1 Embodied Narratives Hannah Zipes Pennsylvania Western University Department of Psychology, Counseling and Art Therapy COUN 7550: Introduction to Research in Art Therapy Dr. Sheila Lorenzo de la Peña & Dr. Carolyn Treadon Summer, 2024 2 Table of Contents Abstract...........................................................................................................................................5 Section I: Introduction....................................................................................................................6 Problem to be Investigated..................................................................................................6 Purpose Statement...............................................................................................................7 Justification.........................................................................................................................7 Terms Related to this Study................................................................................................8 Section II: Literature Review........................................................................................................13 Adversity...........................................................................................................................13 Family Rejection...................................................................................................14 Political Erasure...................................................................................................15 Mental Health Needs.............................................................................................16 Frameworks.......................................................................................................................17 Queer Theory........................................................................................................17 Narrative Therapy.................................................................................................18 Role of Others.......................................................................................................20 Expressive Therapeutic Modalities...................................................................................21 Body Psychotherapy..............................................................................................21 Translating to Art Therapy................................................................................................23 Social-Justice Oriented.........................................................................................23 Social Acceptance.............................................................................................................24 Historical Acceptance of Tattoos..........................................................................25 Historical Acceptance of the Queer Community..................................................26 3 Therapeutic Potentials of Tattooing..................................................................................28 The Human Body as Art........................................................................................29 Tattooing Motivations...........................................................................................29 Tattoos as an Art Therapy Tool............................................................................30 Psychological and Biological Aspects of Pain.....................................................31 Space.................................................................................................................................33 Placement..............................................................................................................33 Holding Space.......................................................................................................35 Limitations........................................................................................................................35 Section III: Methodology..............................................................................................................38 Beneficiaries/Participants.................................................................................................38 Project Design...................................................................................................................39 Procedure..........................................................................................................................40 Week One..............................................................................................................40 Week Two..............................................................................................................41 Week Three............................................................................................................42 Week Four.............................................................................................................42 Six-Month Debrief.................................................................................................43 Section IV: Data Analysis.............................................................................................................45 Rosenberg Self-Esteem Scale...........................................................................................45 Kinetic-House-Tree-Person..............................................................................................46 Purposed Method for Data Analysis.................................................................................46 Section V: Discussion...................................................................................................................48 4 Summary...........................................................................................................................48 Discussion.........................................................................................................................48 Limitations........................................................................................................................50 Suggestions.......................................................................................................................51 References.....................................................................................................................................53 Appendix........................................................................................................................................58 5 Abstract The mental health challenges and needs within the queer community are multifaceted and often influenced by social, cultural, and systemic factors. Addressing these obstacles requires a comprehensive approach that addresses systemic barriers, promotes societal acceptance and inclusion, and provides tailored mental health support and resources for queer individuals. This paper examines the potential of tattoos as an inclusive form of care that bridges the gap between minority health disparities. Tattooing as an art therapy intervention holds promise for addressing mental health issues among queer and trans populations by reclaiming personhood amid oppression. 6 Section I: Introduction The queer community faces unique mental health challenges stemming from societal stigma, discrimination, and lack of affirmation. On average, individuals who identify as lesbian, gay, and bisexual are twice as likely to face discrimination in their lives compared to those who are cisgender and heterosexual (Pachankis & Goldfried, 2010). Considering these challenges, there is a pressing need for culturally competent and inclusive therapeutic interventions that address the specific needs and experiences of queer individuals. Art therapy, particularly through tattoos, offers a promising avenue to promote mental health and identity affirmation among queer individuals. Through an art therapy lens, tattoos can be viewed as a powerful artistic expression with significant meaning. Tattoos, latent with symbolism and personal significance, hold promise as a therapeutic tool for fostering resilience, empowerment, and regulation among queer individuals. The subsequent sections will review existing research on art therapy, tattoos as a therapeutic device, and mental health within the queer community, describe the methodology employed in this study, present the findings, and discuss implications for clinical practice and future research. Problem to be Investigated Individuals in the queer community often face significant challenges related to identity due to systemic marginalization, leading to an increased prevalence of mental health issues (Williams, 2021; Zeeman et al., 2018). This disparity in mental health outcomes underscores the urgent need for effective and innovative treatment modalities tailored to the unique experiences of queer individuals. Historically, tattooing has served as a powerful means of identity expression across various cultures (Atkinson, 2003). However, there is a notable lack of research on the integration of therapeutic tattooing within the context of art therapy. This research 7 proposal aims to address the mental health disparities faced by the queer community by exploring the potential of tattooing as an art therapy intervention. Purpose Statement The purpose of this research is to explore the potential of tattooing as a therapeutic tool within the queer community, focusing on its role in reclaiming personhood and fostering selfexpression amidst oppression. By examining existing literature, this study aims to investigate how tattoos can facilitate agency, identity affirmation, emotional healing, and empowerment among queer individuals. The research seeks to develop a curriculum for utilizing tattoos as an art therapy modality, contributing to a deeper understanding of alternative therapeutic approaches and their effectiveness in helping queer people cope with mental health challenges. Justification The Minority Stress Theory posits that individuals from minority groups are more likely to experience stressors stemming from experiences of prejudice, discrimination, and stigma. The accumulation of stressors in minority groups can have profound effects on an individual’s mental and physical health. This suggests that queer people aren’t having mental health problems because they’re queer but because of the societal stigmas around being queer (Meyer, 2003). Gay-related stress is a manifestation of the external stressors and expectations of rejection as outlined in the Minority Stress Theory (Lewis et al., 2003). The outcomes of these external stressors can be seen in comparison statistics such as; 13% of queer people had a suicidal attempt contrasted with 2% of cis-het individuals (Williams, 2021). Over 50% of queer individuals engaged in suicidal ideation, contrasted with 13.6% in the cis-het population (Williams, 2021). On average, 61% of queer people are diagnosed with anxiety, while only 39.3% of cis-het individuals are diagnosed (Williams, 2021). The alarming difference in these numbers puts queer 8 individuals at a higher risk for developing various mental health disorders as well as a higher risk for houselessness (Williams, 2021; Zeeman et al., 2018). Unfortunately, major psychological and physical health issues are exacerbated by the avoidance of healthcare due to homophobia, heteronormativity, and discrimination (Williams, 2021). Given these profound disparities, it is imperative to develop innovative and effective therapeutic modalities that address the unique challenges faced by queer individuals. This research is motivated by the urgent need to bridge the gap in mental health outcomes and contribute to therapeutic approaches that can empower queer individuals, enhance their mental health, and improve their overall well-being. Research question How does the tattooing process symbolize the development and maintenance of a selfcare routine aimed at reclaiming queer personhood? Terms For this research, the following terms are used. Asexual (Ace) Describes a person who does not experience sexual attraction. An umbrella term that can also include people who are demisexual, graysexual, asexual, and aromantic. Binary construct Traditional understanding of gender as consisting of only two categories: male and female. It assumes that individuals can only identify as either male or female, based on their biological sex. Bisexual A person who can form enduring physical, romantic, and/or emotional attractions to those of the same gender or more than one gender. Bisexual people need not have specific sexual 9 experiences to be bisexual; they need not have had any sexual experience at all to identify as bisexual. Cisgender (Cis) Denoting or relating to a person whose gender identity corresponds with the sex registered for them at birth. Gay Encompassing term for people whose enduring physical, romantic, and/or emotional attractions are to people of the same sex. Alternatively, used to describe a non-woman attracted to another non-women. Gay-related Stress An individual’s minority status conflicts with other roles in which the individual is acting (Lewis et al., 2003). Gender Identity One’s innermost concept of self as male, female, a blend of both, or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth. Grand Narrative A broad, overarching story or metanarrative that attempts to explain the nature of human existence, history, and culture. It is a story that tries to provide a comprehensive and unified view of reality and explain the meaning and purpose of human life. Heteronormative World view that promotes heterosexuality as the normal or preferred sexual orientation. Heterosexual (Het) 10 Sexually or romantically attracted exclusively to people of the other sex. Homophobia Dislike of or prejudice against gay people. Internalized Homophobia The queer person’s direction of negative social attitudes toward the self. Intrapsychic conflict between queer experiences and feeling a need to be heterosexual. Intersectionality The interconnected nature of social categorizations such as race, class, gender, and sexuality as they apply to a given individual/group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage. Intersex Used to describe a person with one or more innate sex characteristics (genitals, internal reproductive organs, and chromosomes) that fall outside traditional conceptions of male or female bodies. Not all intersex folks identify as being part of the queer community. Lesbian A non-man whose enduring physical, romantic, and/or emotional attraction is to other non-men. Minority stress: “...culturally sanctioned, categorically ascribed inferior status, social prejudice, and discrimination, the impact of these environmental forces on psychological well-being and consequent readjustment or adaptation” (Brooks, 1981, p. 107). Non-Binary 11 Describes a person whose gender is not male or female and uses many different terms to describe themselves. Other terms include genderqueer, agender, bigender, genderfluid, and more. None of these terms mean exactly the same thing, but all speak to an experience of gender that is not simply male or female. Queer Personhood The sense of identity, dignity, and agency experienced by individuals who identify as queer. It encompasses the rights, recognition, and validation of one’s identity within society, including aspects such as relationships, family, community, and self-expression. Queer Adjective used by some people whose sexual orientation is not exclusively heterosexual or straight. In this paper, ‘queer’ will be used as an umbrella term for the LGBTQIA+ community. Questioning The ‘Q’ at the end of LGBTQIA+ can also mean questioning as in someone who is questioning their sexual orientation or gender identity. Sexual Orientation An inherent or immutable enduring emotional, romantic, or sexual attraction to other people (this is independent of their gender identity). Transgender (Trans) An umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. People under this umbrella may describe themselves using one or more of a wide variety of terms. A transgender identity is not dependent upon physical appearance or medical procedures. 12 Transphobia Dislike of or strong prejudice against transgender people. Conclusion The queer community faces significant mental health challenges due to societal stigma, discrimination, and lack of affirmation, leading to higher rates of depression, anxiety, substance use, and other adverse outcomes when compared to their cis-het counterparts (Williams, 2021). To effectively address these disparities requires a culturally competent therapeutic modality and intervention, such as art therapy. Art therapy, particularly utilizing tattoos as a form of expression, holds promise for fostering self-affirmation and empowerment among the queer community. There is a gap in understanding the efficacy of tattoo art therapy in this context and this research aims to explore how tattoos, as an art therapy tool, impact self-expression, identity affirmation, and emotional healing within the queer community. The study seeks to contribute to a deeper understanding of alternative therapeutic modalities and their role in promoting wellbeing and resilience among marginalized communities. 13 Section II: Review of Literature A comprehensive review of existing literature is outside the scope of the research parameters. Historical erasure and discrimination have created gaps within literature; often excluding the experiences of further marginalized groups within the queer community, such as people of color, transgender individuals, and those with disabilities. To complicate things further, relevant literature can be dispersed across various fields or not readily accessible. Lastly, identities within the queer community exhibit a spectrum of shades and hues – no single color can encapsulate the complexities of the queer experience, making it difficult to capture all the nuances of the queer experience. Within these limitations, this document introduces tattooing as an art therapy tool to reclaim personhood amid oppression. Engaging in the tattooing creative process allows a queer individual to externalize internal conflicts, develop coping strategies, and gain insight into their experiences, fostering autonomy and cultivating self-acceptance in the face of oppression and adversity. Adversity To adequately address the needs of the queer community’s mental health and comprehend the reasons behind the ineffectiveness of existing interventions, it’s crucial to reflect on the pervasive impact of stigma and discrimination. Stigma and discrimination not only undermine queer individual’s fundamental rights by impeding their ability to live authentically, pursue happiness and participate in society but also exact profound psychological, emotional, and social tolls such as identity concealment, social isolation, minority stress, and vulnerability to victimization. From subtle microaggressions to overt acts of violence, the impact reverberates across every aspect of queer lives, shaping experiences of self-esteem, mental health, access to care, employment opportunities, and overall well-being. 14 Family Rejection The formation of queer identity starts with a complex interplay between internal selfperception and external influences such as societal interactions and cultural norms (Schmitz & Tyler, 2017). A particularly crucial element in this developmental journey is the support and connectedness provided by one’s family, which significantly impacts the maintenance of positive mental health among young queer individuals (Schmitz & Tyler, 2017). Family acceptance emerges as a vital contributor, fostering positive self-esteem and serving as a protective shield against the harmful effects of stigma (Ryan et al., 2009). Contrastingly, instances of family rejection are alarmingly linked with adverse health outcomes (Ryan et al., 2009). Adolescents facing familial rejection due to their queer identity are confronted with staggering negative outcomes when compared to their cis-het counterparts: queer people are 8.4 times as likely to attempt suicide, 5.9 times more likely to report high levels of depression, and 3.4 times more likely to use illegal drugs (Ryan et al., 2009). Moreover, the repercussions extend beyond mental health, contributing to the formation of negative self-perceptions and increasing the risk of houselessness among queer youth (Schmitz & Tyler, 2017). Political Erasure As if the struggle for family acceptance wasn’t difficult enough, queer individuals confront a myriad of additional hurdles across various facets of life, including relationship formation, parenting issues, access to care, immigration status (systemic barriers, legal inequalities, and social biases), eligibility for government benefits (legal recognition, discriminatory practices, gender-affirming care, and marriage), employment, education, and safety. 2023 served as a grim testament to the uphill battle faced by the queer community, witnessing an overwhelming influx of over 520 proposed anti-queer legislature bills, of which 70 15 were ultimately enacted into law (HRC, 2023). These erasure bills are aimed at systematically stripping away legal protections and rights for the queer community (HRC, 2023). A finding by Horne, McGinley, Yel, and Maroney underscored the detrimental impact of such legislative onslaughts, revealing a marked increase in anxiety and depression levels among queer individuals (2021). This outlines an ongoing threat to the mental health and overall welfare of the queer community, underscoring the imperative for continued advocacy and support. To add to these barriers, sexual orientation and gender identity have been historically pathologized by the psychoanalytic school of thought. Prevailing notions include viewing samesex orientation as a developmental deficiency during the Oedipal stage, a deliberate choice to evade psychosis, or as aligning with the 'opposite' sexual archetype. These entrenched beliefs led to the institutionalization, emotional and physical abuse, and dehumanization of many queer individuals in efforts to 'cure' their perceived 'illness.' It wasn’t until 1987 that homosexuality was removed from the Diagnostic and Statistical Manual and, five years later, was mirrored by the World Health Organization in their decision to declassify homosexuality as a disease (Drescher, 2015). It is important to note that the DSM-5 still includes diagnoses related to gender dysphoria. While this aids in accessing gender-affirming treatments, it also perpetuates the medicalization of transgender identities. Dissemination of these beliefs by trained professionals has contributed to the narrative of pathologizing gender and sexual identity, thereby reinforcing and perpetuating stereotypes. The multifaceted effects of oppression within the queer community highlights the complexities of these challenges and amplifies the need of exploration for avenues that foster inclusivity, understanding, and acceptance. This further emphasizes the overwhelming need for a critical 16 framework that understands gender, sexuality, and identity that transcends the fixed categories to embrace diversity, fluidity, and intersectionality (Henderson, 2019). Mental Health Needs Supportive networks play a crucial role in mitigating mental health challenges and fostering resilience among the queer community. The mental health needs of the queer community are complex and often overlooked, with unique obstacles such as stigma, lack of support, and social exclusion (Rees, 2020). Many queer individuals report experiencing stigma and discrimination within mental health care settings, ultimately deterring them from seeking help or disclosing their identities (Rees, 2020). As previously stated, research indicates that queer individuals are at a higher risk for mental health issues such as depression, anxiety, substance use, and suicidal ideation when compared to their cis-het counterparts (Meyer, 2003; Pachankis & Goldfried, 2010; Williams, 2021; Zeeman et al., 2018). Challenges are further exacerbated with intersectional identities, such as race, ethnicity, gender identity, and socioeconomic status, often compounding discrimination and barriers to care (Rees, 2020). These multifaceted challenges illuminate a need for promoting acceptance and inclusion, reducing stigma and discrimination, improving access to affirming care, and fostering supportive communities where queer individuals can thrive. Frameworks Using frameworks that embrace queerness from a mental health perspective is essential for promoting acceptance, inclusivity, and well-being within the queer community. By affirming identities, reducing stigma, providing culturally competent care, empowering self-expression and agency, promoting resilience and well-being, and advancing social justice and equity, these frameworks contribute to creating supportive and affirming therapeutic environments. 17 Queer Theory When researching frameworks that embrace queerness, Queer Theory by de Lauretis emerges as a structure for understanding and critiquing the norms, assumptions, and power dynamics related to identity (de Lauretis, 1991). This theory draws upon ideologies from Foucault, Rubin, Sedgwick, and Butler. Beginning with the norms surrounding sexuality as a construction of power dynamics established to serve, categorize, and regulate individuals' bodies and behaviors (Kurzweil, 1979). Rubin's concept of a sexual behavior hierarchy delves into the hierarchical organization of sexuality within societies, where adherence to normative frameworks determines one's social standing (Rubin, 1975). Sedgwick further explores the gendering of sexuality, emphasizing the mutual constitution of gender and sexuality (Durgin, 2019). To add another layer, Butler views sex and gender as performative acts rather than static concepts, i.e., a set of behaviors performed to conform to societal norms of masculinity and femininity (Butler, 1988). Incorporating queer theory into mental health practices enhances clinicians’ understanding of the unique experiences and needs of queer individuals, promotes affirming and inclusive care, and supports clients in navigating societal challenges to their mental well-being. This underscores a need for a sensitive and anti-oppressive approach to working with the queer community to recenter care and avoid harm (Kapitan & Kapitan, 2022). Using language that acknowledges diversity, affirms identities, and avoids reinforcing stereotypes can make a client feel valued, respected, and understood. Narrative Therapy The importance and power of language is amplified through the core beliefs of narrative therapy. Interestingly, it also incorporates elements of feminist theory and critical social theory. 18 Narrative therapy delves into the understanding of gender and power dynamics to decenter dominant narratives and promote an egalitarian therapeutic relationship – an essential aspect for promoting inclusivity, respect, and empowerment, ultimately facilitating meaningful and effective therapeutic outcomes. Language, once was used for pathologizing and dehumanizing purposes, shifts to elevate narratives that present alternatives and vitality. There are 4 central concepts: giving new meaning to life, meaning shaped through language, frame the story is told in, and externalization. Externalization is the core process that separates the problem from the person. By creating distance, there is a reduction in emotional intensity associated with the problem, enabling clearer thinking and problem-solving. When therapists encourage their clients to explore alternative narratives that reflect their experiences, they create space for them to see themselves as active agents capable of responding to and overcoming the problem. In return, this promotes a collaborative element between therapist and client, allowing them to work together to explore the narrative’s origins, effects, and possible solutions. A therapist’s first instinct wouldn’t be to externalize a queer person from their queer identity. However, when combining narrative therapy and queer theory, one would question the Grand Narrative of heterosexism and the roots it has in defining non-cis-genderedheteronormative narratives (Steelman, 2016). Instead, a therapist should empower clients to transcend imposed labels and boundaries to foster a relationship where one precedes their identity (Steelman, 2016). Coherent life narratives integrate past experiences, present circumstances, and future goals, contributing to a sense of continuity and meaning in life. Internalizing dominant stories can cause individuals to believe the problem is within. Narrative therapy deconstructs this idea, allowing individuals to recreate their life stories. 19 When narrative therapy is applied within the context of art therapy, realities transform into metaphorical narratives, enabling individuals to articulate their challenges through diverse forms or symbols. Additionally, art introduces a literal dimension of re-editing and reinterpretation. The opportunity to visually manifest internal struggles facilitates the process of externalization and offers new perspectives. These narratives are tangible manifestations of a person’s lived experiences and identity (Baştemur, & Baş, 2021). The resulting artworks serve as artifacts, capable of anchoring and reinforcing therapeutic insights and objectives. Role of Others To better reinforce insight, social identity theory can increase comprehension of how individuals cultivate their self-concept through affiliation with various social groups, thereby enriching the understanding of how the resulting artworks function as powerful tools for therapeutic exploration and growth. Social identity theory examines how individuals develop a sense of self-based on their membership in social groups. People categorize themselves and others into groups to establish their social identity, contributing to their self-concept and selfesteem. This provides insights into how social contexts influence behavior and attitudes, emphasizing the importance of understanding group dynamics in various social settings. When applied to the queer community, it provides understanding as to how individuals form and negotiate their identities which can provide insight to their experiences of discrimination, social support, and mental health outcomes. Additionally, it elucidates the complexities of intersectionality, acknowledging that individuals may hold multiple social identities that intersect and influence their sense of self. Lastly, for mental health professionals, it assists in tailoring interventions that affirm identities and address the aberrant challenges, ultimately fostering a more inclusive and affirming environment. 20 On the other hand, sociogenesis investigates how social phenomena emerge and evolve over time within a social context (Atkinson, 2003). While social identity theory focuses on processes involved in individual identity construction, sociogenesis examines the broader social, cultural, and historical factors that shape collective identities. This provides a more comprehensive understanding of the interplay between individual and collective identities in shaping social behavior and group dynamics. More specifically, how societal attitudes, historical events, and cultural shifts have influenced the formation of queer identity throughout time. Together, they offer complementary perspectives for comprehensively analyzing the complexities of identity processes in society. Expressive Therapeutic Modalities By examining how tattoos and queer individuals intersect within societal contexts, and unraveling the motivations behind body modifications, one can seamlessly transition into exploring therapeutic approaches that delve into the mind-body connection. These approaches are centered on exploring and processing emotions, memories, and traumas stored within the body, offering profound insights into the intricate relationship between the physical self and psychological well-being. Body Psychotherapy (BPT) These approaches focus on the mind-body connection and may incorporate techniques to explore and process emotions, memories, and traumas stored within the body. In BPT, mental health professionals work with clients to investigate and address emotional, psychological, and relational issues through the body’s sensations, movements, and expressions. By attending to bodily sensations, therapists can help clients explore underlying emotions, traumas, and psychosomatic symptoms (Leijssen, 2006). Body validation emphasizes the interconnectedness 21 of mind and body, recognizing the body as a source of wisdom, insight, and healing. This not only honors the lived experience of clients but also facilitates the integration of somatic and emotional processes and promotes empowerment and agency by encouraging clients to reclaim ownership of their bodies (Leijssen, 2006). It assists clients in gaining deeper insight into their psychological patterns, develop greater self-awareness, and cultivate more adaptive ways of coping with stress, trauma, and relational challenges. Tattooing can intersect with body psychotherapy in several ways, particularly in how it engages with the body as a site of expression, healing, and transformation. This deliberate, physical alteration of the body often expresses one’s identity, beliefs, or experiences (Pew Research Center, 2023). Like the BPT belief that the body reflects one’s inner experiences, tattooing can reflect embodied expression through externalizing experience. The emphasis on integrating bodily experiences with cognitive and emotional processes mirrors the experience of getting a tattoo. For some, tattoos process and integrate past traumas or emotional experiences symbolically into the body (Alter-Muri, 2020). Integration of experiences creates a pathway to empowerment and agency, a way to assert control over bodies and narratives. In BPT, reclaiming agency over one’s body and experiences is often a central theme. Similarly, getting a tattoo may represent a form of reclaiming ownership and autonomy, especially for marginalized individuals. Lastly, BPT encourages somatic awareness, or the ability to tune into bodily sensations and cues, paralleling itself with tattooing as it requires individuals to be attuned to their body’s responses, such as pain tolerance and comfort levels. Through this heightened somatic awareness, individuals may develop a deeper connection with their bodies and emotions, fostering a sense of embodied mindfulness for both tattooer and client. Moreover, the stop-and-go nature of tattooing simulates pendulation or going 22 from a relaxed to a heightened state back to relaxation. This is based on the concept that the nervous system has an innate capacity to self-regulate and find equilibrium when faced with stress or trauma, ultimately assisting the client in learning to tolerate difficult emotions and sensations without becoming overwhelmed. Tattoo artists may guide clients through these oscillations by employing techniques that help clients manage discomfort and promote relaxation. Ultimately, pendulation when applied to tattooing can help cultivate mindfulness, body awareness, and acceptance, which parallels the starting point of healing (Alter-Muri, 2020). Titration is the gradual introduction or exploration of difficult or distressing material at a pace that the client can manage without becoming overwhelmed. The goal of titration is to prevent re-traumatization or overwhelming emotional responses while still allowing the individual to process and integrate challenging experiences. Titration can also mirror the tattooing process as tattoo artists typically work in layers to gradually build the ink to achieve the desired darkness and saturation as it is crucial to add ink to the skin in controlled amounts to avoid overloading the skin or causing excessive trauma. Also, while not directly related to the process, titration can be applied to managing the pain experienced by the client during the session. Tattoo artists may work in shorter sessions or focus on less sensitive areas first before moving on to more painful areas, allowing the client to gradually acclimate to the sensation of being tattooed. Translating to Art Therapy Social-Justice Oriented The previously mentioned historical foundations of psychological theories have often reinforced a power dynamic where mental health professionals hold authority over their clients. Art therapy, however, offers a distinctively egalitarian approach, centering the client as the 23 expert thus restoring power and agency to them (Baştemur, & Baş, 2021). By incorporating a social-justice-oriented perspective, art therapy holds the potential to confront systemic injustices that contribute to both individual and collective trauma (Karcher, 2017). Creating a therapeutic environment grounded in empowerment, advocacy, and cultural humility can nurture resilience, agency, and community solidarity among clients (Karcher, 2017). This shift can be validating for queer individuals who may have experienced rejection or invalidation in previous experiences. In addition to this restorative element, a unique therapeutic relationship exists between the therapist, client, and artwork. The artwork acts as a bridge between the client’s inner experiences and the external world, expressing complex emotions and experiences that may be difficult to articulate (Hilbuch, et al., 2016). The connection between emotional and physical well-being and self-expression can generate positive results (Pelton-Sweet & Sherry, 2008). Individuals can reclaim agency over their narratives and identities, challenge internalized stigma and shame, and cultivate a sense of pride and empowerment. These collaborative art-making experiences can deepen the interpersonal bond between client and therapist, fostering mutual trust and empathy (Hilbuch, et al., 2016). Through the joint exploration of materials, clients, and therapists collaboratively generate meaning and redefine relational patterns. Simultaneously, by attuning to the client’s material choices and artistic process, therapists access implicit communication channels, enabling them to interpret and navigate the transferential landscape (Hilbuch, et al., 2016). Art is not only a communication medium between art therapists but also between the client and others. When applied to queer clients, art therapy emerges as a tool for navigating the intricate psychosocial challenges they may encounter (Addison, 2003). Its efficacy lies in its capacity to address identity exploration, trauma, and oppression (Addison, 2003; Alter-Muri, 2020). By 24 engaging in the creative process, clients can externalize internal conflicts, develop coping strategies, and gain insight into their lived experiences, thereby fostering agency and cultivating self-acceptance. Social Acceptance Social standards often protect the interests of established groups by reinforcing existing power structures through the promotion of specific behaviors and characteristics which consequently marginalizes and/or stigmatizes deviations from these conventional archetypes (Atkinson, 2003). Thus, granting the established groups power to dictate body norms and designate outsider groups as inferior (Atkinson, 2003; Gröning, 2002). Examining normative dynamics throughout history provides valuable insights into understanding the current social acceptance of queer and trans individuals as well as tattoos. The overlap is created through instances of stigmatization, self-expression, resistance and subversion, shifting attitudes and solidarity. Historical Acceptance of Tattoos As exhibited throughout the marks of history, tattoos have historically been associated with the designation of the ‘lesser’. Afterall, stigma means to prick. Ancient Greece used tattoos to mark slaves and prisoners of war, a form of punitive tattooing (Luzier, 2023). Dynastic China also exploited punitive tattooing, using it as a brand for slaves or punishment (Luzier, 2023). The most memorable form of punitive tattooing was during the Holocaust; tattooing identification numbers as a dehumanization tool (Luzier, 2023). This designation of the lesser is further driven by livestock tattooing, a connection between the objectification of living beings marked to serve others' interests. After World War II, awareness of human rights grew, and punitive tattooing was recognized as a clear violation of fundamental human rights. 25 A new era of tattooing entered the world when the American circus, heavily drenched in racist, ableist, and imperialist ideologies, utilized tattoos as a means of spectacle and entertainment. Tattooed individuals were often showcased as “freaks” or attractions, drawing audiences intrigued by adorned bodies. Fascination became a way to commodify difference and exploit shock. In between the lines of entertainment and monetary value, the American circus played a pivotal role in familiarizing, normalizing, and fostering acceptance of tattoos in the United States (Luzier, 2023). Various cultures worldwide have forms of tattooing that carry deep cultural or spiritual significance, countering negative perceptions of tattooing. For instance, Samoan tatu, or “tatau”, is a traditional practice in Samoa or Polynesian cultures, involving an elaborate and sacred process lasting days or weeks. These tattoos hold deep cultural significance and are considered a rite of passage, marking significant milestones in an individual life. Similarly, the Maori “ta moko” tattoos convey their genealogy, social status, and personal journey. In Japan, traditional irezumi tattoos were historically associated with the criminal underworld but have evolved into a rite of passage that symbolizes devotion, resilience, and a commitment to one’s chosen path. These examples illustrate how tattoos transcend mere decoration, symbolizing identity, belonging, and personal growth across diverse cultures. To align with the narrative of reclamation, both within the world of tattoos and the world of queerness, there will be a focus on ritual/ceremonial tattoos. Ritual tattoos can vary widely in purpose, symbolism, and cultural context, but are typically regarded as more than just decorative body art. They are seen as sacred expressions of identity, tradition, and belief within the context of the community. When compared to the therapeutic setting, rituals create structure, meaning, containment, transition, connection, and trust. Rituals in this mixed therapeutic-tattooing space 26 lean on elements of preparing the body, setting intentions, cleaning skin and space, and the aftercare regimen. This is accompanied by the melody of the needle, wiping the ink away, stretching the skin, marking the skin, layering of ink, and cleaning the tattooed area. While divided opinions of body modification persist, the shift in use and perception may provide opportunities to use tattoos in therapy as part of the client's journey toward emotional healing (Alter-Muri, 2020). Historical Acceptance of the Queer Community The historical acceptance of tattoos has parallels with the acceptance of the queer community. Ancient civilizations such as Greece and Egypt exemplify relatively fluid attitudes towards sexuality and gender, as evidenced by their art and cultural practices (Gröning, 2002). Similarly, in pre-colonial societies, many Indigenous cultures embraced expansive identities, with Two-Spirit individuals playing revered roles that bridge gender divides and promote community harmony (Gröning, 2002). However, the imposition of Eurocentric norms through colonialism and globalization has led to the suppression of expansive identities and the establishment of rigid gender and sexual norms. These values marked a decline in cultural acceptance of queer individuals, often resulting in the criminalization and stigmatization of non-cis-heteronormative individuals and behaviors. Although significant progress has been made, there is still a long journey ahead. Increased visibility and activism have contributed to the decriminalization of queerness and greater recognition of queer rights. The historical acceptance of the queer community has varied significantly across different cultures and periods. In some societies, such as Native American tribes or ancient Greece, there are stories of acceptance and/or reverence for individuals who did not conform to 27 traditional gender or sexuality. However, in many other societies, queer individuals have faced discrimination, persecution, and even violence due to prevailing social, religious, and legal attitudes. The spread of European colonialism and Christian missionaries used subterfuge to impose rigid gender and sexual norms that often criminalized/stigmatized non-cis-het identities and behaviors. Initially, western values characterized a decline in cultural acceptance of queer individuals. Today, attitudes towards the queer community vary widely depending on cultural, religious, and political beliefs. While there have been influential strides in terms of legal rights and social acceptance, discrimination and violence against the queer community persists in many parts of the world. Therapeutic Potentials of Tattooing The Human Body as Art Over the ages, body decoration has persisted as one of humanity’s earliest artistic expressions. The human body has served as a focal point in comprehending identity dimensions like gender, sexuality, race, and ethnicity. Through its diverse forms and practices, body art challenges the hegemony of Eurocentric norms, embracing the richness of cultural pluralism. Additionally, body art reflects the interconnectedness of global cultures by showcasing the ways in which ideas and techniques have been shared, transformed, and reinterpreted across time and space. Mummification in Ancient Egypt symbolized reverence for the deceased by preserving the body as a vessel and was initially practiced by the elite to signify status and social standing. Ancient Greek sculpture evolved from idealizing the human form to expressing extreme emotions; a synthesis of Platonic and Aristotelian views where art serves as both a tool for 28 education and emotional catharsis. The Baroque period utilized dramatic tableaux, employing the body as a symbolic or allegorical device to evoke emotional responses. In the 20th century, artists explored performance art as a declaration of autonomy and a challenge dominant narratives of the human body. Performance art overlaps with body modification to assert individuality and catalyze connections with like-minded individuals. During the 1960s, this physical manifestation of art gained prominence as it emerged as a fundamental aspect of how society understands the gendered body and sexuality. One of the earliest instances of tattoos being utilized as fine art was VALIE EXPORT’s artwork, “Body Sign Action.” EXPORT tattooed a garter strap on her thigh, symbolizing the fetishization and repressed sexuality of women, a declaration of autonomy, and a challenge to societal expectations. The commitment to exploring and challenging how women’s bodies are objectified, commodified, and controlled within a patriarchal society is echoed in Hannah Wilke’s, “S.OS. Starification Object Series.” Using her body as the canvas, Wilke challenges viewers to confront their perceptions of beauty, femininity, and objectification. Tattooing Motivations Humans exist in a web of interdependence, a vacillation between constraint and facilitation of our actions. In this flux and flow, tattoos become constructed social figurations – a way to understand individual behaviors because of collective social activities over extended periods (Atkinson, 2003). This highlights the charged dialogue between agency and structure as tattoos become an accepted form of communication. Having a tattoo is inherently a declaration to non-normative ideologies that represent cultural dislocation and social resistance (Atkinson, 2003). 29 Aligning tattooing with social resistance, individuals can reclaim agency over their bodies through this assertion of ownership and autonomy (Alter-Muri, 2020; Atkinson, 2003). This claim is supported by a study of college students where major reasons for getting tattoos were self-expression, self-identity, and to feel unique and independent (Drews, et al., 2000). Further applying this thought to marginalized communities, tattoos can serve as acts of resistance and empowerment, challenging dominant narratives and reclaiming cultural heritage (AlterMuri, 2020). By choosing to permanently mark their bodies with tattoos that symbolize defiance or resistance, individuals create a lasting testament to their beliefs. Entrenched in symbolism, tattoos can represent resistance, express dissent, nonconformity, or the desire to challenge prevailing attitudes or injustices – a testament to the search for identity against dominant narratives (Atkinson, 2003). Moreover, getting tattoos with shared symbolism can create a sense of belonging and collective strength in the face of adversity. Tattoos as an act of nonconformity can be likened to an act of radical self-love. Radical self-love challenges conventional notions of self-worth and encourages individuals to reclaim their inherent value, dignity, and worthiness. It is a journey of self-discovery, growth, and liberation that can lead to greater fulfillment, resilience, and authenticity in life. Overall, radical self-love is an act of rebellion against systems of oppression that seek to diminish or erase the inherent value of marginalized communities. Through the lens of radical self-love, tattoos become a symbol of strength, signifying the endurance it takes to get tattooed, dedication to the process, reminders of resilience, reflection of identity, and/or a connection to a legacy of strength. Tattoos as an Art Therapy Tool 30 The decision to get tattooed is profoundly personal and multidimensional, influenced by many individual, cultural, and socio-political factors. There are various motivations behind the adornment of bodies with permanent ink, ranging from expressions of identity, belonging, and autonomy to acts of commemoration, rebellion, and transformation (Alter-Muri, 2020). Tattoos serve as embodied symbols that encapsulate personal narratives and emotional truths. When this permanent imagery is used with the Queer population, the permanent imagery can speak to an autobiography of self-reclamation. The transformation starts with a dialogue surrounding imagery. An art therapist can engage the client in conversations surrounding personal narratives which can provide valuable insights into their thoughts, emotions, and experiences (Alter-Muri, 2020). This reflective process can help clients gain insights to the connections between their artwork and lived experience. As a form of nonverbal communication, it assists clients in expressing complex thoughts and feelings that may be difficult to articulate. Exploring and validating the client’s perspective helps foster a sense of agency and autonomy. By providing a canvas for self-expression and transformation, tattoos emerge as a tool for promoting psychological well-being and resilience (Alter-Muri, 2020). The process can inherently be therapeutic as it offers individuals a sense of catharsis, empowerment, and selfdiscovery. In a study by Frederick and Bradley, tattooed participants had significantly lower depression scores than non-tattooed individuals (2000). Additionally, themes of empowerment and self-esteem enhancement suggest that this practice can serve as a mechanism for bolstering confidence and self-image (Frederick & Bradley, 2000). The intricacies of tattoos extend beyond the individual as tattoos can forge connections and foster community among like-minded individuals (Alter-Muri, 2020; Atkinson, 2003). 31 Tattoos are permanent imagery that are literal signs of an individual's connection to themselves and others. The drive for belonging is mirrored within the tattoo studio as well. The collaborative process of creating a tattoo helps build rapport and understanding. Storytelling is a fundamental aspect of human communication that strengthens social bonds, preserves cultural identity, fosters empathy and understanding, inspires action, and creates a sense of belonging within communities. By sharing and listening to stories, individuals form a cohesive and resilient community grounded in shared experiences, values, and aspirations. Psychological and Biological Aspects of Pain In the face of adversity, the queer community remains resilient. The perpetual struggle for visibility can be heard from echoes in the past, insistent sounds of the present, and the distant rumbling of the future. Friedrich Nietzsche said it best, “Suffering is the father of all things.” This belief is attributed to the value of suffering as it exemplifies the strength to endure, awareness of limitations, and a heightened appreciation for life’s joys. Pain’s subjective, personal, and involuntary nature contributes to the perception that something is happening to an individual intimately connected to their sense of self and bodily experience. An alternate definition embraced through the eyes of narrative therapy, would be pain serves as a compelling reason to act. Pain is a fundamental imperative, a call to action to bring the body back into balance (Klein, 2015). The question then becomes...what happens when pain is sought out? What kind of call to action is that? Enter: the realm of masochistic pleasures or enduring pain for something desired (Klein, 2015). This can be exhibited through enjoying the burn of spicy foods, a painful massage, extreme sports, and body modification. This novelty experience of finding the edge of tolerability explores control, boundaries, and emotional regulation skills (Klein, 2015). “So what 32 is pleasant there is the feeling of growing beyond patterns that you’re trapped in: you’re finding out that a slight or a loss that seemed unendurable is perhaps bearable after all. (Klein, p. 180, 2015)” Tattooing can provide a sense of control in situations when the individual feels powerless or overwhelmed. By willingly subjecting themselves to pain, they may feel a sense of agency and mastery over their experiences. Additionally, physical pain can distract from emotional pain or psychological distress as tattooing elicits the endorphin release. Interestingly, the body is unable to tell the difference between emotional or physical pain, thus providing relief to both (Klein, 2015). Lastly, pushing oneself outside of comfort zones allows individuals to gain insight into their limits and capabilities, inevitably leading to personal growth and discovery. Through the lens of pain, tattooing elevates the mind and body connection. The process of getting tattooed requires the client to have a level of mindful awareness; to be present and attentive to the sensations and emotions they experience. The somatic experience of these physical sensations can deepen the mind and body connection by fostering a greater awareness of the interconnectedness between physical sensations, emotions, and cognitive processes. Space To enter a tattooing space is to enter a place of mental and physical vulnerability. To achieve desired results, it’s important to assess the space one enters for comfortability. Next, the individual should consider the amount of exposure that is given to the tattoo artist. Some who have had previous experiences, may feel more comfortable being tattooed in areas that are often covered by clothing. Those getting their first tattoo may opt for something less intimate. Placement 33 Before entering a space, the individual should consider their tattoo placement. Like the design itself, placement can hold various meanings, both culturally and personally. For example, a forearm tattoo is often visible, making a bold statement of self-expression and can allude to strength, confidence, and assertiveness. On the other hand, back tattoos offer a large canvas for intricate designs and storytelling. Some choose to use this as a form of protection as they cover a vulnerable part of the body that is often covered up by clothing. Tattoo pain can vary depending on the placement largely due to differences in skin sensitivity, proximity to bone and nerve endings, and muscle and fat composition. Some of the more painful spots are bony, thin skinned, or highly innervated areas. It’s important to keep in mind that pain tolerance varies from person to person, so what may be painful for one individual may not be as uncomfortable for another. Factors like hydration, fatigue, and emotional state can influence pain perception during the tattooing process. Taking care of these factors can be likened to Maslow’s Hierarchy of needs. At the base of the hierarchy, one must meet physiological and physical requirements, in preparation of a tattoo session. This helps maintain energy levels and prevent fatigue, allowing both parties to endure the session comfortably. Additionally, this helps promote healing as proper nutrition and hydration are essential for the body’s ability to heal and recover. Once physiological needs are met, individuals can focus on seeking safety and security. The tattooing space plays a crucial role in the experience for several reasons. First, the environment should be comfortable and conducive to relaxation for both the client and the tattoo artist. This includes factors such as appropriate lighting, comfortable seating, and music to help create a calming atmosphere. A comfortable environment can help alleviate anxiety and promote a positive tattooing experience. Furthermore, the space should reflect professionalism and 34 respect; this includes maintaining a clean and organized workspace, adhering to ethical guidelines, and treating clients with dignity and respect. Lastly, there should be an overarching prioritization of safety and security to address any unforeseen emergencies or accidents that may arise. After safety needs are satisfied, individuals can facilitate social connections thus cultivating a sense of belonging. As previously mentioned, tattoos can serve as symbols of belonging to certain communities or as a way of making connections with others who share similar interests or values. Connection and belongingness are fundamental to human well-being and play a paramount role in a queer person’s life. A sense of community can negate experiences of historical marginalization and cultivate ones of shared experience, a celebration of intersectionality, and empowerment. In some cases, tattoos can fulfill needs related to cultural or spiritual significance as a means of connecting to one’s cultural heritage, traditions, or spiritual beliefs, providing individuals with a sense of connection to something greater than themselves. Next, individuals strive for self-esteem and recognition from others after individual needs are met. Getting a tattoo can be a way of enhancing self-esteem and confidence. While meanings range from personal achievements, milestones, or overcoming challenges, they can all contribute to boosting one’s sense of self-worth and self-respect. Additionally, receiving positive feedback or admiration from others about their tattoos can further enhance self-esteem. At the top of the hierarchy is self-actualization, which represents the realization of one’s full potential and the pursuit of personal growth, creativity, and fulfillment. Tattoos can fulfill needs related to self-expression and identity as they can be a vehicle for expressing one’s unique identity and striving for personal growth and fulfillment. For some, tattoos represent a form of 35 self-discovery and exploration, allowing them to define and express themselves in meaningful ways. Holding Space Holding space involves being fully present, listening with empathy, and offering unconditional acceptance to others as they navigate their inner experiences and emotions (Nolan, 2021). Creating this environment can provide individuals with the opportunity to confront and process their deepest fears, traumas, and insecurities in a nurturing and compassionate space (Nolan, 2021). By holding space for others, individuals can feel seen, heard, and validated, which can lead to profound emotional healing and transformation. Individuals can cultivate a deeper sense of self-awareness, self-compassion, and self-love. Embracing their vulnerabilities and honoring their authentic selves, individuals can reclaim their personal power and embark on a journey of self-discovery and personal growth. This has significant implications for therapeutic practice as mental health professionals should strive to incorporate the principles of holding space by cultivating presence, empath, and unconditional positive regard. This helps create a conducive environment for healing, growth, and transformation. Limitations One of the primary constraints in the realm of tattooing revolves around age restrictions. Across all 50 states, the minimum age for consenting to the tattooing process is set at 18, symbolizing the transition into adulthood. Nevertheless, there are countries such as Austria and Scotland, where adulthood is recognized at 16. Factors such as personal growth, the lasting nature of tattoos, and the importance of proper after-care contribute significantly to determining the appropriate age of consent. 36 It’s paramount to address client’s concerns regarding stigma, discrimination, and regret associated with tattoos (Alter-Muri, 2020). While the permanence of a tattoo is not inherently negative, it can be a potential drawback due to the lifelong commitment they represent. For instance, what someone finds aesthetically pleasing or meaningful at one point in life may change, leading to potential regret. Moreover, tattoos can impact professional opportunities or personal relationships for some individuals, depending on societal norms and expectations. When considering permanence, the art therapist and client should reflect on imagery and potential symbolism (Alter-Muri, 2020). Remaining culturally sensitive to both the client and other communities. Additionally, the art therapist should be aware of symbols in the queer community that hold significant meanings (Addison, 2003). While some queer iconography, such as the traditional pride flag, maybe overtly recognizable, others may be more subtle, like the green carnation. Lastly, each state may have different regulations for tattooing. License requirements vary from state to state, some requiring specific training while others only need to comply with certain health and safety standards. As working with any population, but especially in the queer community, retraumatizing is a potential risk when using art therapy (Addison, 2003). There is an overwhelming requirement for vulnerability in both the therapeutic and tattooing spaces. Additionally, many queer individuals have experienced various forms of trauma related to their sexual orientation, gender identity, or experiences of discrimination and rejection. Introducing physical touch into the therapeutic setting will be a delicate balance of multiple complexities. Conclusion Tattooing holds potential as an art therapy tool for the queer community for numerous reasons, including identity affirmation, empowerment, reclaiming agency, healing, belonging, 37 visibility, and beyond. By examining the historical marginalization, discrimination, and violence faced by the queer community, art therapists gain a deeper understanding of the systemic obstacles and ongoing challenges they confront. This recognition forms a solid foundation for crafting effective treatments, catalyzes social progress, and validates the queer narrative. Embracing this perspective influences the choice of therapeutic modalities, prompting art therapists to adopt theories that authentically reflect and empower the queer experience, thus fostering self-resilience and efficacy. 38 Section III: Methodology As discussed, mental health disparities persist within the queer community, ultimately leading to barriers to healthcare, diminished employment opportunities, increased prevalence of mental health disorders, and susceptibility to houselessness and substance use. This underscores the overwhelming need for mental health interventions that decenter dominant cisgender heterosexual narratives and empower queer personhood. The tattooing process evolves as an allegory to developing and maintaining a self-care routine that is targeted at reclaiming personhood amid oppression. From beginning to end, getting a tattoo can symbolize agency, reclamation, and self-love. This proposal is designed to propel further research on the therapeutic potential of tattoos for the queer community. Beneficiaries/Participants This is specifically geared towards individuals 18+ in the queer community who are contemplating a ritual-based tattoo. Individuals with medical conditions (any conditions needing immunosuppressants, diabetes, medication/condition related to blood thinning, etc.), skin conditions (eczema, acne in desired tattoo area, psoriasis, etc.), and/or pregnancy will be excluded for health and safety reasons. Individuals who engage in ideations or acts of self-harm will not be included in this study. There are several confounding factors informing this decision, such as health, safety, ethical considerations, indications of other underlying mental health conditions, and respect for autonomy. However, it’s important to note that there could be potential benefits from supportive interventions such as tattooing rather than exclusion. Ideally, the participants would be of varying gender, sexuality, ethnicity, and socioeconomic status. Purposeful sampling can be utilized as an attempt to capture the varying shades and hues of the queer community. To meet expansive goals, the study would be executed 39 virtually and in person cohorts. Groups will first be run in person to gather participant feedback to improve flow. As the project grows, it can be expanded to virtual groups. Ideally, cohorts would have 6-8 participants who would begin and end the process together. Once the project leader has an additional 6-8 individuals interested, a new group can begin. When it comes to recruiting potential participants, referrals should be gathered through queer community centers/affiliated groups and inclusive care health professionals. Lastly, this is designed to be led by a licensed art therapist who is queer and/or has comprehensive knowledge surrounding the queer community. Project Design Using the research compiled through the literature review, several studies and theoretical conceptualizations assess identity construction with or through tattoos. Most of the data was collected through qualitative interviews, surveys, and questionnaires. This represents the prevalence of tattoos, demographics of tattooed individuals, and self-reported attitudes towards tattoos and identity. Additionally, standardized scales have been used to measure self-esteem, body image, and identity formation. This model can be adapted to measure the self-care allegory by compiling a comparative study of non-tattooed and tattooed individuals. Based on this knowledge, the design begins with participants who live in the United States, completing a survey assessing their demographic information, history of tattooing, and experiences with self-expression, identity affirmation, and emotional healing. The survey will extend to a Mental Health Status Questionnaire, similar to the Hospital Anxiety and Depression Scale to assess for depression, self-harm, and suicidal ideation. This will inform the purposeful sampling process to achieve an expansive group of 6-8 queer individuals contemplating a tattoo and an equal size of queer individuals with no desire to be 40 tattooed. Measures of self-expression, identity affirmation, and emotional healing will be analyzed and compared between the two groups using statistical analyses, such as independent ttests or one-way Analysis of Variance, controlling for potential confounding variables such as age, gender, and mental health status. A structured interview will be administered before the group begins and as a 6-month follow-up. Procedure In this four-week program, each week will cover a different topic leading up to getting a tattoo. The group will meet weekly for two hours; the first hour is reserved for artmaking, and the second hour can revolve around reflection and discussion. To accommodate the time variable in waiting for a tattoo appointment, a debrief will be offered every six months to all participants. Week One The first week will involve preparing the mind and body for a tattoo – an important first step to a ritual. Art can be a powerful tool for exploring and defining what self-care means to an individual, offering a starting point for establishing a routine. Creating art based on this topic can facilitate self-reflection, visualize self-care practices, identify emotions and needs, explore limitations, and overall promote a mindful experience. Utilizing visual imagery can assist in generating discussion around what the body needs for a tattoo and ultimately how basic needs catalyze the healing process. Topics can include: ● Sleep and restoration: How does sleep heal? What do individuals notice when they lack sleep? How do individuals feel when they get adequate sleep? Does being rested impact mindfulness? 41 ● Hydration and nourishing the body: How does food impact energy? How are bodies affected by nourishment? Why is it important to find balance? What is the connection between nutrition and sleep? ● Alcohol/drugs and complications: What kind of choices are made when under the influence? How do drugs affect the body? Where does the mind go? Week Two The second week will be centered around imagery exploration and creation. Participants will explore visual references such as tattoo designs, artwork, photographs, and/or symbols to define aesthetic preferences and style. The leader will assist clients in identifying elements or themes that resonate with them and discuss how these visuals can be incorporated into their tattoo design. Additionally, there are unique levels of disclosure to discuss with the participants. The first level of tattoo design is decoration and representational designs. This could be common symbolism representing generalized personality traits (lion for strength, semicolon for hope, etc.). If a tattoo relies on more limited decorative elements, then it can limit communication potential and interaction with other people as viewers may engage with them on a more superficial level, relying on the visual appeal rather than reflecting on significance. The next level evolves into a more relational and representative design. Often, it incorporates more personal symbolism, storytelling elements, and/or cultural awareness which makes room for potential recreation of meaning in conversation. This level of tattoo designs has an openness for collaborative meaning which translates beyond identity creation into the individual’s connection with queerness. Topics to discuss this week can include: 42 ● Representational or relational design: What meanings should the tattoo hold? How does the individual want others to engage with their tattoo? How do representational and relational designs impact levels of safety? How does aesthetic influence meaning? ● Body placement and implications: How would it feel for another person to touch the body? How visible will it be when wearing clothes? What will the intensity of pain be like? Does this spot hold any other memories? What does it mean to bear a tattoo? ● Size and implications: What is the intricacy level of the design? What would it mean for the tattoo to be subtle and simplistic versus expansive and detailed? How does the size tie into reclamation? How does size influence how the wearer engages with it on a physical and emotional level? What is your pain threshold? Week Three This week will center around finding and consulting with a tattoo artist. Picking an artist can mimic how an individual chooses their community. The artist should appeal to them aesthetically but also empathetically. Additionally, building rapport with the artists involves trust and open communication. This bond of trust enables a deeply personal process where clients feel safe expressing their stories and emotions, knowing they will be artistically captured with respect and understanding. This exchange marries vulnerability with creativity, with artists often adopting the mantle of confidants and facilitators of catharsis. When likened to building community, the group can explore characteristics of a safe person, red flags, and building social skills. Furthermore, this encapsulates the question: what does the individual need to feel safe? While searching around for artists, the participants must consider the space that they’re entering. Similar to a therapeutic setting, a ‘safe’ tattoo parlor prioritizes the health, safety, and well-being of both clients and staff. Generally, a parlor should have sterilization practices, 43 properly trained artists, aftercare guidance, and an informed consent process. In a group setting, this can spark conversations around what constitutes a safe space. Week Four Week four will culminate all the previous weeks, leading to a commitment in the form of a deposit for the appointment. Due to a tattoo artist’s availability and booking times, it is unlikely that all the participants can get tattooed during the same week, let alone so soon. The group topic will focus on setting goals and their effect on overall well-being (stress reduction, positive reinforcement, coping skills, etc.). Participants will create art surrounding goals, resolutions, and commitment. Anticipation can stir conversations surrounding: ● Physical sensations and the potential discomfort – what will it be like to have the tattoo artist bear witness? How can pain be managed? ● Seeing their chosen design come to life – what can that mean? How does that impact the body? What will it mean for others to witness this? ● Mindfulness of the connection between mental and physical pain – how does the body signal mental discomfort? What role does pain play? What responses are driven by mental/physical pain? How does one heal? ● The permanent transitional object – what does it mean? How does permanence impact the meaning? What reactions do the participants desire? Six-Month Debrief The debrief will be offered to all cohort members who have either received their tattoo or have decided against getting a tattoo. Art-making will explore the symbolism and meaning of chosen tattoo. Discussion will be centered around themes and emotions that emerged during the 44 project, allowing participants to share their thoughts, feelings, and takeaways from one another. Topics can include: ● What was this process like from beginning to end? How do the participants feel about the art they made in the group? ● What was it like to get tattooed? How did the body and mind affect the tattooing process? How did the individual manage pain? What was it like to have someone witness this process? ● How does the individual feel about their tattoo? Does the tattoo meet their expectations? How has this impacted the participant’s relationship with their body? Are there things they wished they knew or would change about the experience? ● Have individuals been able to apply what they learned in group to their lives? What is their takeaway from this experience? Conclusion The findings of this study will provide valuable insights into the potential therapeutic benefits of utilizing tattoos as an art therapy tool among members of the queer community. By exploring the impact of tattooing on self-expression, identity affirmation, and emotional healing, this research may inform the development of culturally competent interventions and support services tailored to the unique needs of queer individuals. 45 Section IV The purpose of this curriculum is for queer folks to externalize internal conflicts, develop coping strategies, and gain insight into experiences, ultimately fostering autonomy and cultivating self-acceptance in the face of oppression and adversity. To determine whether this curriculum accomplishes the goal, there will be 2 assessments utilized. The first assessment to be administered is the Rosenberg Self-Esteem Scale (RSES) to obtain a baseline measure of the participant’s self-esteem. This is to be followed up by the Kinetic-House-Tree-Person drawing task to help explore the qualitative aspects of the individual’s self-concept and emotional state; ultimately offering a deeper understanding of the factors influencing their self-esteem. Rosenberg Self-Esteem Scale The RSES is a widely used self-report tool in social science research for measuring selfesteem. This assessment assesses positive and negative feelings about the self while demonstrating test-retest reliability and concurrent, predictive, and construct validity. Adding supplementary questions or scales may be beneficial to address further self, expression, identity affirmation, and emotional healing. The additional scales will be kept separate from the RSES to maintain reliability and validity. It’s optimal to use this in a longitudinal study to track changes in self-esteem before the curriculum begins and after getting therapeutic tattoos at the six-month debrief. Addendums to Rosenberg’s Self-Esteem Scale Scores will be calculated as strongly agree = 3, agree = 2, disagree = 1, and strongly disagree = 0. 1. I feel that my identity is valued and affirmed by others. 2. I can heal emotionally from difficult experiences. 46 3. I feel comfortable expressing all parts of my identity. 4. I feel I can emotionally heal from adverse experiences. 5. I am comfortable expressing my identity in all situations. Kinetic-House-Tree-Person After the RSES, the participants will take the Kinetic-House-Tree-Person (KHTP) before the curriculum begins and at the six-month debrief. The KHTP provides a more unified approach to evaluating a client’s psychological state, self-concept, and relationship to their environment. While the reliability and validity of this assessment have not been conclusively proven, it can be a useful tool to gain insights into the participant’s psychological state and their perception of their environment. Combined with the RSES, it can provide a comprehensive evaluation of an individual’s self-esteem. Purposed Method for Data Analysis Data analysis will involve comparing levels of self-expression, identity affirmation, and emotional healing. The results will be analyzed using appropriate statistical tests to determine if there are significant differences in the assessments gathered before the curriculum begins and when the individual receives their therapeutic tattoo. Furthermore, conducting a multiple aggression analysis to explore the relationship between changes in RSES scores and specific features or changes in the KHTP drawings will aid in deciphering the impact of the curriculum. This can help identify which aspects of the drawings are most predictive of changes in selfesteem. For the RSES, the evaluator will calculate means, standard deviations, and other descriptive statistics for the self-esteem scores at both points. Using a paired t-test to compare the RSES scores before the group begins and at the six-month debrief to determine if there is a statistically significant change in self-esteem over time. Since the KHTP is qualitative, the data 47 must be summarized to identify common themes or patterns. Additionally, comparing the KHTP drawings from before the curriculum begins and at the six-month debrief will help identify any changes in themes or patterns that might indicate psychological progress or changes. Analyzing the relationship between changes in the RSES and KHTP drawings, it can pinpoint which aspects of the curriculum are most effective in enhancing self-esteem. This allows for the refinement and enhancement of these components to maximize their impact. Understanding these specific elements of self-expression and identity affirmation that correlate with positive changes in self-esteem can help tailor the curriculum to better meet the diverse needs of participants. This personalization can lead to more meaningful and effective outcomes. Regular analysis of data allows for ongoing assessment and improvement of the curriculum. This iterative process ensures that the curriculum remains relevant and effective over time. By grounding curriculum changes in empirical data, art therapists can adopt evidencebased practices that are more likely to produce desired therapeutic outcomes. This approach enhances the credibility and reliability of the curriculum. Insights gained from data analysis can inform the scalability of the curriculum to different populations or settings. Understanding which components are universally effective versus those that require adaptation can facilitate broader implementation. Conclusion With both assessments, one can compare the RSES score with the themes and indicators found in the KHTP drawing. For instance, low self-esteem on the RSES might correlate with negative or insecure elements in the KHTP drawing, such as small or isolated figures. A high self-esteem score might be reflected in confident and well-integrated figures in the drawing, while discrepancies between the two assessments can highlight areas needing further exploration. The qualitative data from the KHTP can explain the reasons behind the RSES score, offering 48 richer insights for the impact of the curriculum. Using both tools addresses the limitations of each method, with the RSES providing reliable, validated numerical data and the KHTP offering nuanced, context-specific information. Ultimately, this information will highlight the effective curriculum areas that need refinement. Section V: Discussion This section provides an overview of the literature review, influences and potential biases in the program's development, the limitations inherent to this project, and potential avenues for future research. Summary The existing literature underscores a critical need for therapeutic modalities tailored to minority experiences. Art therapy utilizes a distinctive approach to explore self-discovery, healing, and personal growth. By combining the permanence and cultural significance of tattoos with the therapeutic benefits of artmaking, participants can explore their identities, process emotions, and develop a stronger sense of self in a supportive and affirming environment. Engaging in the creative process of tattooing allows queer individuals to externalize internal conflicts, develop adaptive coping strategies, and gain insight into their lives. This process ultimately fosters autonomy and cultivates self-acceptance in the face of societal adversity. The synthesis of tattoo artistry and therapeutic practice presents a promising avenue for addressing the unique challenges faced by marginalized populations, particularly within the queer community. Discussion As adrienne maree brown (2020) eloquently said, “It always feels important to me to reveal who I am as the author of these ideas, and the lineage I draw upon.” In the spirit of 49 transparency and self-awareness, I acknowledge my identity as a white, non-binary, queer, tattooed, student art therapist and artist. My lived experience is shaped through a diptych of privileges afforded by my race and socioeconomic background, while also encountering adversity due to my queer presentation. It is crucial to recognize that my ability to engage in this work is underpinned by the privileges I hold. As this research evolves, my aim is to broaden the discourse to include the various shades and hues of the queer community. My upbringing in a Jewish household was marked by the pervasive myth that “Tattooed Jewish people cannot be buried in a Jewish cemetery.” While the Torah does admonish against desecrating the body, it does explicitly mandate exclusion from burial grounds. This cultural narrative significantly impacted my perception of tattoos. As a child immersed in imagination and creativity, I eagerly awaited the day I could my first tattoo, which, in a twist of irony, was a Hebrew word. My tattoos, whether whimsical or profound, are integral to my identity, making my body feel authentically mine. This journey towards autonomy and self-expression often led to feelings of ostracization, particularly within the context of my artistic and personal endeavors. These experiences underscore my inherent bias: I am a fervent believer in the therapeutic potential and healing power of tattoos. I view tattoos not merely as adornments but as extensions of my identity and memory. This conviction has driven my research interests, and the development of a curriculum tailored for the queer community. My identity as queer and non-binary heightens my sensitivity to issues surrounding identity, sexuality, and self-expression. This personal connection enriches my research and allows for a more nuanced interpretation of participants’ experiences. As an artist and student art therapist, I am uniquely positioned to explore the intersection of creativity and therapy, leveraging my personal insights to inform my work. 50 It is essential to acknowledge that my personal experiences and identity may introduce biases into my research. My interpretation of the data is inevitably influenced by my journey. However, I believe that sharing these aspects of myself enhances the authenticity and depth of my research, providing a richer context for understanding the therapeutic potential of tattoos in fostering self-expression and identity affirmation with the queer community. Limitations As previously mentioned, there is a gap in understanding the efficacy of tattoo art therapy. A crucial concern is to delineate the roles of the tattoo artist and the art therapist to avoid dual relationships and potential conflicts of interest. While tattooing can be therapeutic, it is not a substitute for mental health therapy. The ethical application of tattoo art therapy requires a nuanced understanding of cultural symbolism. Art therapists must exercise caution to avoid the exploitation or misappropriation of cultural symbols in therapeutic contexts. Additionally, tattoos are intertwined with various forms of privilege. People of color often face additional challenges when getting tattoos. The tattoo industry has been criticized for its lack of skill and experience in working with darker skin tones, leading to issues such as less precise lines and blurred images (Assam, 2023). This can make it more difficult for people of color to find artists who can provide high-quality tattoos, thereby limiting their access to this form of self-expression. Furthermore, stigmas surrounding tattoo culture can impact different facets of life. The ability of white individuals to obtain employment while having visible tattoos can be seen as an expression of white privilege. Additionally, the high cost of getting a tattoo can be a barrier for individuals from lower socio-economic backgrounds, allowing those with more financial resources to access better-quality tattoos and more reputable artists. 51 Currently, self-harm and suicidality present significant challenges in my research. On one hand, I recognize the necessity and importance of interventions that are inclusive and understanding of self-injurious behaviors. On the other hand, as a researcher, I am concerned about the potential impact on the validity and outcomes of the study when including individuals with histories of self-harm, as it might shift the narrative towards body hatred and punishment. Within the queer community, self-injurious behaviors are more prevalent due to the oppression and obstacles faced. While it seems unjust to exclude these individuals, my goal is to expand this research to be more inclusive once more data has been collected. Suggestions As this field continues to evolve, interdisciplinary collaboration between mental health professionals, tattoo artists, and researchers will be crucial in refining and validating tattoo art therapy as a legitimate therapeutic modality. Future research should focus on conducting controlled trials, developing standardized protocols, and assessing the psychological and physiological effects of tattoo art therapy across diverse populations. Moreover, folks who are further marginalized in the queer community are crucial to this ongoing conversation to steer the curriculum to one of inclusivity. Additionally, the scales used for measuring the outcome may need to be adjusted as more trials are conducted. It could be beneficial to gather a working list of tattoo artists to collaborate with; both in research and for the participants. A strong relationship with tattoo artist fosters trust and open communication which allows for better collaboration to ensure the final tattoo aligns with their vision. It can also contribute to a more relaxed and friendly atmosphere during the tattooing session, making the experience more enjoyable for the participant. 52 While this research paper explores the role of permanence, further investigation into the differential impacts of permanent versus temporary body modifications could significantly enhance the understanding and effectiveness of the proposed curriculum. Examining the psychological and emotional effects associated with both permanent and temporary modifications, future studies could elucidate the unique benefits and potential drawbacks of each approach. This comparative analysis would not only provide a more comprehensive framework for therapeutic interventions but also underscore the specific advantages of incorporating permanent body modifications, such as tattoos, into therapeutic practices. Such insights could propel the directive of this curriculum, highlighting its efficacy in fostering self-expression, identity affirmation, and emotional healing within expansive populations. Conclusion This research highlights the potential of tattoo art therapy as a transformative modality for addressing the unique challenges faced by the queer community. While promising, the field of tattoo art therapy is still in its nascent stages, necessitating further exploration and validation. Acknowledging the inherent biases and privileges influencing the researcher’s perspective emphasizes the importance of transparency and self-awareness in scholarly work. 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The European Journal of Public Health, 29, 974 - 980. 58 59 60 61 62 63 64 65 66 67 68 Kinetic House Tree Person Assessment Instructions: I would like you to please draw a house, a tree and a whole person on this piece of paper with some kind of action. Try to draw a whole person, not a cartoon or stick person. During administration, pay attention to the subject. Note any unusual body movement, verbalizations, apparent frustration erasures and other items that are unusual. Once the subject has completed the image, subject is asked to tell a story about what is happening in the picture. Specific questions should be asked by the assessor based upon the story told. 69 70 House Tree Person Assessment Instructions: Take one of these pencils, please. I want you to draw me as good a picture of a house as you can. You may draw any kind of house you wish, it is entirely up to you. You may erase as much as you like, it will not be counted against you. In addition, you may take as long as you wish, just draw me as good a house as you can. For the tree and person drawings, the word house is replaced with tree, person or person of the opposite gender 71 During administration, pay attention to the subject. Note any unusual body movement, verbalizations, apparent frustration erasures and other items that are unusual. ● House: age, location, inhabitants, best thing, thing dislike most ● Tree: age, type, location, best thing, thing dislike most ● Person (both): age, name, what need most, best thing, thing dislike most 72 73 74 75 76 77 78 79