Tattoo Designs Among Drug Abusers
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Isr J Psychiatry Relat Sci Vol 43 No. 1 (2006) 28–33
Tattoo Designs Among Drug Abusers
Alexander Borokhov, MD, Roland Bastiaans, MD, and Vladimir Lerner, MD, PhD
Division of Psychiatry, Ministry of Health Mental Health Center, Faculty of Health Sciences, Ben-Gurion University
of the Negev, Beersheba, Israel .
Abstract: Forty-one males with drug abuse who had tattoos with designs related to drug use were selected from a larger
sample of tattooed males in forensic psychiatric wards, prisons and military recruitment centers during the period
1986-2000 in the former Soviet Union. Two-thirds of the tattoo images were related to a specific drug, some served to
hide signs of repeated drug use, others to identify ideal sites for injection. Knowledge of these details may be helpful to
clinicians, although images may be influenced by current trends.
The word “tattoo” entered the English language as groups. Hence, the tattoo itself and its meaning may
an Anglicized version of the Tahitian word “tatau” reflect the inner world of an individual and his/her
(“to mark”). Tattooing is conscious injuring of the relationship with the outside world (6, 7). Moreover,
skin by special tools, which inject color in the skin according to some authors, the high rate of tattoo
with the purpose of obtaining permanent, indelible found among drug abusers may reflect their lack of
images. On the one hand, tattooing thrived through- social adaptability as well as an obstacle to the pro-
out antiquity in China, Japan and North Africa, cess of rehabilitation (8).
and tattoos have been found on skins of Egyptian In spite of the abundant literature on tattoo (his-
mummies dating from 4000 to 2000 B.C.E. On the torical, ethnographical and cosmetic aspects, tech-
other hand, tattooing has been condemned by sev-
nique, and the art of tattooing itself), there are few
eral religions. For example in Leviticus 19:28, God
medical studies on this topic. Most medical investi-
spoke to Moses, prohibiting tattooing as idolatry:
gations concerning tattoos are devoted to personal
“You shall not make any cutting in your flesh nor im-
hygiene, infectious diseases (hepatitis C and HIV)
print any marks on you.” The Prophet Mohammed
and to dermatological problems inherent to tattoo-
issued a similar injunction in the Koran as did Pope
drawing itself (9-12). Since tattooing in jail or prison
Adrian I at the Ecumenical Council at Nicaea in 787
(1, 2). is generally performed by using non-sterile impro-
vised “prickers” such as nails, needles, syringe nee-
The original aim of the tattoo was to serve as a
dles, guitar strings and so on, it is not surprising that
nonverbal symbol for personal identification and for
this practice increases the risk of infection (13). As
making one’s status clear among the other members
mentioned above, psychiatric reports on tattoos and
of society.
their relationship to mental disturbances are rare
In modern society tattoo has some additional and, if at all, they are usually related to antisocial per-
meanings. For example, tattoos may express individ- sonality (14, 15).
ualism, defiance, affection, risk-taking, alliance, sex-
ual preference, beauty, fantasies, freedom, etc. (3-5). The current study is to our knowledge the first re-
For many young individuals the tattoo is a quest for port which makes an attempt to describe different
identity through which he/she is able to make clear images concerned with drug use.
to the world who he/she is, with the expectation of The aim of our study was to investigate tattoos
being accepted as such. The tattoo has also a major and describe their locations as found on the bodies
function in proclaiming one’s allegiance to a specific of substance abusers and to find a possible relation-
group or subculture with its own intrinsic rules, but ship between these images and abuse or dependence
at the same time also it stresses difference from other on various kinds of drugs.
Address for Correspondence: Vladimir Lerner, MD, PhD, Beersheba Mental Health Center, POB 4600, Beersheba,
84170, Israel. E-mail: lernervld@yahoo.comALEXANDER BOROKHOV ET AL. 29
Subjects and Methods was obtained. Our study is only descriptive and
involved no type of intervention, procedure or medi-
During the period 1986-2000 we examined 1,440 cation. However, verbal patient consent was ob-
subjects in Russia, Kazakhstan, Uzbekistan and the tained and documented.
Ukraine. The examination was carried out in five fo-
rensic psychiatric wards, three prisons and two mili-
tar y recruitment centers: 318 prisoners, 255 Results
psychiatric inpatients and 867 conscripts. Among all Forty-one tattooed male subjects with diagnosis of
the examined subjects, 351 persons had 787 tattoos: substance abuse or dependence were selected out of
236 (74.2%) were prisoners, 46 (18.3%) psychiatric 351 screened (11.7%). The subjects were 18-35 years
inpatients and 69 (7.9%) were conscripts. old (mean±SD: 23.7±6.3 years), and had 47 tattoos
In accordance with their meaning all images are related to drug use (6.0% of total tattoos). These im-
divided into criminal, non-criminal or combined ages are divided into: a) a tattoo design related to
tattoos. Criminal tattoos are defined as those images drug use in general (GT); and b) a tattoo design re-
which reflected conflict with the law (criminal viola- lated to a specific drug (DT), (7). Among them 29
tions, number of years served in prison), using co- persons acquired their tattoos in prison and 12 per-
vert or obvious symbols, and/or demonstrated rank sons acquired their tattoos outside prison. Tattoos
in a criminal hierarchy. These images are drawn on were classified according to their location on the
the skin either voluntarily or forcibly. Non-criminal body and according to the specific drug used as well
tattoos are characterized by absence of content re- as the characteristic method of drug ingestion (inha-
garding conflict with the law and reflect the individ- lation, injection, etc.).
ual worldview of the subject; they have usually been Sixteen images (34%) belonged to the GT group
voluntarily acquired. Combined tattoos include im- (Fig. 1, 2), while 31 tattoos fell in the DT group.
ages from both of the above groups (16, 17). Each Among these, 18 tattoos (38%) were related to the
group includes several subgroups reflecting various use of cannabinoids (Fig. 3-6); 8 (17%) were con-
differences in meaning. The full classification of tat- nected to use of opioids (Fig. 7-10); and 5 (11%) tat-
toos has been reported in previous publications (1, toos were found on persons using hallucinogenic
16). drugs (Fig. 11). One person had 4 different tattoos
According to the purpose of the study only tat- that were related to the same theme (cannabinoids),
tooed persons who suffered from substance abuse or another person had 3 tattoos concerning general
dependence (according to DSM-III-R) were se- substance use and in addition one person had 2 dif-
lected. Diagnoses were made on the basis of medical ferent tattoos that were related to opioids.
records (anamnestic data, previous diagnosis con- When shown photographs or pictures of tattoos
firmed during rehospitalization, clinical data, urine related to drug use, 29 subjects with criminal records
analyses for drug exposure) and personal files from demonstrated considerable agreement as to their
different sources (psychological, criminal and so on) symbolism. Images relating to the DT group, such as
were analyzed. Moreover, all subjects were inter- “spiders” (especially in combination with web) were
viewed informally (A.B.) and were asked about the identified by 25 (86%) of the subjects; “genie” was
relationship between the drug used and their tattoos. similarly identified by 15 (51%), and “harem” by 11
In addition, in order to establish that these tattoos (37%) subjects. These images were recognized as
are not casual findings, photographs and pictures of “typical” markers of a person who prefers use of
tattoos from the literature were shown to all subjects, cannabinoids. Variations of “poppy” images (as sym-
and they were asked to choose the tattoos related to bols of opioid use) were identified by 7 (24%) sub-
their personal drug abuse and to explain their mean- jects. Images from the GT group, indicating drug use
ing, purpose, and why a specific location on the body in general, such as symbols of “death” — skulls,
was chosen. bones and skeletons — were identified by 18 (62%)
This study was not performed in an academic set- subjects; images of syringes (symbols of objects used
ting; no approval from an institutional review board in the injection of drugs) were identified by 3 (10%)30 TATTOO DESIGNS AMONG DRUG ABUSERS
Fig. 3. A spider on a web. The location is
under the clavicles, on palm, or on the
Fig. 1. A skull with a snake. The lo- Fig. 2. Half a face and half a skull. The back of the hand, on forearm, shoulder,
cation is on arm, forearm, shoulder location is on chest, shoulder or neck, abdomen, thigh, knee, shank and/or
or shank. shank. feet.
subjects. Even among the subjects who had no crimi- “spiders” were discovered in 19.2% of persons (Fig. 1,
nal records, 5 of 12 (42%) identified “spiders,” 4 2), “poppies” (10.6%) (Fig. 7, 10), “genie,” “genie fly-
(33%) persons identified “leaf of hemp” (a leaf which ing from jug” (Fig.4), and different images of “half-
has a distinctive form [18]), and 2 (17%) persons moon” (oriental motifs indicative of regions where
identified the “genie” as markers related to the use of cannabinoids are grown or easily purchased [6, 7])
cannabinoids. Two persons from this group identified were found in 8.5% of persons, “harem” (another ori-
images of “mushrooms” as a symbol of hallucinogens. ental motif where the central figure is a man smok-
Among the specific tattoos, the GT such as “sy- ing a hookah; figures of naked dancing women
ringes” were found in 12.8% (Fig.7-10) and different indicate sexual fantasy resulting from the use of
symbols of death, such as “skull with snake,” were cannabinoids [17]) in 6.4%, and “leaf of hemp” in
found in 4.3 % of all persons (Fig. 6). The DT such as 4.3% (Fig. 3).
Fig. 4. A spider. The location is on forearm, shank
and/or thigh. Where the spider is drawn heading
downwards, towards the legs, it means that the tat- Fig. 5. The leaf of hemp. Fig.6. Genie flying
tooed person has tried to stop using his drug. If a spi- The location is on fore- from a jug. The loca-
der “creeps” towards the head, it is mean that this arm, shoulder and/or tion is on abdomen,
person declares the intention to continue using drugs. back. thigh or shank.ALEXANDER BOROKHOV ET AL. 31
last was the only location exclusively related to drug
abuse. Less common locations were neck, palm of
the hand, clavicle area and biceps. This is in contrast
to typical criminal images which were usually lo-
cated on shoulders, under the clavicle area and on
fingers (1, 16, 17). In each of these locations only 1
tattoo was found. It should be mentioned that 80.9 %
of all tattoos were found on covered skin, whereas
19.1% were on uncovered skin: hands, dorsum and
palm. Of all tattoos, 93.7% were located on the front
Fig. 7. A syringe and a poppy. The location is on forearm or of the body, and 6.3% on the back. Twenty-one
shoulder.
(44.7%) tattoos were located on the upper extremi-
ties, 13 (27.7%) on the lower extremities, 10 (21.3%)
The consistent identification and interpretation on thorax and abdomen, and 3 (6.3%) on the upper
of particular images from both the DT and GT part of back.
groups demonstrates that the appearance of these Some tattoos in certain places, such as forearms
images in the tattoos of our subjects was not inciden- and the antecubital area, were made in order to hide
tal, and that these images are truly special markers scar tissue or sclerosed veins caused by the injection
among persons using drugs. of drugs. Other tattoos were made with the opposite
Regarding location, 8 (17%) tattoos were found aim — to highlight the area of injection. This in-
on the back of the hands, 6 (14.9%) on the upper ex- cludes specific tattoos showing the place of injection
tremities and 5 (10.5%) on the antecubital area. This for use in case of “emergency,” such as a craving for
Fig. 8. A skeleton leaning on a sy- Fig. 9. A syringe entwined in barbed Fig. 10. A syringe with a poppy on
ringe with the text: “I was like wire of which every “knot” symbol- the end of a needle. The location is
you.” The location is on forearm izes a year of prison (in this case: 4 on the shoulder or inner side of fore-
or shoulder. years), located on the shoulder. arm.32 TATTOO DESIGNS AMONG DRUG ABUSERS
Fig. 12. A “draw-well.” The location
is found on the forearm and
antecubital area (the usual place for Fig. 13. A tiger or cat holding the num-
Fig. 11. A mushroom. The location is on the injecting a drug without needing a ber “13” in its mouth. The location is
lower abdomen. tourniquet). on shoulder or chest.
drugs during withdrawal. In Russian slang, these tat- with specific drugs and the ways in which they are
toos are referred to as “draw-well” and/or “star trace” used.
(Fig. 12). Tattoos such as “syringes with butterfly- Regarding symbolic meaning, the spider (for ex-
wings” or “genie flying out from jug” reflected the ample) is not always easy to understand. Firstly, in
desirable/expected or experienced drug effects, such the 1970s-1980s the spider images were very popular
as a sense of ease or euphoria. among criminal elements of the former USSR, indi-
Nine (21.2%) persons reported a special correla- cating common drug use or sale. Later, the huge
tion between belonging to a certain subculture and prevalence of the use of cannabis products found ex-
their specific tattoo. Moreover, the slang used often pression in tattoos. Most of the subjects examined
provided a “key” to understanding the meaning of could not explain the symbolic meaning of the spi-
the tattoo. der. But some explained the spider-web as a symbol
We found 5 tattoos which had cryptic meanings, of their own imprisonment and hopelessness. The
such as “8” or “13” which stand for the 8th and 13th spider was explained as a symbol for a man who can
letter of the English alphabet, “H” and “M,” which in obtain and distribute drugs. Bennahum suggests an-
turn stand for heroin and marijuana (Fig.13). Simi- other explanation of this symbol, in which “the para-
larly, “3” and “5” refer to the 3rd and 5th letters (“C” lytic poison of the Black Widow may represent the
and “E”), which stand for cocaine and “eater” (an ad- poison of heroin” (19).
dict who takes drugs orally). The numbers “99.9” Drug-related images were shown to have their
and “999” mean “very pure heroin.” own specific symbolism in overt (obvious) motifs
(knife, executioner, syringe, poppy and so on) as well
as “covert” motifs (finger-ring, stars, spider, abbrevi-
Discussion ations and so on). There are common locations for
tattoo placement with both types of images. How-
Our findings show that there are tattoos related to ever, in contrast to GT, there are fixed places only for
drug use and that some of them have standard loca- DT. These tattoos frequently depict drug parapher-
tions. For example, tattoos on the cubital fold may nalia and are strategically placed to conceal injection
have multiple functional purposes: on the one hand marks.
indicating the spot where injections may easily be Several researchers reported that some tattoos
made, and on the other hand masking scar-tissue (such as “spiders,” “syringes” and “images of death”)
and sclerosed veins. We found that certain images and their location (fingers and antecubital area) in-
(poppies, spiders, syringes) have close relationships dicate that its owner belongs to a certain group, thatALEXANDER BOROKHOV ET AL. 33
he prefers a specific drug and/or a specific method of 6. Bitensky V, Khersonsky B, Dvoryak S, Glushkov V.
drug use; the desirable or expected drug effects (6, 7, Drug addiction in adolescents. Kiev: Zdorov’ya, 1989
19) may also be indicated. For example, a signet ring (in Russian).
7. Borokhov A, Popov T, Tumasov S, Gofman V,
with spider or the number “13” indicates that the
Vostrikov V. The significance of tattoos as a marker of
subject prefers cannabinoids (6, 7). self-destructive behaviour in adolescence and youths.
We would like to note that this study has some In: Popov Y, Lichko E, editors. Self-destructive behav-
limitations: This is a descriptive, naturalistic study iour in adolescence. Leningrad: The Bekhterev Insti-
with no control group, which was performed in one tute, 1991: pp. 107-112 (in Russian).
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examined sample is small and includes only males. Symbolic barriers or a handicap to rehablitation.
Hautarzt 1990;41:645-647 (in Russian).
Our results and their implications are circumscribed
9. Onder M, Atahan CA, Oztas P, Oztas M. Temporary
in that this sample included only those substance
henna tattoo reactions in children. Int J Dermatology
abusers who had tattoos related to drug abuse. The 2001;40:577-579.
study may also be relevant only to tattoos acquired 10. Samuel MC, Doherty PM, Bulterys M, Jenison SA. As-
during a given time period, as there are changing sociation between heroin use, needle sharing and tat-
fashions in tattooing. toos received in prison with hepatitis B and C positivity
However, while this article is not a comprehen- among street-recruited injecting drug users in New
sive guide, the results are consistent with our former Mexico, USA. Epidemiol Infect 2001;127:475-484.
findings, namely that tattoos may indicate the use or 11. Lifson AR, Halcon LL. Substance abuse and high-risk
needle-related behaviors among homeless youth in
abuse of certain psychoactive substances. This may
Minneapolis: Implications for prevention. J Urban
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Further prospective studies are needed in this rel- Arriola KJ. Tattooing and body piercing among adoles-
atively untrodden field, and we hope that the present cent detainees: Relationship to alcohol and other drug
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