2(3), 2008.
10. Wendy Haywood et al. “Who gets tattoos? Demographic and behavioral correlates of ever being tattooed in a representative sample of men and women,” Annals of Epidemiology, 22(1), 2012.
11. Aastha Rohilla. “Stockholm: One of the most tattooed city [sic] in the world,” ND. Study in Stockholm. https://studyinstockholm.se/articles/stockholm-one-of-the-most-tattooed-city-in-the-world/.
12. “Legal status of tattooing in the United States.” Wikipedia.
13. “Legal status of tattooing in European countries.” Wikipedia.
14. Joe Lacdan. “Army eases tattoo restriction with new policy,” Army News Service, June 2022.
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19. Muñoz-Ortiz, “Dermatological.”
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21. Petrochko, “Tattoo-associated.”
22. Muñoz-Ortiz, “Dermatological.”
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25. Islam, “Medical complications.”
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30. Cheryl Murphy. “The terrifying trend of eyeball tattoos,” Scientific American, 2017.
31. “Scleral tattooing.” Wikipedia.
32. Marissa Cohen et al. “An observational study of patients’ attitudes to tattoos and piercings on their physicians: The ART study.” Emerg Med J, 35(9), 2018.
33. Scarlet Johnson, Maegan Doi, and Loren Yamamoto. “Adverse effects of tattoos and piercings on parent/patient confidence in health care providers,” Clin Ped, 55(10), 2016.
34. Marcus Ibrahim. “Tattoos in medicine,” HCA Healthcare Journal of Medicine, 3(3), 2022.