The Medium, Not the Message. How Tattoos Correlate With Early Mortality. Henry J. Carson, MD ABSTRACT

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1 The Medium, Not the Messge How Tttoos Correlte With Erly Mortlity Henry J. Crson, MD From Mercy Hospitl, Iow City, IA. Key Words: Tttooing; Autopsy; Forensic sciences; Violence; Suicide; Drug overdose Am J Clin Pthol July 2014;142: ABSTRACT Objectives: At utopsy, tttoos re recorded s prt of the externl exmintion. An investigtion ws undertken to determine whether negtive messges tht re tttooed on decedent my indicte predisposition to certin ftl outcomes. Methods: Tttooed nd nontttooed persons were clssified by demogrphy nd forensics. Tttoos with negtive or ominous messges were reviewed. Sttisticl comprisons were mde. Results: The men ge of deth for tttooed persons ws 39 yers, compred with 53 yers for nontttooed persons (P =.0001). There ws significnt contribution of negtive messges in tttoos ssocited with nonnturl deth (P =.0088) but not with nturl deth. However, the presence of ny tttoo ws more significnt thn the content of the tttoo. Conclusions: Persons with tttoos pper to die erlier thn those without. There my be n epiphenomenon between hving tttoos nd risk-tking behvior such s drug or lcohol use. A negtive tttoo my suggest predisposition to violent deth but is eclipsed by the presence of ny tttoo. Tttoos hve been prt of body rt nd expression in mny cultures since ntiquity. 1,2 The purposes of tttoos re s vried s the people who hve them nd my include such motives s personl expression, identifiction, militry clssifiction, gng ffilition, mrking of prisoners, or memorilizing personl history, mong others. 1-3 The prevlence of tttoos is not certin, but estimtes rnge from 6% to 24% in the United Sttes. 1,4 Tttoos pper to be more prevlent in the teenge nd young dult popultion thn mong people of the older decdes, 1,3,5-7 lthough they re seen in ll ge groups. Until recently, there ppers to hve been preference mong men for obtining tttoos, 7 but they hve become widely ccepted mong women. The circumstnces under which people procure tttoos re vried, including ritul bonding, 7 expression of individulity, the influence of friends, 1 or no reson. 3,6 An ssocition of wide-rnging risk-tking behvior hs been observed mong persons with tttoos, including drug buse, risky sexul behvior, suicidl behvior risk, smoking, nd truncy. 1,2,4,7 Eting disorders my lso be risk fctors mong women with tttoos. 1 While these ssocitions re frequent, it is importnt to note tht tttoos re not cuslly linked to these behviors or risk fctors. 1 Rther, these behviors pper to be ssocitions tht my shre underlying reltionships with the person who hs tttoos, but the tttoos per se do not cuse prticulr outcome. Tttoos re recorded t utopsy s prt of the externl exmintion nd cn be useful for the identifiction of decedent or my sometimes give n indiction of specific risk fctor tht could hve been relted to the cuse of deth, such s gng ffilition in violent deth. This study investigted Am J Clin Pthol 2014;142:

2 Crson / Tttoos t Autopsy whether other ssocitions exist between tttoos nd cuse or mnner of deth, prticulrly whether messges tttooed on decedent might hve connottions tht my indicte predisposition to types of ftl outcomes. regression, nd c 2 tests. Kpln-Meier survivl curves nd Cox proportionl hzrds regression nlyses were performed with the sttisticl pckge MedClc for Windows, version 12 (MedClc Softwre, Ostend, Belgium). Mterils nd Methods Cses from 15-yer period were reviewed ( ). The cses were drwn from the uthor s experience s deputy medicl exminer nd pthologist in Linn County, Iow, nd djcent or nerby counties. All cses with stisfctory records nd reports were reviewed. Exclusions were mde when key dt, such s the cuse of deth, nture of tttoos observed, or toxicology results, were not vilble. Only dults (18 yers or older) were included in the tttooed nd nontttooed groups. All persons were clssified by ge, rce, sex, cuse of deth, mnner of deth, nd toxicology findings. Overdoses included cute drug intoxictions with single drug, multiple drug intoxictions, nd ftl blood lcohol concentrtions. Persons with tttoos were ctegorized bsed on the messges or interprettions of the tttoos, which were correlted with the demogrphic nd forensic dt. In prticulr, tttoos with negtive, frightening, violent, or ominous messges were compred with the subjects outcomes. Specificlly, tttoos tht showed skulls, the Grim Reper, devil, demon, monster, wepons, thretening gng signs, or explicitly negtive sttements (eg, I d feel better ded, n ctul tttoo of suicide victim) were treted s negtive messges. The loctions of tttoos on the subjects were lso noted. The types of messges nd other tttoo content were compred with the demogrphic nd forensic dt. Sttisticl comprisons were mde with stndrd t tests, liner Tble 1 Demogrphics of People With nd Without Tttoos Chrcteristic Men Women Totl Tttoo Men ge, y Rce White Africn Americn Hispnic Nontttoo Men ge, y Rce White Africn Americn Hispnic Asin Totl Vlues re presented s number of subjects unless otherwise indicted. Results The demogrphic dt of the popultion studied re reported in Tble 1. The tttooed popultion consisted of 138 people; the nontttooed popultion consisted of 300 people. By the criteri described in Mterils nd Methods, mny people hd tttoos with negtive content (n = 29), mny more hd tttoos with nonnegtive content (n = 109), nd the lrgest group ws people with no tttoos (n = 300). Men were no more likely to be tttooed thn were women. Hispnics nd Asins were too few in number to be seprted in the sttisticl nlysis. However, there ws highly sttisticlly significnt correltion of tttooing bsed on rce, with Africn Americns much more likely to be tttooed thn whites (P =.0001). Similrly, there ws significnt correltion between ge nd rce, with Africn Americns with tttoos dying t younger ge (men, 32 yers) thn whites with tttoos (men, 40 yers) (P =.0089). In generl, however, people who died t younger ge were more likely to hve tttoos thn did people who died t n older ge (P =.0001). The men ge of deth without djustment for the mnner of deth for tttooed persons ws 39 yers (rnge, yers) compred with 53 yers (rnge, yers) for nontttooed persons (P =.0001). This survivl dvntge ws lso mintined when nlyzing for nturl vs nonnturl/ violent mnner of deth by the Kpln-Meier method (results to follow). The cuses of deth re reported in Tble 2. The cuse of deth ws highly correlted with the presence of tttoos for gunshot wounds (P =.0008) nd overdose (P =.0002). The cuse of deth ws highly correlted with the bsence of tttoos for therosclerotic crdiovsculr disese (P =.0001). There ws no reltionship between the presence nd bsence of tttoos for persons who died of other cuses. Tttoos were distributed on the subjects bodies s follows (the number of subjects on whom tttoos ppered t the given site but not the totl number of tttoos per site; mny persons hd tttoos on mny body sites): hed nd neck (n = 13), chest (n = 31), bdomen (n = 14), bck (n = 34), right upper extremity (n = 80), left upper extremity (n = 73), flnk (n = 1), right lower extremity (n = 21), nd left lower extremity (n = 25). The ctegories of tttoos found on the decedents were s follows (numbers indicte the number of times the specified clss of tttoo ws seen on the tttooed subjects; mny clsses of tttoos could be found on given individul): nmes, personl titles, or initils (n = 51); nimls (n = 50); 100 Am J Clin Pthol 2014;142: Downloded 100 from

3 Tble 2 Cuse of Deth in Tttooed nd Nontttooed Groups Tttooed, Nontttooed, Cuse of Deth No. No. P Vlue Abdominl ortic neurysm 3 7 Alzheimer disese 3 Amyotrophic lterl sclerosis 1 Anphylxis 2 Arrhythmi 5 Asphyxition 4 Asthm 2 2 Atherosclerotic crdiovsculr disese Blunt-force injury Bowel infrction 2 Crbon monoxide poisoning 2 8 Crcinom 1 11 Chronic obstructive pulmonry 1 2 disese Cerebrovsculr ccident 8 Cirrhosis 3 2 Congestive hert filure 2 2 Dibetic ketocidosis 2 6 Diffuse lveolr dmge 2 Drowning 5 Electrocution 1 Ftty liver 2 Gstrointestinl hemorrhge 3 6 Gunshot wound Hnging 8 6 Huntington chore 1 Hypertensive hert disese 6 8 Hypothermi 1 Indeterminte 4 2 Lung disese 3 Myocrditis 2 Obesity 1 Overdose Peritonitis 3 Pneumoni 5 22 Pulmonry embolus 1 5 Seizure 3 Sepsis 1 1 Shrp-force injury 3 2 Strngultion 1 Totl Cuse of deth significntly relted to this popultion. Tble 3 Mnner of Deth nd Content of Tttoo Mnner Negtive Nonnegtive Totl Tttoos, No Tttoo, of Deth Tttoo, No. Tttoo, No. No. No. Accident Homicide Suicide Nturl Indeterminte Survivl Probbility (%) Time (y) Figure 1 Mortlity of persons with tttoos. Kpln-Meier survivl nlysis: line 1 represents persons with no tttoos; line 2 represents persons with tttoos tht do not hve negtive content; line 3 represents persons with tttoos with negtive content. Persons with no tttoos re significntly likely to live to older ges thn persons in both groups. Persons with tttoos of negtive content re significntly likely to die t younger ges thn either group. 2 1 religious symbols or messges (n = 25); symbol other thn religious (n = 23); hert (n = 23); flower (n = 20); skull (n = 18); tribl (n = 16); negtive sttement (n = 7); devil or demon (n = 6); Chinese chrcters (n = 6); Grim Reper (n = 5); overtly sexul (n = 4); monster (n = 3); gng ffilition (n = 3); wepons (n = 3); swords (n = 2); nd miscellneous (n = 18). In summry, 32 subjects hd tttoos considered negtive (ie, skulls, the Grim Reper, devil, demon, monster, wepons, thretening gng signs, or explicitly negtive sttements), while 106 subjects hd neutrl or positive connottions in their tttoo choices. The mnners of deth re summrized in Tble 3. The Kpln-Meier survivl nlysis tested probbility of deth by nonnturl or violent mnner of deth over time, which is presented in Figure 1. Significnt differences were noted between persons with no tttoos, persons bering tttoos with nonnegtive messges, nd persons with tttoos bering negtive messges. Anlyzed this wy, the nontttooed popultion lived to men ge of 67 yers (n = 300), persons with nonnegtive messges lived to men ge of 47 yers (n = 109), nd persons with negtive-messge tttoos lived to men ge of 35 yers (n = 29) (P =.0001). The Cox proportionl hzrds regression nlysis model evluted the potentil contribution of sex, rce, use of drugs or lcohol, presence of tttoos, nd the content of tttoos in mnner of deth. When nlyzed for deth by nonnturl mnner, sex nd rce did not contribute to the risk of deth t younger ge. The use of lcohol nd illicit drugs, however, contributed significntly to deth t younger ge in nonnturl cses (P =.0001). Drug or lcohol use is summrized Am J Clin Pthol 2014;142:

4 Crson / Tttoos t Autopsy in Tble 4. As noted in the Kpln-Meier nlysis, the presence of ny tttoo ws confirmed to hve strong correltion with mortlity by nonnturl mnner (P =.001). As group tken together, tttoos with negtive messges contributed to risk of mortlity by nonnturl mnner (P =.0088). When specific types of negtive tttoos were compred with the presence of ny tttoo, most imges or messges did not hve definite contribution to erly mortlity, but imges of wepons or gng signs my hve importnce in erly nonnturl deth (P =.02). When nlyzed in the Cox nlysis for mortlity by nturl mnner, the bsence of tttoo continued to be ssocited with deth in nonviolent mnner (P =.0006). The presence of ny tttoo contributed to mortlity t younger ge (P =.0066), but the role of negtive messge ws not sufficiently strong to contribute to nturl mortlity t younger ge. Nonwhite rce contributed to nturl deth t younger ge, however (P =.0076). Discussion Tttoos hve long history in mny societies, including ncient Egypt, pre-columbin Americ, Chin, nd Polynesi, mong others. 1,4 The nme of the prctice s we use it tody comes from the Polynesin word tu-tu, mening the tpping of the skin to crete permnent mrking. 1,4 The term entered the Western lexicon through the trvels of Europen silors s they explored the Pcific nd encountered nd then dopted the prctice. Indeed, the so-clled tribl tttoo in current use is nmed fter the designs tht Polynesin tribes used in rites of pssge. The present dt re unvoidbly confounded. Young people re more likely to hve tttoos thn re older people, 1,3,5-7 nd the leding cuses of deth in the United Sttes in the young ge group re ccidents, homicides, nd suicides, which re ll nonnturl mnners of deth. So is the presence of tttoo or the presence of youth the primry risk fctor for these deths? The Cox proportionl hzrds regression nlysis helps to evlute the reltive contributions of the different fctors tht my be involved, but cknowledgment Tble 4 Drug or Alcohol Use in Tttooed nd Nontttooed Groups Drug or Alcohol Use Tttooed Nontttooed P Vlue Prescription drugs Illicit drugs Alcohol Men BAC, mg/dl BAC, blood lcohol concentrtion. Vlues re presented s numbers unless otherwise indicted. of the limittions of the present findings is prudent. Still, the present study identifies significnt difference between the ges of persons who die with tttoos compred with those without tttoos. The difference is 14 yers nd ppers to be independent of sex, rce, or mnner of deth. When mnner of deth is fctored in, the survivl difference is even more pprecible: 20 yers for tttoo with nonnegtive messge nd 32 yers for tttoo with negtive messge. Africn Americns in the study group pper more likely to be tttooed. They lso pper to die t younger ge thn do whites. The confounded dt re clrified bit by the Cox nlysis. The presence of ny tttoo, negtive messge, use of illicit drugs, nd lcohol pper to contribute to deth t younger ge in violent cses, while the presence of tttoo nd nonwhite rce contribute to deth t younger ge in nturl cses. Persons who die from gunshot wounds or overdose re lso more likely to be tttooed, while those who die from therosclerotic crdiovsculr disese re more likely not to be tttooed. The presence of tttoo with negtive content my be ssocited with deth by nonnturl mnner, nd s group, tttoos with negtive messges contribute to the risk of mortlity by nonnturl mnner. Imges of gng signs nd wepons my be prticulrly prone to this risk. Specific correltions between rce nd cuse of deth were found in other studies. 2,7 For exmple, lrge study of tttoos nd mortlity bsed on New Mexico popultion found tht Hispnic ethnicity ws significntly ssocited with the presence of religious tttoo nd tht homicide victims were significntly more likely to hve tttoos thn were victims of ccidents nd were more likely to hve gng tttoo thn others. 7 The significnt difference in ge of deth ws observed in tht study, s in this one. Similrly, smll study of n Austrlin popultion found n ssocition between the presence of tttoo of n ntiestblishment folk hero nd violent deth from suicide or homicide mong reltively young white men. 2 Differences between study groups likely reflect differences in the popultions tht re studied. According to the US Census Bureu, the estimted popultion of Iow is 3,074,186 people, of whom 92.8% re white, 3.2% re Africn Americn, 5.3% re Hispnic, nd 2.0% re Asin. By comprison, of 313,914,040 people in the United Sttes overll, 77.9% re white, 13.1% re Africn Americn, 16.9% re Hispnic, nd 5.5% re Asin. 8 It is likely tht the substntilly lower proportion of Africn Americns nd Hispnics in Iow prevents detection of some correltes tht my be confirmed in lrger, more diverse popultions. Religious iconogrphy nd messges, or folk heroes, my be culturlly dependent nd thus might not be reproducible in different popultions. This rticle s study group is bsed in culture nd sensibility of the Midwestern United Sttes nd my hve too much homogeneity to discern specific ethnic or rcil differences in expressions of tttoo rt. 102 Am J Clin Pthol 2014;142: Downloded 102 from

5 Still, the ssocition between tttoos nd reltively erly deth by ny mnner, not necessrily violent, ws striking. However, the presence of tttoo is not de fcto predictor or mrker of poor outcome in helth nd survivl but rther my represent n epiphenomenon. The ssocition between hving tttoos nd risk-tking behvior hs long been observed cliniclly, 1,2,4,7 especilly with people who obtin tttoos t younger ges. There is n indiction of this observtion t utopsy, in tht persons with tttoos re significntly more likely to hve n illicit drug detected thn persons without tttoos nd re more likely to die by nonnturl mnner with drugs or lcohol. These correltions my be ssocited with the greter incidence of ftlity from overdose in this group. Regrding the messge or imgery of the tttoo, there my be trends suggesting tht some types of tttoos my hve some kind of ssocition with certin outcomes, nd some of the messges tht people imprint in their skin, including negtive ones, pper to be relted to violent or nonnturl deth. However, the remrkble finding in these dt ws tht tttoos of ny kind my be ssocited with erlier deth from mny cuses nd mnners. There hve lwys been inherent risks in the process of tttooing, such s bleeding, ters, infections, llergic or inflmmtory rection, flre rection within the tttoo re ( koebneriztion ), ctivtion of ntive disese such s lupus, pseudolymphomtous rection, or pseudoepitheliomtous hyperplsi. 1,4,5 Some of these risks hve been mitigted by federl regultion of inks nd stte or locl requirements for sterile instruments nd clen procedures. 5 The rte of clinicl complictions from tttoos presently is pproximtely 2%. 4 The behviorl risks tht my ccompny the mind-set tht welcomes tttoo hve been described. 1,2,4,7 They my include live for tody ttitude, in which long-term consequences of personl decisions my not be considered in detil. Indeed, tttooing my be prdigm of this phenomenon: while one embrces certin tttoo t the time he or she receives it, the person my feel differently bout the tttoo lter; removl is firly common some yers fter the originl procedure. 1,5 Such n inclintion to commit to permnent body mrking could be relted to predisposition to mke other short-term decisions tht my hve ftl consequences in serious situtions tht could led to ccidents, suicide, or homicide. This behviorl model is less cler for deth by nturl cuses, however, which is lso correlted with deth t younger ge for mny tttooed persons in the dt shown herein. The exception to this trend is deth from therosclerotic crdiovsculr disese, which remined predominntly n ffliction of nontttooed persons. This difference my simply be result of overll survivl, however; possibly people with tttoos did not live lte enough into middle or elderly ge to develop complictions of therosclerosis. Address reprint requests to Dr Crson: Dept of Pthology, Mercy Hospitl, 500 E Mrket St, Iow City IA 52245; hjcmd@erthlink. net. Source of support: Cross Medicl Lbortories, LLC, Iow City, IA. References 1. Desi NA, Smith ML. Body rt in dolescents: pint, piercings, nd perils. Adolesc Med. 2011;22: Byrd R. Ned Kelly tttoos: origins nd forensic implictions. J Forensic Leg Med. 2011;18: Juhs E, English JC. Tttoo-ssocited complictions. J Peditr Adolesc Gynecol. 2013;26: Shinohr MM, Nguyen J, Grdner J, et l. The histopthologic spectrum of decortive tttoo complictions. J Cutn Pthol. 2012;39: Ortiz AR, Alster TS. Rising concern over cosmetic tttoos. Dermtol Surg. 2012;38: Gllè F, Qurnt A, Npoli C, et l. Body rt prctices nd helth risks: young dults knowledge in two regions of southern Itly. Ann Ig. 2012;24: Komr D, Lthrop S. Tttoo types nd frequencies in New Mexicn white Hispnics nd white non-hispnics. Am J Forensic Med Pthol. 2008;29: US Census Bureu. Stte nd County QuickFcts. quickfcts.census.gov/qfd/sttes/19000.html. Accessed November 25, Am J Clin Pthol 2014;142:

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