PSYCHODYNAMIC IMPLICATIONS OF TATTOOS. Gerald W. Grumet, M.D. Department of Psychiatry, Rochester General Hospital, Rochester, N.Y.

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1 Amer. J. Orthopsychiat. 53(3), July 1983 PSYCHODYNAMIC IMPLICATIONS OF TATTOOS Gerald W. Grumet, M.D. Department of Psychiatry, Rochester General Hospital, Rochester, N.Y. The checkered history of tattooing is reviewed and the psychological motives of those obtaining tattoos are examined. Frequently appearing on individuals of lower socioeconomic background, tattoos are an often overlooked source of psychodynamic information. Suggestions are offered to aid the clinician in the appropriate understanding of the significance of tattoos. psychotherapists usually pay but scant attention to the assortment of nautical, military, patriotic, amorous, or religious motifs sometimes seen on their patients' bodies. Yet the human flesh has proven itself a suitable canvas on which to portray psychologically relevant themes, and tattoos are a frequently overlooked source of substantial diagnostic information. In order to approach the clinical task of "dermal diagnosis," a review of the history and practice of tattooing may help to provide a modern perspective on its meaning. HISTORICAL OVERVIEW In many savage tribes it was the custom to accompany bereavement by slashing the body as evidence of grief and rubbing ashes into the cuts, leaving permanent carbon deposits in the skin. Evidence of these practices dates back to the Stone Age, 12,000 B.C.10 Puncture tattooing is somewhat more modern and remains common today. Here, particles of insoluble pigment are punctured through the epidermis, a transparent outer layer of skin, coming to lodge in the dermis, an underlying and relatively permanent layer of tissue. Archeological explorations of caves in France, Portugal, Rumania, and Scandinavia have revealed bowls containing traces of red and black pigments, along with sharply pointed flints and bone splinters, strongly suggesting that puncture tattooing existed as early as 8000 B.C.42 Tattooing thrived throughout antiquity in China, Japan, and North Africa and can be found on the skins of Egyptian mummies dating from 2000 to 4000 B.C.14 Meanwhile, religious bodies condemned tattooing. In Leviticus 19:28, the Lord spoke to Moses prohibiting tattooing as idolatry: "Ye shall A revised version of a paper submitted to the Journal in December /83/ American Orthopsychiatric Association, Inc.

2 GERALD W. GRUMET 483 not make any cutting in your flesh for the dead, nor imprint any marks upon you." Mohammed, in the Koran, issued a similar injunction, as did Pope Adrian I at the Ecumenical Council at Nicaea in 787. Tattooing is believed to have spread from mainland Asia to the South Sea Islands. In July 1769 Captain James Cook, after his first voyage to Polyne " sia, wrote: Both sexes paint their Bodys, Tattow as it is called in their language. This is done by inlaying the colour of Black under their skins in such a manner as to be indelible. Thus, the word "tattoo" entered the English language, an Anglicized version of the Tahitian word "tatau" ("to mark"). In subsequent years, merchant seamen began to wear the tattoo proudly as a badge of adventure in far-off lands and to mark the man who had faced the challenges of the sea. In about 1880 Samuel F. O'Reilly designed the first electric tattoo machine in New York City; it was improved and patented by his cousin Tom Riley in Britain in 1891,42 making application of a tattoo, formerly a long and painful process, quick and relatively painless. What was once the seafarer's proud and exclusive emblem became progressively plagiarized and readily available to any teenager through an urban tattoo parlor or traveling carnival. Yet modern tattoo styles still reveal their ancient origins. Dainty figures of animals, birds, butterflies, dragons, and snakes are derived from designs of the old master tattooists of Burma and Japan, while explicitly religious, sensuous, or patriotic themes (e.g., eagles, flags, hearts, unclothed women, etc.) came to be known in the profession as "American work." PSYCHOLOGICAL MOTIVES Hambly22 reviewed a host of functions that tattooing served among primitives, many of which remain timely today: puberty ritual, religious emblem, or love charm ; status or identification symbol; protection against danger; sign of mourning for the departed ; identification with special qualities of a totemic animal or symbol; guarantee of safe passage to a life after death; sign of allegiance to families, tribes, or totem groups. Tattoos, so little changed over the ages, are cutaneous expressions of unconscious impulse rooted in the magical and omnipotent fantasies of childhood. But of all the various motives for bearing a tattoo, the quest for personal identity is central. Identity In 1923, Freud wrote, "Theego is first and foremost a bodily ego." An authorized translator's footnote43 added: The ego is ultimately derived from bodily sensa tions, chiefly from those springing from the surface of the body. It may thus be regarded as a mental projection of the surface of the body. Fisher17 has noted that development of clear ego identity requires a highly developed sense of body boundaries, and shows that individuals who view their bodies as sharply bounded and distinct ("high barrier" types) are able to function in a more independent and realistic manner than "low barrier" individuals. The tattoo, an artificial embellishment of the body boundary, can be viewed in this context as a prosthetic attempt to strengthen one s sense of ego definition. May30 described the plight, especially pronounced in adolescents, of fe eling insignificant, anonymous, and depersonalized in the face of modern mass

3 484 TATIOOS education, mass media, and mass technology. Loneliness, anxiety, and alienation result, along with the gnawing conviction, "I do not matter." Feelings of social inconsequence also provided a conceptual cornerstone for Adler,2 who wrote in 1910: Such traits as timidity, indecision, insecurity, shyness, cowardliness, increased need for support, submissive obedience... correspond to the inferiority feeling. Above this network of personality traits, there appear, with defensive and compensatory intent, impudence, courage, impertinence, inclination toward rebellion, stubbornness and defiance accompanied by phantasies and wishes of the role of a hero, warrior, robber, in short, ideas of grandeur and sadistic impulses. For many young individuals, the tattoo is a pictorial quest for self-definition, easing one's sense of inadequacy and isolation by saying, "I know who I am, I belong." It offers the tangible promise of a final identity, the clarified picture of a diffused ego. Tattooing has in fact become a kind of heraldry of the lower classes, the poor man's coat of arms. Edgerton and Dingman 15 noted that... persons who are deprived of the opportunity to acquire or display the common and desirable symbols of self will invariably turn to tattooing as a means of symbolizing the self. Hamburger23 theorized that the tattooees experienced a flaw at some stage in ego development and used their tattoos in a restitutive manner to bolster an underdeveloped ego. Mathis, 29 who described the tattoo as "the personalized Rorschach of its wearer," saw it reflecting... the deep-seated need for the individual to call attention to the body in order to assure himself that he does in fact exist. Scutt and Gotch42 noted that the tattoo bolsters one's own self-esteem, appeal- ing especially to the loner or outsider, providing a sense of belonging and a badge of unity for the outcast or the outlaw: The non-confo rmist needs a bolster for his lack of confidence, a common symbol to show that he does, ironically, conform. Belonging A second major function of the tattoo is to proclaim allegiance to a group, perhaps explaining why about 50% of noncommissioned British and American Navy men are tattooed.41 These percentages grow during wartime; shortly after the outset of World War II an estimated 300 to 500 men were being tattooed daily in the city of Honolulu alone. 49 The tattoo may pledge fidelity to a lover, a parent, a regiment, one's God or country. National motifs like the eagle in America, the shamrock in Ireland, the thistle in Scotland, or the British bulldog or Union Jack proliferated during the World Wars. A British tattooist who placed approximately 90,000 designs on soldiers during World Wars I and II noted an effect on morale:... a good tattoo could help a service man. It strengthened his self-confidence and let even a mummy's boy feel like a man. '" The aspect of belonging is fu rther reflected in a statistical study showing that a tattooee is more than twice as likely to have tattooed family members. 18 Other studies have demonstrated that the overwhelming majority of individuals are accompanied by friends when getting their first tattoos A further feature of tattoos is the sense of belonging in an historical context, as there is a timeless quality about them. Some of the same scrolls, emblems, crests, and mottos used at the

4 GERALD W. GRUMET 485 turn of the last century are still popular today: anchors, skulls, hearts, snakes, flowers, crucifixes, daggers, dragons, and the ever-present mottos, "True Love," "Mother," and "Death Before Dishonor." Scenes of nostalgia and sentimentality prevail, with threemasted schooners, archaic guns and swords aplenty; but no hydrogen bomb or nuclear missile is seen exploding on a well-muscled chest or biceps. Tattoos offer romance and sentimentality in an acceptably masculine context while providing a sense of tradition and historical belonging in those whose personal life history is all too often rootless. Antisociality Belonging has, of course, its antisocial features as well. A fu sion of patriotic and antisocial sentiments was noted among Englishmen at the outbreak of World War I. A tattooist10 reported: Respectable businessmen, civil servants and profe ssional gentlemen asked me for tattoos of the Kaiser on their buttocks. sometimes to be accompanied by very rude words. An even less polite example of antisocial tattooing was presented by Goldstein, 20 who reported an American soldier with large letters printed on the ulnar aspect of his right hand to read, "Fuck the Army." Needless to say, his attempts to salute superior officers were not perceived as entirely respectful. The antisocial importance of an insignia is depicted by the Hell's Angels motorcycle club, whose sinister emblem of a grinning skull with wings reflects defiance of conventional society while serving as a badge of unity for the group. Take, for example, the case of an Angel known as "the Mute" who was arrested in California for speeding, proudly displaying his insignia on a tattered Levi jacket. A patrolman ordered him to shed it, only to find a leather jacket underneath similarly decorated. Beneath it, the dismayed officer confronted a wool shirt also bearing the Club's emblem, and beneath that an undershirt stenciled with the Angel design as well: "Okay, wise guy, take that off too".... With a smirk, the Mute removed his undershirt, and puffing out his chest, brought into full view the Hell's Angels' grinning death's head, which had been tattooed on his body. The policeman threw up his hands in disgust, handed the Mute a ticket and sped off in his patrol car. But the Mute had the last laugh. He was prepared to go all the way. His trousers and shorts were also stenciled. "He was a way-out mother," the Mute's friends agree.46 Some less amusing examples of antisocial tattoos can be found on Richard Speck, the mass murderer, whose left arm bore the slogan, "Born to Raise Hell," and whose right arm pictured a dagger and a snake along with a skull wearing a hat and goggles.48 Truman Capote's novel, In Cold Blood,11 depicted the tattoos worn by the two murderers. Dick's tattoos included... the head of a dragon with a human skull between its open jaws; bosomy nudes; a gremlin brandishing a pitchfork. His colleague Perry revealed some similarly morbid tattoos: Blue-furred, orange-eyed, red-fanged, a tiger snarled upon his left biceps; a spitting snake, coiled around a dagger, slithered down his arm ; and elsewhere skulls gleamed, a tombstone loomed, a chrysanthemum flourished. Sadistically antisocial tattoo themes are complemented by antisocial tattoos with strong masochistic trends. Dr. Michael Baden, a medical examiner in New York City, examined 1000 cadav-

5 486 TATTOOS ers of teenaged addicts, 20% of whom were tattooed. Bitter and antisocial themes prevailed, such as "Born to Lose," "Born to Suffer," "I Don't Believe in Friends," "Hard Luck," and so forth. 3 These findings are in concert with the report by Gittleson and Wallen 18 of a relationship between suicidal attempts and tattoos in men. Also of note is the finding of Howell et af26 that tattooed inmates experienced significantly more psychic pain, depression, and self-degradation than their unblemished counterparts. Protection from Danger The frequency of talismanic or protective tattoo motifs is a curious feature of many tattooed individuals. Most with tattoos are muscular and wellproportioned men who hope to add to their appeal. Crippled or extremely ugly individuals rarely get tattooed and it has been statistically confirmed that tattooees harbor more positive feelings toward their bodies than do their unmarked colleagues. 31 Projective psychological tests confirm that tattoos signify the stereotyped masculine attributes of physical strength and aggressiveness. 25 In practice, tattoos are especially common in individuals who exhibit their bodies at work, such as seamen, loggers, dock workers, oil riggers, construction laborers, military men, boxers, wrestlers, or others involved in hazardous or aggressive endeavors. In the days of sailing ships it was customary for British seafarers to display lavish portrayals of the Crucifixion, sometimes filling the whole chest or back, and it has been speculated that such tattoos served a utilitarian purpose in that those scheduled for punishment by flogging at the mast were spared when their shirts were stripped.'4 Popplestone36 has described the tattoo as an "exoskeletal defense," deriving its name from the hard shell or exoskeleton of the lobster and other arthropods. He suggested that the exoskeletally-defended individual perceives himself in a dangerous environment and remains prepared for external attack. The tattoo of a ferocious animal, for example, may alert others that the bearer is dangerous and may serve to ward off an external threat. Some have noted the related phenomenon that tattooed individuals have in fact a predilection for danger. Yamamoto and coworkers50 administered psychometric tests to 65 tattooed male patients in a VA hospital and concluded that the tattooed individual was more likely to feel compelled to act out in a "macho" manner than was his unblemished counterpart.50 A U.S. Army study quoted by Goldstein20 found that the likelihood of motorcycle accidents correlated more closely with the rider's number of tattoos than with any other variable studied. It was suggested that multiple tattoos reflect "a preference for risk." Sexuality and Exhibitionism No review ofthe psychic implications of tattooing would be complete without noting its sexual features. The skin is the only organ system exposed to view in its entirety, and at the same time remains the focus oftactile and erogenous activities. It is no surprise that some of those feelings projected dermographically upon it in the form of tattoos are of an erotic, amorous, or romantic nature. Ebensten14 noted that a young man's

6 GERALD W. GRUMET 487 first experience at the tattooist, like a first sexual encounter, symbolizes attaining manhood. He also pointed to the sexuality disguised in some typical tattoo themes:... rich. fragrant and billowing roses, hearts and skulls pierced by daggers or knives with curiously phallic handles, carefree sailing ships tossing wildly about on luxurious waves, lithe snakes and dragons curling temptingly along arms or legs, crucifixes and other hints of suffering. Bromberg7 noted the latently homosexual symbolism in getting a tattoo: a young man, usually in the company of his friends and often intoxicated, has his "virgin" skin marked by the tattoo needle and ink, painfully inflicted upon him by an older man. Lander and Kohn,27 in a similar vein, suggested that the heterosexually erotic tattoo may serve to remind the bearer himself, as well as his associates, that he is interested in women. The literature on tattooing is replete with stories, jokes, and banal vignettes on sexual tattoos, many amusing, others vulgar. Some are described by Parry, 33 such as the army man with a green snake tattooed on his body:... the tail of the snake began on his chest and wriggled its way down to the male member, the head of which coincided with that of the snake. Another example is of a woman prostitute with inscriptions beneath her breasts, "Sweet Milk" and "Butter Milk," or of a coworker who had "Admission Fifty Cents" inscribed on her lower abdomen. Tattoo enthusiasts recount numerous silly jokes on this score, like the man who was so often treated for venereal disease that he inscribed "Hi Ya Doc" on his penis.21 A similar traditional joke is that of the older nurse who read the word "Swan" on the penis of a male patient while administering a bath; a younger nurse expressed surprise, for she had read the word "Saskatchewan" the previous day. 8 Those working with populations of military men, alcoholics, drug addicts, or those in the penal system are often confronted by robust samplings of obscene or Rabelasian tattoos which are amply pictured in the literature and need no review here Ambivalence The skepticism with which society at large holds tattooing as an art closely parallels the ambivalence of the tattooee himself toward his decorations. Perhaps it is more than coincidence that "tattoo" and "taboo" are the only Polynesian words commonly used in the English language. Evidence found on Egyptian mummies from 4000 B.C. is reported to indicate attempts at tattoo removal,12 and modem plastic surgeons4 9 attest to both the frequency of requests for tattoo removal as well as the difficulty in doing so. Tattoo artists are estimated to devote a third of their time to covering over designs no longer favored.37 A statistical survey of tattooed psychiatric patients revealed that only 40% definitely wanted their tattoos viewed by others, while 31% were indifferent and 28% did not wish others to view them.19 Similarly, in a survey of 819 tattooed military recruits, fully one half fe lt their markings were a handicap. 34 A further reflection of the ambivalence with which the tattooee holds his tattoos is found in the common report, "I was drunk at the time." so For each individual one encounters wearing his designs in a proud or nonchalant manner, there are scores whose markings connote only the regret or embarrass-

7 488 ment of an absurd moment in adolescence, a foolish reminder of youthful rashness or intoxication. One heavily tattooed man, when asked for his reaction to his designs, noted, "They mark me as a fool.... I used to be young and stupid. Now I'm old and stupid." A major reason for the unhappiness which many experience is simply that tattoos reflect bygone identity struggles which may no longer be relevant. The tattoo is typically an attempt to make permanent that which is fleeting. It becomes a faded reminder of the robust health and bravado of yesteryear; the picture of "who I am" becomes a picture of "who I was." One's quest for selfdefinition at age 18 will likely be irrelevant at age 40, as the cherished memories and maudlin sentiments of today become the embarrassing relics of tomorrow. STATISTICAL STUDIES Statistical analyses of tattooed populations have largely been unidimensional, contrasting massive numbers of tattooed individuals against their unblemished companions in terms of history or behavior, while paying little attention to the specific patterns of the tattoos. Between 1860 and 1873 Italian criminologist Cesare Lombroso examined 6784 tattooed persons, among them 2896 criminals, and published his findings in L'Homme Criminel in This was followed by an avalanche of modern sequels. Not surprisingly, these reports show that the tattooee has more frequently had criminal convictions, 18 felonies especially,6 most commonly robbery, burglary, or larceny. 2 1 The tattooee is usually unmarried when becoming tattooed, 3 5 is more frequently rejected from military service, 27 and has TATTOOS a history of family discord,26 impoverishment, and school dropout. 13 Tattoos found on adult prisoners are often a tipoff of a previous juvenile record and are correlated with heightened hostility and antisociality. 38 Tattooed adolescent boys are found to be more insecure and depressed,47 while tattooed adolescent girls are noted to be a particularly troubled group, more masculine, aggressive, and recalcitrant than their unmarked associates. 44 Unfortunately, these studies often fail to make the critical differentiation between "artistic" or "professional" tattoos on the one hand and the "self-inflicted," "amateur," or "jailhouse" tattoos on the other. Self-inflicted tattoos are typically an autoaggressive activity, born of frustration, boredom, and anger turned inward in delinquent youths during incarceration The early teen years are a peak age for "jailhouse" tattoos, which in the vast majority of cases prove a source of future embarrassment. 28 These tattoos are applied impetuously to exposed bodily parts such as the hands or wrists during the early period of confinement and usually bear a more faithful semblance to the haphazard grafitti of a lavatory wall or school desk than to a permanent bodily adornment. Consequently, the selfapplied tattoo, such as the common " L-o-v-E H-A-T-E " motif placed on the knuckles, has become a hallmark of teen delinquency. Such tattoos are usually applied by a needle around which a thread is tied close to the point. Puncture tattooing is easily accomplished by dipping the point in ink and pricking the skin repeatedly. The sense of reckless disregard for the future among those marking themselves with amateur tattoos is exemplified by

8 GERALD W. GRUMET 489 the case of a 31-year-old man seen by the author in alcoholism treatment. His story was familiar: parental divorce in early childhood, poor school performance, membership in a teen gang, multiple arrests for public intoxication and disorderly conduct. His arms were adorned with an unappealing array of crudely applied tattoos, the largest of which was a giant "wow " covering the inner aspect of his left arm. On questioning, it was learned that during a teenage drinking bout he requested a friend tattoo "MoM " on his arm. The friend complied while sitting beside the patient and it was not until the following morning that both realized the tattoo was applied upside down. He summarized his feelings about his tattoos: "They're a disgrace.... I feel like a dummy." DERMAL DIAGNOSIS This report is predicated upon the belief that tattoos are a form of nonverbal communication that can often be deciphered. As one's lifelong appearance is ordinarily of supreme importance, it is logical that the acquisition of a tattoo and its special meaning for the bearer offer a treasure of psychodynamic material. It was initially hoped that a close scrutiny of tattoos at the time of psychiatric examination would allow for a system of objective analysis. This has proven only partly true, as the choice of tattoo designs is often clouded by extraneous variables of no psychic relevance. The individual being tattooed may be intoxicated or subjected to special peer pressures, and frequently must choose from a limited number of specimen sheet designs. However, a tattoo worn on the skin for many years often assumes symbolic importance, becoming a reservoir of emotionallycharged memories and talismanic meanings for its bearer. This is especially evident in the less verbal patient where the tattoo can be used as a springboard for discussing private feelings. TABLE I provides a skeletal outline for psychodiagnostic inquiry into the hidden vocabulary of tattoos. Of prime importance is the bearer's emotional reaction to his designs, a tipoff to self-esteem, as tattoos represent earlier efforts to galvanize an identity and consequently symbolize the self. An individual may smile with pride, wince with embarrassment, or shrug off the tattoo as insignificant. Next, the number and sequence of tattoos may be examined and it is the author's practice to elicit a tattoo history where appropriate just as one takes a family, vocational, educational, or medical history. The tattooed individual usually retains a surprisingly clear recollection of the sequence of his markings as well as the circumstances of acquisition. Elucidating these data-an Table 1 SOME CONSIDERATIONS IN TATTOO ANALYSIS 1. Patient's emotional reaction to the tattoos 2. Number and sequence of tattoos 3. Circumstance of tattoo acquisition a. Patient's age b. Alone or with peer group c. Incarcerated d. Intoxicated 4. Location of tattoos a. Visible in normal clothing b. Visible when partially clothed c. Visible only on unexposed areas 5. Quality, symmetry and size of tattoos a. "Jailhouse" or amateur b. Professional 6. Tattoo content a. Objective meaning for viewer b. Private meaning for patient c. The "love/hate ratio"

9 490 archeological unearthing of emotional relics-gives important clues to past events and often triggers a chain of recollections and associations. While a single tattoo is usually of no diagnostic significance, tattoos are sometimes found on schizophrenic individuals where they may reveal unusual or idiosyncratic motifs tied to the bearer's psychosis. Additionally, the psychotic person is more likely to have gone to the tattooist alone while the more typical individual has gone with friends to the tattoo parlor. 1 6 The tattoo bearer frequently harbors a personality disorder, sometimes of the antisocial or sociopathic type Further evidence for a sociopathic diagnosis is found in a hodgepodge of unrelated and asymmetrical designs which have been termed "kitsch" tattoos (German for "trash"). Obscene or lewd designs, emblems of a deformed value system, are also frequently seen in sociopaths.24 Lawbreakers are more likely to have received their first tattoos (usually selfinflicted) at an earlier age than noncriminals, one study showing the peak age to be A pattern of tattoo "addiction" is sometimes seen in the multiply-tattooed individual, an expression of personal incompleteness tied to a perennial but elusive quest for that one further design which will make him feel complete. Tattoo location is also of interest, with aggressive or pornographic themes more likely to be placed on exposed bodily surfaces like the external portion of the arm, while sentimental subjects find themselves on protected locations like the inner forearm Criminals are more likely to be tattooed on areas visible in normal clothing (e.g., hands or wrists)19 while noncriminals generally TATTOOS avoid these areas. Tattoos imprinted on normally unexposed bodily areas or the genitals have sexual implications and are found with some frequency in prostitutes and sexual perverts;33 some male homosexuals sport tattoos on their backs or buttocks. 20 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. The quality and symmetry of tattoos are likewise peripheral indicators of self-worth. Individuals with a history of impoverishment or delinquency often bear crude, self-inflicted designs whereas noncriminals are more likely to have professional tattoos showing greater restraint in design, location, and number. 45 Finally, the observable content and meaning of tattoos for the bearer and the viewer should be noted, as tattoos disguise and condense basic thoughts and impulses of a sexual or aggressive nature. One important finding is the proportion of violent and aggressive themes (ferocious animals, daggers, skulls) as compared with friendly motifs (hearts, flowers, butterflies, family inscriptions) which can be called the "love/hate ratio" and gives a clue to the bearer's temperament. In some multitattooed persons one can follow the evolution of character development in the tattoo sequence. For example, an individual known to the writer acquired tattoos with aggressive themes while a teenaged gang leader (a shark, a panther dripping blood) which shifted to transcendent themes (a butterfly, a unicorn with wings) in later years, paralleling his characterological shift from a combative life style to one of escapism and drug abuse. In other individuals the objective meaning of the

10 GERALD W. GRUMET 491 tattoo does not coincide with the private meaning for its bearer. One individual displayed the letters " H-A-T-E " on his knuckles, a grim reminder of his delinquent past. "Now it means, 'happiness all through eternity'," he reported. In some subpopulations of tattooees, dermal cryptograms are observed, requiring decoding by the bearer. For example, the number 4 appeared on a prostitute's knee, denoting a four letter word for intercourse, which she displayed as the situation demanded. 1 While tattoos have traditionally been a male phenomenon, with about 9% of U.S. men and less than 1% of women bearing marks,40 recent reports suggest that more women may be seeking them, paralleling their emancipation from traditional roles. 32 Although the variety of tattoo motifs is limitless, in the writer's experience something of psychodiagnostic relevance can be elicited from virtually every patient whom one takes the time to examine visually and verbally. CONCLUSIONS All tattooed individuals share a basic desire to make external representations of important feelings while fulfilling the fundamental and compelling need to establish a clear personal identity. The universality of some tattoo symbolism in geographically and temporally separate cultures suggests that tattoos derive, at least in part, from collective human strivings and impulses that transcend personal experience. 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. Like the dreaming process, tattoos condense, symbolize, and displace psychic energy to a meaningful image. Through reaction formation, denial, and compensation, failings are disavowed, deficiencies repaired. By incorporation, introjection, identification, and idealization the vaunted attributes of others are internalized and assimilated. Yet beneath heroic tattoo motifs the perceptive viewer can discern a hidden message of existential despair: " At one time I felt incomplete." In some tattooed individuals such designs may provide the key to a nexus of psychopathological factors, while in others they merely enhance the verbal history. Thus, tattoos embellish the psyche as well as the skin, and in a literal sense confirm Rogers's belief39 that man "is in fact the architect of himself." REFERENCES I. AGRIS, J Tattoos in women. Plast. Reconstr. Surg. 60: ANSBACHER, H. AND ANSBACHER, R. eds The Individual Psychology of Alfred Adler. Basic Books, New York. 3. BADEN, M Quoted in Symbols: tattoos on teen-age cadavers. Med. World News 14: BAILEY, B Treatment of tattoos. Plast. Reconstr. Surg. 40: BELL, R Some curious aspects of tattooing. Brit. J. Plast. Surg. 15: BRITT, B., PANEPENTO, E. AND WILSON, I The incidence of tattooing in a male criminal population. Behav. Neuropsychiat. 4: BROMBERG, w Psychologic motives in tattooing. Arch. Neurol. Psychiat. 33: BROMBERG, w Tattooing: psychosexual motivations. Sex. Behav. 2: BUNCKE, H. AND CONWAY, H Surgery of decorative and traumatic tattoos. Plast. Reconstr. Surg. 20: BURCHETT, G Memoirs of a Tattooist. Crown Publishers, New York.

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