Psychosocial Impacts of Radiation Tattooing For Breast Cancer Patients A Critical Review BARBARA CLOW AND JANET ALLEN Cette revue de la littérature rapporte ce que les patientes du tattooing typically involves anywhere from four to twelve cancer du sein ont écrit sur leur connaissance et leur attitude dots—depending on the institution—at points ranging face au tatouage permanent qui définit la surface du corps from the collarbone to the fold under the breast and from à irradier. La communauté médicale accepte généralement the breastbone to underneath the underarm (Karmarnicky, l’usage des marques permanentes, avançant l’hypothèse que les Rosenberg, and Betancourt). While health care provid- tatouages favorisent un traitement radiologique plus précis et ers stress the need for tattoos to ensure accuracy and as a procurent un dossier permanent de l’exposition aux radiations. permanent record of radiation exposure, a growing body Mais il existe de plus en plus de témoignages des femmes qui of research and anecdotal evidence points to an interest s’offusquent des marques permanentes sur leur corps, depuis le in alternatives to and removal of permanent medical tat- rejet catégorique jusqu’à l’indifférence ou encore l’acceptation toos used in radiotherapy (Foreman; Probst et al.). This d’emblée des tatouages en dépit des séquelles éventuelles pour interest seems particularly high among breast cancer pa- leur bien-être psychologique. tients, which supports the conclusion that some women experience distress in response to this treatment practice The emotional and psychological trauma and distress (Alam and Arndt; Billingsley; David, Castle and Mossi; of breast cancer diagnosis, treatment, and recovery are Foreman). well-documented. The existing literature attributes this This discussion is based on an analysis of traditional distress to fears about death, recurrence and overall health peer-reviewed literature and grey literature, defined (Ashing-Giwa et al.), the impact of treatment and recov- as information produced by government, academics, ery on relationships, children or work (Ashing-Giwa et business, industry and the public in both electronic al.; Buick et al.), and concerns about physical changes and print formats but which is not controlled by com- to the breasts resulting from mastectomy, lumpectomy, mercial publishing (Schoepel and Darace). Web-based and other treatments (Deshields et al.). Other studies information, particularly patient/survivor fora and explore possible associations between breast cancer diag- blogs, represents an important source of evidence for nosis and treatment and mental health issues, including this analysis. Our review of literature reveals that women post-traumatic stress symptoms (PTSS) (Andersen et al.; have diverse responses to medical tatooing for radiation Andrykowski and Cordova) and depression (Mosher and treatment, positive and negative, which may affect their Danoff-Burg; Roussi et al.). What is unclear from this experiences of cancer and care. Yet limited attention is research, however, is how the use of permanent tattoos afforded this aspect of cancer treatment, particularly in in radiotherapy for breast cancer affects women’s psy- the peer-reviewed literature. chosocial understandings and experiences of the disease. At the same time, a small body of research suggests that Even research that focuses on patients’ experiences of women’s experiences of medical tattooing may be affected radiotherapy does not directly address the psychological by social location—race, culture, socio-economic status, impact of permanent radiation tattooing (Buick et al.; geography, etc. Discussion of the social determinants Deshields et al.; Siekkinen et al.). of health is also generally absent in the peer-reviewed The current standard of practice for defining the area literature. This dearth of systematic research on cancer to be irradiated for breast cancer treatment is by marking tattooing is disturbing in light of the varied perceptions the skin with small, permanent blue ink dots or “tattoos” and experiences of women living with a diagnosis of (Griffiths et al.; Winer et al.). For breast cancer patients, breast cancer. 46 CANADIAN WOMAN STUDIES/LES CAHIERS DE LA FEMME Theoretical Framework type could sell the war, then it might also promote other products and services” (Jones 17). With this commodi- Women’s voices are all but absent in the literature that ad- fication process firmly entrenched in mainstream media dresses radiation tattooing used in breast cancer treatment. and entertainment, women come to see their breasts as Because a feminist framework positions lived experience as objects for others rather than an aspect of their embodied a valid source of knowledge (Reinharz and Davidman), it is selves (Jones; Millsted and Frith; Young). Currently, there an important lens through which to view the psychosocial is only one “perfect” breast shape—one that is “round, aspects of radiation treatment for breast cancer. Patients’ positioned high on the chest, large and firm” (Jones 18). concerns are evident, not so much in formal research, but While these cultural influences exert pressure on women through anecdotal evidence. For example, online personal to conform to this ideal, it does not mean that women weblog or “blog” entries and discussion groups that address are merely passive vessels for culturally prescribed norms Permanent radiation tattoos pose a significant psychosocial challenge for some women living with breast cancer. Many of those reporting distress see the tattoos as compounding the trials of dealing with significant physical changes to their breasts and bodies arising from diagnosis and treatment. the issue provide a snapshot of attitudes about permanent regarding the “perfect” breast: “women actively negotiate radiation tattoos. Inclusion of these informal sources of their position in relation to a complex web of discourses, information is not intended to replace evidence obtained gazes, audiences, identities and visibilities” (Millsted and through systematic, peer-reviewed research, but simply to Frith 463). provide a preliminary starting point for discussions about how radiation tattooing is currently being defined—or not Psychosocial Impact defined—as a challenge for breast cancer patients. Clearly, further research is needed to explore the themes raised in The role of permanent radiation tattooing in breast cancer this review of the literature from a feminist perspective treatment is neglected in the literature, in part because that accounts for women’s experiential knowing. the marks are sometimes seen—by both patients and It is understandable that both aesthetics and emotional practitioners—as a relatively minor issue in the context significance factor into women’s medical decision-making of managing a disease that is potentially life threatening about their breasts considering the complex, and often (Alam and Arndt; Harris). In support of this view, some contradictory, meanings of women’s breasts in modern women living with permanent radiation marks have re- Western culture. Rachel Millsted and Hannah Frith state ported ready acceptance of the tattoos while others view that “women’s breasts are invested with social, cultural them as a minor nuisance or inconvenience (Foreman). and political meanings which shape the ways in which However, there is also evidence to suggest that permanent we make sense of and experience our embodied selves” radiation tattoos pose a significant psychosocial challenge (455). They are simultaneously sites of maternal nurtur- for some women living with breast cancer. For instance, ing, femininity, and sexual desirability (Jones; Millsted many of those reporting distress see the tattoos as com- and Frith; Young). Early representations of the female pounding the trials of dealing with significant physical breast in art and mythology valued voluptuous, prominent changes to their breasts and bodies arising from diagnosis breasts as symbols of abundance, fertility, and nurturance and treatment (Langellier). Clearly, women experience a (Jones). Standards of beauty shifted in the middle-ages wide range of reactions to radiation tattooing for breast in Europe to a preference for small, round, firm, and cancer and the depth of their reactions as well as the widely-spaced breasts and their role in male sexual pleasure reasons for them vary. and desire overshadowed any maternal meaning (Jones). Breast cancer patients may also object to tattoos for With colonization came nude images of African women cultural and/or religious reasons. One example of this in photographs and art in nineteenth century Europe and potential conflict involves women who observe Orthodox these images clearly depicted African women’s bodies and Judaism because tattooing is explicitly forbidden by the breasts as sagging and used-up—in stark visual contrast to Torah. A website dedicated to Jewish women’s health the perky, eroticized, white aesthetic ideal (Jones). advises readers that temporary markings should be used if The commercial potential of women’s breasts was first at all possible and if not, that the tattooing should be per- realized during World War II when “filmmakers and formed by a non-Jew (Jewish Women’s Health). Similarly, advertisers realized that if the prominent-breasted female Langellier documents a case in which a devout Catholic VOLUME 28, NUMBERS 2,3 47 breast cancer patient—who understood tattooing to be experiences and consequent shifts in personal identity inconsistent