Tattoos, Stigma, Racists, and Psychiatry

Humans have a history of tattooing that stretches millennia into prehistory.  The western ban on tattoos by the early church resulted in a systematic effort to paint tattooed individuals as pagan, primitive, vulgar, criminal, and mentally ill.  Psychiatrists have historically contributed to this characterization but are in a position to help reframe how citizens and policymakers view tattooed individuals. 

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Transcript

Welcome to PsyDactic, I am Dr. O’Leary and today is … In this podcast, I explore topics in psychiatry and neuroscience.  I typically imagine that medical students, psychiatry residents, and fully grown psychiatrists are my target audience, but all are welcome.  I produce this podcast by myself in my free time, so be aware that the content is generated from my brain and not moderated or fact checked or approved by anyone but me.  Everything here is my opinion, for better or for worse.

Today's episode is going to be a little more fun than I am used to having.  A couple years ago, I spent some time researching tattoos for a project that was never completed and I just realized that it would make a great PsyDactic Episode.  I will self-disclose right now that I have two tattoos and did for about 1 year work in a tattoo parlor.  I was also briefly training to be a tattoo artist, and I would like to take this opportunity to apologize to anyone who acted as a canvas for me.  I left this particular occupation before completing my training for reasons other than my lack of skill, but that is a story for another time.

When I was a child, the vast majority of parents forbade their children from getting tattoos, or at the very least admonished them that they would likely regret the decision, be treated like a criminal, or never find a good spouse.  Over the last 30 years, there has been a sea change in how society views tattoos and the chances are, if you are an American adult listening to this podcast, you have at least one tattoo.  Let me backup a little bit, because I realized that I have not yet even defined what a tattoo is.  Let's start there and then give a little history of tattoos.

Tattoos are indelible marks intentionally placed in the skin.  It involves the introduction of foreign substances into the cutaneous tissue, deep enough that it doesn’t slough off with your skin and shallow enough that it can be seen.  This distinguishes tattoos from other marks, like brands, scaring or burns, but often tattoos have or do result in some degree of scarring.  I don’t want to argue over whether, for example, making cuts into skin without adding ink, relying only on the scar to display the mark counts as a tattoo or not.  That is semantics.  The resulting mark sends some kind of message and that is the important part.

The earliest “ink” was likely carbon soot from fires that was placed on the skin as it was being cut in order to leave a more permanent or noticeable mark.  Imagine burning your deceased child and then rubbing their ashes into your lacerated skin as a keepsake.  Since then various metals, minerals, and organic substances have been used, some of which were likely toxic.  Places with modern cosmetics regulations tend to require at least some level of safety to approve inks.  Evidence of tattoos comes from mummies that date to between 5000 and 6000 years ago.  Just because these comprise the earliest evidence doesn’t mean that it wasn’t done before.  We just don’t have a lot of soft tissues preserved by mummification prior to these times.

Some of the earliest tattoos, like those of Ötzi (who was an Iceman from the Alps) are suggestive of use for medicinal purposes, potentially pain relief or healing.  Ancient acupuncture had very little resemblance to what is done today, and used tools likely fashioned from bones, stone, or wood that like resulted in permanent scars.  The scars potentially retained at least some of their healing power.  A frequent motif in early female tattoos is a location in the lower abdomen or pelvis, so may be associated with birth or fertility.  Similarly to the magical nature of conception and birth, tattoos may have imparted protection or supernatural abilities other than procreation.

Prominently displayed tattoos may also have been associated with social status, distinguishing the ruling classes from slaves, married from available, widows and widowers from the never married.  They may have signified accomplishments, abilities, or group membership. Let's not forget that they may be merely a way to look pretty or cool.  What we do know is that tattooing was, before it was banned by certain religions, a widespread global rage with a very deep history.

Emperor Constantine about 1750 years ago banned tattoos, and this negative association has persisted in Western forms of christianity.  Eastern christianity has been more accepting of the practice, especially for religious purposes.  As a child, I was taught that my body was a temple and tattoos desecrated that temple.  These ideas have lost a lot of their sway within the US in the last few decades, but still are prominent in some locations or cultures.  Most of Islam as well as orthodox Jews ban permanent tattoos.  Buddhism and Hinduism have historically embraced tattoos for religious purposes and many tribal societies use tattoos.

In fact, it was sailors who seem to initially have started the reintroduction of tattoos into the West.  I know this is a stereotype, but it has some historical basis.  After the Europeans invaded the Polynesian islands in the 1500s, sailors began to return with souvenirs in their skin.  The word we use for tattoo is likely derived from the Tahitian and Samoan tatau, or Marquesan tatu, which referred to the process of hammering the skin with a sharp stick impressing ink.  Prior to this tattoos in the West were called “stigma,” which referred to a Greek term (stizein) with a similar meaning to tatau.  In early English, stigma also meant to brand the skin with a hot iron.  Stigmata also referred to marks or pains in the hands where Jesus was punctured with a stake.  While the ink forms of stigmata were banned by the church, the holy versions were celebrated.

When we say something has a stigma now, we mean that it is associated with something undesirable.  It is historically significant that stigma was initially a mark on the skin and later became a mark of anti-social tendencies.  Tattoos had long been considered taboo.  Ironically taboo is derived from another Polynesian word from Tonga, which roughly means forbidden. In Christian culture tattoos were taboo because they were signs of paganism, hedonism, or immorality.

The stigma and taboo nature of tattoos in western christianity was adopted by early racists.  Pseudoscientific race theories saw tattoos as primitive and vulgar, a vestige of human races destined to fade into history with the rise of the white man.  In the Modern West, tattoos have a long history of marking members of the outgroup both willingly and by force.  The infamous use of tattoos by the Nazis to mark Jews is a modern example of the stigma that tattoos have historically retained.

In psychiatry in particular, the association of tattoos with depravity and psychopathology has deep roots.  These attitudes and beliefs about tattoos have resulted in an indelible legacy of discrimination that in some degree continues today, despite tattoos increasing popularity.

Early psychiatrists associated tattoos with throwbacks to primitive humanity. A 1896 paper by W. A. McCorn in The American Journal of Psychiatry, echoed the claims of Cesare Lombroso, a physiognomist and proponent of the idea that criminality is inherited and a criminal is identifiable by atavistic physical traits and their associated behaviors of which tattooing is one.  [I Quote] “The indulgence in the practice [tattooing] is often due to idleness and association with those of low mental type…”  Later, a paper describing tattoos among men reporting for military duty during WWII concluded, “[P]sychopathy or social or emotional maladjustment is significantly higher among tattooed than among non-tattooed men. This conclusion is of practical significance to neuropsychiatrists stationed at induction boards, affording a clue to some selectees meriting more careful study.”  Part of the reasons to reject a recruit included homosexuality and the author stated, “There is a reason to suspect strongly homosexual inclinations among tattooed men.”

Later in 1955 an article published in The Psychiatric Quarterly associated tattoos with personality disorders and postulated that while the tattoo was once an important form of social communication in primitive societies, contemporary bearers represented those unable to advance into modern society. “Thus, the tattoo has become the "crest,"... of those who are out of the main stream [sic] of society, of those unable to gain sufficient satisfaction from, and to adjust to, more highly developed mores. Tattooing has become a popular group activity among such people, especially under military or penal conditions.”  The authors continue on to reference studies associating tattoos with criminality, homosexuality, narcissism, and masochistic-exhibitionist drives.

Let’s fast forward to 1983, where we would expect ideas like this to have been quashed.  A psychiatrist named Grumet published his treatise on tattoos and catalogued a long history of psychiatric speculation on the meaning of tattoos. He called tattoos, [QUOTE] “a frequently overlooked source of substantial diagnostic information.” [UNQUOTE]  He defines tattoos as “cutaneous expressions of unconscious impulse rooted in the magical and omnipotent fantasies of childhood.” Tattoos, he wrote, are “a prosthetic attempt to strengthen one's sense of ego definition.”   He cites studies purporting to confirm his suspicions of psychopathology among the tattooed.  [I QUOTE AGAIN]  “Not surprisingly, these reports show that the tattooee has more frequently had criminal convictions… most commonly robbery, burglary, or larceny… is more frequently rejected from military service… has a history of family discord, impoverishment, and school dropout… with heightened hostility and antisociality… [A]dolescent boys are found to be more insecure and depressed, while tattooed adolescent girls are noted to be a particularly troubled group, more masculine, aggressive, and recalcitrant… The tattoo bearer frequently harbors a personality disorder…”  Grumet has no qualms in reporting supposed facts such as “In the author's experience tattoos appearing on the right side of the body are somewhat more likely to be held in positive regard than those on the left.”  He summarizes “In our own culture the tattoo can be viewed as a psychic crutch aimed to repair a crippled self-image, inspire hope, keep noxious emotions at bay, and reduce the discrepancy between the individual and his aspirations. Tattoos accomplish this by working synergistically with a host of psychic defense mechanisms to allay anxiety and protect the ego.”

Gary Waltz, a senior resident in psychiatry at University Hospitals of Cleveland wrote a reply to Grumet stating “... I have been struck by the relatively common appearance of tattoos among enlisted personnel, as well as the relatively infrequent appearance of tattoos among officers.”  He attributes this to the subservient role of the enlisted asserting, “Verbal dialogue between enlisted men and officers is not engendered, which, I believe, leads to other forms of communication being employed to cope with the enlisted man's insecurities, omnipotent drill sergeants, fears of dying, etc. Resorting to a symbolically visual means of communication… allows him to "be seen and not heard"... permits the enlisted man to make some personal statement(s), especially ones contrary to military policy and rules, with impunity.”  From criminality, psychosis, sexual deviance, personality disorder, insecurity, hostility, or impotence, as late as 1983, there doesn’t seem to be much good that can be inferred from a Western person possessing a tattoo.  Conversations like this remind me of being taught the “pink hair sign” in medical school, which was supposed to raise red flags for personality disorders.

Grumet’s context was much different than ours today regarding the demographics of the tattooed population.  He summarized the demographics of tattoos in his time: “While tattoos have traditionally been a male phenomenon, with about 9% of U.S. men and less than 1% of women bearing marks, recent reports suggest that more women may be seeking them, paralleling their emancipation from traditional roles.” Since his writings there has, in fact, been a dramatic shift in the demographics of the tattooed population.  However, stigma, both explicit and implicit, still exists.  A Harris poll conducted periodically since 2003 found in 2015 that 31 percent of females reported at least one tattoo, leading males by an estimated 4 additional percent.  Fifty five percent of those aged 30 to 39 claimed a tattoo in the same year.  As our population ages, the prevalence is going to continue to rise.

It may be tempting to argue that because of these demographic changes and corresponding changes in beliefs and attitudes relating to tattoos, policies toward the possession and display of tattoos in the 21st-century are far more advanced.  For example, one might expect that simply possessing a tattoo would not result in the exclusion of citizens from employment in the military or their involuntary discharge from the military.  However, less than a decade ago, this became the official policy of the U.S. Army.  Tattooing was common among military recruits and incidence rose with increased time in the military.  For example a survey of over 1800 recruits in basic and advanced initial military training in 2000 at one facility found that 36% of recruits had entered the military with at least one tattoo. (Armstrong et al. 2000)  Later, to help increase numbers of recruits during the wars in Afghanistan and Iraq, tattoo restrictions had been greatly relaxed.  Then, in 2011 Sergeant Major of the Army Raymond Chandler proposed new tattoo rules, far more strict than previous rules. In addition to banning tattoos that were extremist, racist, sexist, or lewd, SMA Chandler argued that any tattoo visible within any uniform, including tattoos below the elbow and knees, regardless of content were perceived as contrary to good order and discipline and so reflected poorly on the Army. 

Despite protests by soldiers and many civilians, in 2013 new tattoo restrictions were passed and published in early 2014.  Commanders were required to document all tattoos of all service members to be uploaded to a central database in order to identify any possible new tattoos. While current members could grandfather-in their old tattoos, additional standards severely restricted the number, size, and placement of any additional tattoos.  Those enlisted personnel grandfathered in were barred from commissioning as officers or appointment as warrant officers, greatly limiting their potential for promotion.  Commanders were ordered to check all soldiers for new tattoos yearly. (AR 670-1, 31 March 2014)  The reaction by service members was intense. Additionally, it became more and more difficult to find otherwise qualified recruits who could meet or would submit to the strict tattoo standards.

It is unclear how many personnel this affected because in 2015 the following SMA, Daniel Dailey, dramatically changed course, limiting placement of tattoos to above the wrists and below the neck line unless a waiver was provided. (16)  Except during initial entry, tattoos are no longer required to be documented unless they are otherwise suspected of being extremist, racist, sexist, or indecent.  The definition of each of these is not clear, with “indecent” likely the most difficult to define.  The Army has defined an indecent tattoo as “grossly offensive to modesty, decency, or propriety; shock the moral sense because of their vulgar, filthy, or disgusting nature or tendency to incite lustful thought; or tend reasonably to corrupt morals or incite libidinous thoughts, i.e., naked female or male bodies, graphic body parts, depiction of sexual acts.”

All was mostly quiet on the U.S. Department of Defense (DoD) tattoo front until 2021.  After the January 6 capitol riots, the Pentagon announced it will redouble efforts to exclude extremists from the military and started more thoroughly screening new recruits for extremist tattoos, especially those associated with white supremacy. To do this they use centralized databases maintained by the DoD and the FBI.  Some of the potential symbols include what might otherwise appear to be innocuous objects including of course swastikas but may also include lightning bolts, skulls, eagles, barbed wire, hobnailed boots and hammers.  White supremacist groups have a history of appropriating other cultural symbols in order to hide their presence.  Given that whites can easily draw from the symbology of their European ancestors and American minorities are less likely to do this, it is possible a greater proportion of tattoos of immigrants or persons of color could be distinct enough to be flagged as extremist, while those of white supremacists could slip through as historical. The evaluation process is not simple.

Because our society is increasingly tattooed, the use of tattoos to systematically exclude persons from (for example) military service will increasingly affect the lives of millions of Americans' by removing a potential or actual source of income or access to healthcare. Among civilians, tattoos may also carry stigma associated with assumptions of their personality traits, which can carry financial liabilities, including difficulty acquiring or maintaining employment, especially if the employer is from a previous generation.  Given current trends, employers soon may not be able to find individuals without visible tattoos to fill their positions.  According to a 2019 study, tattooed individuals were also assumed to be more culpable for a medical illness, even if they could have done nothing to prevent it.  As a greater portion of our doctors and nurses sport their own tattoos, this stigma will hopefully resolve.

Humans have a history of tattooing which stretches millenia into prehistory.  The western ban on tattoos by the early Church resulted in a systematic effort to paint tattooed individuals as pagan, primitive, vulgar, criminal, and mentally ill.  Psychiatrists have historically contributed to this characterization but are in a position to help reframe how citizens and policymakers view tattooed individuals.  Finally, if you are thinking about getting a tattoo and are concerned that some extremist or white supremacist group may have appropriated the symbol, you can go to The Anti Defamation League’s website at https://www.adl.org/resources/hate-symbols/search and browse their database.

Thank you for listening.  You can find references in the transcript at PsyDactic.Buzzsprout.Com.  I also hope to have a video companion of this episode finished within the next week which will be available on YouTube, just type @PsyDactic into the search bar.  I am Dr. O’Leary and this has been an episode of PsyDactic.


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