Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece

Rom J Leg Med [26] 21-28 [2018] DOI: 10.4323/rjlm.2018.21 2018 Romanian Society of Legal Medicine FORENSIC PATHOLOGY Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece Konstantinos Katsos 1,*, Konstantinos Moraitis 1, Stauroula Papadodima 1, Chara Spiliopoulou 1 Abstract: In forensic context, tattoos are used mainly for identification purposes, but they can also provide evidence about the lifestyle of the decedent. This retrospective study examined autopsy cases that were conducted in the University of Athens Medical School in a 4-year period (2012-2015). Of a total 4274 autopsies carried out in this period 285 decedents (258 males and 27 females) appeared to have at least one tattoo. The majority of these deaths (61.4%) were determined to be due to non-natural causes. Specific tattoo designs appeared to be directly related to positive history for psychoactive substance abuse or positive toxicological analysis for psychoactive substance use. A high relation between Christian religious symbols and heroin use was notable. Moreover, psychoactive substance abuse was also found to be directly related to the visibility of tattoos as tattoos at the head, the neck and the hands appeared to be related to positive history of substance abuse or to positive postmortem toxicology findings. Further research is needed in the field of tattoos and substance abuse not only in specific social groups, but also in the general population in order to be able to better interpret tattoos on deceased individuals. Key Words: legal medicine, forensic toxicology, tattoos, autopsy, illicit drug use, psychoactive substance abuse. INTRODUCTION Tattoos in the forensic context are used mainly for identification purposes. A tattoo can provide great assistance such as in multiple-casualty incidents or in decomposing bodies, so that visual recognition can assist in the identification process. The exact documentation of a tattoo including location, style and other major features is of great value in every forensic autopsy [1]. Tattoos were always a very intriguing social phenomenon that have occupied many sciences, mainly sociology. The motivation of getting inked have been well studied and analyzed, but conclusions can never be generalized as the motivation can always be different, even if it concerns the same tattoo design. Besides identification, tattoos can provide evidence about the lifestyle of the decedent. Tattoos may reveal occupation, gang affiliation and many other habits and hobbies. In the past, they were used by specific community members (e.g., sailors) and they seem to have more expressive than cosmetic use. Certain tribes, mainly in Africa and Australia, were and are still using tattoos to mark notable landmarks in someone s life. Nowadays, with the wide spread and commercialization of tattoos in western societies, assumptions and estimations cannot anymore provide certain interpretation [2]. However, it is still possible to draw certain inferences from a tattoo design. The last few years, a number of papers concerning the forensic aspects of tattoos have been published [3-7]. The aim of the present study is to explore whether specific tattoo designs and other characteristics can be associated with psychoactive substance use/abuse using an autopsy population sample from Greece. In addition, 1) National and Kapodistrian University of Athens, School of Medicine, Department of Forensic Medicine and Toxicology, Athens, Greece * Corresponding author: National and Kapodistrian University of Athens, School of Medicine, Department of Forensic Medicine and Toxicology, 75 M. Asias Str., 11527 Athens, Greece, Tel. +30-210-7462409, Fax +30-210-7462390, E-mail: d_katsos@yahoo.gr 21

Katsos K. et al. Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece it aims to compare the results of previously published selfreporting studies about tattoos, substance use/abuse and risk-taking behaviour to the findings of the population we examined. 22 MATERIAL AND METHODS This retrospective study used the forensic autopsy cases that were conducted in the Department of Forensic Medicine and Toxicology of the Medical School of National and Kapodistrian University of Athens in a 4-year period (2012-2015). Using the narratives of the death investigation reports and supplemental photographic material, cases in which the decedent appears to have at least one tattoo were identified. Out of a total of 4274 autopsies that were undertaken by the Department in the period of interest, 285 of the decedents were found to have at least one tattoo. The demographic characteristics of the sample are shown in Table 1. Table 2 presents age distribution versus sex and nationality among the 285 decedents. It is significant to note that the Department s jurisdiction includes almost one third of the population of the Attica Prefecture (i.e., the greater area of Athens). Additionally, the municipalities in its jurisdiction are considered as being populated by Athenians of higher socioeconomic status and typically experience lower criminal rating compared with the remaining two thirds of the Greater Athens Area. From the 242 Greek citizens, 154 (63.6%) were Table 1. Demographic information of decedents with at least 1 tattoo (n=285) born, raised and lived in Attica Prefecture, 30 (12.4%) have lived in Attica Prefecture for several years but were born elsewhere in Greece, and 15 (6.2%) were born abroad where they have lived for several years. Twentyseven decedents (11.2%) were born and raised in a region of the Republic of Greece other than Attica and most of these (n=23, 9.5%) have lived in a region in close proximity to Attica. Therefore, the results of this study come mainly from residents of Attica Prefecture and nearby regions. Deaths were classified as natural or nonnatural. Manner of non-natural deaths were classified as homicide, suicide, accident, and undetermined. Tattoo designs were divided into 21 main categories: text (including phrases, initials and other words, dates and other numerals), animals, human figures, Christian religious symbols and images, flowers, stars, tribal designs, non-religious symbols, skulls, demons and reaper, heart, weapons, Chinese characters, dots at the dorsum of the hand, images referring to the sea (including ships, boats, anchors and mermaids), cobweb, national symbols, fairies, angels other than religious, playing cards, feather, sun/moon and other. The categories of animals and symbols other than religious were further subcategorized based on the designs. For animals, the main subcategories were snakes or lizards, dragons, butterflies, lions or tigers, eagles or hawks, and spiders or scorpions. The parts of the body where the tattoos appeared were also recorded. Human body was divided into the Male (n=258) Female (n=27) Total Nationality Greek 218 24 242 Other 38 3 41 Unknown 2 0 2 Marital status Single 104 10 114 Married/Civil Union 49 10 59 Widower/Widow 3 0 3 Divorced 37 3 40 Unknown 65 4 69 Employment status Employed 92 8 100 Unemployed 88 13 101 Unknown 78 0 78 Table 2. Age distribution based on sex and nationality Age Males (Greeks) Males (Other) Females (Greeks) Females (Other) Total % 17 1 0 1 0 2 0.7 18-29 47 9 9 1 66 23.2 30-39 61 9 3 0 73 25.6 40-49 54 5 8 1 68 23.9 50-59 37 12 3 1 53 18.6 60-69 13 3 0 0 16 5.6 70-79 2 0 0 0 2 0.7 80-85 3 0 0 0 3 1.0 Unknown 0 0 0 0 2 0.7 Total 218 38 24 3 285 100.0

Romanian Journal of Legal Medicine Vol. XXVI, No 1(2018) 5 main anatomical regions (i.e., head, neck, torso, upper and lower limbs) each of one was further divided into subcategories. In order to evaluate tattoo visibility, the human body was divided into 4 zones. Zone 1 included the head, the neck and the hands, the areas that are almost always visible by others. Zone 2 included the outside lateral surface of upper arms (except the surface of deltoid muscles), the forearms and the lower legs that are visible at least during spring and summer months. Zone 3 included the torso (except pubic and gluteal surfaces), the surface of deltoid muscles and the thighs, and zone 4 the intimate parts of the body (pubic and the gluteal regions). The final parameter examined was substance abuse with two possible classifications (positive or negative). In order for a positive determination to occur (i) decedents blood and/or urine specimens that were collected at autopsy and analyzed by the in-house accredited forensic toxicology laboratory (confirmed by GC-MS), produced positive results for either illicit drugs (heroin, cocaine, cannabis) or methadone or alcohol (for road traffic accidents a positive result was considered when blood concentration was over 0.5 g/l, which is the limit according to the Greek Highway Code), or (ii) history of psychoactive substance abuse was found in the medical records, police investigative reports or witness statements typically offered by family and friends. In order for a negative determination to occur (i) decedents blood and/or urine specimens that were collected at autopsy and analyzed by the forensic toxicology laboratory, produced negative results for either illicit drugs (heroin, cocaine, cannabis) or for alcohol, and/ or (ii) decedents had negative or unknown history of psychoactive substance abuse. Toxicological analysis was not performed in 53 cases (39 due to natural deaths and 14 due to hospitalization of the deceased for more than three days). RESULTS Age-at-death ranged between 15 and 85 years (16 to 85 years for males and 15 to 55 for females). Mean age was 41.1 and 35.7 years for males and females respectively. Figure 1 illustrates the percentage of tattooed decedents among the overall autopsy population on this study based on sex and age-at-death. Figure 2 illustrates the mean number of distinct tattoos in relation with age and sex of the decedent. Most decedents presented with 1 tattoo (35.1%) or 2 (21.9%), but a notable percentage of decedents (13.8%) presented with more than 6 tattoos. The highest percentage of decedents with 1 tattoo was observed in the age group of 60-69 years-old (43.7%) while the distribution in the other age groups ranged between 34.2% and 39.9%. Regarding decedents with more than 6 tattoos, the highest percentages were observed in age groups of 30-39 and 40-49 years-old with 20.5% and 23.5%, respectively. Only 1 female presented more than 6 tattoos (30 years old with 9 tattoos). The mean age of the 38 male decedents with more than 6 tattoos was 40.3 years (in 1 male the age was unknown), while 14 of them belonged in the 30-39 age group and 16 of them belonged in the 40-49 age group. The mean number of tattoos in this subcategory was 11.6 of which 8 decedents presented with 9 tattoos (including the one female) and 18 decedents presented with 7, 10 and 11 tattoos (each group consisting of 6 males). Tattoo designs differ between the two sexes. Although the most common design both for males and females was text (119 males and 13 females), several designs were not observed in all females (e.g., human figures, Christian religious symbols, national symbols, angels and playing cards) or were presented less frequently compared with males (n=1 for tribal designs, weapons, sea images, cobweb, fairies, and sun/moon). Deaths were due to natural disease in 90 cases (31.6%) but in 6 cases (2.1%) the cause and manner Figure 1. Distribution of tattooed decedents in relation with age at time-of-death. Figure 2. Average number of tattoos based on sex and age. 23

Katsos K. et al. Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece of death could not be determined due to the advanced state of decomposition of the decedent. Fourteen deaths were related to chronic heroin abuse while the remaining 175 cases (61.4%) were classified as non-natural deaths (Table 3). The relation between the manner of death and the total number of tattoos showed that the majority of deaths of the decedents with more than 6 tattoos (78%) were classified as non-naturals, as only 17% have died due to natural causes. For the groups with less than 6 tattoos the percentages of natural and non-natural deaths ranged from 27.3% to 46.1% for natural deaths and 46.1% and 70.7% respectively. In 106 cases the decedent had only 1 tattoo and in 62 cases 2. One hundred and five decedents were found to have at least 1 tattoo located only at the upper limb region, 45 only at the torso and 11 only at the lower limb region. The most common combination of anatomic regions by ascending sequence were torso-upper and lower limbs (n=43), torso and upper limbs (n=39), upper and lower limbs (n=22), torso (n=9). The occurrence of all remaining anatomic location combinations ranged between 1 and 3. Males were determined to display tattoos with frequency greater than 90% in most of their anatomic regions (as well as combinations of anatomic regions) with the exceptions of tattoos located only in the lower limb region (72.7%), only in the torso (77.8%) and their respective combination (88.9%). The majority of decedents (n=217, including 204 males and 13 females) had acquired at least 1 upper limbs tattoo and 143 (128 males and 15 females) presented at least 1 tattoo at the torso. The deltoid region was observed as the most common site (n=101), with 27 decedents Table 3. Manner and cause of death in the cases of non-natural deaths Manner and Cause of Death No. % Accidents 130 74.3 Fatal injuries due to road traffic collision 71 40.6 Drug intoxication 49 28.0 Drowning in the sea 4 2.3 Injuries in the working environment 3 1.7 Fatal injuries due to falls from height 2 1.1 Burns 1 0.6 Suicides 33 18.8 Hanging 22 12.6 Drug intoxication 4 2.3 Gunshot wounds 3 1.7 Burns 2 1.1 Fatal injuries due to falls from height 1 0.6 Knife-related injuries 1 0.6 Homicides 8 4.6 Strangulation 2 1.1 Stabbing 2 1.1 Head injuries 2 1.1 Gunshot wounds 1 0.6 Fatal injuries due to falls from height 1 0.6 Undetermined 4 2.3 Fatal injury due to fall 3 1.7 Drug intoxication 1 0.6 Total 175 - presenting bilateral tattoos. Forearms were the most common anatomic tattoo site for females (n=9, out of 13) while the upper arm region was most common for males (n=101, out of 128). The most popular areas of the torso for the location of the tattoo were the scapular region (n=62), the mammary region (n=55) and the lumbar region (n=35). Females were found to prefer the dorsal trunk (n=13), while males did not present such preference, as 73 and 82 individuals had acquired a tattoo at the frontal and dorsal trunk respectively. For most of the tattoo designs (n=198, including 183 males and 15 females), only black ink was used (overall 69.5%; 70.9% for males, 55.5% for females), while 26 decedents (19 males and 7 females) presented only colored tattoos and 57 (53 males and 4 females) had acquired both black ink and colored tattoos. In 185 of our total decedent population (64.9%) either the postmortem toxicology findings were positive for the aforementioned drugs and/or alcohol or a history of psychoactive substance abuse was found in the medical records, police investigative reports or witness statements typically offered by family and friends. The percentage of male drug users was 67.1% (n=173), whilst females presented a notably lower percentage (44.4%, n=12). Tattoo designs such as Christian religious symbols, dots at the dorsum of the hand, cobwebs and fairies were typically found in decedents with positive history or toxicology (Fig. 3). As previously mentioned, none of the female decedents displayed what was considered to be a Christian religious symbol. The majority of men with positive history and/or toxicology displayed at minimum 1 cross (n=31). Specific animal tattoos were also found in those with positive drug history and/or toxicology (Table 4). The category of other symbols (n=39) was presented as the most heterogeneous but some symbols such as the Yin-Yang symbol, the sign of the TV series character The Saint and chains were also found on decedents with positive drug history and/or toxicology. As mentioned above, these results represent mainly male decedents. For females the designs that Figure 3. Tattoo designs associated with psychoactive substance abuse (a) An archangel attacking Satan, (b) Jesus Christ, (c) Cross, (d) Cross with a phrase stating in Greek Please God, help me to stay drug free forever, (e) Cobweb, (f) Chains. 24

Romanian Journal of Legal Medicine Vol. XXVI, No 1(2018) seems to be associated with heroin abuse were skulls/ demons/reaper and dots at dorsum at the hand (2 out of 2), tribal designs, weapons, cobweb, fairies, sun/moon (1 out of 1), and heart and feather (2 out of 3). The results presented in Table 5 suggest that drug history/toxicology positivity is greater in individuals with multiple tattoos. Concerning tattoo visibility, decedents that had at least 1 tattoo in body zone 1 had the highest chance of drug history/toxicology positivity (79.3%) than those having tattoos in other zones of the body, as zones 2 and 3 were associated with positive history or toxicological findings in 66.7% and 67.9% of our sample and decedents with tattoos in body zone 4 had the lowest probability of drug history/toxicology positivity (58.8%). Tattoos in body zones 1 and 4 were mostly found in young decedents, as decedents aged 18 to 39 years old at time of death represented 60.34% and 58.83%, respectively for the aforementioned zones. Tattoos in body zones 2 and 3, for the same age range, were found in 49.68% and 46.07% respectively. DISCUSSION This is the first descriptive study about tattoos in Greece. We recognize that our decedent population is not representative of the country since postmortem populations suffer from their own unique biases. One of our findings that requires further investigation is whether women in Greece are less tattooed than men. We believe that one significant contributing factor for this finding may be the overall autopsy population sample, which consisted of 2947 males and only 1327 females. Overall, it was determined that only 6.67% of decedents were tattooed but there is a good chance this percentage is not representative of the overall population of Greece because of the selection bias. Forensic autopsies are typically performed in individuals Table 4. Tattoo designs compared to positive drug history/toxicology Tattoo Design Positive history or toxicology % Negative or unknown history and negative toxicology % Total Text 83 62.9 49 37.1 132 Animals 67 69.1 30 30.9 97 Dragons 20 86.9 3 13.1 23 Snakes or lizards 17 77.3 5 22.7 22 Butterflies 15 75.0 5 25.0 20 Lions or tigers 17 89.5 2 10.5 19 Eagles or hawks 10 71.4 4 28.6 14 Spiders or scorpions 12 92.3 1 7.3 13 Christian symbols 42 85.7 7 14.3 49 Human figures 36 75.0 12 25.0 48 Flowers 31 75.6 10 24.4 41 Stars 29 70.7 12 29.3 41 Tribal 30 76.9 9 23.1 39 Skulls/Demons/Reaper 24 71.0 9 29.0 33 Heart 19 73.1 7 26.9 26 Weapons 13 61.9 8 38.1 21 Chinese characters 16 80.0 4 20.0 20 Dots at dorsum of hand 14 87.5 2 12.5 16 Sea related images 10 62.5 6 37.5 16 National symbols 6 54.5 5 45.5 11 Cobweb 9 90.0 1 10.0 10 Fairies 8 80.0 2 20.0 10 Sun/Moon 8 80.0 2 20.0 10 Angels (not religious) 4 50.0 4 50.0 8 Feather 5 62.5 3 37.5 8 Playing cards 4 44.4 5 55.6 9 Total 185 64.9 100 35.1 285 Table 5. Total number of distinct tattoos compared to drug history/toxicology Number of tattoos Positive history or toxicology % Negative or unknown history and negative toxicology % Total 1 58 54.7 48 45.3 106 2 41 66.1 21 33.9 62 3 24 58.5 17 41.5 41 4 9 69.2 4 30.8 13 5 8 72.7 3 27.3 11 6 7 63.6 4 36.4 11 7 38 92.7 3 7.3 41 Total 185 64.9 100 35.1 285 25

Katsos K. et al. Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece who have suffered sudden, unexpected or violent deaths and for whom a forensic autopsy has been ordered by law enforcement agencies or the public prosecutor in order to establish the cause and manner of death. Furthermore, almost two thirds of the total morgue admissions consisted of decedents with age-at-death greater than 60 years. According to the literature, there is not yet established a strong correlation about tattoos and sex since there are studies that show men with both a higher and lower tattoo rates than women [3, 5, 8-17], and studies performed exclusive on males [4, 18-22]. In the present study, females comprised only one tenth of the decedent sample (27 females versus 258 males) and their average number of tattoos was lower (2.58) as compared with the males average of 3.65. As shown in Figures 1 and 2, tattoos appeared to be more frequent in young decedents. Besides this age-related discrepancy, these figures also show an increase of tattooed decedents over the 4-year period examined, which suggests that tattoos are becoming a more common type of body modification in Greece and that those who acquire tattoos are increasingly suffering sudden, unexpected or violent deaths. It is also noticeable that no tattoos were found on female decedents born prior to the 1950s, whereas no tattoo was found in any male born prior to the 1930s. Unfortunately, our research suffered a limitation in that we were not able to establish in any of our cases the exact age at which decedents acquired their tattoos. A strong relation between positive drug history/ toxicology and acquisition of tattoos is shown from the results, as almost 65% of decedents with at least 1 tattoo had either used a legal (e.g., alcohol) or illegal (e.g., heroin) substance prior to death or had a known history of such behavior in the past. Female tattooed decedents presented a lower percentage of positive drug history/ toxicology (44.4%) in comparison to males (65.9%). A possible explanation, besides the aforementioned selection bias is that women may consider tattoos as a form of art and expression, while men may view the acquisition of a tattoo as an expression of masculinity, with a more underground meaning. Past research suggests that there exists a direct relation between tattoos and psychoactive substance abuse [8, 10-12, 14, 16, 17, 23-25]. Our results appear to be consistent with the previous work published on this topic. However, our findings may be under reporting the true extent of this relationship within the Republic of Greece since for 39 decedents in our morgue sample for which toxicology was negative, their history of psychoactive substance use/abuse was unknown. In this respect, we believe that one of our study s strongholds may also be a weakness. Documenting psychoactive substance abuse by means of toxicology testing may not be foolproof. There is no absolute way to determine if the 103 decedents whose postmortem toxicology was negative didn t in fact have a history of psychoactive substance use/abuse (besides intravenous drug use and alcohol abuse which could present certain anatomic findings at autopsy). Carson s study showed early mortality for those who acquire tattoos [7]. Although many possible explanations can be offered for this observation as mentioned by Byard [26]. Our opinion is that it remains unsubstantiated by science to attempt to draw such inferences based solely on a postmortem morgue population. It is well understood that forensic autopsies are undertaken when there is suspicion of a non-natural death. In the present study, fatal blunt force injuries suffered in road traffic accidents, which are considered the most frequent manner of death for young people in Greece, were the most frequent cause of death (24.9% of all deaths and 40.6% of non-natural deaths) for decedents with tattoos. The mean age of these decedents was 30.8 years old (range: 15-63 years) and the majority of them (n=58) were under 40 years at time-of-death. A forensic autopsy is also conducted in unexpected and sudden deaths due to natural causes (mostly due to cardiovascular diseases), which is also one of the most frequent natural causes of death in young people. These facts also support the notion that a morgue population shouldn t typically be considered as representative of the overall population when examining fatality traits, frequencies, and other characteristics, especially based on age at time-of-death. Nevertheless, studies such as the present one can show trends about drug fatalities and their findings can help direct future investigations. As previously mentioned, the present study suggests that there exists a direct relation between tattoos and psychoactive substance use/ abuse. Furthermore, psychoactive substance use/abuse appears to be more frequent in decedents with multiple tattoos and in those where at least 1 tattoo is placed in an almost always visible part of the body. But the most intriguing result was the discovered relation between specific tattoo designs and psychoactive substance use/abuse (Table 4). Religious symbols (primarily Christian symbols which in itself is not surprising since the vast majority of the population living in Greece is Christian Orthodox) mainly crosses or portraits of Jesus were observed mostly in intravenous drug users (n=28), users of cannabis (n=10), and alcohol drinkers (n=5). A possible explanation is that these people use/abuse substances to achieve a more spiritual almost religious state of being (or nirvana). Another could be that these decedents recognized their substance use as an out of control addiction and have used the tattoo to reach out to a higher being or god in hope for assistance, strength and courage. For example, a decedent with documented history of heroin addiction had a tattoo of a cross and a phrase on his back that stated: Please God, help me to stay drug free forever. Another design with a 26

Romanian Journal of Legal Medicine Vol. XXVI, No 1(2018) strong psychoactive substance use/abuse correlation were cobwebs. This tattoo design was found in 9 decedents with documented history of heroin addiction, including 4 whose deaths were directly caused by heroin intoxication. A cobweb represents entrapment similar to the pray of a spider that cannot escape when caught on the spider s web. Similarly, a substance abuse addict may feel trapped in the cobweb of drug addiction with no route of escape in sight. The third design that presented a strong relation was the dots at the dorsum of the hand, which will be discussed below. Wohlrad et al. in their review article, established 10 motivational categories for acquiring a body modification, referring to tattoos and body piercing: beauty-art-fashion, individuality, personal narrative, physical endurance, group affiliations-commitment, resistance, spiritual-traditional tradition, addiction to tattoos, sexual motivation and no specific [27]. Three of these categories may be characterized objectively by an external observer. The first is resistance motivation, meaning as a manner of protest against family or society. Several tattoos can be included in this category, the most known of them is A.C.A.B., which stands for All Cops Are Bastards. In this study, only 1 decedent had this specific tattoo. But there are also other designs, more disguised, that have the same or similar meaning. These designs are the 3 or 5 dots at the dorsum of the hand that forms a triangle or a square respectively. Three dots may represent numerous phrases which consist of three words and most of them express a negative motion against society and a motion of resistance against police authority and police brutality. On the other hand, the design with five dots mostly represents that the person has served a prison sentence, as the four peripheral dots represents the prison walls and the central one shows the prisoner. Both of these designs suggest a history of incarceration and are typically acquired during imprisonment [28-29]. The second is commitment motivation as an expression of friendship and love, which is reflected with hearts, names or initials of friends or other beloved persons and commemorative dates. Our morgue population study sample found a large number of these (132 decedents had a text tattoo, 50 decedents a human figure, and 26 a heart) but due to lack of information regarding the meaning of the displayed tattoo no further processing was possible. The third category is addiction to tattoos. However, it becomes very difficult and subjective to attempt to determine beyond which number of tattoos the addiction motivation may be objectively established. In the present study, 62.8% of the decedents had more than 1 tattoos, with a mean number of 5 tattoos. As shown in Table 3, the majority of decedents with 7 or more tattoos were at the age group of 30 to 49 years, which shows the tendency that in order to acquire several tattoos, age and possibly access to funding are important variables since both are required to acquire such large number of tattoos. Several researchers have studied the significance of tattoo designs [3, 5, 20-22]. Komar and Lathrop presented a study where homicide victims were more likely to have a tattoo as compared to accident victims and that religious designs were more common for white Hispanics in the population they examined [3]. Blackburn et al. reported that certain tattoo designs may actually be associated with homicide victims [5] whereas Penedo and Nasco concluded that psychiatric patients with a history of substance addiction preferred to acquire a text tattoo but that animal and demon designs were their second and third preferences respectively [21]. Borokhov et al. previously described the association between several tattoo designs and the drug that an addict prefers to use [20]. According to that study, symbols of death such as skulls and bones are common indicators of drug use. Spiders and genies were mostly observed in cannabis users. Additionally, it was suggested that the location of a tattoo may indicate use/abuse of a specific drug (typically found in intravenous drug users). This is in agreement with the results of our own study reported above where decedents with tattoos on the head, neck and hands (Zone 1) showed a higher incidence of substance use/abuse than decedents with tattoos in zones 2, 3 or 4. According to Bhargava and Singh, lion tattoos were associated with the use of steroids [22]. In the present study, documented use of steroids was determined only in 4 cases, but in contrast to the study of Bhargava and Singh, lions were found in cases with history of heroin and cannabis use. Consequently, attempts of interpretation and association of specific tattoo designs to specific drugs may be problematic, especially when the inferences are drawn from findings in an autopsy population. Nowadays, tattoos seem to increasingly represent an artistic phenomenon and as many studies point out, tattoos can no longer label the bearer as a drug user/ abuser. Our study, the first of its kind in Greece, shows a high relation between Christian symbols and heroin addiction. However, as the population living within the Republic of Greece is increasingly become more diverse, further studies on the population living within Greece will probably be required in order to better characterize this observation. It is obvious that these results are based on a sample of the population living within one large jurisdiction of the Hellenic Republic (Greece) and it may be ill-advised to attempt to apply our findings to other populations. Further research is required in the general field of tattoos as well as in the field of tattoo and psychoactive substance use/abuse, not only in specific social groups (e.g., autopsied decedents, students, prisoners), but also in the general population in order to be able to draw accurate conclusions about their incidence and interpretation. 27

Katsos K. et al. Tattoos and abuse of psychoactive substances in an autopsy population sample from Greece CONCLUSION Tattoos are of great importance in a forensic autopsy as they may provide clues about the decedent s lifestyle, including social habits regarding alcohol and drug use. It may be possible to infer the use/abuse of certain psychoactive substances, such as alcohol and heroin by the presence of specific tattoo designs. In our studied population, consisted mainly of Christian Orthodox, religious symbols associated with Christianity appeared to be more frequent in cases with positive drug history/toxicology (mainly heroin users). Decedent tattoos in specific visible anatomical regions, such as the head, neck and hands, appear to suggest and predict a positive drug history/toxicology. Conflict of interest. The authors declare that there is no conflict of interest. Acknowledgment. The authors wish to thank Dr Nikolas P. Lemos for his editorial suggestions on this article. References 1. Byard RW. Tattoos: forensic considerations. Forensic Sci Med Pathol. 2013;9:534 542. 2. Cains GE, Byard RW. The forensic and cultural implications of tattooing. In: Tsokos M, editor. Forensic pathology reviews. Volume 5. Totowa, NJ: Humana Press; 2008. p. 197 220. 3. Komar D, Lathrop S. Tattoo types and frequencies in New Mexican white hispanics and white non-hispanics: autopsy data from homicidal and accidental deaths, 2002-2005. Am J Forensic Med Pathol. 2008;29:285 289. 4. Byard RW. Ned Kelly tattoos: origins and forensic implications. J Forensic Leg Med. 2011;18:276 279. 5. Blackburn J, Cleveland J, Griffin R, Davis GG, Lienert J, McGwin G. Tattoo frequency and types among homicides and other deaths, 2007-2008: a matched case-control study. Am J Forensic Med Pathol. 2012;33:202 205. 6. Byard RW. Commemorative tattoos as markers for anniversary reactions and suicide. J Forensic Med Pathol. 2014;24:15 17. 7. Carson HJ. The medium not the message: how tattoos correlate with early mortality. Am J Clin Pathol. 2014;142:99 103. 8. Samuel MC, Doherty PM, Bultrerys M, Jenison SA. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect. 2001;127:475 484. 9. Nishioka SD, Gyorkos TW, Joseph L, Collet JP, Maclean JD. Tattooing and risk for transfusion-transmitted diseases: the role of the type, number and design of the tattoos, and the conditions in which they were performed. Epidemiol Infect. 2002;128:63 71. 10. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics. 2002;109:1021 1027. 11. Brooks TL, Woods ER, Knight JR, Shrier LA. Body modification and substance use in adolescents: is there a link? J Adolesc Health. 2003;32:44 49. 12. Deschesnes M, Finès P, Demers S. Are tattooing and body piercing indicators of risk-taking behaviours among high school students? J Adolesc. 2006;29:379 393. 13. Tiggemann M, Golder F. Tattooing: an expression of uniqueness in the appearance domain. Body Image. 2006;3:309 315. 14. Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol. 2006; 55:413 421. 15. Lise ML, Cataldo Neto A, Gauer GJ, Dias HZ, Pickering VL. Tattooing: profile and discourse of individuals with marks in the body. An Bras Dermatol. 2010;85:631 638. 16. King KA, Vidourek RA. Getting inked: tattoo and risky behavioral involvement among university students. Soc Sci J. 2013;50:540 546. 17. Owen DC, Armstrong ML, Koch JR, Roberts AE. College students with body art: well-being or high-risk behavior? J Psychosoc Nurs Ment Health Serv. 2013; 51:20 28. 18. Kim JJ. A cultural psychiatric study on tattoos of young Korean males. Yonsei Med J. 1991;32:255 262. 19. Pozgain I, Bakić J, Flaković P, Koić O. Tattoo and personality traits in Croatian veterans. Yonsei Med J. 2004;45:300 305. 20. Borokhov A, Bastiaans R, Lerner V. Tattoo designs among drug abusers. Isr J Psychiatry Relat Sci. 2006;43:28 33. 21. Penedo HG, Nasco E. A tattoo s study in toxic substances addict patients. Rev. Hosp. Psiquiátr. La Habana. 2007;4. 22. Bhargava S, Singh R. A short screening of tattoo marks amongst drug addicts. Ann Forensic Res Anal. 2016;3:1024. 23. Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing: body art practices among college students. Clin Nurs Res. 1999;8:368 385. 24. Dhossche D, Snell KS, Larder S. A case-control study of tattoos in young suicide victims as a possible marker of risk. J Affect Disord. 2000;59:165 168. 25. Braithwaite R, Robillard A, Woodring T, Stephens T, Arriola KJ. Tattooing and body piercing among adolescent detainees: relationship to alcohol and other drug use. J Subst Abuse. 2001;13:5 16. 26. Byard RW. Tattoos containing useful messages. Am J Clin Pathol. 2015; 143:908. 27. Wohlrab S, Stahl J, Kappeler PM. Modifying the body: motivations for getting tattooed and pierced. Body Image. 2007;4:87 95. 28. 15 prison tattoos and their meanings. CorrectionsOne.com. 2014. https://www. correctionsone.com/prison-gangs/articles/7527475-15- prison-tattoos-and-their-meanings. Accessed 12 May 2017. 29. Five dots tattoo. Wikipedia. 2017. https://en.wikipedia.org/wiki/five_dots_ tattoo. Accessed 12 May 2017. 28