ABSTRACT

INKING AGENCY: WOMEN’S MASTECTOMY TATTOOS AND EMOTIONAL HEALING

Tattoos can have the power to help people emotionally heal from trauma. They can be used as a way to help an individual cope with physical and emotional stress, such as the loss of a loved one or a physical injury resulting in scars or the loss of a body part. This study was conducted to discover the reasons women reported for getting a mastectomy tattoo and the ways those with mastectomy tattoos use their tattoos to claim bodily agency. Six women who have had mastectomy tattoos were interviewed. Stuart Hall’s encoding and decoding theory along with theories of bodily agency was applied to their responses. The symbolism behind the images participants chose for tattoos included angel wings for women who died with cancer, 3D nipples to look like a natural nipples, feathers to encode God sheltering with His wings, lilies of the valley in bloom to represent Christ and a new beginning, and a phoenix to represent rebirth. The reasons that women chose to get mastectomy tattoos varied. The two reasons that all six women mentioned were to cover up their scars and to spread awareness that this option exists. The tattoo was also transformative in that it helped the women feel confident, gave them the desire to show off their breasts, and helped them heal emotionally.

Amanda Stutsman May 2016

INKING AGENCY: WOMEN’S MASTECTOMY TATTOOS AND EMOTIONAL HEALING

by Amanda Stutsman

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts in Communication in the College of Arts and Humanities California State University, Fresno May 2016 APPROVED For the Department of Communication:

We, the undersigned, certify that the thesis of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the master's degree.

Amanda Stutsman Thesis Author

Kevin Ayotte (Chair) Communication

Marnel Niles Goins Communication

Hillary Jones Communication

For the University Graduate Committee:

Dean, Division of Graduate Studies AUTHORIZATION FOR REPRODUCTION OF MASTER’S THESIS

X I grant permission for the reproduction of this thesis in part or in its entirety without further authorization from me, on the condition that the person or agency requesting reproduction absorbs the cost and provides proper acknowledgment of authorship.

Permission to reproduce this thesis in part or in its entirety must be obtained from me.

Signature of thesis author: ACKNOWLEDGMENTS I would like to thank my husband and parents for their continued encouragement. I would also like to thank Garnet Tattoo for their support and assistance, along with a special thank you to the women who gave their time to participate in this study. This thesis would not have been accomplished without all of your help.

TABLE OF CONTENTS Page

LIST OF TABLES ...... vi

LIST OF FIGURES ...... vii

CHAPTER 1: INTRODUCTION ...... 1

History of Women with Tattoos ...... 2

Significance of Researching Mastectomy Tattoos ...... 7

CHAPTER 2: LITERATURE REVIEW ...... 11

CHAPTER 3: METHODOLOGY ...... 36

Participants ...... 38

Interview Procedures ...... 41

Coding and Analysis ...... 44

CHAPTER 4: DISCUSSION ...... 49

Encoding/Decoding ...... 52

Tattoo Symbolism ...... 53

Emotional Healing ...... 66

CHAPTER 5: CONCLUSION ...... 78

Summary ...... 78

Implications ...... 82

Limitations and Future Research ...... 84

REFERENCES ...... 89

APPENDICES ...... 97

APPENDIX A: CONSENT FORM ...... 98

APPENDIX B: QUESTIONNAIRE ...... 101 LIST OF TABLES

Page

Table 1 Primary Codes ...... 46

Table 2 Secondary Codes ...... 48

LIST OF FIGURES

Page

Figure 1 Lady Viola, photograph by Historical Findings ...... 4

Figure 2 Betty Broadbent, 1939, photograph by The Tattooed Lady ...... 5

Figure 3 The SCAR Project, 2011, photograph by David Jay Photography ...... 20

Figure 4 Humor and Fear, 1999, photograph by Joel-Peter Witkin ...... 21

Figure 5 Inga Duncan Thornell, 2012, photograph by Tina Bafaro ...... 33

Figure 6 Angie, 2015a, reprinted with permission from Shane Wallin ...... 55

Figure 7 Mary, 2015b, reprinted with permission from Shane Wallin ...... 56

Figure 8 Tracy, 2015c, reprinted with permission from Shane Wallin ...... 58

Figure 9 Kim, 2015d, reprinted with permission from Shane Wallin ...... 59

Figure 10 Laura, 2015e, reprinted with permission from Shane Wallin ...... 60

CHAPTER 1: INTRODUCTION

In the never-ending project of women’s self-transformation, tattoos are both an end and a beginning, a problem and a solution. Written on the skin—the very membrane that separates the self from the world—they’re diary entries and public announcements, conversation pieces and counterculture totems, valentines to lovers, memorials to the dead, reminders to the self. They’re scars and symptoms, mistakes and corrections.

– Mifflin, Bodies of Subversion

In 1993, Inga Duncan Thornell had a double mastectomy procedure after being diagnosed with breast cancer (Thornell, 2012). A mastectomy is the surgical removal of the breast (“Mastectomy,” n.d.), a double mastectomy involving both breasts, and a lumpectomy is the surgical removal of lump from the breast (“Lumpectomy,” n.d.). Thornell had already lost her stepmother to breast cancer and her own mother had also been diagnosed with it. Thornell (2012) writes a blog about her experience, on which she states that instead of breast reconstruction through plastic surgery she opted to cover her entire chest with a tattoo that took over two years to complete. Although more than 20 years have passed since Thornell chose to get a mastectomy tattoo, her tattoo is just now starting to get recognized on social media. Thornell (2012) stated on her blog that she still loves her tattoo and says that it is a part of her. In part because of Thornell, the popularity of mastectomy tattoos is rising. Her tattoo has been publicized and helped to change a policy on nudity of a major social media network, which is discussed in chapter two. Although mastectomy tattoos are starting to become more common, very few women know about the option unless there is a need for them to learn about the tattoos. As the results of this study suggest, the more publicity this option 2 2 generates, the more women can discover that a tattoo might help them emotionally heal. The increased publicity of this topic can also provide an avenue for women who have similar experiences to meet and share their stories with each other. Cancer affects both women and men of all races. It is a battle that is fought every day by brave women and men. According to the Susan G. Komen Foundation (n.d.), 246,660 new cases of breast cancer in women and 2,600 new cases for men will be reported in 2016. The number of women who get a mastectomy varies by state due to different reasons. One reason is that radiation is required after a lumpectomy, but not all medical offices have the resources to provide radiation therapy, making it difficult for patients who have to travel long distances to receive the treatment. Therefore, some settle for a mastectomy despite the availability of other options; however, for others, it is a personal choice (Susan G. Komen Foundation, 2015). Although breast cancer also affects men, this thesis focused on women due to availability of participants and the fact that it effects more women than men. Losing breast tissue also effects women’s gender identity differently than men’s. This chapter begins with a brief history of women with tattoos. The second part of this chapter provides a discussion of the rationale for and importance of this study, followed by an explanation of the research questions.

History of Women with Tattoos Scholars do not know when the practice of tattooing began or the reasons why the practice started. Historical evidence has been found of tattoos in almost every culture in the world (Mifflin, 2013). Archeological evidence of tattooing dates back to 30,000 BCE, with some archeologists believing that tattooing could have started much earlier (Rush, 2005). Sanders and Vail (2008) stated that tattoos can provide “symbolic information about the bearer’s personal interests, social 3 3 position, relationships, or self-definition” (p. 21). For example, gang members get specific tattoos to prove they are part of the group. Rush (2005) explained that another reason is the reminder of or dedication to a cause. For example, couples get wedding ring tattoos to symbolize their marriage. A third reason, Rush (2005) stated, is “a glorification of the human body with an enjoyment of fleshiness and sensuality, symbols to be seen and appreciated” (p. 19). This viewpoint seems to be the reason that most people choose to get tattooed. DeMello (2000) established that pilgrims considered these tattoos as “souvenirs of their faith on pilgrimages to the Holy Land” (p. 45). She also explained that North American tattooing actually came from the cultures of the Pacific Islands when westerners were voyaging there for missionary work, colonialism, and discovery. In 1778, Captain Cook and his crew were tattooed in Tahiti. When they returned home, it increased the popularity of tattoos in Europe. While in Tahiti, Captain Cook’s crew reputedly introduced new designs into Polynesian tattoos, including images of cannons and rifles (DeMello, 2000). Captain Cook is also credited with coining the term “tattoo” since he used the Tahitian word ta-tu instead of the English words “pricks” or “marks” that were used at the time (DeMello, 2000, p. 45). It was not until 1848 that the United States had its first professional tattoo artist, Martin Hildebrandt (DeMello, 2000). DeMello (2000) explained that the U.S. American style of tattooing, which involves “strong black lines, typically made with five (or more) needles; heavy black shading; and a dab of color” (p. 50), did not begin until 1891, when the first electric tattoo machine was invented. Govenar (2000) elaborated that articles from this time period do not explain adequately the reasons why individuals tattooed themselves during 1891-1903, but the articles written have a heavy tone of disapproval. 4 4

In the late 19th and early 20th centuries, women started to cover their entire bodies with tattoos and performed in circus freak shows (Fisher, 2015). Most of the women created fake stories about why they were tattooed, which included details about how they were forced to get tattooed, predominately by being kidnapped. These stories were created to sensationalize the women (Mifflin, 2013). However, Mifflin (2013) explained that in the 1920s the stories of forced tattooing and kidnapping started to die down. Figure 1 is a picture of Lady Viola, who was tattooed in the 1920s and traveled with Ringling Bros. Circus and was featured in dime museums (Fisher, 2015). Mifflin (2013) explained that Lady Viola was one of hundreds of women at the time traveling and showing off their tattooed bodies. Tattooing the body became a way for women to be independent and to provide for themselves during the Great Depression (Mifflin, 2013).

Figure 1 Lady Viola, photograph by Historical Findings 5 5

These women may have been providing a life for themselves, but they struggled with the negative stereotyping they received. Betty Broadbent, a tattooed circus woman in the 1920s and 1930s, did not want to be seen as a “carnival floozy” and instead entered the first televised beauty contest in 1939 (Mifflin, 2013, p. 25). She knew she would not win, but did it to showcase to the world that tattoos could be beautiful (Mifflin, 2013). She wanted to debunk the stereotype that only deviants have tattoos by showcasing her “wholesome” image to the world (Mifflin, 2013, p. 25). She used tattoos to empower herself. Figure 2 shows Broadbent participating in the beauty pageant at the World’s Fair in 1939. She was able to travel the world because of the attention she received and she became the first person to be inducted into the Tattoo Hall of Fame (The Tattooed Lady, 2013). Harlow (2008) stated, “tattoos archive the rhetorical rejection of Playboy

Figure 2 Betty Broadbent, 1939, photograph by The Tattooed Lady 6 6 beauty standards – each step rhetorically etched into the skin – to mark and break apart the passive beauty that has attempted to shroud women in silence” (p. 194). Lady Viola, Betty Broadbent, and other circus women were some of the first women to publically create an identity using tattoos. They rejected society’s feminine standards and created their own. Tattoos for women have come a long way in the United States. It was not until 2012 that tattooed women outnumbered tattooed men for the first time in history, by a margin of 4% (Mifflin, 2013). The art of tattooing is becoming more and more popular for women. Women are becoming tattooed at a faster rate than men, making the margin even bigger. A 2015 poll estimates that 58% of women and 41% of men are tattooed; however, men over the age of 65 are three times more likely to be tattooed than women over the age of 65 (Lake, 2015). This statistic is not surprising based on the history of tattoo culture in the United States. Sanders and Vail (2008) stated that tattooing is moving from a “disvalued craft” and tattoo artists are trying to establish it as a form of art (p. 32). The tattoo industry is a $4 billion industry with over 21,000 tattoo shops operating in the United States (Lake, 2015). According to Mifflin (2013), women started to look at tattoos differently in the 1970s and started to use tattoos as a way to embrace their “changing sense of self” (p. 54). In the 1980s and 1990s, women saw tattooing as a way to embrace the rebellious side of themselves, but the tattoo “allowed for visual and symbolic gradations of meaning, and assumed both ritual and therapeutic significance for many women” (p. 73). Tattooing is becoming increasingly important and common and therefore we need to study it. This research is important for the communication discipline, as I detail in the rest of this chapter. I also explain how it can be used as a stepping stone for 7 7 other researchers to help understand the effects that a tattoo can have on women who have undergone physical or emotional trauma.

Significance of Researching Mastectomy Tattoos Amy Black (2014), a tattoo artist, gave an emotional speech for Ted Talks called “The Power of the Two Inch Circle.” The two inch circle refers to the nipple, which women with mastectomies no longer have. She discussed her interactions with women upon whom she tattoos 3D nipples and talked about the power that this small tattoo can have for a woman. She explained that a 3D nipple is powerful for three reasons. The first reason she calls “the drive by.” This is when a woman or man walks past the mirror every morning. If they see their scars, they are reminded that they have had cancer. Women tell her that this tattoo helps to cure that feeling. The second reason she calls “the ripple effect.” The tattoo not only helps to heal the person with the tattoo but their friends and family as well. She explained that when the people who supported their loved one with cancer see that their friend is emotionally healed, then they can also heal because it is hard on those who are supporting the individual with cancer. The third reason is that “art can heal.” She made it clear that not just 3D nipples, but all tattoos and other forms of art such as dance, singing, and writing, can help individuals deal with the emotions from trauma. The goal of this thesis explored how women who have undergone the trauma of a mastectomy have used tattoos to embrace their identity and use it as a platform to talk to others about it. This study offers additional data that expands upon existing knowledge about how people use tattooing to help them heal and to transform their well-being. This research also helps to educate those who have never been through a mastectomy or breast cancer to illustrate how women deal 8 8 with the trauma and how they use their body to claim agency. It is also important to raise awareness that this option exists for women who want to cover up scars or replace a body part that is no longer there, like the nipple. There has been previous research on tattooing in many disciplines. Atkinson (2003) explained that studies of tattooing can be put three general categories: “studies of tattooing as a form of social deviance; analysis of tattoo artists and their everyday experiences in the business; and investigations of the tattoos as a form of political resistance” (p. 55). The images that people choose to have tattooed change over time and relate to the time period in which they live. DeMello (2000) explained that after WWII tattoos changed from images of patriotism and loved ones to a way for people to shape their identity. An example is individuals in biker gangs who choose images of gang signs instead of the American flag or their children’s names. For the participants in this study, women used mastectomy tattoos to identify as breast cancer survivors. Being tattooed is a social act and the tattoo becomes a part of the personal identity of the individual (Sanders & Vail, 2008). Sanders and Vail (2008) elaborated that deviating from societal norms puts a person at risk for “being defined as socially or morally inferior” and society could react negatively to people who are not conforming to these norms (p. 2). Tattoos can be used to alter the physical body to either deviate from social norms or to fit social standards. The 3D nipple is one example. It replaces the nipple was removed and it restores a metaphorical piece of the body. The body can appear as if it is complete, which conforms to social expectations of feminine beauty. This study’s goal uncovered the power of mastectomy tattoos for women who have them. Interviews were conducted with six women who opted for these tattoos after undergoing a mastectomy. They were asked a series of questions to 9 9 help answer two research questions. These questions were developed to try to focus the understanding of the tattoos through encoding/decoding and bodily agency. The first research question is: 1. What reasons do women report for getting mastectomy tattoos? This question seeks to understand why women choose a tattoo. The study also asked participants to discuss how they discovered the option of tattooing after a mastectomy because this option is not widely known. The reasons why women have an intimate part of their body tattooed after going through a traumatic event, like a mastectomy, are unclear. Understanding more about why these women chose a tattoo helps to shed light on their personal journey and helps to address the answers to the second research question. 2. In what ways do those with mastectomy tattoos use their tattoos to claim bodily agency? This question gets to the heart of the study by looking at how they might relate their tattoo to their identity. The body can be tied into the health and well- being of an individual, but it can also be tied to emotional well-being. Michelle Delio (1994) claimed that tattoos have a magical power; they are not only for decoration but can enrich the soul. This question attempts to uncover how women use tattoos to reclaim or create a new sense of self with their body after going through a traumatic experience. After a mastectomy, the body is no longer what society constructs as a normal physical body because the breasts have been altered or removed. Once women have had a mastectomy and no longer have the “normal” two breasts, they tend to need to renegotiate their body’s relationship to their identity. The second research question focuses on how a tattoo can impact the identities of women who have undergone mastectomies. 10 10

In chapter 2, encoding/decoding and bodily agency are discussed in more detail. It explores research done on both the body and tattoos as forms of performing identity. In addition, it discusses how mastectomy tattoos have been covered in news and social media. Chapter 3 explains the methodology used and includes background information about all of the participants for this study. It details the interview procedures and how the data were analyzed. Chapter 4 discusses the results of the analysis. The results divide into two sections: encoding/decoding and emotional healing. In chapter 5, the results are summarized and an explanation is provided of the limitations and implications of the study. Also, insight into how this study could be used as inspiration for future research is provided.

CHAPTER 2: LITERATURE REVIEW

Now, her chest is rich in color and symbolism, and her scars are submerged in life-affirming organic imagery: flowers, fish, a shining heart and a series of eight phases of moon stretch across her sternum. Where her earlier tattoos were gestures of self-expression, this one was an act of self- transformation.

– Mifflin, Bodies of Subversion

This quote is from a woman named Rasner who had undergone a double mastectomy in the mid-1980s (Mifflin, 2013). Rasner had taken before and after photos and explained that she could see the change in her eyes after the mastectomy tattoo was completed, stating that “it’s a feeling of having taken something essentially negative and turned it into something beautiful” (Mifflin, 1997, p. 8). However, who and what defines what is beautiful and what is not? Society plays a major role in how a woman creates her identity and how she feels about her body. This thesis adds ways in which tattoos can help women shape their identity and gain a new sense of self. Bodily agency is used as a way to understand how women are taking control of their bodies and their mastectomies. Stuart Hall’s encoding and decoding theory is also used as a way to understand how men and women encode and decode the messages they read from tattoos and the impact that it has on them. The rest of the chapter explains the research that has been done on how identity is looked at through the use of the body and then through tattoos. Lastly, there is a discussion of how the media communicate about mastectomy tattoos using a broad array of media outlets, including television, newspaper, and social media. 12 12 Bodily Agency An individual can use a tattoo to help create their bodily agency for many reasons. A goal of this study found out the ways in which women who have chosen a mastectomy tattoo create agency through their tattoo. Harlow (2008) explained that the body can be read as a text and that “not only do we read the text but we create it. The body, the place that defines the ‘I’ voice operates not from a passive canvas, but rather a complicated landscape of texts rich with possibility to speak back” (pp. 2-3). She explained that when someone reads a text, they then become engaged with it; if we examine tattooed bodies as texts, then it forces us to read the body (Harlow, 2008). These tattoos become a way for people to use the power of tattoos to create a text all their own. Besides tattoos, women use other techniques to create agency. Thompson and Hirschman (1995) explained that people transform their body into a more desired form, using activities, such as dieting, surgery, and exercise. The use of control through knowledge and technology can help people to take control of their lives and circumstances (Thompson & Hirschman, 1995). Although the body can be thought of as a “socially visible object” that is reconstructed to fit preferred social constructs, it can also be seen as freedom and empowerment, where the body can become anything that the person wants it to be (Thompson & Hirschman, 1995). In other words, the way people create agency with their body depends on whether or not they care about how they are viewed by themselves, society, and the constructs that surround it.

Encoding/Decoding Encoding/decoding is a classic theory about the production and reception of meaning (Ross, 2011). Denotative and connotative meanings can be applied to the analysis of texts. Denotative meanings are the literal meanings of a sign that tend 13 13 to be “universally recognized,” whereas connotative meanings are “less fixed and therefore, more conventionalized and changeable, associative meanings, which clearly vary from instance to instance and therefore must depend on the intervention of codes” (Hall, 2006, p. 168). According to Hall (2006), there can be no “intelligible discourse” without the use of codes (p. 167). Every word or text is part of a code. An individual understands because of his/her familiarity with the codes of language and culture, although some codes are more universally recognized (Hall, 2006). Hall emphasized that meaning emerges when someone encodes it and then a receiver decodes the meaning by “drawing on frameworks of knowledge” that the receiver already knows (Ross, 2011, p. 2). The receiver can only decode using codes that are already familiar to that individual. As cited in Ross (2011), Hall’s definition of a preferred reading is simply a way of saying if you have control of the apparatus of signifying the world, if you’re in control of the media, you own it, you write the texts – to some extent it has a determining shape. Your decodings are going to take place somewhere within the universe of encoding. (p. 3) In other words, women own their bodies and have control over the codes they are sending out into the world to be decoded by others. Harlow (2008) explained that a woman’s body is not simply female because it is designated as one, but it’s female because of society’s construction of that text. The same would be true for the construction of a tattoo. Each tattoo, whether it is of words (e.g. lyrics, Bible verse, or famous quote) or a picture, has a societal construct surrounding each symbol. However, a symbol can mean multiple things to many different people and the reason an individual chooses a particular tattoo can enforce or challenge those constructs. A tattoo has denotative a meaning, but it also has a connotative 14 14 meaning that can have a much stronger impact on the individual with the tattoo and those who read it. Another example is through the use of prison tattoos. Richard Sennett defined decoding in The Fall of Man: Decoding means you take a detail of behavior as a symbol for an entire character state. Just as, say, the color of a scarf or the number of buttons undone on a blouse may symbolize a woman’s sexual looseness, so small details of appearance or manner can symbolize a political stance. These details seem to indicate what kind of person espouses the ideology…In this case, you have decoded what he means by how he looks. (as cited in McNaughton, 2007, p. 136) Simply put, an individual decodes by judging the nonverbal communication of an individual based on the clothes they wear, how they wear those clothes, the types of tattoos they have and where those tattoos are placed on the individual’s body. Bengtsson, Ostberg, and Kjeldgaard (2005) stated that prison tattoos tell the biography of that individual. Phelan and Hunt (1998) explained that prison tattoos can have private meanings that can only be understood by the gang they are associated with and that these tattoos can symbolize the individual’s family history, criminal specialization, or deeds that have been performed while in the gang. Tattooing has not always been voluntary. For example, in World War II, Jews in concentration camps were branded with numbers to mark subordination (Turner, 1999). However, in this situation, the Jews did not have the choice of creating agency through these branding tattoos. They were forced to receive them by those in power. Although the tattoos are prison tattoos, these tattoos were not intended to give the Jews a positive identity with their fellow prisoners and their 15 15 marks did not have private meanings. The oppressive meaning behind these tattoos was clear. Mastectomy tattoos can act as branding, but as a choice of the woman. It can symbolize meaning to the individual or her family and friends that the public may or may not be able to decode. The women may have a preferred meaning that they would like others to be able to decode, but if others have not been in their place and experienced the same trauma, then those who are decoding the meaning can only decode using the codes that are familiar to them. This study expands the research that has been done on women with mastectomies by analyzing if, and how, women add meaning to their tattoos. The encoding and decoding model focuses on “preferred meaning” and “preferred reading,” which Pillai (1992) finds problematic because Hall uses the terms interchangeably when in fact they are quite different. Preferred meaning relies on the dominant codes of the reader and is a “property of the text,” where preferred reading is correspondence depending on how people decode and is a “property of the reader” (Pillai, 1992, p. 222). Basically, the reader has control over how they decode the message, which may or may not be part of the preferred meaning. The encoder may have a preferred meaning in how they want the text to be read by the decoder, but the ownership of decoding is in the hands of the reader. To understand how the reader decodes this information, the following section identifies what the dominant codes (both denotative and connotative) are and how they are used to read the female body, the culture of tattoos, and how women with mastectomies have been portrayed in the media. 16 16 The Body as Identity When the media portrays a healthy female body, they portray soft, smooth skin, without scars. They portray someone in her youth who has a head full of beautiful hair and someone who has all her body parts, including two breasts that are not misshapen or deformed. Basically, they portray someone who fits into what is considered the “normal” body. Where do people get the idea of what is normal? Where do these body-image constructs come from? Balcetis, Cole, Chelberg, and Alicke (2013) looked at what ideal female images are, how they are portrayed in the media, and how they affect women’s self-esteem. They stated that one of the main ideals in media is being thinner than the average women, a standard that is often unrealistic and unobtainable. Balcetis et al. explained that self-esteem is “a core aspect of personal identity” (p. 101). They found that “self- reported awareness of ideal standards and internalization were related to baseline self-esteem,” but even women who resembled the ideal standards still had issues with self-esteem and suffered from the awareness of the ideal standard (p. 106). There are several other studies that demonstrate the impact of an ideal for women in different forms of media (Bazzini, Pepper, Swofford, & Cochran, 2015; Haboush, Warren, & Benuto, 2012). Women are portrayed as having two breasts, but rarely are women portrayed as having none or only one. Those who suffer from illness sometimes perform an illusion of health by using techniques in order to hide their sickness. People use makeup to cover skin discoloration, wear hair pieces to cover up balding spots, or even go through surgical procedures to permanently alter their appearance. However, it is not just individuals with illnesses who use techniques to improve their appearance. Many healthy women use these types of techniques in order to look like a better version of themselves or even to change their appearance temporarily to look different for 17 17 a short period of time. Women not only wear makeup and wigs to hide imperfections, but also to have an alternative option and to give themselves a new look for that particular day. Plastic surgery offices are filled with healthy women trying to improve a part of their body to perform the illusion that they were born looking the way they do. Henriksen and Hansen (2009) stated that a healthy body is “an absent body, fused with the self [in that we are not] continually conscious of our bodies,” whereas an unhealthy body is a marked body, as it becomes “an object of consciousness” to the individual (p. 144). Sometimes people are not aware of an illness or imperfection unless it is something that is not easily hidden. A healthy body does not usually take as much to improve its appearance compared to an unhealthy or disfigured body. Some marks on the body are harder to hide than others. A mastectomy leaves a mark on the body that is not easily hidden. It shouts to the world that one does not have the ideal body, and therefore one must not be healthy. Breast cancer is “a culturally marked illness, a dominant societal symbol that, once applied to a person, spoils radically the individual’s identity and is not easily removed” (Kleinman, as cited in Henriksen & Hansen, 2009, p. 143). Aubrey Arnell (2007) explained that she “didn’t want cancer to be the prominent feature” of her identity (p. 14). She went on to explain that when breast cancer patients opt out of reconstruction, choose not to have nipple reconstruction, or even leave the house without a wig, they are resisting the expectation that being ‘well’ is being restored to the former self, which is never fully possible. (p. 22) Once a mastectomy is completed, the individual is now marked as ill unless they undergo reconstruction or wear breast prostheses to hide the loss from the public. 18 18

Henriksen and Hansen (2009) shared the narrative of Liselotte, a 41-year-old woman diagnosed with terminal breast cancer, who states that I am not an actor and therefore I am not used to ‘adopt[ing] another character.’… It is not just the hair that’s gone. The exterior ‘I’ has also gone … I don’t know if I can get used [to] the picture of myself that now greets me in the mirror. Every morning I put on my breast prostheses. And now also my wig. To look normal. To look like a woman as much as possible. But it doesn’t make me feel like a woman. I don’t feel like anything at all anymore. (p. 146) She tries to perform the identity of a woman in front of others by “adopt[ing] another character,” but it is simply to look the part of being a healthy woman and not one that she feels is “pitiful,” “frightening,” and “disfigured” (p. 145). Being able to see the body as healthy connects back to self-esteem. She has a lower self- esteem since she no longer looks like a healthy woman without ‘adopting’ a healthy character for her to act out. Piot-Ziegler, Sassi, Raffoul, and Delaloye (2010) looked at how women construct their body image shortly after having a mastectomy. They found that women who have this type of body transformation feel a sense of mutilation and strangeness. They explain that a woman’s identity is challenged by this procedure, which leads to “a re-evaluation of her existential values” (Piot-Ziegler et al., 2010, p. 479). Henriksen and Hansen (2009) also shared the narrative of Heidi, who is 31 and had a double mastectomy. She attempts to perform acts of normalcy with her body to hide the effects of her disease. The marks that are left by breast cancer and the mastectomy are “marks of truth on the body” in that they tell those who look at them that her body was not, or currently is not, healthy (Henriksen & Hansen, 2009, p. 144). They explained that her experience with performance is a 19 19 way to “re-create her former appearance to reconstruct or maybe rather preserve her identity” and that “she recognizes that she has changed and that wearing a wig and breast prostheses is a trick, a game resembling children’s play” (p. 148). According to Piot-Ziegler et al. (2010), even when a woman is given the opportunity to have corrective surgery, she still mourns the loss of her past body, which makes her question her identity. They stated that “for two women, the loss of a breast represented a past that will be lost forever” (Piot-Ziegler et al., 2010, p. 490) and that one woman explained the day before her mastectomy surgery that when she wakes up afterwards she will bury her past life. Piot-Ziegler et al. (2010) stated that a mastectomy is not just surgery, it is “a traumatizing experience, which will shake the foundations of the women’s lives and challenge their identity” (p. 494). A woman’s identity is more than just her breasts, but it is a part of what makes her a woman and losing that part can challenge how a woman views and identifies herself. Breasts are hyper-sexualized. A woman’s sexuality is linked with breasts in Western culture. For example, there is a debate in the United States about whether or not women should be allowed to breast-feed in public. Katherine Foss (2013) explained how the breasts are sexualized in media in television shows and how that affects the way that women who breastfeed in public are treated. The SCAR Project is trying to combat this identity anxiety by having women with mastectomy scars show off their bodies to demonstrate to other women who have had mastectomies that they can use their bodies to heal and create their own identities. This project involves brave women with mastectomies, with or without tattoos, getting photographed and showing the different types of mastectomies and the variety of scars that women receive. Their mission is on the surface an awareness raising campaign for young women, [but] the SCAR Project’s deeper message is one of humanity. Ultimately, the SCAR 20 20

Project is not about breast cancer, but the human condition itself; the images transcend the disease, illuminating the scars that unite us all. (“The SCAR Project,” 2015)

Figure 3 The SCAR Project, 2011, photograph by David Jay Photography

Similar to the SCAR Project, Millett (2008) took a look at photographer Joel-Peter Witkin and his photographs of amputees. She explained how his artwork disrupts “medical models for disability by presenting disabled and disfigured bodies as objects of art, design, and aesthetic magnificence, particularly because of their curious and spectacular, abnormal bodies” (Millet, 2008, p. 8). She also argued that because the models are willing to be photographed, they participate in performing a spectacle where they are unashamedly parading the “so-called abnormal body” (Millet, 2008, p. 8). Joel-Peter Witkin portrays the abnormal body as a work of art, like the SCAR Project; however, he does it in a 21 21 much more grotesque manner. He turns it into a freak-show style of photography by adding additional elements of the abnormal and paranormal realms. He turns what society generally sees as disfigured bodies into showcased works of art. His photography diverges from what is considered a normal body and turns it into a magnificent carnival of abnormality on display (Millet, 2008). His photographs turns amputees into a showcase as though they are in a carnival and are to be stared at and looked at as different. He highlights those differences that are not part of the norm.

Figure 4 Humor and Fear, 1999, photograph by Joel-Peter Witkin

Beauty is all over all types of media. Magazines, television and movies, tell people what is beautiful, what is unattractive, what is normal, what is grotesque, what is acceptable, and what should be hidden away from society. Standards of beauty and fashion are constantly changing and the media is a major influence on those standards. Anne Jerslev (2006) stated that “beauty is a unique imprint of a 22 22 historically given ideal of beauty” (p. 142). In other words, what is considered beautiful is based on the societal constructs of a given time period. The body images that are considered beautiful today may not have been beautiful in the past and vice versa. Whether or not someone is watching a commercial of an overly sexualized model pretending to eat a hamburger or a reality show, society is infiltrated with beauty standards. According to Mazur (1986), beauty ideals change over time; for example, the “bosom mania” of the 1950s and 1960s portrayed the ideal woman as having large breasts. More recently, 2014 was nicknamed the “year of the butt” based on songs by Beyoncé and Meghan Trainor, and other celebrities, such as the Kardashians (Fallon, 2014, para. 1). Mazur (1986) explained that women have pressure on them to conform to whatever is on the current cover of Vogue magazine. For example, Mazur (1986) stated that the ideal beauty standard is “a slender body with trim hips” (p. 281); Sohn (2009) stated that the media act like the images they portray as beautiful are easily attainable for women and therefore women are pressured to look like these women in the media. This pressure comes from men and other women expecting all women to look like that as well as their own desire to look like that. However, Ciochina (2013) stated that the advertising world is not a faked one, but beyond terms as ‘truth’ or ‘lie’, as it represents a coherent system of signs, codes and forms, structured as to generate an effect of reality, but not the reality in itself. (p. 27) According to Mazur (1986), women have more pressure on them to conform to feminine beauty standards than men do to masculine standards because men place more emphasis on women looking beautiful than women do on how men should look. However, that opinion is now changing. There are several studies that show 23 23 ideal masculine body images and standards and men’s pressure to conform (Agliata & Tantleff-Dunn, 2004; Diedrichs, 2010; Nikkelen, Anschutz, Ha, & Engles, 2012). Some commercials, like the Dove campaign for Real Beauty, are trying to redefine standards of female beauty, although that campaign still relies on what is considered beautiful in order to redefine beauty. Advertisers help to imprint these ideals into the minds of consumers. Having self-confidence is an aspect of beauty. TV shows, like Extreme Makeover and The Swan, exploit the lack of self-confidence in women who do not fit the standard of beauty and emphasize that one who is not confident and secure in his or her looks is therefore not beautiful (Jerslev, 2006). According to Jerslev (2006) these shows turn all the contestants into mind-clones where they all have a “multiplication of sameness,” meaning they have the same or similar features when their surgeries are finished and the only thing that makes them unique in the end are their personal stories (p. 138). They all have large breasts, a similar nose, a smaller waist-line, and all seem to match what they would see on the cover of a magazine. The producers seem to exploit women who feel the need to change their looks in order to be happy and feel beautiful. The women may be better off going to therapy to talk with a counselor than simply changing their physical appearance. Josh Adams (2009) explained that [w]hile media outlets have the ability to frame social issues and direct public discourse, they often rely on preexisting understandings of ideas and simply reproduce symbolic meanings rather than overtly reinterpreting them, problematizing the media’s role as both information provider and moderator of a collective dialogue. (p. 104) This may be why shows like Extreme Makeover and The Swan and commercials for hamburgers stick to a certain type of beauty. It is already what people 24 24 recognize and therefore it is easy to approximate how the consumer will respond. Imagine if the hamburger ad had a heavy-set, elderly woman or a balding man eating a burger in the same sexy way. How would consumers respond? It would no longer be sexy but funny. It would change the entire meaning of the ad. Advertisers use what consumers and society agree on as beautiful and sexy to sell their products. Sticking to a similar idea of beauty across media creates oneness, but keeps it easier for advertisers to predict consumer responses. In mass-mediated news, however, the average woman getting a mastectomy does not tend to make it into the press. That is starting to change. With the help of celebrities like Angelina Jolie, the process of mastectomies is starting to gain media attention. Fortunato (2014) wrote about an article posted in the New York Times about Jolie’s preventative double mastectomy; however, if Jolie were not a celebrity, they would likely not have mentioned this topic. Having Jolie’s story in national news headlines brought awareness to the topic and, according to Fortunato (2014), Jolie’s celebrity status made it important enough to be covered in the news in the first place. Fortunato (2014) explained that breast cancer is a long-standing topic and notes that now there needs to be something special about it to make it worth the media’s time to cover it. The concept of tattooing over mastectomy scars seems to be something different enough for the media to take notice.

Tattoos as Identity How people identify with their body depends on many factors. A new option available for women with mastectomies to help them perform a new identity and gain a new sense of self is tattooing. Mastectomy tattoos are typically designed to cover up the scars left behind by the multiple surgeries. It is vital to 25 25 understand the impact that tattoos can have on self-esteem and how they can alter a person’s identity or their performance of an identity. This study was designed to add to the existing research by analyzing six women’s personal accounts of their experience receiving a mastectomy tattoo. This section discusses how tattoos can be used to create a new identity through building up self-confidence and changing beauty standards. It also discusses ways to create a new identity and how tattoos can function as a form of healing. First, tattoos can build up self-confidence. The Breast Cancer Recovery Act of 1999 allowed doctors to bill insurance companies for tattooing services, which are so popular now that tattoo artist Mary Jane Haake claims that she does about one a day (Mifflin, 2013). Rasner, who was quoted at the beginning of this chapter, used her mastectomy tattoo as a way to rebuild her sexual self-image (Mifflin, 2013). She stated that the American Cancer Society basically “all but demands that post-mastectomy patients wear prostheses in the name of looking ‘normal,’” but her tattoo gave her the satisfaction of controlling her own image without concealing her illness from the public (as cited in Mifflin, 1997, p. 154). Modesti (2008) stated that “tattooing lends an understanding of surroundings by providing a sense of empowerment.…[T]attoos can be a disconcerting performance of ferocity, can signify conscientious radical self-definition, may signify sexual independence for women, and ultimately help people reclaim their physical bodies” (p. 202). She explains that tattoo parlors are a place where women can go to construct their identity as they want themselves to see it, giving those women a new sense of self. Tattoos can also construct an identity for the rest of the world to see. Those who see it might be limited depending on the location of the tattoo, but for those who do, whether it is her spouse, other family members, friends, or complete 26 26 strangers, the woman can help construct how she wants these individuals to see her. This was evident at the Fresno Tattoo Convention in 2015. Many tattoo artists advertised their cosmetic craft by showcasing before and after photos of women who have had cosmetic tattoo procedures done, such as permanent eyeliner, lipstick, and eyebrows. Each of these advertisements showed women how they can change a part of their body that they feel does not fit into societal ideals through the use of tattoos. Tattoos can help women find a way to recover and gain a new identity and perception of their own body image. Second, tattoos can help change beauty standards. The Suicide Girls are an online group of heavily tattooed women who pose in revealing clothes, and sometimes nude, to put their bodies and their tattoos on display. Their slogan is “what some people think makes us strange, or weird, or fucked up, we think is what makes us beautiful” (SuicideGirls, 2015). They celebrate a body image that is not the standard seen in magazines and on television. Harlow (2008) viewed the Suicide Girls as a performance of the rejection of gender stereotypes. She stated that “tattoos archive the rhetorical rejection of Playboy beauty standards – each step rhetorically etched into the skin – to mark and break apart the passive beauty that has attempted to shroud women in silence” (Harlow, 2008, p. 194). Gilles stated that “the skin…becomes a fetish when its color diverges from the commonplace, when it feels so beautiful and silky; when it is adorned with tattoos; when it calls forth a cannibalistic sensuality” (as cited in Harlow, 2008, p. 193). In other words, the skin can be transformed through tattoos, which in turn can transform our identity and self-image. Third, tattoos can create a visual argument for one’s identity. For example, in Japan, tattoos are not commonplace and are associated with membership in a gang, such as the Yakuza (Rush, 2005). Tattoo performance has been studied as a 27 27 way to create new identities by looking at identity in prisons. Melanie McNaughton (2007) discussed prisons as a place where identity performance functions as “visual argumentation” (p. 134). Like Rasner, McNaughton (2007) explained that tattooing is a form of control; instead of controlling how someone feels about their own body, tattoos in prisons are an argument for membership within social constructs that include autonomy, masculinity, social status, and belonging in the prison community. Tattoos in prison can work in a different manner from mastectomy tattoos in that prisoners “are stripped of independence and freedom” in order to fit in with the prison society (McNaughton, 2007, p. 138). Mastectomy tattoos, by contrast, are meant as a way to inspire and showcase freedom by being free of disease. Instead of losing independence and being beholden to something other than themselves, women are using tattoos as a way to showcase that they are now free to live their life, unbound to their disease and death. Turner (1999) explained that tattoos historically indicated a man was a member of the working-class, symbolizing hardship and work, while now, during a time of high unemployment, a tattoo might symbolize alienation, depending of the type of tattoo and where it is located. Turner’s study and McNaughton’s (2007) study argued that tattoos are still seen by many as a way to showcase deviance. However, Bengtsson et al. (2005) explained that tattoos have undergone a type of renaissance that has made tattoos a fashion accessory made possible by consumer culture. They proclaim that our bodies represent ourselves and should be consistent with our personal narrative, but that “the body becomes a malleable material that can be used for manifesting and representing identities” (Bengtsson, et al., 2005, p. 264). In prison, showing one’s masculinity can help an individual survive. McNaughton (2007) explained that tattooing is associated more with men 28 28 for “cultural resistance” because it is very painful and that “to be masculine is to be tough, to be able to withstand pain” (p. 140). In a similar way, mastectomy tattoos are a form of expression where women can show toughness and strength simply by having a tattoo. Finally, tattoos can offer a way to heal. Turner (1999) explained that tattooing was originally done in pre-literate cultures as a way of signifying life transitions that could easily be decoded by the culture unambiguously. Bengtsson et al. (2005) explained that in contemporary Western culture, tattooing has become a highly individualistic form of expression, but the inclusion of tattooing name brand-symbols, such as Harley Davidson, Nike, and the Lego Brick, has made tattooing less unique and authentic. However, this is not always the case. Bengtsson et al. (2005) explained that sometimes these brand symbols are altered, such as reversing the symbol or adding elements to the symbol, in order to have a more personal meaning. Therefore the symbol is “decommodified, removed from the exchange system and placed into the sacred realm of the body” (Bengtsson et al., 2005, p. 266). These brand images may have had an impact in the individual’s life that they may have related to in ways that they either enjoy or help them heal. Mifflin (1997) referred to tattoos acquired during times of transition as “psychic armor” (p. 106). An example Mifflin (2013) described is the story of a woman who got a tattoo of a turtle to remind her of the shell that she built up between her and the world when she had to wear a back brace through the majority of her childhood and as a reminder to drop those defenses. A unique, and increasingly popular, way people use tattoos to help them heal emotionally is a technique known as memorial tattooing. Memorial tattoos involve putting the ashes of a loved one in the tattoo ink to have them permanently tattooed into the skin. The cremation ashes are sifted until there is just a fine dust 29 29 that is then sterilized and added to the ink and tattooed into the skin (RedInc Tattoos and Body Piercing, 2012). Not all tattoo artists offer this service, but it is written about in tattoo articles and has even made it into the news. RedINK, a tattoo and body piercing company in the U.K., explained that memorial tattoos are an innovative way to bring a deeper meaning to a tattoo (RedInc Tattoos and Body Piercing, 2012). They discussed the memorial tattoo Hannah Walters, a TV actress on Whitechapel, had with her mother’s ashes tattooed on her foot. Walters stated that she did it as a tribute to her mom (The Citizen, 2013). Memorial tattoos help to bridge the gap between the natural and supernatural worlds by bringing the dead back into a living body. Some tattoo artists, on the other hand, warn people about unrealistic expectations about healing from tattoos. Tattoo artist Laura Vida stated that one cannot expect a tattoo to do too much (Mifflin, 2013). Some people expect a tattoo to effect a transformation for them, which is not always the case. For example, an individual will get a tattoo of someone’s name to win that person’s affections or someone will get a memorial tattoo and expect that it will help them to cease suffering the loss of their loved one. People sometimes have unrealistic expectations of what getting a tattoo can accomplish. Instead of expecting the tattoo do the healing, people must recognize that it is a stepping stone to help individuals recover and/or heal from some experience.

Mastectomy Tattoos in Media Mastectomy tattoos are starting to gain media attention. The average woman getting a mastectomy tattoo does not make it into the mass-mediated news. Fortunato (2014) explained that there was not a single broadcast about mastectomies in the news since 2010 and that Jolie’s story created at least five 30 30 additional stories. As stated before, Fortunato (2014) also explained that the reason for this is that health issues, such as cancer, are considered a constant and therefore need to have something special about them to make them newsworthy. Media attention is beginning to increase with the help of some organizations. P.ink, which stands for Personal Ink, is an organization that aims to bring awareness of mastectomy tattooing to breast cancer survivors by supporting them and offering them the chance to get a mastectomy tattoo (P.ink, 2015). They state that “our goal is to connect breast cancer survivors with the tattoo artists who can provide a form of healing that no one else can” (P.ink, 2015, para 1). P.ink is trying to combat the negative stereotypes associating tattoos with Navy sailors or those with poor reputations by raising awareness that tattoos can create a greater and more positive impression (Franus, 2013). As this thesis demonstrates, this form of cosmetic tattooing serves more than just the purpose of fitting into an ideal body shape or look, but instead is discussed as being able to help a woman heal mentally from the scars of surgery and the loss of part of her body. In October 2013, a few months after Jolie’s news media attention about her preventative double mastectomy, HuffPost Live (2013) talked with Noel Franus, founder of P.ink; Joy Rumore, a tattoo artist; and Megan Hartman, a recipient of a mastectomy tattoo. They discussed P.ink’s inaugural event in Brooklyn, where 10 women received tattoos from volunteer artists to cover up scars left by mastectomies. The interview was about the personal story of Megan and why she chose to do a preventative double mastectomy. The interview makes Megan’s story seem unique in comparison to other women who have had this procedure performed, when it is not, as this thesis shows. Similar to Jerslev (2006) and Fortunato (2014), the interviewer used Megan’s personal story to diminish the “sameness” of beauty 31 31 standards and create a more personalized narrative. What makes this story even more newsworthy and unique is the added aspect of the tattoo. Megan stated that women in locker rooms would want to stare but did not want to be rude, which made it awkward for her and it created a tense atmosphere; however she feels “that these tattoos are a talking point” and that “now it gives a nice segue to open up conversation” (HuffPost Live, 2013). Megan also explained that the tattoo makes people feel more comfortable asking her about it and allows her to share her story and advocate against cancer (HuffPost Live, 2013). P.ink has been monumental in getting different types of media to give attention to women like Megan (HuffPost Live, 2013). It is also responsible for promoting quality tattoo artists like Shane Wallin from Garnet Tattoo in San Diego, who are now able to specialize in mastectomy tattoos because of the media attention they have received. Wallin hosted P.ink’s second annual event at his other tattoo studio in Minnesota in 2014 and was a part of the third annual event in 2015 located at his studio in San Diego. This organization is getting media involved in these events to educate women about getting themselves checked through mammograms and performing self-evaluations. Famous celebrities are starting to jump on the bandwagon too and helping to spread awareness of the option of mastectomy tattoos to help cover scars and help women change their identity with their bodies or to transform their scars and breasts into something else entirely. For example, George Takei, who posts articles on his Facebook page on a broad range of topics that includes everything from cancer survivor stories to political topics to funny animal videos and has over 9.5 million followers, has helped to spread awareness of mastectomy tattoos. He posted an article in June 2015 that displayed mastectomy tattoos and how they can be turned into art (Ford, n.d.). One of Wallin’s tattoos was featured in this article. 32 32

These images showcase how unique, innovative, and personal these tattoos are. Having an iconic celebrity like Takei post articles helps to spread the word to a multitude of people who may not otherwise have encountered of it. It is becoming more popular in tattoo magazines as well, and media channels like HuffPost Live, MSNBC, and news stations from South Korea and Brazil are starting to discuss mastectomy tattoos. Although awareness is growing, it still has a way to go. There has been limited coverage of this topic in the past, so any mass media attention is an improvement. One feature on Facebook that helps to spread the word is that when someone clicks the “like” button on a Facebook article, it brings up suggested articles that are similar. If the reader liked an article about mastectomy tattoos, then that reader could see other articles about the same topic. “Liking” this article brought up articles such as Caitlin Kiernan’s (2014) “A Tattoo that Completes a New Breast” and Sara Gates’s (2013) “Facebook Removes Photo of Breast Cancer Survivor’s Tattoo, Users Fight Back.” Kiernan’s (2014) article called tattoo parlors “a Mecca” for women with breast cancer. The tattoo artist, Vinnie Myers, has had women travel all the way from India to his studio in Maryland to obtain a 3D nipple tattoo and has a waiting list of about six months (Kiernan, 2014). This shows how important it is to these women to have a nipple look natural. Cosmetic surgeons can create a fake nipple, but it is one-dimensional and can only pass for a real nipple if not looked at too closely (Kiernan, 2014). The second article by Gates (2013) raises a lot of discussion among media and consumers. It includes one of the most famous images of mastectomy tattoos circulating in the media. It is also the image that sparked the idea for this thesis. As mentioned in the introduction, Inga Duncan Thornell’s mastectomy tattoo was 33 33 controversial. Figure 5 is a picture of her tattoo. It was originally posted on Facebook by Custom Tattoo Design. Facebook deleted it, then Custom Tattoo Design reposted it and asked that people repost it in order to spread awareness of breast cancer and to spread awareness that this option exists for women. Facebook has such a strict nudity violation policy that any picture of breasts is taken down, whether or not it is being used in a sexual fashion; however, their policy is starting to be relaxed due to consumer complaints (Gates, 2013). Lee Roller, of Custom Tattoo Design, stated that Facebook keeps removing the post in 24hour as an offensive photo do [sic] to nudity. However we feel this woman is both brave and strong so we’re going to post it anyways and ask for your awareness and support. Please like and share this photo quickly to show your support for this and many other women who have lost so much. (as cited in Gates, 2013)

Figure 5 Inga Duncan Thornell, 2012, photograph by Tina Bafaro 34 34

Facebook now allows this photo and other mastectomy pictures to be shown on their site; however they still censor other non-sexual images of breasts. They removed four breast-feeding pictures from the “Respect the Breast” page and even censored a picture of a woman’s elbow because it looked like breasts (Gates, 2013). The controversy around this image has been covered by other media sources, which creates even more awareness about breast cancer and the option of tattooing that many women may not have realized was available to them. One of the most popular ways women are learning about mastectomy tattoos is through Pinterest, where many women (including the ones interviewed for this study) have found ideas about mastectomy tattoos and found out about P.ink. P.ink’s Pinterest page is designed for women who have never thought about getting a tattoo before so that they may be inspired and find beauty in a way they could never have imaged (HuffPost Live, 2013). The research that has been done in the past has helped to create understanding about how people construct bodily agency through various techniques, such as tattoos, photography, bodily reconstruction surgeries, makeup, et cetera. This study contributes a deeper understanding of the reasons why women chose tattoos after a mastectomy and how that tattoo helped them to heal emotionally from the trauma. Thompson and Hirschman (1995) explained that a body can be reconstructed to be what an individual wants it to be. The individual then has the power and the freedom to choose the technique that best suits them. The technique can be used as a power and control over how others view them and how they view themselves. However, it is not possible to control completely others’ perceptions. An individual can encode the message that they want decoded, but it does not mean 35 35 that it will be decoded correctly. Even if it is decoded the way it was supposed to be, that does not mean that the message will be understood with the same amount of complexity and depth that the encoder intended. A person can only decode upon the codes that are familiar to them, which are determined by their own personal experience, societal constructs, language, and mass media, among other sources. The following chapter discusses the methodology used and explains the reasoning behind each methodological choice that was made.

CHAPTER 3: METHODOLOGY

I’ve heard there are troubles of more than one kind. Some come from ahead and some come from behind. But I’ve bought a big bat. I’m all ready you see. Now my troubles are going to have troubles with me.

– Dr. Seuss

This thesis adopted a qualitative research methodology, using the interpretation and analysis of interview data as a way to understand meanings and relationships between the variables in the data (Tracy, 2013). In other words, it aimed to analyze personal accounts and detailed information from participants to understand better what they went through with their mastectomy and if there was any impact that the tattoo had on their self-esteem or body image. In order to analyze the data collected from the research, this study focused the research questions around bodily agency and the process of encoding and decoding, which are: 1. What reasons do women report for getting mastectomy tattoos? 2. In what ways do those with mastectomy tattoos use their tattoos to claim bodily agency? The current study was interpretive. Lindlof and Taylor (2002) listed the components, of such an approach which include: “evidence for claims about social action should be recorded and expressed using verbal and narrative means” and “realities are socially constructed by and between human beings in their expressive and interpretive practices” (p. 11). This paradigm was used since it requires a personal and individual understanding of what each participant experienced. How each participant views their own reality is expressed through the narratives they provide while being interviewed. An obstacle in doing any type of research is keeping an open mind and not allowing the investigator’s own 37 37 cultural viewpoints to interfere with the data. Since tattoos can carry symbolic and cultural meanings, I needed to be able to separate my own personal feelings and emotions about tattoo styles and meanings in order to understand more openly the influence the tattoos have had on a participant. For example, Mie Hiramoto (2014) explained that Polynesian tattoos are specifically designed for each individual and have different meanings depending on the symbols chosen, but if the person is not aware of the symbolic meanings then they could misunderstand (or in some cases get tattooed on them) tattoos “that are unsuitable in ways that extend beyond linguistic inaccuracy” (176). In other words, people may be getting a symbol tattooed on them when they are unaware of what that symbol really means. For example, Rebel Circus (2015) discussed a story about a person who liked an image and wanted it tattooed on them, but the tattoo artist recognized it as the Hell’s Angels’ logo and did not want to be responsible for tattooing that on them. The individual requesting the tattoo was unaware of what the symbol meant and chose it because the person liked the design. The researcher’s own perception of tattoos as art, as well as any personal connection to a symbol or image, has to be put aside in order to understand what the participants originally thought about tattoos and the transformation they experienced after getting one. The researcher cannot assume what the participant’s perceptions of tattoos were before they chose to get one over their mastectomy. As an interviewer for this study, the role and the objective of the researcher was to talk with women who have had tattoos inked over their mastectomy in order to find out the motivations and reasons behind getting them. Interviewing also aided in understanding how these women perform their identity using their tattoos. Although I do have tattoos, I do not have personal experience with mastectomies or getting a tattoo over scars. Obtaining first-hand accounts from 38 38 women who have undergone this process is vital to understanding the reasons for these tattoos and what these tattoos can do for a woman’s identity. Approval to interview was granted by the human subjects review committee. Six women were interviewed about their experiences with mastectomies and the process of getting tattooed.

Participants Over 20 organizations and tattoos shops were emailed asking for information and help in finding participants. A simple email was sent out stating my name, contact information, and a brief description of the thesis and why participants were needed. Some organizations would not place a post on their website due to confidentiality concerns; others did not allow a post because it was for research and not for medical or support purposes. Out of all the requests sent, one tattoo shop responded from the western United States. They asked my permission to share my contact information with clients they felt would be willing to participate and be interviewed. Many of the contacted clients responded. All six participants, who fit the criteria for this study and were interviewed for this thesis, came from this studio and contacted me through email. Interview dates and times were set up individually based on the participants’ schedules. In order for the participants to qualify to be interviewed, they had to meet certain criteria. First, they had to have had a mastectomy or double mastectomy. Second, the women needed to have had a tattoo on or near their breasts due to the mastectomy. The type of tattoo did not matter, whether it was a 3D nipple tattoo or an image covering their scars. In some cases, it was both. Having or having had cancer was not a criterion since many women have mastectomies for preventative reasons. 39 39

Each of the participants were given a consent form (Appendix A) and were also given a pseudonym to protect their identity and to allow them to feel more comfortable sharing their personal stories. The topic of mastectomies can be very personal for some women, so this protection provides the participants with more confidentiality. All but one participant stated the pseudonym was unnecessary because they were very open about talking about it. Nevertheless, the pseudonyms given to the participants are Sara, Tracy, Kim, Mary, Angie, and Laura. Five of the participants were Caucasian and one was African American. They ranged from 39 to 70 years in age. Each of the participants had a unique story for the reasons they got a mastectomy and a tattoo. Sara was 39 years old and has a history of breast cancer (and other cancers) in her family. She was diagnosed with cancer in her right breast and decided to get a double mastectomy in order to prevent getting cancer in her left breast. Although it was not required for her to have a double mastectomy, she opted for it and so her left side was removed as a preventative measure. She had reconstructive surgery, but she will eventually have to have her implants replaced. Because the doctors will be able to use the same incision point for the replacement surgery, she did not want her scars covered up with a tattoo and opted for her breast area instead. Tracy was 52 years old and also has a family history of cancer. Although she was never diagnosed with cancer, she opted to have a preventative double mastectomy after her father and sister died from breast cancer. She had reconstruction performed twice due to complications. Her tattoo covers both her breasts. She has written a blog post on Tattoo Artist Magazine’s website explaining her story. 40 40

Kim was 53 and had a double mastectomy performed after she was diagnosed with breast cancer. When she was 26, she had another form of cancer; however, the doctors used twice as much radiation as they would use today and the doctors now believe that caused her breast cancer. She had reconstructive surgery on both breasts and selected a tattoo covering her left one. She has also written a blog post on Tattoo Artist Magazine’s website. Mary had a double mastectomy when she was 39 years old. She has no family history; she had genetic testing done that came back negative. Despite this, she got stage two aggressive cancer and went through six rounds of chemotherapy. She had reconstructive surgery done on both her breasts, but chose to tattoo only over her right breast. She has also written a blog post on Tattoo Artist Magazine’s website. Angie was a two-time cancer survivor and has no family history of breast cancer. She was 53 years old, but she was in her twenties when she was first diagnosed with breast cancer. She had her left breast removed at that time; however, 24 years later, cancer was discovered in her right breast so she had another mastectomy. She had both her breasts reconstructed at the time of each mastectomy. Her tattoo covers both breasts. She has also written a blog post on Tattoo Artist Magazine’s website. Laura was 70 years old. She was a 25-year cancer survivor who has undergone a double mastectomy and multiple reconstructions. Two of her family members have had mastectomies. She chose a tattoo to cover the left side of her breast. Laura has also written a blog post on Tattoo Artist Magazine’s website. 41 41 Interview Procedures Interviews were conducted as a way to allow the researcher to ask questions and respond to participants’ statements. According to Tracy (2013), interviews are particularly valuable for accessing background information that cannot otherwise be observed. For this study, interviews were the best way to learn about the personal choices of the participants. Hearing the narratives from each participant made the data more personal and the women were able to explain their own unique journeys. Using surveys or analyzing written material may not have yielded the same results. Individual interviews were chosen over group interviews to allow the women to feel more open in sharing their stories and give each of them a chance to speak with more privacy. Observing a woman getting a mastectomy tattoo would not yield nearly the amount of detailed insight that an interview with the woman can. The process of deciding to get a mastectomy tattoo is not an easy one. Women go through numerous traumatic experiences before they decide to choose a tattoo. Interviews help a researcher to ask more detailed questions in order to strengthen the data collected and provide the interviewee an opportunity to defend, verify, or expand on a particular question or subject (Tracy, 2013). Personal stories and experiences can be highlighted in a way that only the participants can explain. Five of the interviews were recorded and transcribed by the researcher. Due to technical problems, one of the interviews was not recorded but notes were taken during the interview and additional notes were audio recorded immediately afterward. Each participant agreed to have the interview recorded and was informed that they could opt out of any question they did not wish to answer; however, none of the participants opted out of any question. All face-to-face interviews were in the western United States; four were conducted in the city 42 42 where the participant lived. One interview was conducted sitting outside of a Starbucks and lasted 29 minutes. Another interview was conducted in a tattoo studio with the owner’s permission and took 34 minutes. A third interview was at a quiet restaurant and lasted an hour and 20 minutes. The last face-to-face interview was also at a quiet restaurant and was 13 minutes in length. When possible, face-to-face interviews were conducted; however, two of the interviews were phone interviews due either to distance or convenience for the participant. One of the participants lived in the Midwest and, due to financial constraints, the researcher was unable to fly out for a face-to-face interview. This interview was 18 minutes long. The other phone interview was of a participant who lives in the western United States and was unable to meet in person. Her interview was 18 minutes in length. In order to maximize the opportunity of the interviews, the interview questions needed to be written in a way that got to the heart of the study. They were designed to tap into the experiences of the participants in order to discover their unique story and allow them to talk more freely about what they find important (Tracy, 2013). This candor was vital for this research because the research questions focus on the personal choices of the participants, their own personal reasons for opting to get a tattoo, and how the tattoo affected their identity and well-being. The majority of questions were open-ended. The purpose was to guide the interviewee to discuss a particular topic while leaving the question open for them to answer however they wished. They were able to share their stories as they related to each question. For example, one of the first questions was “How did you hear about the idea for this type of tattoo?” This question allowed the participant to explain how they found out about mastectomy tattoos and their experience 43 43 researching the type of tattoo they wanted. Another question was, “What was your opinion of tattoos before you received this one?” This allowed the participant to voice their own perceptions without being lead to any particular answer. After the participants were asked what made them decide to get a tattoo, they were asked to describe their experience getting it. This gave the women an opportunity to go into as much detail as they felt was important or that they were comfortable with providing. Another question was, “What have been the responses from your family and friends?” This question allowed them to explain their experiences about their mastectomy tattoo with others. Questions about motives were extremely valuable for this study because they relate to the research questions. Questions that were introduced, if the answer was not already stated by the participant, were, “Why did you decide to get a tattoo?” and “Why did you choose the design that you did?” These questions needed to be open-ended to allow the participant to respond in a personal way without introducing the researcher’s assumptions or preconceptions about motives. At the end of the interview, each participant was asked if and why they would recommend this type of tattoo to someone who has undergone a mastectomy. The last question asked was, “Is there anything else you would like to add that you feel is important that was not discussed during the interview?” This provided the opportunity for a topic or idea to be mentioned that the interviewer had not considered or anticipated. A full list of questions is included in Appendix B. Each interview that was recorded was transcribed and audio notes were transcribed for the interview that was not recorded. Transcription allows a researcher to examine interview data more closely and to double-check their data (Tracy, 2013). It makes the coding process easier, as well, when everything is 44 44 written out. In the end, there were a total of 53 pages of transcription. The main reason for transcribing, according to Tracy (2013), is to understand accurately what the participants said in the data as the researcher listens to each interview multiple times. The interviews were recorded on an audio recorder. Each interview was listened to multiple times and nuances in the voice, such as tone, laughter, and fillers were written down as well.

Coding and Analysis In order to manage the amount of data, the researcher needed to employ a form of data management, which is the ability to gain control over the large amount of data present and then filter that data based on what is of higher use and priority than the rest (Lindlof & Taylor, 2002). Some field notes were taken to remember something particular significant about what the participant said or how she said it. Before attempting to code, each interview transcript was read in its entirety to identify larger concepts and themes. After the initial reading, they were then re-read and categorized. Categorization is “the process of categorizing the meaning of a unit of data with respect to certain generic properties” (Lindlof & Taylor, 2002, p. 214). This allows the researcher to look at phenomena and categorize them into “concepts, constructs, themes, and other types of ‘bins’ in which to put items that are similar” (Lindlof & Taylor, 2002, p. 214). The goal of this research aimed to find themes across the interviews as to why women get mastectomy tattoos and how it has influenced the performance of their identities. There needs to be enough data relating to each theme throughout all of the data to qualify as a category. One way to identify themes is to look at a larger-scale theory or construct against which to compare the themes emerging from the data. The process of 45 45 encoding and decoding, along with bodily agency, were some of the larger theories that informed this study. According to Lindlof and Taylor (2002), “the literature can be used to stimulate theoretical sensitivity to clues of meaning in the data, suggest questions that can be asked of the data, and act as a source of supplementary validation” (p. 214). In other words, a larger overall theory validates the themes by linking them to a larger construct that has already been studied by multiple researchers. Themes also add to the scholarly conversations that are taking place. In order to make sure each category was not an isolated incident, as Lindlof and Taylor (2002) suggest, the researcher conducted several close readings through all of the data. The next step was to code. Codes help to forge a link between the data and the categories the researcher developed. Lindlof and Taylor (2002) explained that the main reason for coding is to mark lines of data and relate them to categories, such as themes and constructs. The researcher began with initial codes and then found additional more complex codes or related codes with each additional reading until no more codes were discovered. Even the participant’s tone of voice was coded to make the text as accurate as possible. Coding consists of marking up the transcription to provide clarity and to aid in discovering themes that may not have originally been clear. The process used for this study was the manual approach. This approach was chosen because it was a convenient and easy way to access the data. All the coding was done on hard copy, where each unit of data had codes written next to it that described it. Coding was a two-step process. First, primary coding was done to establish general categories based on the initial reading. Primary coding is initial coding that is completed when reading the transcripts for the first time (Tracy, 2013). It entails writing key words or phrases next to a line to capture the “essence” of the comment (Tracy, 2013). The codes in 46 46 this step focus more on describing what is in the data, for example writing down if the person was laughing or if they said anything that stood out in that sentence. In order to keep the codes straight, a codebook was created. A codebook is a list of the codes being used and the definitions of each code (Tracy, 2013). This codebook was a reference used throughout the analysis as a quick reference guide. Table 1 shows the list of primary codes. The primary codes F.O., CaEx, Rec, Reason, Supp, TaEx, TM, and Trans have questions tied to them. The rest emerged from their responses.

Table 1

Primary Codes Abbreviation Code Description Discussion of expenses for cancer treatments $ Expenses and the tattoo Describes their family history of cancer and CaEx Cancer Experience the cancer and their mastectomy How they found out about mastectomy F.O. Found Out tattoos Discussion of the pain of the mastectomy Pain Pain tattoo Discussion of whether or not they Rec Recommendations recommended it to others

Reason Reasons Mentions of why they chose to get a tattoo Scar Scars Mentions of their scars Support and nonsupport of family members Supp Support and friends Discussion of their experience receiving the TaEx Tattoo Experience tattoo Discussion of the meaning of the image that TM Tattoo Meaning they chose Mention of how they felt the tattoo helped them identify with their post-mastectomy Trans Transformational body

Secondary-cycle coding came next. Secondary coding transforms the primary coding into one that is hierarchical (Tracy, 2013). The codes that are on 47 47 the top of the hierarchy are those that relate to the research questions more than the others, which requires the researcher to take a closer look at the data and analyze it to see if there are hierarchical attributes and what those might be. In this case, the secondary codes that are directly related to questions are Fam (Supp), Friends Supp, Scar/Reason, and Em (Trans). Table 2 shows the secondary-cycle codebook that was created and lists the primary code that it originated from. The codebook made it much easier to organize the transcripts and to code more consistently. After all of the coding and categories were finalized, themes emerged from the data. These are more focused than primary codes and helped to organize, synthesize, and categorize the primary codes (Tracy, 2013). For example, the primary code, Supp, contained both family and friends responses. It was divided into two secondary codes: Fam and Friend Supp. These helped to separate family from friends. The primary code words, Scars and Reason, were closely related to each other. When the two codes were intertwined it was placed into a secondary category of Scar/Reason. The primary code Trans was large so it was divided into sub-categories in order to distinguish the different types of transformation. These sub-categories are: Em (Trans), Heal, and Complete. The primary code Em contained emotions for both Trans and CaEx so it was divided into two separate categories. The next chapter presents the findings of the coded interviews. In order to answer the research questions, it also discusses how the participants found out about mastectomy tattoos. Since public knowledge about these tattoos is lacking, it is important to share how they discovered this option in order to understand how they came to the decision to get tattooed. Secondly, there is a discussion on encoding and decoding followed by emotional healing. 48 48

Table 2

Secondary Codes Primary Abbreviation Code Code Description When feelings (other than pain) were expressed dealing with the Em (TaEx) Emotions TaEx experience of the tattoo process

When feelings (other than pain) were expressed about what they felt about Em (Trans) Emotions Trans the tattoo after it was complete Mentions of their family members Fam Family Supp responses to the tattoo Mentions of their friends responses to Friend Supp Friends Supp the tattoo

They discuss the ways in which the Heal Healing Trans tattoo helped them emotionally heal Mentions of feeling as if their cancer It's Over Finally Over Reason is finally done Mentions of how they feel complete Complete Feeling Complete Trans physically

Was a common way how the women P.ink P.ink F.O. found out about mastectomy tattoos Scars and reason went together so often that in secondary coding they were combined into the theme of Scar/Reason Scars/Reasons Scars emotional healing

CHAPTER 4: DISCUSSION

As a scar or tattoo heals, the skin sloughs away, in the same manner as that of the shedding snake. For sure, then, one who has been scarred or tattooed dies to his or her old self/flesh and, through the symbolism of tissue regeneration, is reborn.

– Rush, Spiritual Tattoo

Interviewing women who opted for a mastectomy tattoo provides insight into the reasons why they choose the option of a tattoo and how they use their tattoo to claim bodily agency. This chapter separates the themes based on the research questions and is divided into two sections: encoding/decoding and emotional healing. Encoding and decoding help to answer research question 1, “what reasons do women report for getting mastectomy tattoos?” Emotional healing helps to answer research question 2, “in what ways do those with mastectomy tattoos use their tattoos to claim bodily agency?” However, this section also aids in understanding research question 1. “Encoding” represents an individual’s ability to code an image for others to be able to understand the meaning of the intended message (Hall, 2006). “Decoding” represents an individual’s ability to understand the encoded message, which can “influence, entertain, instruct or persuade, with very complex perceptual, cognitive, emotional, ideological or behavioral consequences (Hall, 2006, p. 165). The image of a tattooed breast is not a common one. Looking at mastectomy tattoos through encoding and decoding helps to explain how women can use mastectomy tattoos to bring awareness of the option to others. This section is divided into themes: tattoo symbolism, advocacy, and resistance. “Emotional healing” discusses how the women felt as if they were healed emotionally by the tattoo and the process of receiving one. Emotional healing is 50 50 broken down into three categories: restoration, transformation and pain, and transformation and well-being. Restoration is about the healing that comes from restoring the physical body through covering scars and the act of getting tattooed. Transformation and pain is about how the women were emotionally healed through the pain of getting the tattoo. Transformation and well-being discusses the effect the tattoo has had on the women’s self-esteem and confidence. Phelan and Hunt (1998) explained that identity is not something that just happens; instead, it “is an ongoing process that emerges from individuals’ interpretative and communicative efforts” (p. 278). The concept of bodily agency helps to explain how women can use mastectomy tattoos to change their identity by changing how they view their body. First, there is a discussion about how the women discovered the option of mastectomy tattoos.

Path of Discovery In order to answer research question 1, which asks the reasons why women get mastectomy tattoos, one needs first to understand how the women heard of mastectomy tattoos. The majority of people have never heard of mastectomy tattoos, and even if they have, they may not realize this type of tattoo is not your average tattoo. Most of the participants had never heard of such tattoos until they went through the mastectomy procedure. However, women are starting to learn of this option now that television and internet sites are covering the topic more, thanks to the organization P.ink and the famous Facebook image of Inga Duncan’s tattoo (figure 2.3 in chapter 2). The reason that many may not know about this option is that women may not pay attention to it until they are in a situation where this option applies to them. There are tattoo artists who specialize in these tattoos, but there are not many. The women in this study discovered this option after 51 51 choosing to undergo a mastectomy and found their tattoo artist in a similar way. It is important to study the effects of tattoos over scars because of the impact they can have on the individual. The most common way these women learned about mastectomy tattoo was through the non-profit organization P.ink (personal communication, May 25- August 8, 2015). Angie found P.ink via a friend’s Facebook post, but she also heard about the organization in magazines like Oprah and Ebony (personal communication, June, 23, 2016). She said she looked at all the women on their site and started crying. Angie called the organization, and they found her an artist to create a tattoo for her. Tracy looked online with her sister (who also has had a mastectomy) to find tattoos when she came across P.ink (personal communication, May, 25, 2015). She also found them on Instagram. Tracy contacted the organization but was told it would take her up to a year on the wait list. Unlike Angie, she decided to contact a tattoo studio directly and obtain it sooner. Sara found out in a fashion similar to Tracy (personal communication, May, 27, 2015). She was discussing her options with her family. She learned about nipple tattoos from her doctor and while searching online for tattoos, she discovered P.ink. She was inspired by Molly’s (the woman who founded to organization) story to go beyond a nipple tattoo and come up with a more elaborate design. Kim originally found out about nipple tattoos from her doctor and had them done (personal communication, May, 27, 2015). However, she was not satisfied with the results. They were just flesh-tone circles, so she started looking on Facebook and found P.ink. Laura and Mary also found P.ink, but their experiences were not as straight- forward. Laura originally learned about mastectomy tattoos by attending a cancer fashion convention (personal communication, August 8, 2015). These conventions 52 52 are typically a fashion show to raise money for cancer organizations, such as the American Cancer Society and the Bay Area Breast Cancer Grants Program. She saw photos of mastectomy tattoos there and went home to look up more photos of these types of tattoos and found P.ink. Mary found out about nipple tattoos from her doctor, who recommended a permanent makeup artist (personal communication, July, 29, 2015). However, when she visited the artist’s website, she was not happy with the pictures she saw. She already had tattoos and knew a good artist, but the artist did not see this tattoo as different from her other work. Mary explained that this tattoo was more significant for her, so she wanted to find someone who specialized in this type of tattoo. After two years of searching, she found P.ink on Facebook, which is how she located the artist for this tattoo. P.ink has been a major way in which these participants found out about mastectomy tattoos, but the reason they chose to obtain one and how it affected them varies.

Encoding/Decoding As established in the previous chapter, tattoos can have personal meanings to the encoder that may or may not be decoded in the way an individual who encoded them intended. Atkinson (2003) explains that research often views tattooing as a “uniformly decodable practice” (p. 55). Such research assumes that the meanings attached to tattooing in general, as well as to specific tattoos, are universally understood, although that is not always the case. Connotative meanings are not always comprehended by those attempting to decode the message. Moriarty (2005) explains that connotation “reflects cultural meanings, mythologies, and ideologies,” but that meaning starts with denotation (p. 231). In order to understand the denotative and connotative meanings of the tattoos, this section begins by exploring the thought that went into these women’s tattoo 53 53 designs. It then explores how the women wanted the tattoos decoded by others, how they and others relied on universal symbols to decode the tattoo, and the role that encoding and decoding of symbolism played choosing an image.

Tattoo Symbolism The meaning of symbols can depend upon a person’s culture and individual experiences. Symbolic meanings can also aid in understanding research question 1 by providing insight into the reason a person would choose tattooing. Images can evoke feelings and meanings and can even convey a sense of smell without a smell attached to it (Smith, 2005). For example, a picture of an individual smelling a flower can make the reader imagine the smell of the flower. Moriarty (2005) explained the significance of symbolism as “a complex process with various steps and levels, all of which offer points for individual personalization of meaning by the receiver” (p. 232). How individuals read an image and the symbolism they attach to it is personal. For example, a simple butterfly tattoo may be more than just a beautiful design; it may have multiple meanings, depending on what the individual who chose it wanted it to mean. Venefica (2015a) listed the general symbolism of the butterfly for different cultures. The universal symbolism is that the butterfly represents the cycle of life and that everything changes, grows, and evolves; in Japanese culture it can also depict delicate feminine attributes; in Chinese culture the butterfly can represent joy, good luck, abundance, blessing, and health; in Christian traditions it can represent immortality; in Celtic culture it can be the symbol of the soul (Venefica, 2015a). A butterfly is also a common tattoo for lesbian women because it symbolizes metamorphosis or a “new life from an old imprisonment – a body that perhaps did not ‘fit’” (Rush, 2005, p. 61). How one 54 54 encodes and decodes a symbol depends on their own personal experiences and their culture. How one picks an image that will be decoded by others depends on who that person is and how they want their symbol decoded. Not everyone is going to be able to decode an image the way it was intended, due to their own personal relationship to that image; however, not every image is meant to be decoded completely by everyone who reads it. Some individuals may prefer to have the meanings of their tattoos private or limited to certain individuals. This study focused on how the women encoded their message. Since decoders were not interviewed, this discussion focuses on encoding. Some of the women went into detail about the meanings of their image during the interviews; others did not. One participant, who has the largest tattoo of all the participants, was very clear about the image she chose. Angie chose angel wings that cover both of her breasts, her sternum, and part of her upper chest. Figure 6 shows the before and after photos. She chose this design “for all my sisters who died from breast cancer.” The denotative meaning of wings can indicate wings for any creature, from an angel to an animal. The wings can be decoded to take on a meaning of spirituality, lightness, or freedom from the earth (Carrillo de Albornoz & Fernandez, 2014). Once the reader knows they are angel wings, then the meaning can have a deeper spiritual meaning, such as God’s protection or the purity of angels (Carrillo de Albornoz & Fernandez, 2014). However, Angie’s encoded meaning for the angel wings is not something everyone will be able to decode initially. She chose them to honor women who did not survive the fight. Knowing Angie’s background gives the angel wings and their symbolism much more depth. Once Angie explains the symbolism, the reader 55 55

Figure 6 Angie, 2015a, reprinted with permission from Shane Wallin can now connect angel wings to life after death, although not everyone will be able to decode the symbolism of the wings, even if they know the story. Ross (2011), explains that the receiver can only decode based on the codes with which they are currently familiar. Although the person may know Angie’s story, that does not mean that they will decode the meaning that Angie intended. However, such differences in interpretation do not diminish the meaning of her message since her message is both personal and public. Although readers may not be able to read the connotative meaning of her tattoo, the symbolism of the image is meaningful to Angie. She can pick and choose when she wants to discuss the connotative meanings with others and when she does not. This gives her the ability to take control of her personal life by choosing not to divulge personal information about her life to others. Unlike Angie, Mary chose to get a 3D nipple along with a design. She explained that even though many women were not getting their nipples replaced or were replacing them with other designs, she felt those choices were not for her. 56 56

She explained, “I hated looking in the mirror and thinking that I was missing something.” She discovered the design she wanted, nipples with flowers, through watching the television show Ink Masters. She took the initial idea to her artist, who created a similar design that was more personalized to Mary (Figure 7). She did not go into as much detail about the meaning of the design as other participants did, instead emphasizing being able to encode/decode natural and complete breasts for her own meaning-making. For her, the connotative meaning was much more private and personal.

Figure 7 Mary, 2015b, reprinted with permission from Shane Wallin

Sara had a harder time coming up with ideas about what to have tattooed. Her faith is incredibly important to her, so she looked into religious images, such as a cross or an anchor. However, she decided to go with lilies because Lilies of the Valley represent Christ in her religious culture. She also incorporated an anchor on one side of her breast and a treble clef on the other because music is also a big part of her life. The flower looks like it’s blooming in order to “signify a 57 57 new beginning.” She was able to incorporate many images into the tattoo to symbolize what was most important to her. She was able to encode all of what she considered to be important images into one tattoo. Similar to Sara, Tracy’s ideas for a tattoo changed a couple of times. She knew she did not want flowers and wanted something different than what she has seen on other women who had mastectomy tattoos. She reported at first she only wanted the tattoo for her. It had a very personal meaning for her and she did not want others to be able to see it. However, she has changed her mind and a picture of her mastectomy tattoo has even been included in an article posted on George Takei’s Facebook page. She decided on feathers because they have no hard lines and have a soft feel, but she struggled to select the type of feathers. Choosing the right image was a delicate balance of what she wanted the feathers to communicate and what others could say about the style of the image. The colors, the size, and the hard or soft lines of the image all are decoded by the reader. Tracy chose codes that are familiar to her in order to encode the image in a way she desires it to be decoded. To increase the symbolism of the feathers, she also added lyrics from a song underneath the feathers that reads, “He will cover you with his feathers, He will shelter you with his wings” (Figure 8). The lyrics provide more detail and help readers to decode it. Aiello (2006) states that the function of the denotative message is “a necessary support for the connotative message” (p. 95). The denotative message in Tracy’s tattoo is the feathers and the lyrics. This supports the connotative message of the feathers being a way that God is sheltering and protecting her. 58 58

Figure 8 Tracy, 2015c, reprinted with permission from Shane Wallin

Kim received nipple tattoos from her doctor, but she was not pleased with them. She stated that she was left with brown flesh-tone circles instead of nipples. Figure 9 shows the stages she went through with her tattoos. The top left picture is what her breasts looked like after the mastectomy. The middle left picture depicts what the nipples looked like after she obtained the nipple tattoo from her doctor. Since she was not satisfied with the outcome from the doctor, she found an artist to place a 3D nipple tattoo atop her other tattooed nipple. The bottom left picture is the 3D nipple tattoo. After her nipples were completed, she decided to obtain another tattoo over the rest of her breasts and received a full floral bra. Kim did not mention the meaning behind her floral design, except to cover up scars. Thompson and Hirschman (1995) call these “camouflaging efforts” (p. 148) because she is camouflaging her scars and the loss of her nipples by tattooing new ones and encoding a sense of normalcy, which is what all of the women were doing. Individuals are conditioned to think of women as having two breasts with nipples because that is the image that is displayed in social media, television, and the 59 59 internet. This conditioning by society, Aiello (2006) writes, happens because the exchange of communication has “been produced in the course of cultural histories” (p. 91). The way an image gets encoded and decoded is based on historical influences. A reader may decode tattooed nipples positively or negatively based on their own history, but Kim can encode the images based on her own viewpoint and feelings about her own tattoo of her 3D nipples. Similarly, the same can be said about her floral bra. Since the meaning behind the floral design was not specified, the way it was intended to be encoded is unknown. The floral design she chose can be encoded as feminine, because of the association of flowers with femininity in U.S. culture, but how a reader seeing her photographs would decode it depends on the reader’s repeated associations or past experiences with the images (Moriarty, 2005). This image may bring back memories that have nothing to do with the encoded meanings that Kim may have intended.

Figure 9 Kim, 2015d, reprinted with permission from Shane Wallin 60 60

Laura opted out of nipple tattoos and chose to tattoo only one breast. The image she chose was a Phoenix (Figure 10). She stated that this image represents “rebirth and freedom” and she finds it to be a “very empowering and beautiful symbol.” She also chose it because it represents someone who rises from the ashes. She had cancer and was able to rise up, fight the disease, and win. She was able to use her life as inspiration and connect it to the connotative meaning of the phoenix. She was able to encode the way she was feeling on the inside by translating it to the image of the bird. Rush (2005) refers to tattooing as “impregnation” because a person comes up with an idea or belief and is able to “mentally move from the outside (the event in nature, an image, etc.), to inside (one’s thoughts), to the outside” where the tools of tattooing can place that image on the skin (p. 5). Laura moved from the outside (having cancer) to the inside (the way she felt about her body and health), and she moved it back to the outside (her Phoenix tattoo). Venefica (2015b) explains that the phoenix can symbolize victory over death, healing, cleansing, passion, and energy. This tattoo is an excellent metaphor for those who have undergone mastectomies.

Figure 10 Laura, 2015e, reprinted with permission from Shane Wallin 61 61 Advocacy Another reason women repot for getting a mastectomy tattoo is advocacy. All six woman wanted to spread awareness about the option of obtaining a tattoo after a woman has had a mastectomy. However, spreading awareness is not always easy to do. The ways in which tattoos are encoded and decoded depends on the person’s culture and experience. This means not everyone will decode an image the way the encoder intended. Even if it is decoded the way the encoder intended, the person doing the decoding may not have the same values and opinions as the encoder. The decoder may understand the message, but that does not mean the individual agrees with the decision of the encoder to get a tattoo or the meaning encoded in it either. One thing Mary explained was that women who go through the trauma of getting a mastectomy meet others who are going through it too and they are now part of a special kind of club. Women can use membership in this type of club to advocate for options, such as tattooing, to each other. Women will call each other and support one another as they go through more testing and treatments. They are able to decode the terminology and the experiences much more personally than someone who has not undergone the same experience. There is only so much a person can learn by reading or talking to someone. If the person has not been through the same experiences, then they will not be able to decode the meanings of words or images in the same manner as someone who has experienced it. Mary has a friend who is going through chemotherapy treatments now and she tells her friend, “cover it up [with a tattoo] and it just goes away and you just move on.” She tries to encourage and educate others by explaining to them her experience and that this option exists. She is advocating for a mastectomy tattoo, which she believes will help them to take control of how they encode their body image so 62 62 that others will decode it the way that the woman wants it to be understood. However, it is not always possible to encode the entire meaning of a message in an image. There are limitations of interpretation which makes it challenging to have certainty of meaning. Angie explained that she gets compliments of her tattoo all the time, but people do not understand the entire meaning encoded in it. She uses the challenges that individuals face when they decode her tattoo as an opportunity to advocate and educate others about breast cancer. She shares that she is a two-time breast cancer survivor, and she tells women to make sure to keep up with their regular checkups. Kim also explained that “I feel it’s my place to share and help other women, you know, feel uplifted too.” They want to advocate for each other and advocate to let other women know that they are not alone. Some of the women interviewed knew each other from the tattoo studio and were supporting one other. One mentioned that she wished she could be a fly on the wall when the other women were going to be interviewed in order to hear their experiences, because she was interested to see how her experiences compared to others who have been through something similar. Mass media are now starting to catch up with the increasing demands for public exposure for mastectomy tattoos and scars. Five out of the six participants heard about these tattoos from the internet and all six used the internet as a way to learn more and get ideas about what others in their situation have done. However, it was not something they knew much about until they had a reason to get a mastectomy. Laura saw the same episode of Ink Master that Mary did and said that it was very inspiring. She has since put pictures of her tattoo on the web. She explained that she hesitated at first, but if her photo inspires women like the women on Ink Master, then she is fine with it. She wanted to use her experience 63 63 and her tattoo to advocate by increasing exposure to other women. The tattoo artist who did the tattoos for these women is starting to draw attention as well. Not only does he get publicity from P.ink, but he has been interviewed by a Korean television station and has been covered in a Brazilian newspaper. Unexpectedly, three of the participants thanked me for doing this research. Laura said thank you for the research and explained that this option needs to be publicized more. She said that although she knows a lot of women who have had mastectomies, she does not know any other woman with a mastectomy tattoo. Tracy stated, “I just think it’s a fantastic thing…I’m glad you’re doing this. This is good.” Angie explained how she felt about this research project by saying I’m so happy. You can be out there and let other women know because a lot of women, like I said, I didn’t know. It’s been what, over 20 some years. If I had known about that I would have been in a long time ago. She stated how excited she was when she was selected by P.ink to get her tattoo saying, “I was so happy when they called me…that was like the best birthday, Christmas, anniversary all in one. I was happy and I was so honored.” Angie was even able to do a photo shoot after the tattoo was completed. She said “I felt so privileged and honored that this photographer wanted to photograph me to do this…I had wore a wig, but I rocked it bald.” All six of the participants mentioned that their friends and family were all very supportive. Mary described her husband’s response saying that he told her “whatever you want to do I support what you want.” She said that “it wouldn’t have mattered if I wanted to tattoo my entire chest all the way down to my knees. He wouldn’t care if that made me happy.” Tracy explained that her husband was much more practical about the tattoo than she was. He did not want her to change her mind six months down the road and wanted her to think about it longer. He 64 64 was not opposed to it, but he did not want her to rush into it. She said that he loves it and held her hand through the tattooing process. Angie’s five-year old grandson told her after he had seen a picture of her tattoo and said “Nana that’s so beautiful.” He is still too young to decode the full symbolism of the tattoo and the reason she got it, but one day he will.

Resistance A tattoo can be encoded in any way the individual wants it to be, but that does not mean that the reader will understand and agree with the image the receiver has chosen. Cultural and personal bias against people with tattoos makes advocacy challenging. Mary said she would not want to show any of her friends who have not been through it because she felt that they would not understand and she did not want to be looked at differently. All six participants for this study, along with organizations like P.ink, want to educate people about the option of tattooing over scars, but there can be some push-back from other individuals and organizations. The perception that there could be push-back could prevent some women from seeking tattoos as an option. Not everyone has the same acceptance level of tattoos. Laura mentioned some of her friends are not fond of tattoos so they do not want to see it. Laura’s friends do not like what they perceive to be the style of people who have tattoos; however, they were okay with her getting this particular tattoo because she got it for a good reason. She explained that they told her they were accepting of her tattoo because the reason she got it was inspiring. Her friends were looking at the connotative and stereotypical meanings they associated with people who have tattoos and not at the tattoo itself. For Laura’s sake, they attempted to decode the 65 65 symbolism of the action as inspiring while trying to avoid applying their stereotypical ideas about tattoos in general. Some of the push-back can be seen through online social media. People decode stories that they discover online; however, connotative meanings can be misunderstood. In order for corporations to protect their image they can create strict policies on certain issues, for example, nudity on the web. As mentioned in chapter 2, Facebook has a strict policy regulating nudity (Gates, 2013). Mary says she does not understand why the policy should apply to a 3D nipple because “it’s not even a nipple. It’s just a tattoo. That’s all it is, is a tattoo. There’s nothing there prior to, so I don’t understand that.” Two of the participants uploaded photos of their mastectomy tattoo onto their own Facebook page, but the company took them down. Sara explained that some people were shocked that she posted a picture of herself without a top on online, but Sara laughed and said, “It’s about so much more than me topless…it’s showing this to other women that this is an option…just trying to be that inspiration for somebody else.” She is trying to get her message decoded as inspirational and educational instead of it being about sex or a topless woman. Sara and Facebook are not decoding the images in the same way. Facebook is decoding the image of the breast as nudity, even though it is covered with a tattoo. They also do not take into account that the nipple is not real but is just an image of a nipple. Sara, on the other hand, is looking at the breast as being covered up by the tattoo, including the 3D nipple tattoo, and, therefore, does not see this as nudity. Not all sites have as strict a nudity policy as Facebook. Some of the woman have taken advantage of these other outlets: five of the women have uploaded their pictures on Tattoo Artist Magazine’s website, where they have yet to be censored. 66 66 Emotional Healing There are moments in people’s lives that change them forever. Some can be subtle while others are much more dramatic. Each of these women went through a traumatic experience that made them the women they are today. There are techniques people utilize to help them get through life’s traumatic events. Atkinson (2003) stated that “tattoo enthusiasts regularly speak of how tattooing can be liberating emotionally, a way of venting emotions publicly through the body” (p. 194). This section provides answers to both research questions. Research question 1 asks the reasons women report for getting a mastectomy tattoo. Research question 2 asks in what ways do those with mastectomy tattoos use their tattoos to claim bodily agency. This section will first discuss emotional healing through restoration and then the transformative power of pain and well-being the tattoos have had on the women. Mastectomy tattoos can provide a form of emotional healing. Tattoo artist Julia Moon describes her work and tattoos in general as “healing that wounded child, that hurt place, the pain that’s left over from the slings and arrows of outrageous past lives” (as cited in Mifflin, 2013, p. 74). Mastectomy tattoos are, in a sense, marking the body as a transition in a woman’s life. There are two main topics that the women in this study talked about when it comes to emotional healing. One is coded as restoration. Restoration includes the physical restoration of covering the scars left after a mastectomy and also includes the feeling of being complete as a woman or as a physical body. The other topic is coded as transformation of well-being.

Restoration There was one topic that all six women discussed, the physical restoration of covering scars. Sara discussed P.ink, stating that the organization has “helped a 67 67 lot of women just with that emotional healing and being able to look in the mirror again and see something pretty versus…some big scar. It’s hard to look in the mirror and see that.” Rush (2005) would call these tattoos “spiritual tattoos,” because “the metaphor of spiritual tattoo is the removal of the old self, physically and emotionally, and allowing the beauty inherent in the aches and pains of life to come through in your sacred writings, your tattoos or scars” (p. 196). For one of the women, this was her second tattoo covering a scar. Angie had received burn marks from the IV that infiltrated her hand, so she had a small tattoo to cover that up before she got the angel wings tattoo to cover her mastectomy scars. She did not want to see her scars, so she chose a tattoo to cover it up. Kim had a similar response saying she “would be covered up all the time, wouldn’t think about putting on a bathing suit top, you know, because you, you have scars.” Mary also explained that her scars were more substantive than she originally anticipated and after going through five surgeries she was no longer comfortable in a bathing suit either. Tracy, who had her mastectomy done as a preventative measure, explains that even though she has scars under her tattoo that it is okay because she didn’t have cancer and this was her choice. She said that I'm okay with these that I have these scars, but I don’t particularly want to walk around you know too. I don’t like walk around everywhere without a top, but I’d be absolutely fine and every time I look at them I can’t tell there’s any scars behind there and I think they make me smile every time I see them. Even though she was okay with her scars under her tattoo, she was able to use the tattoo to restore her self-image so that she smiles now when she sees her tattoo. Laura’s self-image was also restored through the use of the tattoo. She explained 68 68 that the tattoo has been wonderful for her because mentally it helped her cover up her scars. It helped her to look at her breasts in a different light. She stated that instead of looking in the mirror and seeing scars she could see the beautiful design and that it really helped her in a positive way. This was her first tattoo and now she’s even thinking about getting another one because the experience was so positive. Others had mentioned feeling complete as a woman or as a physical body. Some did this by having 3D nipples tattooed on them. Mary explained that she did not think much about nipple reconstruction in the beginning. People would ask her if she was going to get nipples tattooed on her, but she was so focused on getting through the treatments and the surgeries that she did not think much about nipple reconstruction. However, once her treatments were finished she decided to get them. She explains that You can almost feel like you’re whole again…I wouldn’t leave it unfinished. I would try to put it back the way it was and I felt that every tattoo option is different. You know you could just go get your nipples done if you just want to do that…it’s just that womanly connection you know. If you look down one day and they’re gone it’s kind of traumatic. It’s almost as if you don’t feel like a woman anymore. Societal constructs of what a woman’s body is supposed to look like can affect women. Not achieving the standards of beauty set by society can lower a woman’s self-esteem (Balcetis et al., 2013). Although receiving a nipple tattoo can make the breasts appear to be normal by having nipples, the tattoos of the images are not part of the normal body. It is not always about fitting in to societal ideals, but increasing the women’s well-being. Mary is able to feel like a woman again now that she is able to use her nipple tattoo to re-identify as a woman. Mary’s husband 69 69 told her right after the tattoo was complete that “he just gave you back, you know, something that was taken away.” She goes on to explain that when you put them back and you put them back in the sense where they look good, it’s not that you’re out flaunting, but it’s like self-closure. You know, you look at it and you know that when you look…you’re kind of who you are, who you once were. Angie made similar comments. She is single, but did not date because she was not comfortable with herself. She said I felt so uncomfortable because of how my breast looked. I knew I was a woman and I know breasts didn’t make me. I felt so uncomfortable because of how my breasts looked. I felt like I was Dr. Frankenstein’s bride or something. I look like the doctor took one breast off one woman and then he took another breast off a different woman and put and that it looked like they took one breast off of one woman and put …[those] breasts on me. However, the tattoo made her feel confident about herself; she stated “I got my sexy back...I’m happy” and that “the inner beauty now is inside and outside.” Her family and friends have even noticed the difference in her. Restoration is about the body, but it also includes restoring self-esteem and self-closure. Amy Black (2014) gave a speech about art and tattoos; she stated, “art can heal.” It can emotionally restore the person who has undergone a mastectomy. Balcetis et al. (2013) explain that ideal standards of what defines a person affects their self-esteem. A woman may not want to replace her nipples with 3D nipple tattoo, and may opt to replace them with other images, such as stars. However, if a woman wants natural-looking nipples, but they are not done in a way that makes them look natural, it may not have the same healing effects. For example, Kim had nipple tattoos from a plastic surgeon, but was unhappy with the results. She said 70 70 that she looked at the round circles the surgeon gave her and said to herself “Is this all I get?” That is when she decided for the more realistic 3D nipple. She also explains that after the cancer treatments were over and “your hair’s coming back finally, you want to look human again. You want to look like your old self or your new old self.” The act of getting the tattoo was also part of the women’s emotional healing and part of their journey. It can be a more intimate experience than a regular tattoo for some women because although many women have tattoos on intimate parts of their body, not all women are comfortable having a stranger look at and touch their breasts. All of the women were very picky when finding an artist for this particular tattoo and each woman recommended her artist. After going through the trauma that each of these women went through, it could be very difficult for a woman to have to take her shirt off in front of a stranger and have them touch and tattoo a very sensitive and private part of their body. Mary explained that it was not just another tattoo for her. This tattoo meant something more to her. It was not just about tattooing an image onto her skin. This tattoo was about her identity by getting her physical body to more closely resemble what it looked like before her mastectomy. She wanted to encode what she had decoded from societal constructs of what a woman’s body is: having natural-looking nipples. Because this tattoo was more personal to her, she wanted a tattoo artist who had experience tattooing over scars. Three of the women mentioned tattoo shops that they had seen, both here in the United States and overseas, that were dirty or had a lot of drastic flash art of skulls, people getting killed, or other art that was not inviting on the walls. Mary’s husband went with her and the artist’s wife was there, but when he asked Mary to take her shirt off she belted out, “Awkward,” and got everyone 71 71 laughing. She explained that doing that in a doctor’s office was normal, but it was not normal for her in a tattoo studio; however, this studio was an inviting and clean place. Mary, Tracy, Angie, and Laura stated that the tattoo artist and his wife made the experience the great experience that it was because of their professionalism and how much they cared about them. Two of the women explained that the day they got tattooed was emotional for them. Sara explains that “It was very emotional for me and…I think it was a pretty emotional day for everybody there.” She had her tattoo almost one year to the day from her mastectomy. She stated that “the emotions from just everything came back” and that “it was exhausting, it was such an emotional day, but…emotional in a good way.” Mary said something very similar. When her tattoo was completed, she started to cry, she said; she rarely cries. When she stood up and saw the tattoo, she got emotional. She explains that “I was like WOW, because now I don’t feel ashamed.” The experience of getting a tattoo can help people to heal emotionally because it can hide physical imperfections, such as scars, but it can also help them feel restored by increasing their self-esteem. Although emotional healing helps to answer research question 1, it also aids in understanding the transformational change that women go through and how they claim bodily agency.

Transformation and Pain Research question 2 asks how women with mastectomy tattoos use their tattoos to claim bodily agency. In addition to the emotional healing that comes from covering the scars and going through the experience of receiving a tattoo, these women also discussed how tattoos transformed their well-being. The Oxford dictionary defines well-being as “the state of being comfortable, healthy, and 72 72 happy” (“Well-being,” 2016) The quote at the beginning of this chapter relates a tattoo to snake skin, suggesting that by scarring the skin the person is shedding their old skin and is becoming a new person (Rush, 2005). There are two ways that the women described the experience as being transformative: the pain of getting a tattoo and the effect the tattoo had on their well-being. Pain can be transformative. Atkinson (2003) explained that some tattoo enthusiasts use pain as a way to help cope with and purge their traumatic experiences. Rush (2005) explained that the pain from tattooing is not meant as a punishment, but “can be used instead as a tool to gain access to and retranslate unpleasant and/or traumatic events in history, to initiate one’s physical healing” (p. 178). It can be an avenue to help those who are suffering to focus the emotional or physical pain they are feeling and convert it into another type of pain. Tattoos are painful, but the pain from tattoos is something that the person willingly experiences. The pain from cancer treatments and mastectomies is pain that the patients have no control over. They either endure the pain of the treatments or die. Getting tattooed is optional. Rush (2005) stated that “pain alters awareness; it is a focal point that turns us inward, into the psyche” (p. 178). He explains that receiving pain willingly leads the person through transitions to victory, a conquest much more mental/symbolic than is the mere permanent (mental and [emphasis original] physical) scarification or tattoo; ideas and verbal commitments can fade into the past – tattoos and scars are permanent. Either way, emotional and/or physical pain alters awareness, and altered awareness is a primary ingredient in hypnosis and trance states. (p. 186) This trance-like state can help individuals focus their pain and have a beautiful tattoo when the pain is over. 73 73

Tracy stated that the pain helped her heal emotionally and that the pain added to the experience. She explained she feels empowered by it. She made it clear that she hated the word “empowerment,” because it is over-used, but she did not know how else to describe the experience. She looked at the pain as an example of what she can get through and how happy she is with the results. She said, you know these are scars that you, that you earned certainly, but now you got this tattoo that you also earned that you went through some pain for and I think it adds to the feeling…maybe that you’ve taken back a little bit. You’ve taken back some control that maybe you lost. The pain from the tattoo was something that she felt she earned and gave her control over her body. Each of the women described the pain they went through. The pain of a mastectomy tattoo is not necessarily the same as it is for another tattoo. However, not all of the women looked at pain as transformation or control. It was instead used as a comparison to other types of pain. Kim compared the pain of getting the tattoo to the pain she had with cancer. She said that “the pain is minor compared to some of the things that you go through having cancer.” Laura stated that the pain she went through with the tattoo was nothing compared to what the tattoo did for her. Mary, who has multiple tattoos, explained this is because of the scarring and what happens is when you have a mastectomy they remove all your nerves and your tissue so it’s very hypersensitive…. [T]hat immediate area wants to experience the pain, but because there’s no feeling it radiates the pain elsewhere. So when he was tattooing the top of it, like where the nipple portion would be…it radiated to my chest bone and into my left arm and he was tattooing my right side. 74 74

Angie had a similar experience of feeling the pain in other parts of her body. The doctors took muscle from her back to rebuild her breast tissue and she said “I was getting muscle spasms when he was doing my breasts, I was getting, where they took the muscle off of my back back there, I was getting muscle spasms in that spot.” All six women made it clear that the pain was worth it. It was Sara’s first tattoo and she said that she would do it “a hundred times over again.” However, not everyone was enthusiastic about going through the process again. Mary had one breast done, but after the amount of pain she went through, she decided not to do her other side. Angie did not have the colors on her tattoo deepened. She decided she was happy with the way it looked and did not want to experience any more pain. She is very happy with the tattoo and said “I feel wonderful,” but she stated that if she got any more scars “I wouldn’t get more tattoos…I would have to live with that scar.” Although they all stated that the pain was worth the transformation that they felt when it was completed, there are mixed results for how transformational the pain of the tattoo was for them.

Transformation and Well-being Tattoos transform in more ways than just pain. They help women heal emotionally by affecting the person’s well-being. Sara stated that I mean you looked in the mirror before and I mean I still see my scars. It’s not that I didn’t cover, completely cover them up…I looked in the mirror and I looked at my tattoos and to be honest when I get ready in the morning I wait as long as I can to put my shirt on because it’s just they’re so pretty and makes me feel good and like this is kind of sexy. 75 75

She also laughed as she said that she feels more feminine and pretty and that she left the tattoo studio feeling like “a new person again and more.” She says that women can make themselves beautiful. They can change the way they feel about their body and create a new identity with it. They have the power to be able to use tattoos to conform or not conform to societal constructs of feminine beauty. She explains, “it’s so much more than, you know, showing off your breasts. Boy, it’s not about that at all. It’s about what the tattoo is and…the healing.” For Sara, her transformation was about healing from the experience of having cancer and a double mastectomy. Kim was an advocate for self-esteem. She explained that “it’s a self-esteem issue and I’m feeling more confident” and that the tattoo experience was “uplifting” and was a “self-esteem booster.” She had double reconstruction and implants and explained that, “yeah, of course boobs are nice and they would sit up and I wouldn’t have to worry about wearing a bra, but umm, as far as, you know, anybody seeing them, I wasn’t comfortable before the tattooing process.” Kim explained that she now feels like a piece of artwork. Five of the women stated that after the tattoo they are now comfortable enough to show off their tattooed breasts to people. Both Sara and Tracy stated that they flash people to show off their tattoos. Sara said that she flashed everyone she could when she got it and said that it was amazing what some artwork can do because it “it really, truly does make a big difference.” Tracy originally wanted something small that would only cover the scars, but then she would be the only one to see it. She said that now practically everyone she knows has seen them. Mary also has showed people her tattooed breasts. She said she has “no shame in showing it now” and has even posted it on Facebook. Though it was flagged for nudity and was taken down, she commented that, “I must think that 76 76 any woman who’s been through it, they may say it doesn’t matter, its fine the way it is, but deep down inside it matters.” Laura said something very similar. She explained that she was self-conscious about taking her top off in front of other women, but after the tattoo she does not care and likes to show it off. She also mentioned that the tattoo changed the way she feels about herself and her body. It made her happy and proud of her breasts. Angie also likes to show people her tattoo. She says that she wears all kinds of “life’s little dresses now” and that she does not mind showing them off. Her grandchildren like to “paint her” by coloring parts of her tattoo that come up over her clothes. The day of the interview her grandchildren had even added sparkles to it. She stated that the tattoo made her feel totally different because she can physically see the difference. Although tattoos can create bodily agency, Tracy stated that she feels disconnected from her body. She explained that “It’s a weird thing…the idea that they’re so beautiful…that I want everyone to see them…Once you have this reconstruction and you have implants they’re not really like your own breasts anyways.” There is a feeling of disconnect where it is her body, but at the same time it’s not. Tracy goes on to explain that “there’s not this notion that I need to keep them hidden…it was almost like these belong to the plastic surgeon” and that the artwork belongs to the tattoo artist. Instead of gaining agency, she has had an emotional transformation from shame to pride in her new breasts. How a person perceives their own body will help them to determine how they want to portray it to the world. Everyone encodes their messages, but they do not always have control over how they are decoded. Personal and cultural experiences play a major role in how one is perceived. This is especially true of tattoos. The women in this study have chosen to take control of the emotional and 77 77 physical trauma that they have endured. All six participants were restored or transformed through the process of tattooing and although they dealt with pain and some discomfort, they came through it and it helped them heal. Tattoos can transform a woman’s well-being by increasing her self-esteem and helping her to feel restored or transformed.

CHAPTER 5: CONCLUSION

My skin is my canvas. The artwork on it represents something that is very powerful and meaningful in my life. I look at my skin as something of a living diary because all my tattoos represent a time in my life. And I never wish to shut the door on the past, so I carry it all with me.

– Dave Navarro

Tattoo artists refer to those who receive tattoos as canvases. People are the canvas for their artwork that will be displayed everywhere people go. The idea behind this quote by musician Dave Navarro is not uncommon. Many people look at their tattoos as a life diary that they can keep with them all the time. Johnny Depp is another celebrity who talks about his body as his journal and his tattoos as his story (as cited in Goodreads, 2016). The famous tattoo artist Kat Von D stated that “I am a canvas of my experiences, my story is etched in lines and shading, and you can read it on my arms, my legs, my shoulders, and my stomach” (as cited in Goodreads, 2016). The women interviewed for this study are doing something similar. They are turning their bodies into canvases and letting the artist turn their scars into beautiful works of art. This chapter summarizes the results and connects them to the overall theory of encoding and decoding. It discusses the emotional healing that the tattoo can provide and how some women use the tattoos to create agency. Secondly, it discusses the practical applications of the study. Finally, the limitations of this research shed light on where future research could expand scholarly and public knowledge of mastectomy tattoos.

Summary This study adds to encoding and decoding theory by applying it to breast cancer survivors and the culture of tattooing. As Pillai (1992) explained, the 79 79 problem with Hall’s theory is that he “uses the terms ‘preferred meaning’ and ‘preferred reading’ interchangeably, assuming an equivalence between them” (p. 222). This current study shows how the meaning of the text, in this case a tattoo, can be read differently than the encoder intends it to be. Failed decoding experiences relayed in this study were not due to misunderstanding what the tattoo image is but by not knowing the deeper meaning behind the tattoo and the reason for it. Preferred meaning and preferred reading differ based on the culture and personal experiences of the reader. Emotional healing and the transformative power of tattoos depend on how the tattoo affects the well-being of the individual. Answering research question 1 provided answers for the reasons these women chose to get tattooed. The symbolism chosen for a mastectomy tattoo depends on what the woman wants encoded in the image. Symbols can communicate multiple meanings depending on the culture and experience of the person who decodes it. For example, the angel wings on Angie’s chest have a much deeper meaning than just a pair of beautiful wings. The wings represent women who have suffered and died from breast cancer. When people ask her about the tattoo or compliment her on the angel wings, she uses it as an opportunity to share the connotative meaning behind them and open up communication about breast cancer. She is able to use what people decode from an image and adjust her encoding in order to help people to understand and decode the entire meaning behind the image. Culture and society play a major role in the expectations of what a female body should look like. According to Harlow (2008), gendering occurs because of performance rituals that are created through discourse. A female body is encoded as feminine because of society’s constructs of what a female should be. Atkinson (2003) stated that “feminist research underscores how women’s bodies are texts 80 80 upon which cultural codes of femininity are produced and contested” (p. 15). A woman who has scars on her breasts, or is missing her breasts, due to a mastectomy can be decoded, by some, as less than a woman. However, some women use tattoos over a mastectomy to help them fit into the standards of feminine beauty. Tattoo images are decoded by society as well through culture and personal experiences; however, a woman with tattoos can still be looked at by society as deviant or trying to defy society’s standards of what a woman should be (Mifflin, 2013). For example, Kim and Mary both got nipple tattoos in order to replace the ones they lost. Mary stated that she wanted to replace what she felt was missing. They use tattoos to help them gain back some of the feminine beauty they feel that cancer took from them. They are encoding a sense of body normalcy for themselves by having their nipples tattooed. This study helps to analyze some of the stereotypes about tattooing and the multiple reasons and meanings behind tattoos. Tattoos can be encoded in multiple ways. They can have private meanings for the individual that are not meant to be shared with others. However, the results of this study show that although the meaning and tattoo were sometimes originally meant only for recipient, this can change. One of the women changed her mind about keeping her tattoo private and was excited to show off her tattoo to others and even posted a picture of it online. Two women had friends who had not seen their tattoos simply because their friends do not like the culture associated with tattoos, and therefore those friends are not decoding the mastectomy tattoos with as much enthusiasm as others. However, they are still supportive because of the encoded meaning behind the tattoo. The symbolism and the reason behind the tattoo seem to be able to break down barriers for how people decode messages. Encoding seems to be able to take away negative stereotypes and replace them with more positive ones that are 81 81 considered acceptable given the circumstances. Mifflin (2013) described the story of a female Lutheran minister, Nadia Bolz-Weber, by explaining that “her designs were primarily a form of self-definition, but they also serve as a kind of outreach” (p. 138). The reader may not be able to decode the religious images the way that Nadia intended, but the tattoos provide her with a talking point that allows her to use her tattoos to minster to people, just like Angie uses her tattoo to promote dialogue. Research question 2 provided ways in which women with mastectomy tattoos use their tattoos to claim bodily agency. Tattoos can have a transformative power by allowing women to claim agency with their bodies. They can help women to heal emotionally by restoring the physical body and can help women transform their sense of well-being and become a new person. Not all women who get a tattoo choose it for a deep personal meaning. Many consider tattoos a way of decorating the body how they want (McBeth, 2015). But the women in this study each talked about how they felt transformed, happier, sexier, and able to replace what was missing; they achieved higher self-esteem. The mastectomy scars were a major reason for their lack of confidence and poor self-image. All six of the women talked about how the scars were not something they wanted to see every day. The scars reminded the women of what happened and that their breasts did not look like they had before. The pain of the tattoo can also serve as a moment of transformation. Pain can be a focal point that turns the psyche inward and can alter a person’s awareness (Rush, 2005). Every tattoo is painful; some are more painful than others, depending on the area of the body being tattooed. The breast and sternum area are considered some of the more painful places a woman can be tattooed, and the damage caused by mastectomy scarring can make it even more painful. This 82 82 intense pain can aid in the transformational process. As Tracy explains, pain can help women realize that if they can get through this then they can get through anything. For these women, tattooing was a way to take back what they lost by taking control of the scars and the image that people, including themselves, saw. They were able to take control of their bodies by not allowing their scars to define them. Harlow (2008) explained that the body is a complicated landscape that has the possibility to talk back. Tattooing gives women the option to be able to change the text of their body (e.g., scarring from a mastectomy) to any encoded symbol they prefer. The image can be a simple 3D nipple to make the breasts look like what breasts look like naturally or something completely different. Cancer treatments took away control from the women and now they have the power to take that control back.

Implications This study researches an important topic. A large number of women get breast cancer every year and choose a mastectomy. They need to know what kind of options they have after their treatments are finished. Just because a woman has been through chemotherapy, has had a mastectomy, and is now cancer-free does not mean her journey or trauma is over. She is left with scars that are constant reminders of what she has been through. This study has many practical applications. One of the most important reasons to do a study is to have the ability to change lives. The power these tattoos have had for the participants is something that needs to be researched further. The practical applications include: finding financial support, understanding the tattooing options available, and increasing awareness of this option. 83 83

One of the biggest hurdles women with cancer face is the cost. Treatments and reconstruction can cost upwards of $100,000 – and in some cases close to $300,000 (Costhelpter, n.d.). If the person is lucky enough to have insurance, it can still cost $20,000 out-of-pocket (Nance-Nash, 2011). All but one of the women in this study mentioned the cost. P.ink helps to pay for women to have these tattoos done. According to Toni Wallin (personal communication, June 23, 2015), from Garnet Tattoo Studio, nipple tattoos can range from $600-$2,500. After going through and paying for all of the treatments and surgeries these women have had, they are left with scars showcasing their trauma. In order to cover their scars, they face the extra cost of getting the tattoo. Some insurance companies will cover a nipple tattoo, but others will not, claiming it is cosmetic and not necessary. Hopefully, more research on this topic can show the importance of nipple tattooing and help to create more fundraising for breast cancer survivors who would like this option but cannot afford it. Another application is that women do not always know the tattoo options available. This research shows a lack of awareness about the tattoo options that are available to women after their treatments are done. There are plenty of cancer websites devoted to support for breast cancer survivors. Some plastic surgeons recommend tattooing a nipple and even recommend an artist; however, they tend to not be adequate and do not look real. Tattooing is not the same as plastic surgery, and many surgeons may not know what it takes to create a quality nipple tattoo. Toni Wallin (personal communication, June 23, 2015) explains that it takes six or eight different pigments and requires skill to layer the colors and add highlights and lowlights to make the nipple look realistic. Plastic surgeons focus on the skin and make the breasts symmetric, but they do not create art on the skin. The participants for this study were not satisfied with the nipple tattoo options 84 84 offered to them by their plastic surgeons. The women had to seek out a tattoo artist who specialize in mastectomy tattoos on their own. The more research done and the more people who start talking about mastectomy tattoos, the more women will be educated about the tattoo options they have. Another application is to show the importance of awareness. Although people are aware of tattoos, the idea of a mastectomy tattoo is rarely discussed. Having this option mentioned on public news channels and social media can educate women about their options and can give the women a sense of support. The news media are starting to cover this topic more frequently, but it is not enough. Many women only find out by doing their own research about options to cover up scars and find out about tattooing on their own. Hopefully, with more research being done, this topic can expand into other disciplines and provide enough awareness for people to take notice and learn about it. Getting more scholars to research this topic will help spread awareness and educate those who have mastectomies that this option exists. It may not have been an option a woman originally thought would help her, but through more research she might find it is exactly what she wants to help her emotionally heal from her trauma. If something like a tattoo can create such a transformation in a person, then it should be something that people know about.

Limitations and Future Research No study is without limitations, and recognition of limitations opens the door for future research. Understanding what the study set out to do and understanding the boundaries can help us to make better sense of the results. This study contributes to the field of communication by providing a baseline of data 85 85 about the topic of mastectomy tattoos that did not exist before, but there are some limitations. One limitation is that the sample size is small. Due to time constraints and difficulty gaining access to women who fit the criteria for this study, the sample size of six women was only enough to obtain preliminary data to answer the research questions. How many participants would be needed for theoretical saturation is unknown. Theoretical saturation is when the researcher has no more new data that add value to the existing data (Tracy, 2013). Although it may seem that there was saturation with this study because of the similarity of responses across participants, a study that includes a larger sample size could add more data and themes that were not present or discovered in this study. Another limitation is the lack of diversity in the sample. It is unclear if the lack of diversity affected the results since the data were consistent for all participants. However, with a small sample size it is not possible to generalize the data and apply it to all women with mastectomy tattoos. Culture can have a major impact on how a person views tattoos and the meanings behind them. The cultural symbolism behind tattoo images could possibly influence the results. A future study that focuses on women with mastectomies by looking at the cultural impacts of their tattoo choice could help to further understanding of the transformational process and how people encode and decode messages. Culture can affect data in more ways than just encoding and decoding. It can also affect how likely the participants are to get tattooed or their ideal of the feminine body. Another limitation is that all of the participants’ tattoos are fairly recent. Each of the participants obtained their tattoo within a year of when they were interviewed. This is a limitation because the effects of the tattoo could change over time. It would be beneficial to interview these same women in the future to find 86 86 out if the transformational effects are long-lasting or if the effects they are feeling now wear off. It would also be beneficial to interview other women who have had mastectomy tattoos done in the past to see what they thought it would mean when they first got it compared to how they feel now. When someone receives a new tattoo, they tend to get excited about it and want to show it off. There are websites that have articles devoted to people who dress to show off their tattoos as though it were a fashion accessory, such as rebelsmarket.com, glamour.com, and bustle.com. One website, Offbeat Bride, is devoted to helping women find wedding dresses to show off their tattoos (Devon, 2015). There are also boards on Pinterest devoted to clothes designed for those with tattoos. Angie likes to buy dresses now to show off as much of her tattoo that her clothes will allow. The tattoo can transform how the person views their body and that in turn can change how they dress. Whether or not these women will still love their tattoos and will still be showing them off next year, five years, or ten years from now would be beneficial to research. Does the tattoo still have the same meaning in the future as it does for them currently, or is its import simply from the newness of the experience and tattoo? For example, Rasner, a tattooed woman, had a wedding band tattooed on her finger, but the tattoo took on a different meaning for her after her husband died (Mifflin, 1997). She stated that “she had no idea that the symbolism of her tattoos would change during her life, then change the quality of her life itself” (Mifflin, 1997, p. 8). Meanings can change and how an individual feels about images and life events can change. However, not everyone agrees that tattoos have transformative power. Mifflin (1997) explained that critics assert that these women are not actually finding solace and transformation, but instead “are no different from women for 87 87 whom shopping and exercise are substitutes for problem-solving” (p. 116). They are, in a sense, allegedly dealing with trauma by focusing their attention on something else. However, women in this study and the stories other women have written about in blogs or in books tell a tale of emotional healing and happiness when they look in the mirror and no longer see their scars. These women provide data to contradict the critics. The women in this study prove that tattoos can provide emotional healing and transformation. Future research could take the concept of this study and apply it to explore other types of transformational tattoos. Tattooing over scars is not just for women who have had mastectomies. There are many tattoos that cover up scars from amputations and other very serious injuries. It would be interesting to compare the symbolism between those with mastectomies and those with other types of scars. For example, do those who have a tattoo over an amputation have the same transformational experience? Some amputation tattoos tend to be more comical in nature, such as a limb made to look like a shark or the words “do not cut above line” with a pair of scissors next to it (Angula, 2014). Based on the research for this study, there were not many women choosing mastectomy tattoos who took the comedic route. Also, there may be a difference between different groups and the style and meanings of tattoos they choose to cover up scarring. The transformational aspect of tattoos for breast cancer survivors might be applicable to anyone who has suffered a traumatic experience. Tattoos could be used to cover up scars of any kind, as long as it is physically possible for the artist. This research can be applied to all kinds of people who use tattoos as a way to transform themselves and take control over their bodies. This study is important for research on tattooing done for transformational purposes. There are numerous possibilities when it comes to studying mastectomy tattoos. This option for breast 88 88 cancer survivors is starting to come out of the underground tattoo community and it is finally being seen as an option for everyone who has gone through the trauma of a mastectomy. P.ink is one organization that is helping bring this option to the public, but there is much more that can be done. Tattoos have the power to give women back their self-esteem and confidence. They can cover up scars and provide women with the sense of body normalcy. For some of the women in this study, the tattoo gave them a level of confidence that allowed them to pose topless and have their picture posted on the internet. A practice that has the potential to provide women with the amount of confidence that tattooing has deserves more research devoted to it.

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Witkin, J. P. (1999). Humor and fear [Photograph]. Retrieved from http://edelmangallery.com/artists/artists/o-z/joel-peter-witkin.html#?id=3077

APPENDICES

APPENDIX A: CONSENT FORM 99 99 Consent Form – Body Image Perceptions for Mastectomy and Amputee Tattoos

I am a student at California State University, Fresno, and my graduate advisor is Dr.

Kevin Ayotte. I am conducting interviews for my Graduate Thesis. I am studying the effects of body image and identity by the use of tattoos.

During this study, you will be asked to answer some questions as to why you decided to get your tattoo(s). This interview was designed to be approximately 30 minutes to one hour in length. However, please feel free to expand on the topic or talk about related ideas. Also, if there are any questions you would rather not answer or that you do not feel comfortable answering, please say so and we will stop the interview or move on to the next question, whichever you prefer.

All the information will be kept confidential. Each participant will be given a pseudonym that will be used in the thesis to protect the identity of the participant. All interview notes and audio tapes will be kept on file for two years. Only my graduate committee and I will have access to this information. Upon completion of this project, all audio tapes and notes will be stored in a secure desk located in my home office for two years.

Participant's Agreement:

I am aware that my participation in this interview is voluntary. I understand the intent and purpose of this research. If, for any reason, at any time, I wish to stop the interview,

I may do so without having to give an explanation.

The researcher has reviewed the individual and social benefits and risks of this project 100 100 with me. I am aware the data will be used in a Graduate Thesis that will be publicly available at the Henry Madden Library on the California State University, Fresno

Campus. I have the right to review, comment on, and/or withdraw information prior to the Graduate Thesis's submission. The data gathered in this study are confidential with respect to my personal identity unless I specify otherwise. I understand if I say anything that I believe may incriminate myself, the interviewer will immediately rewind the tape and record over the potentially incriminating information. The interviewer will then ask me if I would like to continue the interview.

If I have any questions about this study, I am free to contact the student researcher

(Amanda Trumbower,[email protected], 260-403-6331) or the graduate adviser

(Prof. Kevin Ayotte, [email protected], 559-278-4086).

I have been offered a copy of this consent form that I may keep for my own reference. I have read the above form and, with the understanding that I can withdraw at any time and for whatever reason, I consent to participate in today's interview.

______

Participant's signature Date

______

Interviewer's signature

APPENDIX B: QUESTIONNAIRE 102 102

Questionnaire

1) How did you hear about the idea for this type of tattoo?

2) Why did you decide to get this tattoo?

3) What was your opinion of tattoos before you received this one?

a. Did you already have tattoos?

i. If yes, why did you get those?

ii. If no, would you consider getting another one?

4) Why did you choose the tattoo design that you did?

5) What have been the responses from your family and friends?

6) Does your tattoo make you feel differently about your body?

a. If yes, in what ways?

b. If no, why not?

7) Has it changed the way you talk about your mastectomy to others?

8) Would you recommend this type of tattoo to someone who is considering

getting one?

a. Why or why not?

9) Is there anything else you would like to add that you feel is important that

was not discussed? Fresno State

Non-Exclusive Distribution License (to archive your thesis/dissertation electronically via the library’s eCollections database)

By submitting this license, you (the author or copyright holder) grant to Fresno State Digital Scholar the non-exclusive right to reproduce, translate (as defined in the next paragraph), and/or distribute your submission (including the abstract) worldwide in print and electronic format and in any medium, including but not limited to audio or video.

You agree that Fresno State may, without changing the content, translate the submission to any medium or format for the purpose of preservation.

You also agree that the submission is your original work, and that you have the right to grant the rights contained in this license. You also represent that your submission does not, to the best of your knowledge, infringe upon anyone’s copyright.

If the submission reproduces material for which you do not hold copyright and that would not be considered fair use outside the copyright law, you represent that you have obtained the unrestricted permission of the copyright owner to grant Fresno State the rights required by this license, and that such third-party material is clearly identified and acknowledged within the text or content of the submission.

If the submission is based upon work that has been sponsored or supported by an agency or organization other than Fresno State, you represent that you have fulfilled any right of review or other obligations required by such contract or agreement.

Fresno State will clearly identify your name as the author or owner of the submission and will not make any alteration, other than as allowed by this license, to your submission. By typing your name and date in the fields below, you indicate your agreement to the terms of this distribution license.

Embargo options (fill box with an X).

Make my thesis or dissertation available to eCollections immediately upon X submission.

Embargo my thesis or dissertation for a period of 2 years from date of graduation.

Embargo my thesis or dissertation for a period of 5 years from date of graduation.

Amanda Stutsman

Type full name as it appears on submission

April 26, 2016

Date