Introduction
Tattoos are a form of body modifications which is made by inserting tattoo ink or pigments into the dermis to create a design. Tattoos have a long cultural tradition and have been present in the world for at least 5000 years. Their history begins in palaeolithic times with the oldest surviving indirect evidence such as tools with traces of ink from Ushki V archaeological site [1] or ivory figurines from Punuk culture depicting tattooed individuals [2]. However, the oldest discovery of the tattooed human skin is Ötzi the Iceman dating to between 3370 and 3100 BC [3].
In the ancient times tattoos were used by ancient Greeks and Romans to stigmatize slaves or criminals [4]. Some religious groups in the ancient Mediterranean world got tattoos, which possibly was later a reason for banning tattoos by the Emperor Constantine in Ancient Rome and Egypt because they were considered as an insult to God [5]. Tattoos were forbidden also among Christians by Pope Hadrian I in 787, however the practice of tattooing was secretly maintained in some places of Christian worship [5]. In the 17th century tattoos were done by pilgrims to the Holy Lands, who had Jerusalem crosses tattooed to commemorate their travels [6].
Tattoos have grown more and more popular in the Western world after the ocean expeditions of Captain James Cook in the 18th century [5]. In the 1800s tattoos spread among all social classes [5], however at the beginning of this century they were rather associated with sailors and criminals [7]. In the 20th and 21st century, tattoos became mainstream and were popular among pop stars and celebrities making them more acceptable in society [8].
The functions of tattoos have changed over the time. Among Austronesian societies tattoos were part of initiation rites, magical ward against illness or indicators of status, skill and beauty [3]. The Polynesian people of New Zealand did facial tattoos to emphasize social position [2]. In the Roman Empire tattoos were done among prisoners and slaves, and years later prisoners in the Nazi camps had an identification number tattooed [3]. In the gang cultures tattoos were means of communication to the social groups and membership to the brotherhood was emphasized [9]. Nowadays, tattoos are a mass phenomenon and have become an aesthetic object that reflects self-expression and beauty [10].
There is also a category of tattoos called a medical tattoo which is used to communicate medical information, or mark a body location for treatment. For example, tattoos during World War II were used to mark soldiers of the Waffen-SS of Nazi Germany with their blood type [3]. Nowadays, medical tattoos are used as fiducial markers for repeated application of radiotherapy [11].
Alexithymia is a complex personality structure that includes emotional deficits such as weakened ability to experience spontaneous, variable feelings and cognitive deficits such as difficulty in recognizing and describing feelings [12]. People with alexithymia show little sensitivity to the emotional meaning of verbal terms and encounter difficulties in using metaphors. The presence of alexithymia is associated with many psychiatric and neurological diseases [13–15] as well as with self-harm behaviours [16, 17].
Aim
The aim of this study was to assess the prevalence of alexithymia among tattooed individuals. Considering the fact that tattooing is a form of self-injury, it was assumed that the prevalence of alexithymia can be higher in tattooed individuals than in the general population. Moreover, we aimed to check if the type of tattoo is related to alexithymia.
Material and methods
This was a cross-sectional survey, conducted on 403 individuals from Poland. 200 of them had a tattoo and were assigned to the study group, and 203 of them had no tattoo and were assigned to the control group.
Tattooed individuals were recruited via social network Facebook®, where the self-created questionnaire was posted on social groups dedicated to people interested in tattoos. Respondents determined their level of education, reported how many pieces of tattoos they have, when they got their first and last tattoo, what the locations of tattoos were, what the motives for tattoos were, why they decided to do them, if they plan to get some tattoos in the future and if they are satisfied with their appearance after getting a tattoo. Respondents were instructed to assess their body surface covered with tattoos by using their palms. One palm indicated that 1% of the body was covered with tattoos. At the end respondents were asked to say if they want to remove their tattoo in the future and if they regret getting a tattoo.
The study group was then divided into two subgroups dependent on the motifs of their tattoos. In the first group individuals with verbal, personal tattoos such as names, important dates, mottos, and initials were included. The second group was focused on respondents with non-verbal tattoos. The study group was also analysed regarding their motive for getting tattoos. One subgroup included respondents who got their tattoos for different psychological reasons such as to express their emotions or enhance their self-esteem and the second subgroup included individuals who did tattoos mainly for aesthetic reasons.
Non-tattooed individuals were recruited by sending an online survey to Polish people. Participation in the study was voluntary, with WhatsApp®, Facebook® or e-mail invitation containing a direct link to the questionnaire. Based on the snowball sampling technique [18], each participant was able to send the link further and invite additional participants.
This project was conducted in accordance with the principles of Good Clinical Practice and the principles of the Helsinki Declaration of the World Medical Association and was approved by the Ethical Committe of Wrocław Medical University (SUBZ.C260.24.003).
Alexithymia was assessed with the use of the Toronto Alexithymia Scale (TAS-20) [19]. The questionnaire consists of 20 questions, each rated on the 5-point Likert scale (1 point – strongly disagree, 2 points – disagree, 3 points – neither agree nor disagree, 4 points – agree and 5 points – strongly agree). Five of the items are reverse-scored. The TAS-20 assesses three domains of alexithymia: difficulty in identifying feelings (DIF), difficulty in describing feelings (DDF) and externally oriented thinking (EOT). The maximum score of the instrument is 100 points. Scores of 61 points or higher indicate alexithymia. The Polish validated language version of TAS-20 by Ścigała et al. [20] was employed for this study.
Statistical analysis
Statistical analysis was performed using the software Statistica 13 (Dell, Inc., Tulsa, USA). The mean and SD were calculated. Differences between groups were determined using t-test. Spearman’s rank correlation coefficient (rs ) was used to name the strength of the relationship between variables. Statistical significance was set at p < 0.05. The data were collected and analysed anonymously.
Results
This study involved 403 individuals from Poland. 297 (73.7%) participants were females and 106 (26.3%) were males, aged from 17 to 72 years (mean age ± SD = 37.8 ±13.5 years). The study group was divided into a subgroup with tattoos and a subgroup without tattoos. 200 (49.6%) individuals reported to have a tattoo. The detailed characteristics of the study group are presented in Table 1.
Table 1
The detailed characteristics of the study group
Tattoo characteristics
48 (24%) respondents had one tattoo, 35 (17.5%) two tattoos, 23 (11.5%) three tattoos, 17 (8.5%) four tattoos, 43 (21.5%) from five to ten tattoos and 34 (17%) more than eleven tattoos. The mean age of getting the first tattoo was 26.6 ±10.5 years, and the last tattoo was 31.8 ±11.4 years. The mean self-assessed body surface covered with tattoos was 8.8 ±10.9%.
140 (29.8%) tattoos were located on forearms and palms, 102 (21.7%) on arms, 62 (13.2%) on lower legs and feet, 53 (11.3%) on the abdomen and chest, 51 (10.9%) on the back, 39 (8.3%) on thighs, 19 (4%) on the head and neck and 4 (0.8%) on intimate places.
104 (21.8%) tattoos had a plant motif, 87 (18.2%) animal motif, 67 (14%) were symbols, 60 (12.6%) were inscriptions, 42 (8.8%) had a mythical motif, 23 (4.8%) were letters or initials, 22 (4.6%) had a feminine motif, 21 (4.4%) had a geometrical motif, 18 (3.7%) had a motif connected to death, 13 (2.7%) a religious motif, 9 (1.8%) were tribals, 7 (1.5%) were dates, and 4 (1.1%) had a musical motif.
93 (20.7%) subjects admitted that they got a tattoo to express their personality, 82 (18.2%) did it for aesthetic reasons, 56 (12.4%) feel more confident thanks to a tattoo, 44 (9.8%) got a tattoo to express their feelings and emotions, 39 (8.7%) to commemorate important events, 33 (7.3%) to commemorate their beloved ones, 24 (5.3%) wanted to distinguish themselves, 20 (4.4%) wanted to have the same tattoo as another person, 7 (1.6%) to cover their scars, 7 (1.6%) did it because of a trend. For 45 (10%) subjects that was a spontaneous decision.
197 (98.5%) respondents do not regret getting a tattoo in the past and 179 (89.5%) individuals are willing to get a new tattoo in the future. 12 (6%) people removed or plan to remove one of his/her tattoos. Overall, 194 (97%) respondents are satisfied with their appearance after getting their last tattoo.
Alexithymia
In the study group, 80 (19.9%) respondents were classified as alexithymic ones. Out of them, 47 (11.7%) individuals had tattoos and 33 (8.9%) belonged to the non-tattooed group. Significantly more respondents in the tattooed group gained more than 61 points than in the non-tattooed group (23.5% vs. 16.2%; p < 0.05), so they were classified as alexithymic ones. The mean total score of the TAS-20 in the tattooed group was 47.8 ±13.4 points and did not significantly differ from the mean total score in the non-tattooed individuals – 46.9 ±12.6 points. No difference in the domains of the TAS-20 were observed in both groups (Table 2).
Table 2
Scores of the TAS-20 and its domains in the studied groups
Results of the TAS-20 and its domains were also analysed in the subgroups which were created depending on the tattoo motif and reasons for getting the tattoo.
35 (17.5%) respondents with non-verbal tattoos were screened as alexithymic, while 12 (6%) individuals with verbal, personal tattoos were classified as alexithymic ones (p < 0.05). The total score of the TAS-20 and all its domains were higher in the individuals with non-verbal tattoos, however the statistical difference was reached only for the EOT domain (Table 3).
Table 3
Scores of the TAS-20 and its domains in the subgroups with different tattoo motifs
22 (11%) respondents who got their tattoos for psychological reasons and 25 (12.5%) individuals who made their tattoos for aesthetic reasons were classified as alexithymic (NS). The total score of the TAS-20 and all its domains were only numerically higher in the subgroup of respondents who got their tattoos for aesthetic reasons (Table 4).
Table 4
Scores of the TAS-20 and its domains in the subgroups with different tattoo motives
The mean score of the TAS-20 poorly correlated with age, age of getting the first and last tattoo. Of note, the overall score of TAS-20 was weakly correlated with body surface covered with tattoos (rs = –0.136, p < 0.05) and there was no relationship between TAS-20 scores and the number of tattoos (rs = –0.132, NS) (Table 5). Similarly, all three domains of the TAS-20 poorly correlated with the number of tattoos and body surface covered with tattoos among individuals (Table 6).
Table 5
Spearman’s rank correlation coefficient (rs) between data in the tattooed group
Table 6
Spearman’s rank correlation coefficient (rs) between particular domains of the TAS-20 and data collected in the study
Discussion
For the past 20 years, body modification such as tattooing has become tremendously popular in Western countries [21]. The overall prevalence of tattooing in the general population is around 10–20% [22–24], and is still rising [21]. Our study showed that most respondents got their tattoos to express their personality and emotions, or to enhance their self-confidence rather than for aesthetic reasons. These observations seem to be confirmed in the literature. The study of 432 volunteers conducted by Stirn et al. [25] showed that respondents got tattoos to express their individuality, to demonstrate autonomy and rarely to represent their belonging to specific social groups or for aesthetic reasons. Our other study which included 4809 individuals reported that 20.6% of volunteers got their tattoo for self-expression, 14.5% for self-confidence and 11.9% for aesthetic reasons [26].
Alexithymia affects around 10–13% of people in a community sample [27–29]. In our study 16.2% of respondents from the control group were screened as alexithymic, which is slightly higher than in the general population. It is worth emphasizing that this study was conducted in 2024, so in a short time after the COVID-19 pandemic, which caused serious long-term psychological problems in the society [30]. Isolation, social distance and feeling of loneliness in pandemic years, nowadays could have an impact on the psychological state of individuals, and supposedly also on the level of alexithymia.
The aim of this study was to determine the prevalence of alexithymia among tattooed individuals. According to our paper, 23.5% of respondents were classified as alexithymic with the mean global TAS-20 score of 47.8 ±13.4 points. This result is comparable with some dermatological diseases such as psoriasis (24.8%) [31] or atopic dermatitis (27.7%) [32], and lower than in acne (31.3%) [33] or in hidradenitis suppurativa (41.0%) [34]. These observations show that tattoos as a body modification can be a manifestation of impairment of self-confidence supposedly to the same extent as some dermatological conditions. The studies of alexithymia in tattooed populations are scarce. One study conducted by D’Ambrosio et al. [35] showed that the mean global score of TAS-20 among tattooed volunteers was 55.1 ±9.8 points. However, this study was conducted only on 25 individuals which in our opinion cannot provide unequivocal conclusions.
Some cases of getting tattoos, which are made mainly for feeling pain, could be an indicator of non-suicidal self-injuries (NNSI) which are deliberate, self-inflicted lesions, without suicidal intent [36]. According to Solís-Bravo et al. [36], adolescents with tattoos compared to the group without tattoos were significantly more likely to manifest more self-injury episodes, negative thoughts and social dysfunctions. It is also proven that elevated levels of alexithymia are positively correlated with NNSI [37, 38] as well as with SSI (suicidal self-injuries) [38, 39]. Of note, the research conducted by O’Connor et al. [40] found that the prevalence of suicide attempts among people with a history of NNSI is 40%. In our research, significantly more respondents with tattoos presented a tendency to alexithymia compared to non-tattooed ones (23.5% vs. 16.2%; p < 0.05). Taking all this into consideration, it could be assumed that tattoos could be indicators of alexithymia and further of NNSI or SSI. It would be advisable to screen this group of patients for self-harm behaviours in clinical practice.
Our study has some limitations, which in our opinion do not lessen the results obtained. Firstly, this paper was based on online questionnaires and despite our efforts some questions could have been misunderstood or misinterpreted. Moreover, using this methodology we are not able to provide the exact response rate and this may create the bias of the final results. Finally, it is worth emphasizing that all information was gained anonymously, which makes it impossible to verify. Nevertheless, this survey analysed the correlation between tattoos and alexithymia, which represents the main strength of this paper.
Conclusions
Subjects with tattoos should be regarded as a group with increased prevalence of alexithymia. Individuals with non-verbal tattoos had a higher tendency to be screened as alexithymic ones. Motivation for getting a tattoo does not seem to have a significant impact on the prevalence of alexithymia. As alexithymia may have a negative influence on the therapeutic process in various diseases, early detection of the problem can help clinicians apply a holistic approach to specific groups of patients.
