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Study |

Motivation for Contemporary Tattoo Removal:  A Shift in Identity FREE

Myrna L. Armstrong, EdD, RN, FAAN; Alden E. Roberts, PhD; Jerome R. Koch, PhD; Jana C. Saunders, PhD, RN; Donna C. Owen, PhD, RN; R. Rox Anderson, MD
[+] Author Affiliations

Author Affiliations: School of Nursing, Texas Tech University Health Sciences Center (Drs Armstrong, Saunders, and Owen), and Department of Sociology, Anthropology, and Social Work, Texas Tech University (Drs Roberts and Koch), Lubbock, Texas; and Harvard Medical School and Wellman Center for Photomedicine, Massachusetts General Hospital, Boston (Dr Anderson).


Arch Dermatol. 2008;144(7):879-884. doi:10.1001/archderm.144.7.879.
Text Size: A A A
Published online

Objective  To compare the results of a 1996 study of tattoo possession and motivation for tattoo removal with those of a 2006 study, in light of today's current strong mainstream tattoo procurement and societal support within the young adult population.

Design  Descriptive, exploratory study.

Setting  Four dermatology clinics in Arizona, Colorado, Massachusetts, and Texas.

Participants  The 2006 study included 196 tattooed patients (66 men and 130 women).

Main Outcome Measures  Incidence of purchase and possession risk, as measured by a 127-item survey and factor analysis.

Results  In contrast to the 1996 study, more women (69%) than men (31%) presented for tattoo removal in 2006. Women in the 2006 study were white, single, college educated, and between the ages of 24 and 39 years; they reported being risk takers, having stable family relationships, and moderate to strong religious beliefs (prayer and closeness to God). Commonly, tattoos were obtained at approximately 20 years of age, providing internal expectations of uniqueness and self-identity. Tattoo possession risks were significant, cited when the quest for uniqueness turned into stigmata ( < .001), negative comments ( < .003), and clothes problems ( < .004).

Conclusions  In both the 1996 and the 2006 studies, a shift in identity occurred, and removal centered around dissociating from the past. However, in the 2006 study, more women than men were notably affected by possession risks. Societal support for women with tattoos may not be as strong as for men. Rather than having visible tattoos, women may still want to choose self-controlled body site placement, even in our contemporary society.

Tattoos continue to appeal.16 The incidence of tattoos among young adults aged 18 to 30 years is approximately 25%,1,4,713 and it is estimated to approach 40% in the next few years.2 In Texas, registered tattoo studios (>1300 in 2006) have increased 55% annually since 1996.14

While a tattoo is often thought to be a masculine trait,9,15 it has been reported that women make up 45% to 65% of the tattooed population.16,17 Uniqueness and gender seem to be motivating factors in tattoo procurement. In one study involving career-oriented women with tattoos,17 many of whom were counselors, nurses, physicians, lawyers, and business managers, deliberate decision making and self-controlled body site placement were described as assistive for their tattoo satisfaction. The tattoos symbolized individuality and identity,17 projecting both femininity and personal strength.18,19 Tying in with gender, findings from multiple body art studies cite “it helped me feel unique”4,912,15,17,20 as a major purpose for getting a tattoo. Risk taking is normal when pursuing their need for uniqueness and is viewed as a positive way to “build their personal distinctiveness.”2,10,21,22

While the vast majority of individuals who are tattooed are pleased with their skin markings (up to 83%),4,713 the popularity and prevalence of tattoos often mean that dermatologists are increasingly hearing stories of regrets and requests for tattoo removal.23 Estimated prevalency rates of dissatisfied tattoo wearers hover around 20%,2,8 with a smaller number who actually seek removal (6%).3 In 2006, the American Society of Dermatologic Surgery reported a reduction in laser procedures for tattoo removal in 2005 (6%) compared with 2001 (8%) and 2003 (9%).2 The reason for this reduction could be the transition of tattoo removal services from medical offices to “spa or clinic” environments (or even tattoo studios), creating an underreporting of removal activities. Tattoos, which have classically been considered as “socially marginal products,” can create purchase and possession risks that could be strong motivators for removal.15,20,24 Purchase risks center around procedural problems with the artist, product, expense, pain, and/or inexperience concerning decision making about the tattoo.24 Possession risks include the dissonance between the purpose (or meaning) of the tattoo and the societal response to it.24

Motivation for tattoo removal was initially studied in 1996 with 105 patients. The study included men (61%) and women (38%) between the ages of 17 and 62 years.25 Many (75%) of them were single adolescents between 12 and 19 years of age at the time of their tattooing. The purposes cited for the tattoos included impulsive decision making, “to be part of a group,” “just wanted one,” and “for the heck of it.” While the tattoos were acquired for internal expectations of self-identity at an early age, tattoo removal also seemed to be internally motivated to dissociate from the past and to improve self-identity. Similar findings were cited in a study involving 68 patients in Wales.26 Waiting time for removal in both studies was at least 14 years.25,26

DESIGN

To compare the motivation for tattoo possession and removal in 1996 with today's contemporary acceptance and removal of tattoos, we conducted a descriptive, exploratory study at several locations. Exempt study status for this research was granted from the institutional review board of the Texas Tech University Health Sciences Center, Lubbock. Since 1999, the author team has collected and published data on tattooing and body piercing research (http://www2.tltc.ttu.edu/jkoch/Research/Tattoo%20Team.htm).

QUESTIONNAIRE

The study purpose and benefits were presented on the front page of the survey, and participants were told that completion of the survey indicated their voluntary participation. No names or clinics were asked to ensure candidness. Risks, other than those normally found in day-to-day activities, were not anticipated. Data were collected using a 127-item survey, which was written at a 7.7 grade level and based on current information in the medical literature as well as on applicable, reliable questions from previous body art studies. Two scales used in previous body art research were included in the survey4,9: the reliabilities-for-the-purpose scale was 0.86 and the risk scale was 0.84.

The 2006 survey included the following sections: (1) obtainment of the tattoo, 37 questions (Cronbach α = 0.73); (2) removal of the tattoo, 11 general questions, 13 questions regarding reason for removal (Cronbach α = 0.81), and 26 questions regarding contributing factors (Cronbach α = 0.92); and (3) general subject demographics, with 40 questions regarding risk taking, education, and religious perspectives. The questions were either multiple choice or Likert-type statements with scores ranging from 1 (strongly disagreed or unlikely) to 5 (strongly agreed or very likely). Ethnicity was included to note tattoo acquisition patterns; the ethnic categories were not defined and participants self-reported.

DATA COLLECTION AND ANALYSIS

Letters of agreement for data collection were obtained from 4 clinics providing tattoo removal services in Arizona, Colorado, Massachusetts, and Texas. Clinic representatives estimated the survey tools that they thought might be completed, and a total of 750 surveys were sent. Data collection ran from May 2005 through January 2006. According to institutional review board stipulations to avoid coercion, a notice was posted in waiting areas of the respective clinic lobbies inviting clients who were there to request laser tattoo removal to complete a survey. No tabulation was kept on how many individuals either saw or reviewed the survey. If the clients completed the survey (20-30 minutes), they placed the survey within a provided envelope, which they then sealed and gave to the office staff; 196 (26%) usable surveys were returned. The surveys were kept in a secured drawer until it was time to send them to the statistician. A commercially available statistical software package (SPSS Version 14; SPSS Inc, Chicago, Illinois) was used for data analysis. Cross-tabulation and χ2 analysis were performed.

The typical respondents in our 2006 study, which examined tattoo possession and motivation for removal, were female (69%), white, single, college educated, and between the ages of 24 and 39 years (Table 1); their religious beliefs (prayer and closeness to God) were moderate to strong. Hispanics, the second highest represented ethnic group, also had more tattooed women than men.

Table Graphic Jump LocationTable 1. Demographics of 196 Tattooed Subjects Requesting Tattoo Removal
TATTOO PROCUREMENT

More than half of the tattoos (Table 1) were obtained between the ages of 16 and 23 years (mean [SD] age, 20 [6.6] years). While both men and women obtained significantly more tattoos in high school and college, fewer women sought them in the elementary grades and military. Other nonsignificant gender differences included (1) having stable and/or positive family relationships, (2) more than half (60%) reporting pleasure with their tattoo, and (3) having a lifetime tattoo (men, 170 tattoos; women, 355 tattoos). More tattoos were placed in visible (arms or ankles, 49%) locations than in semivisible (chest or back, 39%) or intimate (groin or breasts, 20%) sites. Major purposes for getting a tattoo included “helped me feel unique” (n = 82 [44%]), “helped me feel independent” (n = 60 [33%]), and “made life experiences stand out for me” (n = 52 [28%]). Factor loadings of the purpose scale indicated a strong associated underlying theme that the tattoo supported internal expectations of uniqueness and self-identity (eigen value, 5.2 [47% of variance]; range, 0.59-0.79).

TIME OF TATTOO REMOVAL

Respondents were between the ages of 14 and 73 years (mean [SD] age, 30 [ 8.6] years) and had waited an average of 10 years before seeking removal. Again, there were no significant gender differences regarding reasons for being at the removal clinics. The participants came (1) requesting tattoo removal for the first time (25%), (2) returning, as part of a removal series (55%), or (3) returning, this time for more tattoos to be removed (20%); some had already tried other removal methods, such as recoloring (n = 43 [23%]) and retattooing (n = 38 [20%]). More than half (66%) of the respondents were not interested in getting more tattoos, but one-third (34%) said they would seek them again.

Two methods were used to examine motivation for tattoo removal: (1) purchase and possessions risks25 were reviewed and possession risks were evident; and (2) the conceptual integrity of the scales for tattoo removal reasons and contributing factors were evaluated to better understand the motivation for removal. The main reasons and contributing factors for tattoo removal are summarized in Table 2. The major themes (factor loadings) of the tattoo removal reason and contributing factor scales were highly associated with internal influences about their unique product: “they were tired of it,” “they just grew up,” “it was embarrassing them,” “they now had to hide their tattoo,” and “they wanted to remove it.” A “new job/career” was another reason for tattoo removal.

Table Graphic Jump LocationTable 2. Ranked Items of Reasons and Contributing Factors for Tattoo Removal
WOMEN SEEKING TATTOO REMOVAL

While the women had been pleased with their tattoos when they first got them, possession risks (Table 3) over the past 1 to 5 years had affected their present feelings about their tattoos. These women had experienced significantly more negative comments ( < .003) and stigma problems ( < .001) in public, workplace, or school settings than had the men with tattoos. Problems with clothes were also significant (< .004) and led them to use cosmetics, creams, and adhesive bandages to cover their tattoos.

Table Graphic Jump LocationTable 3. Factors That Significantly Affected Tattooed Women to Request Tattoo Removal
SEEKING UNIQUENESS

Among those respondents who had answered that their tattoo had “helped me feel unique” (n = 82 [44%]), gender differences were again evident (Table 3); more women than men were significantly worried about “going too far or becoming addicted” to tattoos; they also had significantly more piercings (average number, 1.9) and remained satisfied with the piercings. Also, this subset of women who had used their tattoos to help them feel unique reported significantly more “risk-taker” and “deviancy” feelings at the time of tattooing.

The 2006 study provided a snapshot of those individuals who were dissatisfied with tattoos and who sought tattoo removal. It presented another opportunity to examine underlying motivations that had not been examined in sufficient depth in previous studies.25,26 Yet, the study sample and the conclusions we can draw from the study results are constrained by (1) the use of self-reporting anonymous surveys, which can produce bias, inaccurate recall, or inflation; and (2) the small cross-sectional sample of respondents who described their opinions regarding why they wanted their tattoos removed. This survey methodology did allow us to identify the key factors behind motivation for tattoo removal and enabled us to develop better scales to describe and monitor changes in body art trends more completely.

When the results of the 1996 study outcomes25 were compared with those of the 2006 study, a different societal picture of tattooing was noted. Respondents in the 2006 study had more tattoos (2.8 vs almost 2.0), were older when they got the tattoo (16-23 years of age in high school and college vs 12-19 years of age in high school), and were younger when they presented for removal (average age, 30 years vs 33 years). Waiting time for removal was shorter (10 years vs 14 years). Tattoos in general, and especially those on women, were worn on more visible body locations (88%) than they were 10 years ago (82%).35 Unfortunately, no relational questions were asked about body placement and specific tattoo removal sites. Also, even though the subjects were seeking tattoo removal, more than one-third of them were still interested in getting more tattoos, suggesting that further research should be conducted on whether the removal of the tattoo is more about an actual design problem than about the feelings and effects associated with the tattoo.

Tattoos can be obtained to demonstrate group affiliation,3,8,13 which then puts them into a subculture of their own. Yet, while tattoos can be used to establish group identity, they can also be used for individual differentiation.8,9,12 More than 40% of the persons who had chosen the tattoo to help them feel unique or to seek uniqueness were disillusioned because their unique product had lost its luster and excitement.10 In such cases, faster decisions of removal could be made, especially with readily available removal services, equipment, and personnel. Individual actions regarding removal were still about dissociating from the past,25 as well as about shifting identity focus, to “move on,” perhaps even to seek other products (or for some, another tattoo) that would again contribute to the need for uniqueness. Tiggemann and Golder22 suggest that further research should be conducted in the tattooed population to examine whether seeking uniqueness is more important in the motivation-for-procurement phase or in the possession phase.

A new job or career was also a motivation for tattoo removal. Negative attitudes toward tattoos in the workplace could revert to “negative overt behavior,” with perceived interference for a tattooed individual's achievement.2730 Findings of perceived lowered credibility,28 competence, and sociability30 still continue to surface and to diminish the image of tattoo wearers in the workplace. While some employers (eg, Boeing, Wal-Mart, Wells-Fargo, Yahoo, and Ford Motors) support the perceived distinctiveness (uniqueness) of nonoffensive tattoos in the workplace, others do not (eg, Tenet Healthcare, Starbucks, and White & Case).31

Historically, getting a tattoo has been a male-dominant activity, but now women have more than half of the tattoos. For women, their tattoo procurement may be a way to break out of the gender norms and take some social risk by visually displaying their assertive identity. Yet, there still may be many members of society who consider tattoos on women to be a “transgression of gender boundaries.”25,27

In the 2006 study, a shift in gender presentation for tattoo removal was observed; in the 1996 study, more men than women requested tattoo removal, but in the 2006 study, more women (including Hispanics)9 did. While men also reported some of these same tattoo problems leading to removal, there seemed to be more societal fallout for women with tattoos, as the tattoos began to cause embarrassment, negative comments, and clothes problems and no longer satisfied the need for uniqueness. These negative internal and external outcomes contributed to the possession risks and to the subsequent identity shift for tattoo removal.16,17,25

Negative responses were also documented among career-oriented women with tattoos.25 Strong tattoo support from their significant others and friends was counterbalanced by negative remarks about the tattoos from their fathers, physicians, and the public. It is evident, then, that negative societal connotations still exist for women with tattoos. Therefore, for women to avoid the possession risks of their tattoos, as in the past, they may still need to deliberately think about controlling the body placement of their tattoos to reduce cognitive dissonance and to increase their psychological comfort.

In summary, tattooing is ancient, but popularity, social acceptance, tattoo inks, and laser technology are rapidly changing. How these changes will affect tattooing and tattoo removal is unknown. In the 2006 study, there was a prevalence of women seeking tattoo removal; their motivations for obtaining tattoos were often a desire for uniqueness, whereas self-reported embarrassment, negative comments, and clothes problems were motivations for tattoo removal, diminishing their feelings of uniqueness associated with the tattoo.

Correspondence: Myrna L. Armstrong, EdD, RN, FAAN, School of Nursing, Texas Tech University Health Sciences Center, TTU-Highland Lakes, 806 Steven Hawkins Pkwy, Marble Falls, TX 78654 (myrna.armstrong@ttuhsc.edu).

Accepted for Publication: September 20, 2007.

Author Contributions: Dr Armstrong takes responsibility for the accuracy of the data analysis. Dr Roberts had full access to all the data in the study and takes responsibility for the integrity of the data. Study concept and design: Armstrong, Roberts, Koch, Saunders, Owen, and Anderson. Acquisition of data: Armstrong, Roberts, and Koch. Analysis and interpretation of data: Roberts. Drafting of the manuscript: Armstrong, Roberts, Saunders, Owen, and Anderson. Critical revision of the manuscript for important intellectual content: Armstrong, Roberts, Koch, Saunders, and Owen. Statistical analysis: Roberts. Obtained funding: Armstrong. Administrative, technical, and material support: Armstrong and Owen. Study supervision: Armstrong, Roberts, Koch, and Saunders.

Financial Disclosure: Dr Armstrong is an education consultant for Freedom2Ink. Dr Anderson is a cofounder and a consultant for Freedom-2, LLC; he also conducts research with laser equipment under sponsored research agreements with his employing institution.

Funding/Support: This work was supported in part by the Research and Practice Committee of the School of Nursing, Texas Tech University Health Sciences Center.

Role of Sponsor: The funding sponsor had no role in the design or conduct of the study; in the collection, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: Pam Gandy, School of Nursing, Texas Tech University Health Sciences Center, and the office staff and physicians in Arizona, Colorado, Massachusetts, and Texas assisted with data collection.

 Ink me, stud – survey data on consumer attitudes towards body decoration – brief article – statistical data included. BNET Web site. http://findarticles.com/p/articles/mi_m4021/is_2001_Dec_1/ai_80408793. Accessed August 25, 2005
Anderson  RR Commentary: tattoos and body piercing. J Am Acad Dermatol 2006;55 (3) 422
PubMed Link to Article
Mayers  LBJudelson  DAMoriarty  BWRundell  KW Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77 (1) 29- 34
PubMed Link to Article
Armstrong  MLRoberts  AEOwen  DCKoch  JR Toward building a composite of college student influences with body art. Issues Compr Pediatr Nurs 2004;27 (4) 277- 295
PubMed Link to Article
Anderson  RR Regarding tattoos: is that sunlight, or an oncoming train at the end of the tunnel. Arch Dermatol 2001;137 (2) 210- 212
PubMed
Huxley  CGrogan  S Tattooing, piercing, health behaviors and health value. J Health Psychol 2005;10 (6) 831- 841
PubMed Link to Article
 A third of Americans with tattoos say they make them feel more sexy. Harris Interactive Web site. http://www.harrisinteractive.com/harris_poll/index.asp?PID=407. Accessed June 1, 2006
Laumann  AEDerick  DJ Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55 (3) 413- 421
PubMed Link to Article
Armstrong  MLOwen  DCRoberts  AEKoch  JR College students and tattoos: more than skin deep. Dermatol Nurs 2002;14 (5) 317- 323
Armstrong  MLRoberts  AEKoch  JRSaunders  JCOwen  DC Investigating the removal of body piercings Clin Nurs Res 2007;16 (2) 103- 118
PubMed Link to Article
Forbes  GB College students with tattoos and piercings: motives, family experiences, personality factors, and perception by others. Psychol Rep 2001;89 (3) 774- 786
PubMed Link to Article
Drews  DRAllison  CKRobst  JR Behaviorial and self-concept differences on tattooed and nontattooed college students. Psychol Rep 2000;86 (2) 475- 481
PubMed Link to Article
Hargrove  TStempel  GH A marked divide: tattooing rate varies by generation. Ohio University Web site. http://www.newspolls.org/story.php?story_id=19. Accessed May 25, 2005
Armstrong  ML Tattooing, body piercing, and permanent cosmetic state regulations: a historical and current view of state regulations with continuing concerns. J Environ Health 2005;67 (8) 38- 43
PubMed
Armstrong  MLMurphy  KPSallee  ASWatson  MG Tattooed army soldiers: examining the incidence, behavior, and risk. Mil Med 2000;16537- 40
PubMed
Stephens  MB Behavorial risks associated with tattooing. Fam Med 2003;35 (1) 52- 54
PubMed
Armstrong  ML Career-oriented women with tattoos. Image J Nurs Sch 1991;23 (4) 215- 220
PubMed Link to Article
Schildkrout  E Inscribing the body. Annu Rev Anthropol 2004;33319- 344
Link to Article
Hawkes  DSenn  CYThorn  C Factors that influence attitudes toward women with tattoos. Sex Roles 2004;50 (9/10) 593- 604
Link to Article
Armstrong  MLPace-Murphy  K Tattooing: another risk-behavior in adolescents warranting national health teaching. Appl Nurs Res 1997;10 (4) 181- 189
PubMed Link to Article
Lynn  MSynder  CR Uniqueness seeking. Synder  CRLopez  SJHandbook of Positive Psychology. New York Oxford University Press2002;395- 410
Tiggemann  MGolder  F Tattooing: an expression of uniqueness in the appearance domain. Body Image 2006;3 (4) 309- 315
PubMed Link to Article
Solis  RRDiven  DGColome-Grimmer  MISnyder  N  IVWagner  RF  Jr Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg 2002;28 (1) 83- 86
PubMed Link to Article
Sanders  C Tattoo consumption: risks and regret in the purchase of a socially marginal service. Hirscman  EHolbrook  MAdvances in Consumer Research. Provo, UT Association for Consumer Research1985;17- 22
Armstrong  MLStuppy  DJGabriel  DCAnderson  RR Motivation for tattoo removal Arch Dermatol 1996;132 (4) 412- 416
PubMed Link to Article
Varma  SLanigan  SW Motivation for tattoo removal. Arch Dermatol 1996;132 (12) 1516
PubMed Link to Article
Degelman  DPrice  ND Tattoos and ratings of personal characteristics. Psychol Rep 2002;90 (2) 507- 514
PubMed Link to Article
Seiter  JSHatch  S Effect of tattoos on perceptions of credibility and attractiveness. Psychol Rep 2005;96 (3, pt 2) 1113- 1120
PubMed Link to Article
Stuppy  DJArmstrong  MLCasals-Ariet  C Attitudes of health care providers and students towards tattooed people. J Adv Nurs 1998;27 (6) 1165- 1170
PubMed Link to Article
Bekhor  PSBekhor  LGandrabur  M Employer attitudes toward persons with visible tattoos. Australas J Dermatol 1995;36 (2) 75- 77
PubMed Link to Article
Org  M Tattoos and piercings come out at the office. The Wall Street Journal Online Web site. http://collegejournal.com/forms/printcontent.asp?url+http%3A//www.collegejournal. Accessed October 24, 2005

Figures

Tables

Table Graphic Jump LocationTable 1. Demographics of 196 Tattooed Subjects Requesting Tattoo Removal
Table Graphic Jump LocationTable 2. Ranked Items of Reasons and Contributing Factors for Tattoo Removal
Table Graphic Jump LocationTable 3. Factors That Significantly Affected Tattooed Women to Request Tattoo Removal

References

 Ink me, stud – survey data on consumer attitudes towards body decoration – brief article – statistical data included. BNET Web site. http://findarticles.com/p/articles/mi_m4021/is_2001_Dec_1/ai_80408793. Accessed August 25, 2005
Anderson  RR Commentary: tattoos and body piercing. J Am Acad Dermatol 2006;55 (3) 422
PubMed Link to Article
Mayers  LBJudelson  DAMoriarty  BWRundell  KW Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77 (1) 29- 34
PubMed Link to Article
Armstrong  MLRoberts  AEOwen  DCKoch  JR Toward building a composite of college student influences with body art. Issues Compr Pediatr Nurs 2004;27 (4) 277- 295
PubMed Link to Article
Anderson  RR Regarding tattoos: is that sunlight, or an oncoming train at the end of the tunnel. Arch Dermatol 2001;137 (2) 210- 212
PubMed
Huxley  CGrogan  S Tattooing, piercing, health behaviors and health value. J Health Psychol 2005;10 (6) 831- 841
PubMed Link to Article
 A third of Americans with tattoos say they make them feel more sexy. Harris Interactive Web site. http://www.harrisinteractive.com/harris_poll/index.asp?PID=407. Accessed June 1, 2006
Laumann  AEDerick  DJ Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55 (3) 413- 421
PubMed Link to Article
Armstrong  MLOwen  DCRoberts  AEKoch  JR College students and tattoos: more than skin deep. Dermatol Nurs 2002;14 (5) 317- 323
Armstrong  MLRoberts  AEKoch  JRSaunders  JCOwen  DC Investigating the removal of body piercings Clin Nurs Res 2007;16 (2) 103- 118
PubMed Link to Article
Forbes  GB College students with tattoos and piercings: motives, family experiences, personality factors, and perception by others. Psychol Rep 2001;89 (3) 774- 786
PubMed Link to Article
Drews  DRAllison  CKRobst  JR Behaviorial and self-concept differences on tattooed and nontattooed college students. Psychol Rep 2000;86 (2) 475- 481
PubMed Link to Article
Hargrove  TStempel  GH A marked divide: tattooing rate varies by generation. Ohio University Web site. http://www.newspolls.org/story.php?story_id=19. Accessed May 25, 2005
Armstrong  ML Tattooing, body piercing, and permanent cosmetic state regulations: a historical and current view of state regulations with continuing concerns. J Environ Health 2005;67 (8) 38- 43
PubMed
Armstrong  MLMurphy  KPSallee  ASWatson  MG Tattooed army soldiers: examining the incidence, behavior, and risk. Mil Med 2000;16537- 40
PubMed
Stephens  MB Behavorial risks associated with tattooing. Fam Med 2003;35 (1) 52- 54
PubMed
Armstrong  ML Career-oriented women with tattoos. Image J Nurs Sch 1991;23 (4) 215- 220
PubMed Link to Article
Schildkrout  E Inscribing the body. Annu Rev Anthropol 2004;33319- 344
Link to Article
Hawkes  DSenn  CYThorn  C Factors that influence attitudes toward women with tattoos. Sex Roles 2004;50 (9/10) 593- 604
Link to Article
Armstrong  MLPace-Murphy  K Tattooing: another risk-behavior in adolescents warranting national health teaching. Appl Nurs Res 1997;10 (4) 181- 189
PubMed Link to Article
Lynn  MSynder  CR Uniqueness seeking. Synder  CRLopez  SJHandbook of Positive Psychology. New York Oxford University Press2002;395- 410
Tiggemann  MGolder  F Tattooing: an expression of uniqueness in the appearance domain. Body Image 2006;3 (4) 309- 315
PubMed Link to Article
Solis  RRDiven  DGColome-Grimmer  MISnyder  N  IVWagner  RF  Jr Experimental nonsurgical tattoo removal in a guinea pig model with topical imiquimod and tretinoin. Dermatol Surg 2002;28 (1) 83- 86
PubMed Link to Article
Sanders  C Tattoo consumption: risks and regret in the purchase of a socially marginal service. Hirscman  EHolbrook  MAdvances in Consumer Research. Provo, UT Association for Consumer Research1985;17- 22
Armstrong  MLStuppy  DJGabriel  DCAnderson  RR Motivation for tattoo removal Arch Dermatol 1996;132 (4) 412- 416
PubMed Link to Article
Varma  SLanigan  SW Motivation for tattoo removal. Arch Dermatol 1996;132 (12) 1516
PubMed Link to Article
Degelman  DPrice  ND Tattoos and ratings of personal characteristics. Psychol Rep 2002;90 (2) 507- 514
PubMed Link to Article
Seiter  JSHatch  S Effect of tattoos on perceptions of credibility and attractiveness. Psychol Rep 2005;96 (3, pt 2) 1113- 1120
PubMed Link to Article
Stuppy  DJArmstrong  MLCasals-Ariet  C Attitudes of health care providers and students towards tattooed people. J Adv Nurs 1998;27 (6) 1165- 1170
PubMed Link to Article
Bekhor  PSBekhor  LGandrabur  M Employer attitudes toward persons with visible tattoos. Australas J Dermatol 1995;36 (2) 75- 77
PubMed Link to Article
Org  M Tattoos and piercings come out at the office. The Wall Street Journal Online Web site. http://collegejournal.com/forms/printcontent.asp?url+http%3A//www.collegejournal. Accessed October 24, 2005

Correspondence

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
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