“Art is just something that makes people heal” - A Qualitative Investigation of Tattoo Artists’ Perspectives on Cancer Survivorship Therapeutic Tattoos

“Art is just something that makes people heal” - A Qualitative Investigation of Tattoo Artists’ Perspectives on Cancer Survivorship Therapeutic Tattoos | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “Art is just something that makes people heal” - A Qualitative Investigation of Tattoo Artists’ Perspectives on Cancer Survivorship Therapeutic Tattoos Adam Daly, Johannes Karl, Simon Dunne This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4570179/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Sep, 2024 Read the published version in Journal of Cancer Survivorship → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Many cancer treatments can lead to a disrupted body image and identity. One intervention to address these outcomes is therapeutic tattooing. However, despite the wide dissemination of this practice for cancer survivors (CSs), current research on it is lacking. This study aimed to identify tattoo artists’ (TAs’) perspectives on the types, impacts, barriers and facilitators of therapeutic tattooing for CSs and the impact of doing this work on themselves. Methods Twenty-two international TAs who tattoo CSs were interviewed and resultant transcripts were analysed thematically. Results The following themes emerged: Emotional Management of Artists, Emotional Transformation of CSs, Stigma and its effects on CSs, Artist Barriers, CS Barriers, Artist Facilitators, and CS Facilitators. The findings also identify a typology of cancer survivorship therapeutic tattoos. Conclusion This is the first study to identify barriers/facilitators of therapeutic tattooing, a typology of cancer survivorship therapeutic tattoos, TAs’ perspectives on therapeutic tattooing, and potential negative outcomes from this practice. The findings indicate that therapeutic tattooing can be both beneficial and harmful for CSs and TAs, that there is a need for better therapeutic tattooing training for TAs and healthcare providers (HPs), increased awareness of therapeutic tattoos, a reduction in barriers to the practice and greater collaboration between HPs and TAs. Implications for Cancer Survivors: Findings from this study have major policy implications for healthcare systems, non-profit organizations, and regulatory bodies, which could serve to empower cancer survivors to make more informed decisions about their bodies and support enhanced training and accreditation of this practice. Therapeutic Tattooing Tattoo Body Modification Cancer Survivorship Psycho-oncology Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Due to medical advances in cancer detection and treatment techniques, the number of cancer survivors (CSs) is increasing annually, particularly in high-income countries [ 1 ]. However, many cancer treatments are still aggressive, including radiotherapy or surgical procedures that may involve the removal or damaging of body part(s) that hold the cancerous cells and neighbouring cell [ 2 , 3 ]. Such treatments often have negative effects on the bodies of CSs; for example, skin discoloration and surgical tattoo marks from radiation therapy [ 4 , 5 ], port-scarring from chemotherapy [ 6 ], amputation of body parts such as the breast(s) in mastectomies [ 7 ], etc. The consequences of cancer treatments can also cause a disrupted body image and identity in CSs [ 8 , 9 ]. Due to this, body modifications have been implemented to support CSs. Body modifications are defined as an intervention that voluntarily changes an individual's body permanently or non-permanently [ 10 ] for primarily aesthetic purposes [ 11 ], including minimally invasive modifications such as using wigs [ 12 ] and makeup [ 13 ] to more invasive surgical cosmetic procedures [ 14 ]. Exploring the efficacy of such interventions is important, as research would suggest that body modifications themselves can improve the body image and identity of CSs [ 15 ], and that having more information regarding their body modification options can improve CSs’ satisfaction with their chosen body modification [ 16 ]. One such body modification is therapeutic tattooing, the pseudo-permanent pigmentation of the skin [ 17 ] performed to improve aesthetic and psycho-social outcomes, e.g. nipple reconstructions [ 18 ] or scar coverups [ 19 ]. Therapeutic tattooing is already being offered to different CSs across multiple countries with several international organizations being created to facilitate its use as an aesthetic intervention; P.ink [ 20 ], Tittoo [ 21 ] and The Alliance of Medical Tattooing [ 22 ]. While health professionals (HPs), such as physicians and nurses, perform therapeutic tattooing in many countries, the practice is also commonly performed by tattoo artists (TAs) [23.24]. A small body of research on this practice has identified that tattooing is related to positive outcomes in CSs. A recent scoping review found that CSs who have received nipple-areola tattoos experience improved self-perception and identity, etc [ 25 ], but 9/11 studies included were considered to have weak quality. Furthermore, a systematic review on the use of tattooing to support the aesthetic outcomes of individuals with a variety of medical conditions found that CSs found high satisfaction rates following nipple-areola tattoos [ 23 ]. Although Maselli and colleagues [ 25 ] identify some of the psychosocial effects of therapeutic tattoos, both reviews reflect the broader issues of current research in CS therapeutic tattooing, which focus almost entirely on white, Western, female breast CSs who have received nipple-areola tattoos, with a view to determining “outcome satisfaction”. To our knowledge, there also appears to be a complete absence of published literature on negative experiences of therapeutic tattoos among CSs. This demonstrates a clear gap within the literature for research that comprehensively examines the psychosocial impact of therapeutic tattoos among CSs, including males and those with cancer types other than breast cancer. Similarly, there is an absence of literature on the perspectives of, and effects on, the artists who do this work, as well as the potential barriers/facilitators for CSs and artists to engage with this practice. Artists’ perspectives on these issues are important, considering their unique position in engaging with multiple CSs who are seeking a therapeutic tattoo. Understanding their views and experiences can provide a more holistic perspective on the variety of these tattoos, the potential effects of this practice, as well as the barriers and facilitators to engagement with it. To address these gaps in the literature, and to contribute to the emerging literature in this area, this study aimed a) to identify the types of therapeutic tattoos CSs receive, b) to identify the impacts of therapeutic tattooing on both artists and CSs, and c) to identify the barriers/facilitators of this practice on both artists and CSs, from the perspective of artists. Materials & Methods Design This study used a cross-sectional qualitative research design. Semi-structured interviews were employed to ensure the flexibility needed for the inductive approach of this research [ 26 ], due to the dearth of literature on this topic, allowing the researcher to react to and investigate new information as it was brought up by the participants. In-depth one-on-one interviewing was employed due to the potential for the interview to focus on confidential subjects relating to CSs who had been tattooed and who could have been identifiable. Participants and Recruitment This study consisted of a sample of 22 international TAs. To be eligible for inclusion, participants had to be over the age of 18, a fluent English speaker and worked for at least one year as a TA, tattooing at least one CS. These criteria were chosen to ensure that participants had experience, both working as a TA and with the population of interest, to guarantee an expert opinion on the topic. Before official recruitment, 73 artists from P.ink.org were contacted to confirm their interest in participation in this project. Following ethical approval, those who expressed interest were followed up with, and additional participants were recruited using two other publicly available databases of artists who tattoo CSs: Tittoo.org and The Alliance of Medical Tattooing. The researcher also contacted local tattoo shops in Dublin, and used snowball sampling on this group, due to the small population of TAs with experience working with CSs in Ireland. These targeted recruitment approaches were carried out by contacting the artists through the medium they conducted their work i.e., Email, Instagram, WhatsApp, SMS Text, Facebook, and in-person. Data Collection Upon initial contact, artists were given a PLS statement to read and afterward, a consent form to sign. Following this artists were able to book an interview specifying whether their preference between Zoom, FaceTime, and Face-to-face for it to be held. All artists (n = 22) chose to do the interviews via Zoom (M = 64 minutes, SD = 12 minutes). A semi-structured interview guide was developed based on findings from previous research which has identified the process of tattooing and practical design choices [ 27 ] as well as the impacts and symbolism of the tattoos [ 28 ] as important. Furthermore, broader literature was utilized to develop questions pertaining to identity, social dynamics, and culture [ 29 – 31 ]. Additionally, the first author leveraged their own experiences of the impact, barriers, and facilitators of getting tattooed as a non-CS to contribute additional questions. The questions within the interview schedule centred on five main domains: sociodemographic information of the artists, the psycho-social effects on artists and CSs, the process of therapeutic tattooing, the experience of living with tattoos of the artists and CSs, and the role of non-profits as well as the healthcare system in the practice. Through these domains, participants were asked to share their own experiences and their perspectives on the experiences of the cancer survivors they worked with. Due to some missing sociodemographic information some participants were followed up with to gather this data. Further, due to apparent importance of images in demonstrating the effects of these tattoos; positive and negative, an additional consent form was sent to tattoo artists to request the use of their images. The resultant set of images include those which appear in the figures and tables of the current manuscript. Where images contained faces or identifying watermarks, they were blurred or cropped and no images are attributed to individual artists, as measures to protect their anonymity and the anonymity CSs they had tattooed. Data analysis The data was transcribed by the first author in preparation for thematic analysis, with any identifiable or irrelevant information being omitted from each transcript. The transcripts were uploaded to NVivo for analysis using Braun & Clake’s’ reflexive thematic analysis [ 32 ]. Further during the familiarisation phase, all identifiable information was removed from the transcripts such as names, specific locations, etc. Finally, due to the inherent subjectivity of reflexive thematic analysis, and their own experiences with tattoos, the first author monitored their bias through regular reflection on coding and consultation with the corresponding author. Results Twenty-two interviews were conducted. Of the 20 artists that reported the number of CSs they had tattooed, their collective experience of performing CS therapeutic tattoos comprised a total of 8,712 male and female CSs (calculated using the lowest estimates from these artists). Twenty artists also reported their time spent tattooing CSs (M = 9.5 years, SD = 4.71) Further details on participant characteristics are provided in Table 1 . All interviews were included in the final analysis. Table 1 Participant Sociodemographic Information Pseudonym Gender Age Estimated No. of Years Tattooing CSs Estimated No. of CSs Tattooed Types of Cancer Worked With Countries CSs Tattooed In Current Country of Residence Emma Female NR NR 5 Breast USA, Russia USA Sarah Female 36 10 100 Breast, Lung, Bowel, Bone, Skin Ireland, Spain Ireland Catherine Female 36 10 200 Breast UK, USA USA Alice* Female 31 5.5 300 Breast Ireland, Canada Ireland Riley Non-Binary 31 9 50 Breast USA USA Adel* Female 30 8 15 Breast, Cervical USA, France, Germany USA Aurora* Female 41 5 500+ Breast, Bone, Lung, Skin USA USA Mr. G* Male 47 4 25 Breast USA USA The Priestess* Female 54 14 1680 Breast, Ovarian, Skin USA, Netherlands, Germany, Montenegro, UK USA Mac* Female 40 13 2,000 Breast, Brain, Skin, Thyroid, Testicular USA USA Harriot Female 40 15 100–200 Breast, Skin, Pancreatic, Colon, Ovarian USA, Canada Canada Sandy Female 25 3 5 Breast, Lymphoma USA USA Bailey Female 42 8 NR Breast, Thyroid UK UK Jane* Female 42 6 1,000+ Breast, Oral, Prostrate, Uterine USA USA Laura B* Female 33 5 12 Breast, Throat, Lung, Skin Canada Canada Rob Male 44 23 NR Breast, Cervical, Lung USA USA Reggie* Male 55 8 600 Breast USA USA Charlotte Female 39 NR 50–100 Breast, Stomach France France Andre* Male 33 7 20 Breast, Colon, Lung, Skin USA USA Tonya Female NR 10 1,600+ Breast Canada Canada Rose* Female 41 16 50 Breast, Colon, Ovarian, Stomach, Pancreas USA USA Tav* Female 48 11 400 Breast Canada Canada 1 “*” indicates a self-selected pseudonym. 2 NR indicates information that was not reported. Throughout the interviews, artists described different types of therapeutic tattooing. For the purposes of this manuscript, we have classified these types of therapeutic tattoos as medical reconstructive, medical decorative, non-medical reconstructive, and non-medical decorative (See Table 2 for further details and definitions). Following reflexive thematic analysis, seven themes were identified: Psychological Impact on Artists, Psychological Impact on CSs, Stigma and its effects on CSs, Artist Barriers, CS Barriers, Artist Facilitators, and CSs Facilitators . These themes comprised several subthemes (See Supplementary file for review). In what follows, where quotations have been contracted, ellipses are inserted in square brackets, and where context was needed for the quotations, further contextual information has been placed in square brackets. “You focus on the happy things and the positives”: Psychological Impact on Artists Several artists spoke of how doing this work was meaningful for them, supporting them in finding purpose . Aurora, a CS herself, exemplified this, recounting that becoming a TA who tattoos CSs allowed her to fulfil a promise she made to herself: “During my cancer treatments, I asked the universe to keep me alive and [promised] “I'll donate my life to help others in some way shape or form” and I've kept that promise.” Similarly, almost all artists agreed that this work helped them in feeling fulfilled . Jane described her view that, as much as CSs benefit from this work, she does too through the positive feelings it gives her: “It makes me feel good too, honestly, from a selfish perspective, I feel really fulfilled.” The Priestess developed this point further by talking about how she believes that doing this work has allowed her to become a better person: “If I didn't do this, I’d be so gnarly. I'd be so fucking hardcore and regressive. No, this is good for me because it reminds me of my heart and my compassion.” However, as much as this work has positives, it was clear across interviews that the emotional weight of doing this work and being impacted by stories from CSs burdened artists. Bailey described this by recounting an experience she had where she tattooed a terminally ill CS with pictures his children drew so that he could take a part of his kids with him in death: I'm used to [Clients being] like “I want this tattoo because it looks cool”, not like “I want this tattoo because daddy’s taking it to heaven”. I’m like, “I fucking can’t cope [with that]”, so some of the stuff is like pretty impactful. Similarly, numerous artists expressed being concerned about the results and the stress they feel about providing a good tattoo for CSs, as well as the shame they feel when they cannot. For example, Riley described the anxiety she feels about the possibility of giving CSs a negative experience: “The cons are kind of what comes with all this work, which is like “what if like- did I give them a thing that they wanted or was it something that was a negative experience?” . Tonya, an ex-nurse, explained her own experience with this, learning how to do medical tattooing as a nurse and her shame now from the damage she was doing to CSs due to her lack of training: I literally watched a nurse do one tattoo and then I was turned loose. With this permanent machine, I can't even lie, Permanent makeup machine and needles and a patient, and I was not prepared [at] all, it was like, “do one, see one”, to “teach one” […] It's terrible. Shameful. I'm appalled. It was me and I'm appalled. (Insert Fig. 1 here) Many artists also described the coping mechanisms they employed to deal with this emotional burden. Jane, for example, was able to rely on her support network, like her husband or therapist, to cope with the emotional backlash of this work: I have a husband who’s also a tattoo artist; he doesn't do the medical tattoos, but he really relates to a lot of stuff I go through during the day with those frustrations and then he's so willing to listen to me emotion-wise; [I’m] so lucky that way, therapy is great too. In contrast, Andre indicated that he relied on potentially unhealthy coping mechanisms such as substance abuse: There was a lot of just pushing stuff down, a lot of substance abuse. Just long nights, Needless tears. I think it's really easy for somebody going through all of that to go overboard on empathy. And start to take on some of the burden of these people's struggles. “It's a huge transformation right there”: Psychological Impact on CSs Artists consistently spoke about memories they had where CSs had experienced regaining body confidence following a tattoo. Mr. G described his experience with CSs on whom he had performed medical reconstructive nipple-areola tattoos, with him being shocked that something as small as a reconstructed nipple improved these individuals' body image so much: It's crazy that something as small as two little 50 Cent pieces as a tattoo could just absolutely change someone's mental focus where they're not staring at themselves in the mirror saying, “How can someone love me, how can someone look at me?” Similarly, Sarah described a specific CS to whom she gave a medical decorative tattoo, who went from lacking body confidence to walking around topless after the tattoo: “I had someone who had a double mastectomy, [who] decided to just get one really long Rose floral [tattoo]. […] She couldn't take her top off at the gym beforehand, but now she's walking around topless.” Aside from feeling more confident in their bodies, many artists perceived that these tattoos allowed CSs to develop the perception of feeling at home in their new bodies . Jane spoke about a particular CS who appeared to have this experience, with her feeling naked for the first time in years after receiving a medical reconstructive tattoo: “We did the stencils […] Then she's like “I feel naked”, she says “I haven't felt naked in over 10 years” and I, right there, I mean she started crying.” Similarly, Rose perceived that getting these tattoos allowed CSs to reclaim their bodies and feel at home in them again: Choosing to get tattooed, choosing to change one's body in that way, they become like more embodied, more whole, they can reclaim all the things that they feel like they lost, or reclaim body parts that look different. (Insert Fig. 2 here) Similarly, many artists spoke of how getting these tattoos allowed CSs to begin reinventing or reclaiming their identities following treatment. Bailey explained that some CSs she had worked with had changed their identities by choosing the symbols that will mark their bodies. They get to reinvent themselves, of what they want to live with, so it becomes something that's almost like they get to choose either who they want to become, they get to choose how they represent their journey, and they get to choose how they're going to see themselves from then on. (Insert Fig. 3 here) However, despite all artists speaking of the positive effects that therapeutic tattoos had on the CSs they had worked with, it was also clear that these tattoos could be equally harmful when performed incorrectly, causing CSs to go through experiencing trauma all over again. For example, Bailey described a particular case where she was unable to tattoo a CS whose skin was saturated with ink due to having received so many poor-quality tattoos from HPs, resulting in this CS being unable to look at her own body: She got to a point where the skin is that damaged and that saturated with pigment, the skin will only hold so much pigment before it becomes saturated [and] we can't do anything. […] She is that mortified and mentally scarred by what she's got that she won't get naked, she doesn't want to see it, so she literally bathes with a bra on, so she doesn't have to look at the shit job that she's got. (Insert Figs. 4 here) Bailey also explained how HPs often don’t receive this feedback as CSs don’t want to appear ungrateful: They [Healthcare Providers] came back to me and went “well we’ve never been told” and I'm like “who the hell would come to the NHS after they’ve saved your life and gone “this nipple tattoo is shit and thanks for saving my life”?”. “A lot of them even can still feel that taboo of having a tattoo”: Stigma and its effects on CSs Artists described their perceptions of how stigma negatively affected the decisions of CSs to receive therapeutic tattoos on multiple levels through the cultural, external, and systemic judgment of the tattoo decision . Emma described the internal stigmatization that some cultures have regarding tattooing, preventing CSs from getting certain designs following their treatment: [In] Russia, like, no ways; they never ask [for a] “real” tattoo; they [ask instead] "can we do a nipple tattoo, like areola?" Like, yea of course, why not, but I never asked “would you like to move it into [Decorative] tattooing?” because it's like 100% no. Further, Tonya illustrated the external stigma CSs may be anxious about, through an example of a CS who received a negative reaction from family: “I'm like, “good for you.” And she said, you know, her family was like mean to her. […] When she wanted to get the tattoo, they were really mean to her and not supportive at all” . Jessie further described how some HPs can systematically judge the decision of CSs to get a tattoo, including discouraging them to do so: A lot of the stuff that I've heard from my clients and how, not only have they not been recommended to look into it as an option from their medical providers, but they've been actively discouraged a lot of the time. Similarly, misinformation surrounding tattoo ink potentially created additional stigma towards tattoos for CSs and HPs, particularly surrounding how dangerous tattoo ink was for the body. For example, Bailey also described how a HP working in the oncology department of her local hospital incorrectly told a CS that the ink from a tattoo artist could give them cancer again, which was resolved when Lucy found that she and the HP were using the same ink. I had one oncology person in my local hospital who turned around and told the client who came for a consultation with me that my pigment in my tattoo ink would give her cancer again, Which is why we did the Freedom of Information [request] because I was like “we use the same brand, mate”. However, outside of the actions of any individual or organization, artists espoused their views that the cultural shift of tattoo valuations in western cultures is leading to tattoos becoming more accepted. Artists indicated that this may decrease levels of stigma and anxiety, which affects CSs decision-making surrounding their therapeutic tattoos. Sandy described this cultural shift by explaining how tattoos are now more valued in modern society. We're in 2024 now but I think that, every year, it's getting better and, every year, it's becoming more and more awesome and more and more valued to people you know it's not trashy as some people may say, it’s meaningful it's life-changing. “We've been tattooing bodies since they've been painting on cave walls”: Artist Barriers Several artists noted that issues with finances were a barrier in place for them to tattoo CSs due to the costs of tattooing. Mr. G explained how he tries to avoid charging CSs for this work; however, ultimately that decision actively harms his financial situation: “The financial aspect of it is pretty difficult and it's been a struggle. It takes away from my everyday financial independence”. This was described further by Andre who feels uncomfortable charging CSs: “I usually do not feel comfortable charging these people the way I should be charging them […] But I keep doing it because people need it”. Furthermore, numerous artists commented about the lack of HP collaboration , which made doing this practice more difficult. Mac spoke of her own experience with HPs who refused to stop performing medical tattooing on CSs despite being less skilled at it: I still have a few surgeons that refuse to let go of it and I'm like “Why are you still doing [this]? You're great at reconstruction. I'm pretty good at what I do. Let's divide and conquer. Similarly, Artists commented that they had experienced stigma as TAs which made it more difficult for them to collaborate with HPs to tattoo CSs. Bailey described her perspective that she is not trusted by healthcare services because she is a heavily tattooed artist: “I think if I wasn’t so heavily tattooed, I would be more of a trusted source maybe for the [healthcare service] because they’re very hard to outsource”. In addition to this, several artists highlighted their concerns with their inability to advertise their work to CSs, particularly through social media. On this, Alice explained how her posts kept getting blocked on social media due to being considered sexual content, regardless of whether she did decorative or reconstructive tattooing over CSs’ breasts: For the last two years, everything [Images of tattoos] just keeps getting blocked because everything is automatic now on Instagram. So, they see a nipple or even my decorative stuff, they're like “No that's too sexual”, and I'm like “fuck right off, like, that's ridiculous.” Equally, being able to learn how to tattoo CSs was a barrier for many artists because of the lack of training available for TAs, meaning that many had to develop their skills on their own, through trial and error. Sandy explained that, like many of the other artists, she had to train herself how to tattoo CSs: I had to study it all on myself on my own and I had to sketch and color and look at the different color palettes versus the different skin tones and there's a lot involved and being able to recreate it properly. Artists mentioned that this barrier to training was particularly important in medical reconstructive and decorative tattoos, due to the scarred and post-reconstruction skin being more difficult to tattoo, as Bailey described: Because [With] reconstructions you can have chest tattoo like chest skin and stomach skin so you're tattooing two different types of skin. So, if you don't have knowledge, because these are all these things [to] take into consideration, and that's without how the skins been affected if it's still got the same vascular formation. Because, obviously, all the nerve endings and all the blood vessels have been cut, so it doesn't really work like normal skin “The deck’s really stacked against these patients”: CS Barriers The potential issues of CSs having the finances for these tattoos was evident across several interviews, with artists from the EU, America, Canada, and the UK, describing how this work was typically not covered by private medical insurance or public healthcare when undertaken by TAs. An exception to this was that, in rare instances, financial coverage was given where artists had a good relationship with insurance providers or where they worked within a doctor’s office. Tonya described the situation in America; despite national policies entitling CSs to all stages of reconstruction, her CSs still struggled to be reimbursed for tattoos performed by artists: “This federal law Bill Clinton passed in ‘98 states that every woman has a right for breast cancer reconstruction. [...] The way they get around not covering people like me is that we are not [considered to be] “in-network providers”” . Similarly, Alice described a similar situation in Ireland where tattoos by artists are not funded by insurance or public healthcare: “It's not cheap and, unfortunately, insurance doesn't cover anything; it doesn’t even cover the nipple tattoos, which it should [when it is done by an artist]. […] But, because they’re a doctor, they're like “Yeah, do whatever you want.”” Further, Rob described how these tattoos are often expensive making them unaffordable for CSs who may already be struggling financially: We're not cheap, you know, and a lot of people, when they're going to something like this, they can't afford [them]. [...] You know, they might be on disability in the United States, and that barely pays part of your bills and your food. Being able to get these tattoos was also more difficult for CSs due to difficulty accessing artists , particularly ones who perform medical tattoos on CSs, with CSs often struggling to find a practitioner. On this, Tav explained how some CSs search for years to find an artist who has the skills to tattoo what they want over their scarred skin. I know there's not enough [artists doing medical tattooing] by way of conversation [with CSs] and options [for getting medical tattoos from TAs]. I know a lot of women come to me and they've been looking for years for somebody. [...] I know that there aren't many options for people out there. Similarly, difficulty accessing quality tattoos was a barrier that artists identified CSs face, particularly regarding finding an artist or HP that has the necessary skills. Aurora reinforced this and described how HPs do not need additional certification to do this work, meaning there is not a standard of quality or skill for this work among HPs: “There's no requirement or extra licensing needed in any state for a doctor or nurse to learn how to tattoo; they work under their license and the state seems to be fine with that”. The Priestess added to this by highlighting how there is also no standard system for Tas either: “We’re not organized, you know, anybody, any failed musician, band guy can pick up a tattoo machinery”. Further, a lack of information about therapeutic tattooing for CSs was described across several interviews as a barrier, which artists suggested led to a lack of awareness of the practice among CSs. Reggie supported this, speaking about how he commonly hears that CSs did not get tattoos post-treatment as they weren’t aware of them: “One of the most common things I hear is "I would have done this years earlier if I knew this was a thing."" “It's a blessing for us to be able to give back”: Artist facilitators. When artists and their supporters could advertise this practice, they described how it facilitated them to continue tattooing CSs through increased awareness of the practice among CSs. Particularly, artists recounted the importance of word-of-mouth advertising from CSs, which was deemed extremely important. Jane said that, from her perspective, word-of-mouth advertising from CSs was integral to the practice: That’s the great thing about breast CS groups too, you get one person that posts something in there, and, suddenly, you get like a little flood of things because they rely so heavily on each other, it's like it's a club. For some artists, personal and financial business support facilitated them to carry out their work. Tonya’s husband, for example, made sacrifices to allow her to keep doing this work: “He [Husband] took a second job at the hospital part-time so I- we can have health insurance for our family. And so that way, I can do what I wanna do” . Similarly, financial support from the local community facilitated Mr G to continue tattooing CSs in his area: We've started a nonprofit here, so I don't charge for any of these procedures. […] I found some people in the community who are willing to support what I'm doing and so they donate money to me to help me cover my costs. Another facilitator for artists was co-learning and having experience , whereby artists develop their expertise by doing this work collaboratively or sharing tips with other artists. For instance, despite the current lack of standardized training, Andre spoke about how members of the tattooing community teach each other different techniques and skills, allowing them to improve at this practice: Tattooing is such a cool community where we can really reach out to just about any tattoo [artist, and an artist that] you reach out to is gonna tell you a secret, or a trick, or give you advice, if you make it apparent that you’re someone who gives a damn. Conversely, Bailey spoke about how having a lot of tattooing experience would make transitioning into medical tattooing easier for artists: “I think it's more easy for the transition of a TA that’s probably got five years experience”. Numerous artists’ also spoke about how being perceived as more professional by CSs facilitated them to do this work. For example, Jane described her decision to work in a medical office to avoid the potentially uncomfortable environment associated with tattoo shops: I opened my office because most of my clients are not people who generally get tattooed and so walking into an environment where there's a lot of heavily tattooed people and loud music, which in general is fun, but if you're not into that environment it can be super intimidating […] so that was a big priority for me to move into a medical office - that comfortability [for clients]. Similarly, Tonya believes that her previous training as a nurse gives her more credibility to CSs: The fact that I have a nursing license, I think that's a huge thing because people know I'm going to be aseptic, and I tattoo out of clean medical environments and positions like that. So, I definitely think that's to my, you know, like to my bonus. “By the time they're with me, they've already worked that out”: CS Facilitators Participants identified the value of non-profit organizations and TAs providing financial support to cover the costs of therapeutic tattoos as key facilitators to CSs who wanted to get tattooed. Catherine explained how shocked some CSs were when she refused to accept any payment for the service she provides: “They’re always very shocked I don't want money for this, even tips” . Tonya described how non-profit organizations organize fundraisers to cover the costs for CSs to go to TAs: “They [non-profit organization] helped pay for different things related to cancer treatment, but tattooing is one of them and then [other non-profit organization] does a fundraiser every year for things that insurance may deem medically not necessary like nipple tattoos.” Similarly, participants perceived that CSs having access to information about TAs who can perform tattoos for them, as well as what those tattoos may look like, facilitated some CSs to follow through on their decision about getting a therapeutic tattoo. Jessie mentions that nurses played a key role in giving this information, often unofficially telling CSs about local artists who tattoo CSs: It's usually nurses that will, like, on the side, pull them aside and be like,” you should totally like look into it [getting a tattoo from an artist]. [...] They would tell the patient to do it but it's not, they're not allowed to, most of the time. Tonya, on the other hand, explained how she sent a friend of hers who had undergone a mastectomy, temporary tattoos so that she could see what a medical reconstructive nipple-areola tattoo would look like: “I mailed her some. Little temporary nipple tear like tattoos, little temporary ones, and she put him on, and she was like, “oh my god, give me your next appointment.”” Discussion To the authors’ knowledge, this is the first study to describe the perspectives of TAs on the psychosocial impact of CS therapeutic tattoos, the first to identify barriers/facilitators to the practice, and the first to identify consequences of poor-quality therapeutic tattoos. Further, of the 20 artists that reported the number of cancer survivors they had tattooed a total of 8,712 was found (See Table 1 ). This suggests that these artists can speak on the impacts and experiences of cancer survivors in a broader context and on their own experiences. Based on this, seven themes and several sub-themes were identified. This includes three themes regarding the psychosocial impact of engaging with this practice for artists and CSs: Psychological Impact on Artists (Finding Purpose, Feeling Fulfilled, Being Impacted by Stories, Being Concerned About the Results and Coping Mechanisms), Psychological Impact on CSs (Regaining Body Confidence, Feeling At Home in a New Body, Reinventing or Reclaiming Identity and Experiencing Trauma) and Decisional Effects of Stigma for CSs (Judgment of the tattoo decision, Misinformation and Cultural shift of tattoo valuations). Additionally, two themes regarding the barriers in place for artists and CSs to engage with this practice were identified: Artist Barriers (Finances, Lack of HP Collaboration, Inability to Advertise and Lack of Training) and CS Barriers (Finances, Difficulty Accessing Artists, Difficulty Accessing Quality Tattoos and Lack of Information). Finally, we identified two themes describing the separate facilitators of engaging with this practice for artists and CSs: Artist Facilitators (Ability to Advertise, Business Support, Co-learning and Having Experience and Being Perceived as More Professional) and CS facilitators (Financial Support and Access to Information). An additional unexpected finding of this research was the development of a typology of CS therapeutic tattoos. These findings suggest artists who tattoo CSs may benefit from this work, which they perceive as personally rewarding and impactful. However, a surprising finding was the negative emotional impact these artists experience. This finding reflects similar literature with HPs, such as nurses, who experience similar negative emotional impacts from working with CSs [ 33 ]. How some artists coped with emotions was concerning; although some artists spoke to healthy coping mechanisms, such as using social support networks [ 34 ] or therapy [ 35 ], others either resorted to alcohol and, in one case, substance abuse or lacked a coping mechanism. Further, artists perceived that the CSs they worked with experienced positive outcomes, which is supported by previous literature [ 36 , 19 ]. However, to our knowledge, this is the first study to report on the potential trauma experienced by CSs who receive low-quality therapeutic tattoos. This finding contradicts previous quantitative research which finds high levels of satisfaction from CSs receiving tattoos from HPs [ 23 , 25 ]. This lack of previous reporting could be due to CSs who had negative outcomes not wanting to communicate this, in fear of appearing ungrateful, as suggested in other research [ 37 ], and as Bailey, an artist in this study, pointed out. Regarding barriers and facilitators for artists to engage with this practice, there were several important findings. Artists described how pro bono work created a financial barrier for them to continue this work or negatively affected their personal finances. Another key issue raised was the lack of standardized training, which acted as a barrier to artists being able to learn and perform well in doing this work. Although there are some options available for standardized training, such as A.R.T (Artistic Restorative Tattoo) certification training 1 [38], this currently costs $ 4,500 2 , which may be inaccessible for artists already dealing with financial issues. Paired with an inability to advertise the work that they do online or collaborate with HPs, this could affect how reputable artists are considered to be by CSs. Nonetheless, the practice is currently facilitated by business and financial support, which can supplement any lost profits from doing these tattoos. Similarly, this work is facilitated where artists can advertise and spread awareness of the business, and work with other artists to skill-share and co-learn (a practice which has been shown to be effective within other contexts [ 39 ]. This research also highlights several key barriers and facilitators for CSs to engage in this practice. Findings such as finances being a barrier for CSs is consistent with the literature; on average, CSs in the USA, Canada and Australia spend 16% of their annual income on out-of-pocket expenses related to cancer [ 40 ] and Irish CSs lose an average of €18,323 annually due to cancer [ 41 ], meaning CSs may lack disposable income to spend tattoos [ 42 ] due to the costs of other aspects of survivorship, such as medications. Likewise, access to appropriate therapeutic tattoo artists acted as a barrier for CSs. This is unsurprising, as there were less than 350 practitioners identified in existing artist databases included in this study, with the majority being in the USA, and more limited artists being located across the UK, Ireland, Canada, Chile, Portugal, France, Italy, Montenegro, Sweden, the Netherlands, and France [ 20 – 22 , 43 ]. Furthermore, previous literature has identified that 84% of an American sample of HPs don’t currently recommend tattoos from TAs to breast CSs, despite not having evidence about the quality of their tattoos [ 44 ], clearly demonstrating the barrier in place for some CSs to gain information on therapeutic tattooing from TAs as identified in this study. Related to the above, artists highlighted a significant degree of societal stigma relating to therapeutic tattooing, which participants indicated had an effect on CSs perceptions of such tattoos. A particularly unexpected finding was HPs giving some CSs misinformation regarding tattoos (e.g. relating to the carcinogenic properties of ink used by certain TAs) or even directly discouraging CSs from attending TAs for their tattoos. Such misinformation, or encouragement to not seek out accurate information seems to contribute to the development of several health-related misconceptions regarding tattoos and how dangerous they and their inks can be, despite numerous restrictions and standards of practice being established to ensure that both the process of the tattoo and the ink of the tattoo are safe across the EU and America [ 45 ]. Furthermore, it seems that the general societal stigma towards tattoos [ 46 ] is also present for CSs, with concerns surrounding public or familial reactions to tattoos being noted by several participants. As described by one participant, there seems to be added stigma towards decorative tattooing as they are not reconstructive, and therefore more akin to a traditional tattoo, which may prevent CSs from fully exploring their design options. Despite this, it was suggested that the stigmatization of tattoos is slowly dissipating in the modern age. Strengths/Limitations A major strength of this study is its novelty, addressing several gaps in the literature surrounding the barriers/ facilitators of cancer survivorship therapeutic tattoos for both the artists and CSs, the impact of such tattoos on both groups, the types of these tattoos, and the artists’ perspectives on these. Despite the small total population of TAs who tattoo CSs, we were able to recruit a diverse group of international artists. Finally, to our knowledge, we have developed a typology of the therapeutic tattoos available for CSs for the first time; while this broad typology may be in need of subsequent refinement, it is a necessary first step which allows for the development of consistent language and terminology for therapeutic tattoos to enable better communication between CSs, Artists, and HPs. However, it is important not to over-generalize the results of this study; due to the diverse sample across countries, some reported barriers and facilitators may be specific to a given country or health system; further research is needed to understand if these barriers and facilitators occur across different health systems. Additionally, the findings relating to CSs’ barriers/facilitators and experiences are based on second-hand accounts from TAs and future research is needed to confirm their veracity. Nonetheless, the artists' accounts are informed by a wealth of collective experience tattooing thousands of CSs and witnessing their impact on CSs. Implications Artists identified that tattoos are typically not covered by private insurance providers or public healthcare systems internationally. More specifically, in America, the Women’s Health and Breast Cancer Rights Act 1998 entitles breast CSs to all stages of reconstruction [ 47 ]; however, it appears that CSs struggle to receive reimbursement for medical reconstructive tattoos from TAs. This is similar in Ireland and the UK, where insurers do not provide financial coverage for therapeutic tattoos performed by TAs. Given the potential for improved outcomes when tattoos are performed by TAs, formal recognition of TAs as providers of therapeutic tattoos for CSs done by TAs is necessary by insurers and healthcare systems. To support artists being recognized as appropriate providers of therapeutic tattooing in this way, there is a need for standardized training to provide such tattoos, particularly regarding medical tattooing on scarred skin. Furthermore, internationally recognized accreditation for the completion of such training may help build TAs’ reputability among insurers and healthcare systems. Such training may not be applicable to HPs who lack prior years of experience with tattooing; despite this, including HPs in the co-creation of training for artists is important, due to their medical knowledge and role as key stakeholders in the treatment of CSs, which may ultimately be an opportunity to break down any existing tattoo stigma. The lack of collaboration between HPs and TAs, and lack of integration of TAs within existing healthcare systems was found to act as a barrier for the provision of therapeutic tattoos to CSs. This is concerning, particularly considering the misinformation spread about tattoos by some HPs towards CSs. Based on this, it is clear that there is a need for interventions to foster a more constructive relationship between TAs and HPs, and for campaigns and initiatives to share information regarding therapeutic tattooing with HPs and CSs. This could take the form of artists providing decisional aids to CSs such as temporary tattoos, or through artists being more integrated into the treatment process. Such measures may decrease the spread of misinformation about therapeutic tattooing amongst HPs, reduce negative tattooing outcomes, and potentially enhance the options of CSs for, and increase their satisfaction with, body image interventions following cancer treatment [ 16 ]. However, such practical changes must be predicated on further research in this area. Particularly, there is a distinct need for high quality quantitative research on the effects of therapeutic tattoos on CSs [ 25 ], including research that quantifies the negative impact of poor-quality tattoos on CSs. Furthermore, the current research highlights the need for further research on the quality of life of artists and the development and evaluation of psycho-social interventions to deal with the emotional impact of doing this work amongst TAs and the trauma experienced from a bad tattoo amongst CSs. Finally, it is necessary to replicate this study within a cohort of CSs who have received tattoos to identify if the barriers/facilitators described by artists are relevant to them, and to investigate if there are any other barriers/facilitators to therapeutic tattooing amongst CSs from their perspectives. Declarations Compliance with Ethical Standards This study was self-funded Conflict of interest Authors Karl & Dunne declare they have no conflicts of interest to support. Author Daly is on the Board of Directors for the Alliance of Medical Tattooing and receives no compensation for this role. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. We received formal ethical approval for the study from Dublin City University Psychology Ethics Committee (DCUPEC_2024_102) as well as approval for an amendment of some content from the same committee (DCUPEC_2024_102_A01). Informed consent Informed consent was obtained from all individual participants included in the study. Consent to publish Authors affirm that the relevant research participants provided informed consent for the publication of the images in Figs. 1–17 Author Contribution A.D. contributed to Conceptualization, Methodology, Data curation, Data analysis and interpretation and Original manuscript preparation. J.K. contributed to Data analysis and Interpretation. S.D. contributed to Conceptualization, Data curation and design, Supervision, Data analysis and Interpretation. All authors reviewed and edited the final manuscript. Data Availability The data that support the findings of this study are available upon reasonable request to the authors, but restrictions apply to the availability of these data, which were used with permission of the participants and so are not publicly available. References Torre LA, Siegel RL, Ward EM, Jemal A. Global Cancer Incidence and Mortality Rates and Trends—An Update. Cancer Epidemiology, Biomarkers & Prevention. 2016 Jan 12;25(1):16–27. Jones C, Lancaster R. Evolution of Operative Technique for Mastectomy. Surgical Clinics. 2018 Aug 1;98(4):835–44. Shahzad H. Neoplasm. BoD – Books on Demand; 2018. 256 p. Fowble B, Yom SS, Yuen F. Types of Radiation-Related Skin Reactions. In: Fowble B, Yom SS, Yuen F, Arron S, editors. Skin Care in Radiation Oncology: A Practical Guide [Internet]. Cham: Springer International Publishing; 2016 [cited 2024 Mar 11]. p. 15–29. Available from: https://doi.org/10.1007/978-3-319-31460-0_3 Naidoo W, Leech M. Feasibility of surface guided radiotherapy for patient positioning in breast radiotherapy versus conventional tattoo-based setups- a systematic review. Technical Innovations & Patient Support in Radiation Oncology. 2022 Jun 1;22:39–49. Voci A, Lee D, Ho E, Crane-Okada R, DiNome M. Impact of port site scar on perception of patients with breast cancer: patient-reported outcomes. Breast Cancer Res Treat. 2018 Aug 1;170(3):569–72. Nowicki A, Licznerska B, Rhone P. Evaluation of the quality of life of women treated due to breast cancer using amputation or breast conserving surgery in the early postoperative period. Pol Przegl Chir. 2015 Apr;87(4):174–80. Miller LE. “People Don’t Understand That It Is Not Easy Being a Cancer Survivor”: Communicating and Negotiating Identity Throughout Cancer Survivorship. Southern Communication Journal. 2015 Jan 1;80(1):1–19. Fingeret MC, Teo I, Epner DE. Managing body image difficulties of adult cancer patients: Lessons from available research. Cancer. 2014;120(5):633–41. Cervantes-Luna BS, Alvarez-Rayón G, Gomez G, Díaz J. Reliability and constuct validity of the Body Modification Scale in adolescent males. Salud Mental. 2013 Nov 1;36:487–92. Lane DC. Understanding body modification: A process-based framework. Sociology Compass. 2017;11(7):e12495. Zannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. ‘My wig has been my journey’s companion’: perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. European Journal of Cancer Care. 2012;21(5):650–60. Taggart LR, Ozolins L, Hardie H, Nyhof-Young J. Look good feel better workshops: a ‘big lift’ for women with cancer. J Cancer Educ. 2009;24(2):94–9. Dieckmann KP, Anheuser P, Schmidt S, Soyka-Hundt B, Pichlmeier U, Schriefer P, et al. Testicular prostheses in patients with testicular cancer - acceptance rate and patient satisfaction. BMC Urol. 2015 Mar 13;15(1):16. Mohammadi SZ, Khan SM, Vanaki KZ. Reconstruction of feminine identity: the strategies of women with breast cancer to cope with body image altered. International Journal of Women’s Health. 2018 Nov 1;10:689–97. Fagerlin A, Lakhani I, Lantz PM, Janz NK, Morrow M, Schwartz K, et al. An informed decision?: Breast cancer patients and their knowledge about treatment. Patient Education and Counseling. 2006 Dec 1;64(1):303–12. Haney B. Permanent and Semi-permanent Micro-Pigment Treatments. In: Haney B, editor. Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology [Internet]. Cham: Springer International Publishing; 2020 [cited 2024 Mar 11]. p. 59–66. Available from: https://doi.org/10.1007/978-3-030-19948-7_7 Sisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, et al. Nipple-areola complex reconstruction techniques: A literature review. European Journal of Surgical Oncology (EJSO). 2016 Apr 1;42(4):441–65. Koller V, Bullo S. “Fight Like a Girl”: Tattoos as Identity Constructions for Women Living with Illness. Multimodal Communication [Internet]. 2019 Jun 1 [cited 2024 Feb 1];8(1). Available from: https://www.degruyter.com/document/doi/10.1515/mc-2018-0006/html P.ink.org [Internet]. Fuck Cancer c2022 [Cited 2023, Oct 2]. Available from: https://www.p-ink.org/ Tittoo.org [Internet]. Tittoo c2023 [Cited 2023, Oct 2). Available from: https://tittoo.org/ The Alliance of Medical Tattooing c2023 [Cited 2023, Oct 2). Available from: https://allianceofmedicaltattooing.com/ Becker SJ, Cassisi JE. Applications of Medical Tattooing: A Systematic Review of Patient Satisfaction Outcomes and Emerging Trends. Aesthet Surg J Open Forum. 2021 May 4;3(3):ojab015. Somogyi RB, Ziolkowski N, Osman F, Ginty A, Brown M. Breast reconstruction: Updated overview for primary care physicians. Canadian Family Physician. 2018 Jun 1;64(6):424–32. Maselli D, Torreggiani M, Livieri T, Farioli G, Lucchi S, Guberti M. Tattooing to reconstruct Nipple-Areola Complex after oncological breast surgery: a scoping review. Support Care Cancer. 2024 Feb 10;32(3):153. Horton J, Macve R, Struyven G. Qualitative Research: Experiences in Using Semi-Structured Interviews1. In: Humphrey C, Lee B, editors. The Real Life Guide to Accounting Research [Internet]. Oxford: Elsevier; 2004 [cited 2024 Mar 19]. p. 339–57. Available from: https://www.sciencedirect.com/science/article/pii/B9780080439723500220 Allen D. Moving the Needle on Recovery From Breast Cancer: The Healing Role of Postmastectomy Tattoos. JAMA. 2017 Feb 21;317(7):672–4. Reid-de Jong V, Bruce A. Mastectomy tattoos: An emerging alternative for reclaiming self. Nursing Forum. 2020;55(4):695–702. Gerber JP. Social Comparison Theory. In: Zeigler-Hill V, Shackelford TK, editors. Encyclopedia of Personality and Individual Differences [Internet]. Cham: Springer International Publishing; 2020 [cited 2024 Jan 8]. p. 5004–11. Available from: https://doi.org/10.1007/978-3-319-24612-3_1182 Greup SR, Kaal SEJ, Jansen R, Manten-Horst E, Thong MSY, van der Graaf WTA, et al. Post-Traumatic Growth and Resilience in Adolescent and Young Adult Cancer Patients: An Overview. Journal of Adolescent and Young Adult Oncology. 2018 Feb;7(1):1–14. Kira I. Toward an Integrative Theory of Self-Identity and Identity Stressors and Traumas and Their Mental Health Dynamics. Psychology. 2019 Mar 6;10(04):385. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019 Aug 8;11(4):589–97. Corner J. Nurses’ experiences of cancer. European Journal of Cancer Care. 2002;11(3):193–9. Tolsdorf CC. Social Networks, Support, and Coping: An Exploratory Study. Family Process. 1976;15(4):407–17. Algorani EB, Gupta V. Coping Mechanisms. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK559031/ Stutsman, A. Inking agency: women’s mastectomy tattoos and emotional healing. California State University, Fresno. 2016;122. Ozakinci G, Swash B, Humphris G, Rogers SN, Hulbert-Williams NJ. Fear of cancer recurrence in oral and oropharyngeal cancer patients: An investigation of the clinical encounter. European Journal of Cancer Care. 2018;27(1):e12785. A.R.T. [Internet]. A.R.T Areola Certification Training c2023 [Cited 2024, Feb 8 th ]. https://www.artschool.ink/offers/j3BdjqCP/checkout Wu LW, Lin JR. Knowledge sharing and knowledge effectiveness: learning orientation and co-production in the contingency model of tacit knowledge. Journal of Business & Industrial Marketing. 2013 Jan 1;28(8):672–86. Iragorri N, de Oliveira C, Fitzgerald N, Essue B. The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review. Current Oncology. 2021 Apr;28(2):1216–48. Irish Cancer Society [Internet]. The Real Cost of Cancer Report c2019 [Cited 2024, Feb 8 th ]. https://acrobat.adobe.com/id/urn:aaid:sc:EU:d0c037ff-b5a8-49df-b853-c3c294d22da3 Sanders Cr. Colourful Writing: Conducting and living with a tattoo ethnography. In: Ethnographies Revisited. Routledge; 2009. Nipple Innovation Project [Internet]. NIP c2018 [Cited 2024, Feb 8 th ]. https://www.nipcharity.org/ DiCenso D, Fischer-Cartlidge E. Nipple-Areola Tattoos: Making the Right Referral. ONF. 2015 Nov 1;42(6):E376–81. European Society of Tattoo and Pigment Research. Tattoo Legislation [Internet]. c2024 [cited 2024, May 28]. Available from: https://estp-research.org/ Broussard KA, Harton HC. Tattoo or taboo? Tattoo stigma and negative attitudes toward tattooed individuals. The Journal of Social Psychology. 2018 Sep 3;158(5):521–40. U.S. Department of Labour [Internet]. Women's Health and Breast Cancer Rights Act c1998 [Cited 2024, Feb 8 th ]. https://www.dol.gov/general/topic/health-plans/womens Footnotes A type of training offered by ART, a training organization mentioned in several interviews. There is up to $ 1,000 dollars in discounts offered for artists already with experience working on scarred skin. Table 2 Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files ArtisjustsomethingthatmakespeoplehealJCSSupplementaryFile.docx ArtisjustsomethingthatmakespeoplehealJCSTable2.docx Cite Share Download PDF Status: Published Journal Publication published 28 Sep, 2024 Read the published version in Journal of Cancer Survivorship → Version 1 posted Editorial decision: Revision requested 06 Sep, 2024 Reviews received at journal 26 Jun, 2024 Reviewers agreed at journal 20 Jun, 2024 Reviewers invited by journal 20 Jun, 2024 Editor assigned by journal 14 Jun, 2024 Submission checks completed at journal 14 Jun, 2024 First submitted to journal 12 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4570179","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":319102132,"identity":"71d92e84-fc3f-4638-b530-f7c7aa230b86","order_by":0,"name":"Adam Daly","email":"","orcid":"","institution":"Dublin City University","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"","lastName":"Daly","suffix":""},{"id":319102133,"identity":"7d383bf9-e564-4764-9fe7-eebbc4e0585d","order_by":1,"name":"Johannes Karl","email":"","orcid":"","institution":"Dublin City University","correspondingAuthor":false,"prefix":"","firstName":"Johannes","middleName":"","lastName":"Karl","suffix":""},{"id":319102134,"identity":"40cbab04-0e43-4e53-bf0f-88413b1c9b72","order_by":2,"name":"Simon Dunne","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYDACZgTJ+IAHSLKRooXZgDgtSBrZJHiIUSvfzp34uIDBOnG7dPOxijc1hxn42BvwazE4zLvZeAZDeuLOOcfSbs45dpiBjecAAS3MvNukeRgOJ264kWN2m7cBqEUigYDDmuFa8r8Vg7XIPyDgmcMIW9iYIbYQ0AH2C49BuvGGG2nGknOOpfOw8RByWP/ZjY95KqxlN9xIfvjhTY21nHz7AQLWQOxCMImKmlEwCkbBKBgFBAAA2jE7WUUDer8AAAAASUVORK5CYII=","orcid":"","institution":"Dublin City University","correspondingAuthor":true,"prefix":"","firstName":"Simon","middleName":"","lastName":"Dunne","suffix":""}],"badges":[],"createdAt":"2024-06-12 12:23:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4570179/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4570179/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11764-024-01682-4","type":"published","date":"2024-09-28T15:56:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60197188,"identity":"f5f764ff-92af-4f81-a36b-606785da62dd","added_by":"auto","created_at":"2024-07-13 01:55:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":402304,"visible":true,"origin":"","legend":"\u003cp\u003eTattoo artists’ analysis of two low quality medical reconstructive tattoos done by healthcare providers.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/a4e15919779b39790333eaf3.png"},{"id":60197191,"identity":"6635e4ba-adca-4aab-9209-de4956be8502","added_by":"auto","created_at":"2024-07-13 01:55:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":510209,"visible":true,"origin":"","legend":"\u003cp\u003eCollection of four before and after images of medical reconstructive tattoos performed by tattoo artists on breast cancer survivors.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/d35ba01f2d472fe9c0b76530.png"},{"id":60198028,"identity":"5c672abc-2516-4da7-b42e-1b637c7c82d6","added_by":"auto","created_at":"2024-07-13 02:03:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":412184,"visible":true,"origin":"","legend":"\u003cp\u003eGallery of medical and non-medical decorative tattoos, performed on several different types of cancer survivors by tattoo artists.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/63323ed964110384988dd7a6.png"},{"id":60197187,"identity":"3407d99f-76ba-4b48-aed6-5f66350a5348","added_by":"auto","created_at":"2024-07-13 01:55:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":266154,"visible":true,"origin":"","legend":"\u003cp\u003eTwo low-quality nipple tattoos performed by healthcare providers.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/8e06c000c2af13a4c1330b98.png"},{"id":65627068,"identity":"6b8f2f3c-18f8-462b-8dc4-0f2461e7ef63","added_by":"auto","created_at":"2024-09-30 16:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2324065,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/d3763ec6-7999-4946-8a14-c602f5274e40.pdf"},{"id":60197184,"identity":"3687c0c8-0aaa-4fc0-9d85-a18ae9c10b75","added_by":"auto","created_at":"2024-07-13 01:55:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":26964,"visible":true,"origin":"","legend":"","description":"","filename":"ArtisjustsomethingthatmakespeoplehealJCSSupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/971f7ae7bb349047bf16bee8.docx"},{"id":60197190,"identity":"d92b5a60-551d-47b8-9ec5-c6b5d537137f","added_by":"auto","created_at":"2024-07-13 01:55:12","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":433175,"visible":true,"origin":"","legend":"","description":"","filename":"ArtisjustsomethingthatmakespeoplehealJCSTable2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4570179/v1/5d68bd457b87ce83cb762038.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Art is just something that makes people heal” - A Qualitative Investigation of Tattoo Artists’ Perspectives on Cancer Survivorship Therapeutic Tattoos","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDue to medical advances in cancer detection and treatment techniques, the number of cancer survivors (CSs) is increasing annually, particularly in high-income countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, many cancer treatments are still aggressive, including radiotherapy or surgical procedures that may involve the removal or damaging of body part(s) that hold the cancerous cells and neighbouring cell [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Such treatments often have negative effects on the bodies of CSs; for example, skin discoloration and surgical tattoo marks from radiation therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], port-scarring from chemotherapy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], amputation of body parts such as the breast(s) in mastectomies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], etc. The consequences of cancer treatments can also cause a disrupted body image and identity in CSs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Due to this, body modifications have been implemented to support CSs. Body modifications are defined as an intervention that voluntarily changes an individual's body permanently or non-permanently [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] for primarily aesthetic purposes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], including minimally invasive modifications such as using wigs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and makeup [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] to more invasive surgical cosmetic procedures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Exploring the efficacy of such interventions is important, as research would suggest that body modifications themselves can improve the body image and identity of CSs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and that having more information regarding their body modification options can improve CSs\u0026rsquo; satisfaction with their chosen body modification [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. One such body modification is therapeutic tattooing, the pseudo-permanent pigmentation of the skin [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] performed to improve aesthetic and psycho-social outcomes, e.g. nipple reconstructions [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] or scar coverups [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therapeutic tattooing is already being offered to different CSs across multiple countries with several international organizations being created to facilitate its use as an aesthetic intervention; P.ink [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], Tittoo [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and The Alliance of Medical Tattooing [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While health professionals (HPs), such as physicians and nurses, perform therapeutic tattooing in many countries, the practice is also commonly performed by tattoo artists (TAs) [23.24].\u003c/p\u003e \u003cp\u003eA small body of research on this practice has identified that tattooing is related to positive outcomes in CSs. A recent scoping review found that CSs who have received nipple-areola tattoos experience improved self-perception and identity, etc [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], but 9/11 studies included were considered to have weak quality. Furthermore, a systematic review on the use of tattooing to support the aesthetic outcomes of individuals with a variety of medical conditions found that CSs found high satisfaction rates following nipple-areola tattoos [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Although Maselli and colleagues [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] identify some of the psychosocial effects of therapeutic tattoos, both reviews reflect the broader issues of current research in CS therapeutic tattooing, which focus almost entirely on white, Western, female breast CSs who have received nipple-areola tattoos, with a view to determining \u0026ldquo;outcome satisfaction\u0026rdquo;. To our knowledge, there also appears to be a complete absence of published literature on negative experiences of therapeutic tattoos among CSs. This demonstrates a clear gap within the literature for research that comprehensively examines the psychosocial impact of therapeutic tattoos among CSs, including males and those with cancer types other than breast cancer.\u003c/p\u003e \u003cp\u003eSimilarly, there is an absence of literature on the perspectives of, and effects on, the artists who do this work, as well as the potential barriers/facilitators for CSs and artists to engage with this practice. Artists\u0026rsquo; perspectives on these issues are important, considering their unique position in engaging with multiple CSs who are seeking a therapeutic tattoo. Understanding their views and experiences can provide a more holistic perspective on the variety of these tattoos, the potential effects of this practice, as well as the barriers and facilitators to engagement with it. To address these gaps in the literature, and to contribute to the emerging literature in this area, this study aimed a) to identify the types of therapeutic tattoos CSs receive, b) to identify the impacts of therapeutic tattooing on both artists and CSs, and c) to identify the barriers/facilitators of this practice on both artists and CSs, from the perspective of artists.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study used a cross-sectional qualitative research design. Semi-structured interviews were employed to ensure the flexibility needed for the inductive approach of this research [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], due to the dearth of literature on this topic, allowing the researcher to react to and investigate new information as it was brought up by the participants. In-depth one-on-one interviewing was employed due to the potential for the interview to focus on confidential subjects relating to CSs who had been tattooed and who could have been identifiable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Recruitment\u003c/h2\u003e \u003cp\u003eThis study consisted of a sample of 22 international TAs. To be eligible for inclusion, participants had to be over the age of 18, a fluent English speaker and worked for at least one year as a TA, tattooing at least one CS. These criteria were chosen to ensure that participants had experience, both working as a TA and with the population of interest, to guarantee an expert opinion on the topic.\u003c/p\u003e \u003cp\u003e Before official recruitment, 73 artists from P.ink.org were contacted to confirm their interest in participation in this project. Following ethical approval, those who expressed interest were followed up with, and additional participants were recruited using two other publicly available databases of artists who tattoo CSs: Tittoo.org and The Alliance of Medical Tattooing. The researcher also contacted local tattoo shops in Dublin, and used snowball sampling on this group, due to the small population of TAs with experience working with CSs in Ireland. These targeted recruitment approaches were carried out by contacting the artists through the medium they conducted their work i.e., Email, Instagram, WhatsApp, SMS Text, Facebook, and in-person.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003e Upon initial contact, artists were given a PLS statement to read and afterward, a consent form to sign. Following this artists were able to book an interview specifying whether their preference between Zoom, FaceTime, and Face-to-face for it to be held. All artists (n\u0026thinsp;=\u0026thinsp;22) chose to do the interviews via Zoom (M\u0026thinsp;=\u0026thinsp;64 minutes, SD\u0026thinsp;=\u0026thinsp;12 minutes).\u003c/p\u003e \u003cp\u003eA semi-structured interview guide was developed based on findings from previous research which has identified the process of tattooing and practical design choices [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] as well as the impacts and symbolism of the tattoos [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] as important. Furthermore, broader literature was utilized to develop questions pertaining to identity, social dynamics, and culture [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Additionally, the first author leveraged their own experiences of the impact, barriers, and facilitators of getting tattooed as a non-CS to contribute additional questions. The questions within the interview schedule centred on five main domains: sociodemographic information of the artists, the psycho-social effects on artists and CSs, the process of therapeutic tattooing, the experience of living with tattoos of the artists and CSs, and the role of non-profits as well as the healthcare system in the practice. Through these domains, participants were asked to share their own experiences and their perspectives on the experiences of the cancer survivors they worked with.\u003c/p\u003e \u003cp\u003eDue to some missing sociodemographic information some participants were followed up with to gather this data. Further, due to apparent importance of images in demonstrating the effects of these tattoos; positive and negative, an additional consent form was sent to tattoo artists to request the use of their images. The resultant set of images include those which appear in the figures and tables of the current manuscript. Where images contained faces or identifying watermarks, they were blurred or cropped and no images are attributed to individual artists, as measures to protect their anonymity and the anonymity CSs they had tattooed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data was transcribed by the first author in preparation for thematic analysis, with any identifiable or irrelevant information being omitted from each transcript. The transcripts were uploaded to NVivo for analysis using Braun \u0026amp; Clake\u0026rsquo;s\u0026rsquo; reflexive thematic analysis [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Further during the familiarisation phase, all identifiable information was removed from the transcripts such as names, specific locations, etc. Finally, due to the inherent subjectivity of reflexive thematic analysis, and their own experiences with tattoos, the first author monitored their bias through regular reflection on coding and consultation with the corresponding author.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-two interviews were conducted. Of the 20 artists that reported the number of CSs they had tattooed, their collective experience of performing CS therapeutic tattoos comprised a total of 8,712 male and female CSs (calculated using the lowest estimates from these artists). Twenty artists also reported their time spent tattooing CSs (M\u0026thinsp;=\u0026thinsp;9.5 years, SD\u0026thinsp;=\u0026thinsp;4.71) Further details on participant characteristics are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. All interviews were included in the final analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Sociodemographic Information\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudonym\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimated No. of Years Tattooing CSs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEstimated No. of CSs Tattooed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTypes of Cancer Worked With\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCountries CSs Tattooed In\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCurrent Country of Residence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA, Russia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSarah\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Lung, Bowel, Bone, Skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIreland, Spain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatherine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUK, USA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlice*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIreland, Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRiley\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Binary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdel*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Cervical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA, France, Germany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAurora*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e500+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Bone, Lung, Skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMr. G*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Priestess*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1680\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Ovarian, Skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA, Netherlands, Germany, Montenegro, UK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMac*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Brain, Skin, Thyroid, Testicular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarriot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u0026ndash;200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Skin, Pancreatic, Colon, Ovarian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA, Canada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSandy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBailey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Thyroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJane*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,000+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Oral, Prostrate, Uterine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaura B*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Throat, Lung, Skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRob\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Cervical, Lung\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReggie*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharlotte\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Stomach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndre*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Colon, Lung, Skin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTonya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,600+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRose*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast, Colon, Ovarian, Stomach, Pancreas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTav*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003e1\u003c/sup\u003e \u0026ldquo;*\u0026rdquo; indicates a self-selected pseudonym.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003e2\u003c/sup\u003e NR indicates information that was not reported.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThroughout the interviews, artists described different types of therapeutic tattooing. For the purposes of this manuscript, we have classified these types of therapeutic tattoos as medical reconstructive, medical decorative, non-medical reconstructive, and non-medical decorative (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for further details and definitions).\u003c/p\u003e \n \u003cp\u003eFollowing reflexive thematic analysis, seven themes were identified: \u003cem\u003ePsychological Impact on Artists, Psychological Impact on CSs, Stigma and its effects on CSs, Artist Barriers, CS Barriers, Artist Facilitators, and CSs Facilitators\u003c/em\u003e. These themes comprised several subthemes (See Supplementary file for review). In what follows, where quotations have been contracted, ellipses are inserted in square brackets, and where context was needed for the quotations, further contextual information has been placed in square brackets.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;You focus on the happy things and the positives\u0026rdquo;: Psychological Impact on Artists\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral artists spoke of how doing this work was meaningful for them, supporting them in \u003cem\u003efinding purpose\u003c/em\u003e. Aurora, a CS herself, exemplified this, recounting that becoming a TA who tattoos CSs allowed her to fulfil a promise she made to herself: \u003cem\u003e\u0026ldquo;During my cancer treatments, I asked the universe to keep me alive and [promised] \u0026ldquo;I'll donate my life to help others in some way shape or form\u0026rdquo; and I've kept that promise.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSimilarly, almost all artists agreed that this work helped them in \u003cem\u003efeeling fulfilled\u003c/em\u003e. Jane described her view that, as much as CSs benefit from this work, she does too through the positive feelings it gives her: \u003cem\u003e\u0026ldquo;It makes me feel good too, honestly, from a selfish perspective, I feel really fulfilled.\u0026rdquo;\u003c/em\u003e The Priestess developed this point further by talking about how she believes that doing this work has allowed her to become a better person: \u003cem\u003e\u0026ldquo;If I didn't do this, I\u0026rsquo;d be so gnarly. I'd be so fucking hardcore and regressive. No, this is good for me because it reminds me of my heart and my compassion.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eHowever, as much as this work has positives, it was clear across interviews that the emotional weight of doing this work and \u003cem\u003ebeing impacted by stories\u003c/em\u003e from CSs burdened artists. Bailey described this by recounting an experience she had where she tattooed a terminally ill CS with pictures his children drew so that he could take a part of his kids with him in death:\u003c/p\u003e \u003cp\u003eI'm used to [Clients being] like \u0026ldquo;I want this tattoo because it looks cool\u0026rdquo;, not like \u0026ldquo;I want this tattoo because daddy\u0026rsquo;s taking it to heaven\u0026rdquo;. I\u0026rsquo;m like, \u0026ldquo;I fucking can\u0026rsquo;t cope [with that]\u0026rdquo;, so some of the stuff is like pretty impactful.\u003c/p\u003e \u003cp\u003eSimilarly, numerous artists expressed \u003cem\u003ebeing concerned about the results\u003c/em\u003e and the stress they feel about providing a good tattoo for CSs, as well as the shame they feel when they cannot. For example, Riley described the anxiety she feels about the possibility of giving CSs a negative experience: \u003cem\u003e\u0026ldquo;The cons are kind of what comes with all this work, which is like \u0026ldquo;what if like- did I give them a thing that they wanted or was it something that was a negative experience?\u0026rdquo;\u003c/em\u003e. Tonya, an ex-nurse, explained her own experience with this, learning how to do medical tattooing as a nurse and her shame now from the damage she was doing to CSs due to her lack of training:\u003c/p\u003e \u003cp\u003eI literally watched a nurse do one tattoo and then I was turned loose. With this permanent machine, I can't even lie, Permanent makeup machine and needles and a patient, and I was not prepared [at] all, it was like, \u0026ldquo;do one, see one\u0026rdquo;, to \u0026ldquo;teach one\u0026rdquo; [\u0026hellip;] It's terrible. Shameful. I'm appalled. It was me and I'm appalled.\u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMany artists also described the \u003cem\u003ecoping mechanisms\u003c/em\u003e they employed to deal with this emotional burden. Jane, for example, was able to rely on her support network, like her husband or therapist, to cope with the emotional backlash of this work:\u003c/p\u003e \u003cp\u003eI have a husband who\u0026rsquo;s also a tattoo artist; he doesn't do the medical tattoos, but he really relates to a lot of stuff I go through during the day with those frustrations and then he's so willing to listen to me emotion-wise; [I\u0026rsquo;m] so lucky that way, therapy is great too.\u003c/p\u003e \u003cp\u003eIn contrast, Andre indicated that he relied on potentially unhealthy coping mechanisms such as substance abuse:\u003c/p\u003e \u003cp\u003eThere was a lot of just pushing stuff down, a lot of substance abuse. Just long nights, Needless tears. I think it's really easy for somebody going through all of that to go overboard on empathy. And start to take on some of the burden of these people's struggles.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;It's a huge transformation right there\u0026rdquo;: Psychological Impact on CSs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eArtists consistently spoke about memories they had where CSs had experienced \u003cem\u003eregaining body confidence\u003c/em\u003e following a tattoo. Mr. G described his experience with CSs on whom he had performed medical reconstructive nipple-areola tattoos, with him being shocked that something as small as a reconstructed nipple improved these individuals' body image so much:\u003c/p\u003e \u003cp\u003eIt's crazy that something as small as two little 50 Cent pieces as a tattoo could just absolutely change someone's mental focus where they're not staring at themselves in the mirror saying, \u0026ldquo;How can someone love me, how can someone look at me?\u0026rdquo;\u003c/p\u003e \u003cp\u003eSimilarly, Sarah described a specific CS to whom she gave a medical decorative tattoo, who went from lacking body confidence to walking around topless after the tattoo: \u003cem\u003e\u0026ldquo;I had someone who had a double mastectomy, [who] decided to just get one really long Rose floral [tattoo]. [\u0026hellip;] She couldn't take her top off at the gym beforehand, but now she's walking around topless.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAside from feeling more confident in their bodies, many artists perceived that these tattoos allowed CSs to develop the perception of \u003cem\u003efeeling at home in their new bodies\u003c/em\u003e. Jane spoke about a particular CS who appeared to have this experience, with her feeling naked for the first time in years after receiving a medical reconstructive tattoo: \u003cem\u003e\u0026ldquo;We did the stencils [\u0026hellip;] Then she's like \u0026ldquo;I feel naked\u0026rdquo;, she says \u0026ldquo;I haven't felt naked in over 10 years\u0026rdquo; and I, right there, I mean she started crying.\u0026rdquo;\u003c/em\u003e Similarly, Rose perceived that getting these tattoos allowed CSs to reclaim their bodies and feel at home in them again:\u003c/p\u003e \u003cp\u003eChoosing to get tattooed, choosing to change one's body in that way, they become like more embodied, more whole, they can reclaim all the things that they feel like they lost, or reclaim body parts that look different.\u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSimilarly, many artists spoke of how getting these tattoos allowed CSs to begin \u003cem\u003ereinventing or reclaiming their identities\u003c/em\u003e following treatment. Bailey explained that some CSs she had worked with had changed their identities by choosing the symbols that will mark their bodies.\u003c/p\u003e \u003cp\u003eThey get to reinvent themselves, of what they want to live with, so it becomes something that's almost like they get to choose either who they want to become, they get to choose how they represent their journey, and they get to choose how they're going to see themselves from then on.\u003c/p\u003e \u003cp\u003e(Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHowever, despite all artists speaking of the positive effects that therapeutic tattoos had on the CSs they had worked with, it was also clear that these tattoos could be equally harmful when performed incorrectly, causing CSs to go through \u003cem\u003eexperiencing trauma\u003c/em\u003e all over again. For example, Bailey described a particular case where she was unable to tattoo a CS whose skin was saturated with ink due to having received so many poor-quality tattoos from HPs, resulting in this CS being unable to look at her own body:\u003c/p\u003e \u003cp\u003eShe got to a point where the skin is that damaged and that saturated with pigment, the skin will only hold so much pigment before it becomes saturated [and] we can't do anything. [\u0026hellip;] She is that mortified and mentally scarred by what she's got that she won't get naked, she doesn't want to see it, so she literally bathes with a bra on, so she doesn't have to look at the shit job that she's got.\u003c/p\u003e \u003cp\u003e(Insert Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBailey also explained how HPs often don\u0026rsquo;t receive this feedback as CSs don\u0026rsquo;t want to appear ungrateful:\u003c/p\u003e \u003cp\u003eThey [Healthcare Providers] came back to me and went \u0026ldquo;well we\u0026rsquo;ve never been told\u0026rdquo; and I'm like \u0026ldquo;who the hell would come to the NHS after they\u0026rsquo;ve saved your life and gone \u0026ldquo;this nipple tattoo is shit and thanks for saving my life\u0026rdquo;?\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;A lot of them even can still feel that taboo of having a tattoo\u0026rdquo;: Stigma and its effects on CSs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eArtists described their perceptions of how stigma negatively affected the decisions of CSs to receive therapeutic tattoos on multiple levels through the cultural, external, and systemic \u003cem\u003ejudgment of the tattoo decision\u003c/em\u003e. Emma described the internal stigmatization that some cultures have regarding tattooing, preventing CSs from getting certain designs following their treatment:\u003c/p\u003e \u003cp\u003e[In] Russia, like, no ways; they never ask [for a] \u0026ldquo;real\u0026rdquo; tattoo; they [ask instead] \"can we do a nipple tattoo, like areola?\" Like, yea of course, why not, but I never asked \u0026ldquo;would you like to move it into [Decorative] tattooing?\u0026rdquo; because it's like 100% no.\u003c/p\u003e \u003cp\u003eFurther, Tonya illustrated the external stigma CSs may be anxious about, through an example of a CS who received a negative reaction from family: \u003cem\u003e\u0026ldquo;I'm like, \u0026ldquo;good for you.\u0026rdquo; And she said, you know, her family was like mean to her. [\u0026hellip;] When she wanted to get the tattoo, they were really mean to her and not supportive at all\u0026rdquo;\u003c/em\u003e. Jessie further described how some HPs can systematically judge the decision of CSs to get a tattoo, including discouraging them to do so:\u003c/p\u003e \u003cp\u003eA lot of the stuff that I've heard from my clients and how, not only have they not been recommended to look into it as an option from their medical providers, but they've been actively discouraged a lot of the time.\u003c/p\u003e \u003cp\u003eSimilarly, \u003cem\u003emisinformation\u003c/em\u003e surrounding tattoo ink potentially created additional stigma towards tattoos for CSs and HPs, particularly surrounding how dangerous tattoo ink was for the body. For example, Bailey also described how a HP working in the oncology department of her local hospital incorrectly told a CS that the ink from a tattoo artist could give them cancer again, which was resolved when Lucy found that she and the HP were using the same ink.\u003c/p\u003e \u003cp\u003eI had one oncology person in my local hospital who turned around and told the client who came for a consultation with me that my pigment in my tattoo ink would give her cancer again, Which is why we did the Freedom of Information [request] because I was like \u0026ldquo;we use the same brand, mate\u0026rdquo;.\u003c/p\u003e \u003cp\u003eHowever, outside of the actions of any individual or organization, artists espoused their views that \u003cem\u003ethe cultural shift of tattoo valuations\u003c/em\u003e in western cultures is leading to tattoos becoming more accepted. Artists indicated that this may decrease levels of stigma and anxiety, which affects CSs decision-making surrounding their therapeutic tattoos. Sandy described this cultural shift by explaining how tattoos are now more valued in modern society.\u003c/p\u003e \u003cp\u003eWe're in 2024 now but I think that, every year, it's getting better and, every year, it's becoming more and more awesome and more and more valued to people you know it's not trashy as some people may say, it\u0026rsquo;s meaningful it's life-changing.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;We've been tattooing bodies since they've been painting on cave walls\u0026rdquo;: Artist Barriers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral artists noted that issues with \u003cem\u003efinances\u003c/em\u003e were a barrier in place for them to tattoo CSs due to the costs of tattooing. Mr. G explained how he tries to avoid charging CSs for this work; however, ultimately that decision actively harms his financial situation: \u003cem\u003e\u0026ldquo;The financial aspect of it is pretty difficult and it's been a struggle. It takes away from my everyday financial independence\u0026rdquo;.\u003c/em\u003e This was described further by Andre who feels uncomfortable charging CSs: \u003cem\u003e\u0026ldquo;I usually do not feel comfortable charging these people the way I should be charging them [\u0026hellip;] But I keep doing it because people need it\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFurthermore, numerous artists commented about the \u003cem\u003elack of HP collaboration\u003c/em\u003e, which made doing this practice more difficult. Mac spoke of her own experience with HPs who refused to stop performing medical tattooing on CSs despite being less skilled at it:\u003c/p\u003e \u003cp\u003eI still have a few surgeons that refuse to let go of it and I'm like \u0026ldquo;Why are you still doing [this]? You're great at reconstruction. I'm pretty good at what I do. Let's divide and conquer.\u003c/p\u003e \u003cp\u003eSimilarly, Artists commented that they had experienced stigma as TAs which made it more difficult for them to collaborate with HPs to tattoo CSs. Bailey described her perspective that she is not trusted by healthcare services because she is a heavily tattooed artist: \u003cem\u003e\u0026ldquo;I think if I wasn\u0026rsquo;t so heavily tattooed, I would be more of a trusted source maybe for the [healthcare service] because they\u0026rsquo;re very hard to outsource\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn addition to this, several artists highlighted their concerns with their \u003cem\u003einability to advertise\u003c/em\u003e their work to CSs, particularly through social media. On this, Alice explained how her posts kept getting blocked on social media due to being considered sexual content, regardless of whether she did decorative or reconstructive tattooing over CSs\u0026rsquo; breasts:\u003c/p\u003e \u003cp\u003eFor the last two years, everything [Images of tattoos] just keeps getting blocked because everything is automatic now on Instagram. So, they see a nipple or even my decorative stuff, they're like \u0026ldquo;No that's too sexual\u0026rdquo;, and I'm like \u0026ldquo;fuck right off, like, that's ridiculous.\u0026rdquo;\u003c/p\u003e \u003cp\u003eEqually, being able to learn how to tattoo CSs was a barrier for many artists because of the \u003cem\u003elack of training\u003c/em\u003e available for TAs, meaning that many had to develop their skills on their own, through trial and error. Sandy explained that, like many of the other artists, she had to train herself how to tattoo CSs:\u003c/p\u003e \u003cp\u003eI had to study it all on myself on my own and I had to sketch and color and look at the different color palettes versus the different skin tones and there's a lot involved and being able to recreate it properly.\u003c/p\u003e \u003cp\u003eArtists mentioned that this barrier to training was particularly important in medical reconstructive and decorative tattoos, due to the scarred and post-reconstruction skin being more difficult to tattoo, as Bailey described:\u003c/p\u003e \u003cp\u003eBecause [With] reconstructions you can have chest tattoo like chest skin and stomach skin so you're tattooing two different types of skin. So, if you don't have knowledge, because these are all these things [to] take into consideration, and that's without how the skins been affected if it's still got the same vascular formation. Because, obviously, all the nerve endings and all the blood vessels have been cut, so it doesn't really work like normal skin\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;The deck\u0026rsquo;s really stacked against these patients\u0026rdquo;: CS Barriers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe potential issues of CSs having the \u003cem\u003efinances\u003c/em\u003e for these tattoos was evident across several interviews, with artists from the EU, America, Canada, and the UK, describing how this work was typically not covered by private medical insurance or public healthcare when undertaken by TAs. An exception to this was that, in rare instances, financial coverage was given where artists had a good relationship with insurance providers or where they worked within a doctor\u0026rsquo;s office. Tonya described the situation in America; despite national policies entitling CSs to all stages of reconstruction, her CSs still struggled to be reimbursed for tattoos performed by artists: \u003cem\u003e\u0026ldquo;This federal law Bill Clinton passed in \u0026lsquo;98 states that every woman has a right for breast cancer reconstruction. [...] The way they get around not covering people like me is that we are not [considered to be] \u0026ldquo;in-network providers\u0026rdquo;\u0026rdquo;\u003c/em\u003e. Similarly, Alice described a similar situation in Ireland where tattoos by artists are not funded by insurance or public healthcare: \u003cem\u003e\u0026ldquo;It's not cheap and, unfortunately, insurance doesn't cover anything; it doesn\u0026rsquo;t even cover the nipple tattoos, which it should [when it is done by an artist]. [\u0026hellip;] But, because they\u0026rsquo;re\u003c/em\u003e a \u003cem\u003edoctor, they're like \u0026ldquo;Yeah, do whatever you want.\u0026rdquo;\u0026rdquo;\u003c/em\u003e Further, Rob described how these tattoos are often expensive making them unaffordable for CSs who may already be struggling financially:\u003c/p\u003e \u003cp\u003eWe're not cheap, you know, and a lot of people, when they're going to something like this, they can't afford [them]. [...] You know, they might be on disability in the United States, and that barely pays part of your bills and your food.\u003c/p\u003e \u003cp\u003eBeing able to get these tattoos was also more difficult for CSs due to \u003cem\u003edifficulty accessing artists\u003c/em\u003e, particularly ones who perform medical tattoos on CSs, with CSs often struggling to find a practitioner. On this, Tav explained how some CSs search for years to find an artist who has the skills to tattoo what they want over their scarred skin.\u003c/p\u003e \u003cp\u003eI know there's not enough [artists doing medical tattooing] by way of conversation [with CSs] and options [for getting medical tattoos from TAs]. I know a lot of women come to me and they've been looking for years for somebody. [...] I know that there aren't many options for people out there.\u003c/p\u003e \u003cp\u003eSimilarly, \u003cem\u003edifficulty accessing quality tattoos\u003c/em\u003e was a barrier that artists identified CSs face, particularly regarding finding an artist or HP that has the necessary skills. Aurora reinforced this and described how HPs do not need additional certification to do this work, meaning there is not a standard of quality or skill for this work among HPs: \u003cem\u003e\u0026ldquo;There's no requirement or extra licensing needed in any state for a doctor or nurse to learn how to tattoo; they work under their license and the state seems to be fine with that\u0026rdquo;.\u003c/em\u003e The Priestess added to this by highlighting how there is also no standard system for Tas either: \u003cem\u003e\u0026ldquo;We\u0026rsquo;re not organized, you know, anybody, any failed musician, band guy can pick up a tattoo machinery\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFurther, a \u003cem\u003elack of information\u003c/em\u003e about therapeutic tattooing for CSs was described across several interviews as a barrier, which artists suggested led to a lack of awareness of the practice among CSs. Reggie supported this, speaking about how he commonly hears that CSs did not get tattoos post-treatment as they weren\u0026rsquo;t aware of them: \u003cem\u003e\u0026ldquo;One of the most common things I hear is \"I would have done this years earlier if I knew this was a thing.\"\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;It's a blessing for us to be able to give back\u0026rdquo;: Artist facilitators.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen artists and their supporters could \u003cem\u003eadvertise\u003c/em\u003e this practice, they described how it facilitated them to continue tattooing CSs through increased awareness of the practice among CSs. Particularly, artists recounted the importance of word-of-mouth advertising from CSs, which was deemed extremely important. Jane said that, from her perspective, word-of-mouth advertising from CSs was integral to the practice:\u003c/p\u003e \u003cp\u003eThat\u0026rsquo;s the great thing about breast CS groups too, you get one person that posts something in there, and, suddenly, you get like a little flood of things because they rely so heavily on each other, it's like it's a club.\u003c/p\u003e \u003cp\u003eFor some artists, personal and financial \u003cem\u003ebusiness support\u003c/em\u003e facilitated them to carry out their work. Tonya\u0026rsquo;s husband, for example, made sacrifices to allow her to keep doing this work: \u003cem\u003e\u0026ldquo;He [Husband] took a second job at the hospital part-time so I- we can have health insurance for our family. And so that way, I can do what I wanna do\u0026rdquo;\u003c/em\u003e. Similarly, financial support from the local community facilitated Mr G to continue tattooing CSs in his area:\u003c/p\u003e \u003cp\u003eWe've started a nonprofit here, so I don't charge for any of these procedures. [\u0026hellip;] I found some people in the community who are willing to support what I'm doing and so they donate money to me to help me cover my costs.\u003c/p\u003e \u003cp\u003eAnother facilitator for artists was \u003cem\u003eco-learning and having experience\u003c/em\u003e, whereby artists develop their expertise by doing this work collaboratively or sharing tips with other artists. For instance, despite the current lack of standardized training, Andre spoke about how members of the tattooing community teach each other different techniques and skills, allowing them to improve at this practice:\u003c/p\u003e \u003cp\u003eTattooing is such a cool community where we can really reach out to just about any tattoo [artist, and an artist that] you reach out to is gonna tell you a secret, or a trick, or give you advice, if you make it apparent that you\u0026rsquo;re someone who gives a damn.\u003c/p\u003e \u003cp\u003eConversely, Bailey spoke about how having a lot of tattooing experience would make transitioning into medical tattooing easier for artists: \u003cem\u003e\u0026ldquo;I think it's more easy for the transition of a TA that\u0026rsquo;s probably got five years experience\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eNumerous artists\u0026rsquo; also spoke about how \u003cem\u003ebeing perceived as more professional\u003c/em\u003e by CSs facilitated them to do this work. For example, Jane described her decision to work in a medical office to avoid the potentially uncomfortable environment associated with tattoo shops:\u003c/p\u003e \u003cp\u003eI opened my office because most of my clients are not people who generally get tattooed and so walking into an environment where there's a lot of heavily tattooed people and loud music, which in general is fun, but if you're not into that environment it can be super intimidating [\u0026hellip;] so that was a big priority for me to move into a medical office - that comfortability [for clients].\u003c/p\u003e \u003cp\u003eSimilarly, Tonya believes that her previous training as a nurse gives her more credibility to CSs:\u003c/p\u003e \u003cp\u003eThe fact that I have a nursing license, I think that's a huge thing because people know I'm going to be aseptic, and I tattoo out of clean medical environments and positions like that. So, I definitely think that's to my, you know, like to my bonus.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;By the time they're with me, they've already worked that out\u0026rdquo;: CS Facilitators\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants identified the value of non-profit organizations and TAs providing \u003cem\u003efinancial support\u003c/em\u003e to cover the costs of therapeutic tattoos as key facilitators to CSs who wanted to get tattooed. Catherine explained how shocked some CSs were when she refused to accept any payment for the service she provides: \u003cem\u003e\u0026ldquo;They\u0026rsquo;re always very shocked I don't want money for this, even tips\u0026rdquo;\u003c/em\u003e. Tonya described how non-profit organizations organize fundraisers to cover the costs for CSs to go to TAs: \u003cem\u003e\u0026ldquo;They [non-profit organization] helped pay for different things related to cancer treatment, but tattooing is one of them and then [other non-profit organization] does a fundraiser every year for things that insurance may deem medically not necessary like nipple tattoos.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSimilarly, participants perceived that CSs having \u003cem\u003eaccess to information\u003c/em\u003e about TAs who can perform tattoos for them, as well as what those tattoos may look like, facilitated some CSs to follow through on their decision about getting a therapeutic tattoo. Jessie mentions that nurses played a key role in giving this information, often unofficially telling CSs about local artists who tattoo CSs:\u003c/p\u003e \u003cp\u003eIt's usually nurses that will, like, on the side, pull them aside and be like,\u0026rdquo; you should totally like look into it [getting a tattoo from an artist]. [...] They would tell the patient to do it but it's not, they're not allowed to, most of the time.\u003c/p\u003e \u003cp\u003eTonya, on the other hand, explained how she sent a friend of hers who had undergone a mastectomy, temporary tattoos so that she could see what a medical reconstructive nipple-areola tattoo would look like: \u003cem\u003e\u0026ldquo;I mailed her some. Little temporary nipple tear like tattoos, little temporary ones, and she put him on, and she was like, \u0026ldquo;oh my god, give me your next appointment.\u0026rdquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the authors\u0026rsquo; knowledge, this is the first study to describe the perspectives of TAs on the psychosocial impact of CS therapeutic tattoos, the first to identify barriers/facilitators to the practice, and the first to identify consequences of poor-quality therapeutic tattoos. Further, of the 20 artists that reported the number of cancer survivors they had tattooed a total of 8,712 was found (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This suggests that these artists can speak on the impacts and experiences of cancer survivors in a broader context and on their own experiences. Based on this, seven themes and several sub-themes were identified. This includes three themes regarding the psychosocial impact of engaging with this practice for artists and CSs: \u003cem\u003ePsychological Impact on Artists (Finding Purpose, Feeling Fulfilled, Being Impacted by Stories, Being Concerned About the Results and Coping Mechanisms), Psychological Impact on CSs (Regaining Body Confidence, Feeling At Home in a New Body, Reinventing or Reclaiming Identity and Experiencing Trauma)\u003c/em\u003e and \u003cem\u003eDecisional Effects of Stigma for CSs (Judgment of the tattoo decision, Misinformation and Cultural shift of tattoo valuations).\u003c/em\u003e Additionally, two themes regarding the barriers in place for artists and CSs to engage with this practice were identified: \u003cem\u003eArtist Barriers (Finances, Lack of HP Collaboration, Inability to Advertise and Lack of Training)\u003c/em\u003e and \u003cem\u003eCS Barriers (Finances, Difficulty Accessing Artists, Difficulty Accessing Quality Tattoos and Lack of Information).\u003c/em\u003e Finally, we identified two themes describing the separate facilitators of engaging with this practice for artists and CSs: \u003cem\u003eArtist Facilitators (Ability to Advertise, Business Support, Co-learning and Having Experience and Being Perceived as More Professional)\u003c/em\u003e and \u003cem\u003eCS facilitators (Financial Support and Access to Information).\u003c/em\u003e An additional unexpected finding of this research was the development of a typology of CS therapeutic tattoos.\u003c/p\u003e \u003cp\u003eThese findings suggest artists who tattoo CSs may benefit from this work, which they perceive as personally rewarding and impactful. However, a surprising finding was the negative emotional impact these artists experience. This finding reflects similar literature with HPs, such as nurses, who experience similar negative emotional impacts from working with CSs [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. How some artists coped with emotions was concerning; although some artists spoke to healthy coping mechanisms, such as using social support networks [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] or therapy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], others either resorted to alcohol and, in one case, substance abuse or lacked a coping mechanism.\u003c/p\u003e \u003cp\u003eFurther, artists perceived that the CSs they worked with experienced positive outcomes, which is supported by previous literature [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, to our knowledge, this is the first study to report on the potential trauma experienced by CSs who receive low-quality therapeutic tattoos. This finding contradicts previous quantitative research which finds high levels of satisfaction from CSs receiving tattoos from HPs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This lack of previous reporting could be due to CSs who had negative outcomes not wanting to communicate this, in fear of appearing ungrateful, as suggested in other research [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and as Bailey, an artist in this study, pointed out.\u003c/p\u003e \u003cp\u003eRegarding barriers and facilitators for artists to engage with this practice, there were several important findings. Artists described how pro bono work created a financial barrier for them to continue this work or negatively affected their personal finances. Another key issue raised was the lack of standardized training, which acted as a barrier to artists being able to learn and perform well in doing this work. Although there are some options available for standardized training, such as A.R.T (Artistic Restorative Tattoo) certification training\u003csup\u003e1\u003c/sup\u003e [38], this currently costs \u003cspan\u003e$\u003c/span\u003e4,500\u003csup\u003e2\u003c/sup\u003e, which may be inaccessible for artists already dealing with financial issues. Paired with an inability to advertise the work that they do online or collaborate with HPs, this could affect how reputable artists are considered to be by CSs. Nonetheless, the practice is currently facilitated by business and financial support, which can supplement any lost profits from doing these tattoos. Similarly, this work is facilitated where artists can advertise and spread awareness of the business, and work with other artists to skill-share and co-learn (a practice which has been shown to be effective within other contexts [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis research also highlights several key barriers and facilitators for CSs to engage in this practice. Findings such as finances being a barrier for CSs is consistent with the literature; on average, CSs in the USA, Canada and Australia spend 16% of their annual income on out-of-pocket expenses related to cancer [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and Irish CSs lose an average of \u0026euro;18,323 annually due to cancer [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], meaning CSs may lack disposable income to spend tattoos [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] due to the costs of other aspects of survivorship, such as medications. Likewise, access to appropriate therapeutic tattoo artists acted as a barrier for CSs. This is unsurprising, as there were less than 350 practitioners identified in existing artist databases included in this study, with the majority being in the USA, and more limited artists being located across the UK, Ireland, Canada, Chile, Portugal, France, Italy, Montenegro, Sweden, the Netherlands, and France [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Furthermore, previous literature has identified that 84% of an American sample of HPs don\u0026rsquo;t currently recommend tattoos from TAs to breast CSs, despite not having evidence about the quality of their tattoos [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], clearly demonstrating the barrier in place for some CSs to gain information on therapeutic tattooing from TAs as identified in this study.\u003c/p\u003e \u003cp\u003eRelated to the above, artists highlighted a significant degree of societal stigma relating to therapeutic tattooing, which participants indicated had an effect on CSs perceptions of such tattoos. A particularly unexpected finding was HPs giving some CSs misinformation regarding tattoos (e.g. relating to the carcinogenic properties of ink used by certain TAs) or even directly discouraging CSs from attending TAs for their tattoos. Such misinformation, or encouragement to not seek out accurate information seems to contribute to the development of several health-related misconceptions regarding tattoos and how dangerous they and their inks can be, despite numerous restrictions and standards of practice being established to ensure that both the process of the tattoo and the ink of the tattoo are safe across the EU and America [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Furthermore, it seems that the general societal stigma towards tattoos [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] is also present for CSs, with concerns surrounding public or familial reactions to tattoos being noted by several participants. As described by one participant, there seems to be added stigma towards decorative tattooing as they are not reconstructive, and therefore more akin to a traditional tattoo, which may prevent CSs from fully exploring their design options. Despite this, it was suggested that the stigmatization of tattoos is slowly dissipating in the modern age.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStrengths/Limitations\u003c/h2\u003e \u003cp\u003eA major strength of this study is its novelty, addressing several gaps in the literature surrounding the barriers/ facilitators of cancer survivorship therapeutic tattoos for both the artists and CSs, the impact of such tattoos on both groups, the types of these tattoos, and the artists\u0026rsquo; perspectives on these. Despite the small total population of TAs who tattoo CSs, we were able to recruit a diverse group of international artists. Finally, to our knowledge, we have developed a typology of the therapeutic tattoos available for CSs for the first time; while this broad typology may be in need of subsequent refinement, it is a necessary first step which allows for the development of consistent language and terminology for therapeutic tattoos to enable better communication between CSs, Artists, and HPs.\u003c/p\u003e \u003cp\u003eHowever, it is important not to over-generalize the results of this study; due to the diverse sample across countries, some reported barriers and facilitators may be specific to a given country or health system; further research is needed to understand if these barriers and facilitators occur across different health systems. Additionally, the findings relating to CSs\u0026rsquo; barriers/facilitators and experiences are based on second-hand accounts from TAs and future research is needed to confirm their veracity. Nonetheless, the artists' accounts are informed by a wealth of collective experience tattooing thousands of CSs and witnessing their impact on CSs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eArtists identified that tattoos are typically not covered by private insurance providers or public healthcare systems internationally. More specifically, in America, the Women\u0026rsquo;s Health and Breast Cancer Rights Act 1998 entitles breast CSs to all stages of reconstruction [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]; however, it appears that CSs struggle to receive reimbursement for medical reconstructive tattoos from TAs. This is similar in Ireland and the UK, where insurers do not provide financial coverage for therapeutic tattoos performed by TAs. Given the potential for improved outcomes when tattoos are performed by TAs, formal recognition of TAs as providers of therapeutic tattoos for CSs done by TAs is necessary by insurers and healthcare systems.\u003c/p\u003e \u003cp\u003eTo support artists being recognized as appropriate providers of therapeutic tattooing in this way, there is a need for standardized training to provide such tattoos, particularly regarding medical tattooing on scarred skin. Furthermore, internationally recognized accreditation for the completion of such training may help build TAs\u0026rsquo; reputability among insurers and healthcare systems. Such training may not be applicable to HPs who lack prior years of experience with tattooing; despite this, including HPs in the co-creation of training for artists is important, due to their medical knowledge and role as key stakeholders in the treatment of CSs, which may ultimately be an opportunity to break down any existing tattoo stigma.\u003c/p\u003e \u003cp\u003eThe lack of collaboration between HPs and TAs, and lack of integration of TAs within existing healthcare systems was found to act as a barrier for the provision of therapeutic tattoos to CSs. This is concerning, particularly considering the misinformation spread about tattoos by some HPs towards CSs. Based on this, it is clear that there is a need for interventions to foster a more constructive relationship between TAs and HPs, and for campaigns and initiatives to share information regarding therapeutic tattooing with HPs and CSs. This could take the form of artists providing decisional aids to CSs such as temporary tattoos, or through artists being more integrated into the treatment process. Such measures may decrease the spread of misinformation about therapeutic tattooing amongst HPs, reduce negative tattooing outcomes, and potentially enhance the options of CSs for, and increase their satisfaction with, body image interventions following cancer treatment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, such practical changes must be predicated on further research in this area. Particularly, there is a distinct need for high quality quantitative research on the effects of therapeutic tattoos on CSs [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], including research that quantifies the negative impact of poor-quality tattoos on CSs. Furthermore, the current research highlights the need for further research on the quality of life of artists and the development and evaluation of psycho-social interventions to deal with the emotional impact of doing this work amongst TAs and the trauma experienced from a bad tattoo amongst CSs. Finally, it is necessary to replicate this study within a cohort of CSs who have received tattoos to identify if the barriers/facilitators described by artists are relevant to them, and to investigate if there are any other barriers/facilitators to therapeutic tattooing amongst CSs from their perspectives.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompliance with Ethical Standards\u003c/h2\u003e \u003cp\u003eThis study was self-funded\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eAuthors Karl \u0026amp; Dunne declare they have no conflicts of interest to support. Author Daly is on the Board of Directors for the Alliance of Medical Tattooing and receives no compensation for this role.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. We received formal ethical approval for the study from Dublin City University Psychology Ethics Committee (DCUPEC_2024_102) as well as approval for an amendment of some content from the same committee (DCUPEC_2024_102_A01).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eAuthors affirm that the relevant research participants provided informed consent for the publication of the images in Figs.\u0026nbsp;1\u0026ndash;17\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.D. contributed to Conceptualization, Methodology, Data curation, Data analysis and interpretation and Original manuscript preparation. J.K. contributed to Data analysis and Interpretation. S.D. contributed to Conceptualization, Data curation and design, Supervision, Data analysis and Interpretation. All authors reviewed and edited the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available upon reasonable request to the authors, but restrictions apply to the availability of these data, which were used with permission of the participants and so are not publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTorre LA, Siegel RL, Ward EM, Jemal A. Global Cancer Incidence and Mortality Rates and Trends\u0026mdash;An Update. Cancer Epidemiology, Biomarkers \u0026amp; Prevention. 2016 Jan 12;25(1):16\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eJones C, Lancaster R. Evolution of Operative Technique for Mastectomy. Surgical Clinics. 2018 Aug 1;98(4):835\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eShahzad H. Neoplasm. BoD \u0026ndash; Books on Demand; 2018. 256 p. \u003c/li\u003e\n\u003cli\u003eFowble B, Yom SS, Yuen F. Types of Radiation-Related Skin Reactions. In: Fowble B, Yom SS, Yuen F, Arron S, editors. Skin Care in Radiation Oncology: A Practical Guide [Internet]. Cham: Springer International Publishing; 2016 [cited 2024 Mar 11]. p. 15\u0026ndash;29. Available from: https://doi.org/10.1007/978-3-319-31460-0_3\u003c/li\u003e\n\u003cli\u003eNaidoo W, Leech M. Feasibility of surface guided radiotherapy for patient positioning in breast radiotherapy versus conventional tattoo-based setups- a systematic review. Technical Innovations \u0026amp; Patient Support in Radiation Oncology. 2022 Jun 1;22:39\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eVoci A, Lee D, Ho E, Crane-Okada R, DiNome M. Impact of port site scar on perception of patients with breast cancer: patient-reported outcomes. Breast Cancer Res Treat. 2018 Aug 1;170(3):569\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eNowicki A, Licznerska B, Rhone P. Evaluation of the quality of life of women treated due to breast cancer using amputation or breast conserving surgery in the early postoperative period. Pol Przegl Chir. 2015 Apr;87(4):174\u0026ndash;80. \u003c/li\u003e\n\u003cli\u003eMiller LE. \u0026ldquo;People Don\u0026rsquo;t Understand That It Is Not Easy Being a Cancer Survivor\u0026rdquo;: Communicating and Negotiating Identity Throughout Cancer Survivorship. Southern Communication Journal. 2015 Jan 1;80(1):1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eFingeret MC, Teo I, Epner DE. Managing body image difficulties of adult cancer patients: Lessons from available research. Cancer. 2014;120(5):633\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eCervantes-Luna BS, Alvarez-Ray\u0026oacute;n G, Gomez G, D\u0026iacute;az J. Reliability and constuct validity of the Body Modification Scale in adolescent males. Salud Mental. 2013 Nov 1;36:487\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eLane DC. Understanding body modification: A process-based framework. Sociology Compass. 2017;11(7):e12495. \u003c/li\u003e\n\u003cli\u003eZannini L, Verderame F, Cucchiara G, Zinna B, Alba A, Ferrara M. \u0026lsquo;My wig has been my journey\u0026rsquo;s companion\u0026rsquo;: perceived effects of an aesthetic care programme for Italian women suffering from chemotherapy-induced alopecia. European Journal of Cancer Care. 2012;21(5):650\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eTaggart LR, Ozolins L, Hardie H, Nyhof-Young J. Look good feel better workshops: a \u0026lsquo;big lift\u0026rsquo; for women with cancer. J Cancer Educ. 2009;24(2):94\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eDieckmann KP, Anheuser P, Schmidt S, Soyka-Hundt B, Pichlmeier U, Schriefer P, et al. Testicular prostheses in patients with testicular cancer - acceptance rate and patient satisfaction. BMC Urol. 2015 Mar 13;15(1):16.\u003c/li\u003e\n\u003cli\u003eMohammadi SZ, Khan SM, Vanaki KZ. Reconstruction of feminine identity: the strategies of women with breast cancer to cope with body image altered. International Journal of Women\u0026rsquo;s Health. 2018 Nov 1;10:689\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eFagerlin A, Lakhani I, Lantz PM, Janz NK, Morrow M, Schwartz K, et al. An informed decision?: Breast cancer patients and their knowledge about treatment. Patient Education and Counseling. 2006 Dec 1;64(1):303\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eHaney B. Permanent and Semi-permanent Micro-Pigment Treatments. In: Haney B, editor. Aesthetic Procedures: Nurse Practitioner\u0026rsquo;s Guide to Cosmetic Dermatology [Internet]. Cham: Springer International Publishing; 2020 [cited 2024 Mar 11]. p. 59\u0026ndash;66. Available from: https://doi.org/10.1007/978-3-030-19948-7_7\u003c/li\u003e\n\u003cli\u003eSisti A, Grimaldi L, Tassinari J, Cuomo R, Fortezza L, Bocchiotti MA, et al. Nipple-areola complex reconstruction techniques: A literature review. European Journal of Surgical Oncology (EJSO). 2016 Apr 1;42(4):441\u0026ndash;65. \u003c/li\u003e\n\u003cli\u003eKoller V, Bullo S. \u0026ldquo;Fight Like a Girl\u0026rdquo;: Tattoos as Identity Constructions for Women Living with Illness. Multimodal Communication [Internet]. 2019 Jun 1 [cited 2024 Feb 1];8(1). Available from: https://www.degruyter.com/document/doi/10.1515/mc-2018-0006/html\u003c/li\u003e\n\u003cli\u003eP.ink.org [Internet]. Fuck Cancer c2022 [Cited 2023, Oct 2]. Available from: https://www.p-ink.org/\u003c/li\u003e\n\u003cli\u003eTittoo.org [Internet]. Tittoo c2023 [Cited 2023, Oct 2). Available from: https://tittoo.org/\u003c/li\u003e\n\u003cli\u003eThe Alliance of Medical Tattooing c2023 [Cited 2023, Oct 2). Available from: https://allianceofmedicaltattooing.com/\u003c/li\u003e\n\u003cli\u003eBecker SJ, Cassisi JE. Applications of Medical Tattooing: A Systematic Review of Patient Satisfaction Outcomes and Emerging Trends. Aesthet Surg J Open Forum. 2021 May 4;3(3):ojab015. \u003c/li\u003e\n\u003cli\u003eSomogyi RB, Ziolkowski N, Osman F, Ginty A, Brown M. Breast reconstruction: Updated overview for primary care physicians. Canadian Family Physician. 2018 Jun 1;64(6):424\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eMaselli D, Torreggiani M, Livieri T, Farioli G, Lucchi S, Guberti M. Tattooing to reconstruct Nipple-Areola Complex after oncological breast surgery: a scoping review. Support Care Cancer. 2024 Feb 10;32(3):153. \u003c/li\u003e\n\u003cli\u003eHorton J, Macve R, Struyven G. Qualitative Research: Experiences in Using Semi-Structured Interviews1. In: Humphrey C, Lee B, editors. The Real Life Guide to Accounting Research [Internet]. Oxford: Elsevier; 2004 [cited 2024 Mar 19]. p. 339\u0026ndash;57. Available from: https://www.sciencedirect.com/science/article/pii/B9780080439723500220\u003c/li\u003e\n\u003cli\u003eAllen D. Moving the Needle on Recovery From Breast Cancer: The Healing Role of Postmastectomy Tattoos. JAMA. 2017 Feb 21;317(7):672\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eReid-de Jong V, Bruce A. Mastectomy tattoos: An emerging alternative for reclaiming self. Nursing Forum. 2020;55(4):695\u0026ndash;702. \u003c/li\u003e\n\u003cli\u003eGerber JP. Social Comparison Theory. In: Zeigler-Hill V, Shackelford TK, editors. Encyclopedia of Personality and Individual Differences [Internet]. Cham: Springer International Publishing; 2020 [cited 2024 Jan 8]. p. 5004\u0026ndash;11. Available from: https://doi.org/10.1007/978-3-319-24612-3_1182\u003c/li\u003e\n\u003cli\u003eGreup SR, Kaal SEJ, Jansen R, Manten-Horst E, Thong MSY, van der Graaf WTA, et al. Post-Traumatic Growth and Resilience in Adolescent and Young Adult Cancer Patients: An Overview. Journal of Adolescent and Young Adult Oncology. 2018 Feb;7(1):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eKira I. Toward an Integrative Theory of Self-Identity and Identity Stressors and Traumas and Their Mental Health Dynamics. Psychology. 2019 Mar 6;10(04):385. \u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019 Aug 8;11(4):589\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eCorner J. Nurses\u0026rsquo; experiences of cancer. European Journal of Cancer Care. 2002;11(3):193\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eTolsdorf CC. Social Networks, Support, and Coping: An Exploratory Study. Family Process. 1976;15(4):407\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eAlgorani EB, Gupta V. Coping Mechanisms. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 Mar 20]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK559031/ \u003c/li\u003e\n\u003cli\u003eStutsman, A. Inking agency: women\u0026rsquo;s mastectomy tattoos and emotional healing. California State University, Fresno. 2016;122.\u003c/li\u003e\n\u003cli\u003eOzakinci G, Swash B, Humphris G, Rogers SN, Hulbert-Williams NJ. Fear of cancer recurrence in oral and oropharyngeal cancer patients: An investigation of the clinical encounter. European Journal of Cancer Care. 2018;27(1):e12785.\u003c/li\u003e\n\u003cli\u003eA.R.T. [Internet]. A.R.T Areola Certification Training c2023 [Cited 2024, Feb 8\u003csup\u003eth\u003c/sup\u003e]. https://www.artschool.ink/offers/j3BdjqCP/checkout\u003c/li\u003e\n\u003cli\u003eWu LW, Lin JR. Knowledge sharing and knowledge effectiveness: learning orientation and co-production in the contingency model of tacit knowledge. Journal of Business \u0026amp; Industrial Marketing. 2013 Jan 1;28(8):672\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eIragorri N, de Oliveira C, Fitzgerald N, Essue B. The Out-of-Pocket Cost Burden of Cancer Care\u0026mdash;A Systematic Literature Review. Current Oncology. 2021 Apr;28(2):1216\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eIrish Cancer Society [Internet]. The Real Cost of Cancer Report c2019 [Cited 2024, Feb 8\u003csup\u003eth\u003c/sup\u003e]. https://acrobat.adobe.com/id/urn:aaid:sc:EU:d0c037ff-b5a8-49df-b853-c3c294d22da3\u003c/li\u003e\n\u003cli\u003eSanders Cr. Colourful Writing: Conducting and living with a tattoo ethnography. In: Ethnographies Revisited. Routledge; 2009. \u003c/li\u003e\n\u003cli\u003eNipple Innovation Project [Internet]. NIP c2018 [Cited 2024, Feb 8\u003csup\u003eth\u003c/sup\u003e]. https://www.nipcharity.org/\u003c/li\u003e\n\u003cli\u003eDiCenso D, Fischer-Cartlidge E. Nipple-Areola Tattoos: Making the Right Referral. ONF. 2015 Nov 1;42(6):E376\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eEuropean Society of Tattoo and Pigment Research. Tattoo Legislation [Internet]. c2024 [cited 2024, May 28]. Available from: https://estp-research.org/\u003c/li\u003e\n\u003cli\u003eBroussard KA, Harton HC. Tattoo or taboo? Tattoo stigma and negative attitudes toward tattooed individuals. The Journal of Social Psychology. 2018 Sep 3;158(5):521\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eU.S. Department of Labour [Internet]. Women\u0026apos;s Health and Breast Cancer Rights Act c1998 [Cited 2024, Feb 8\u003csup\u003eth\u003c/sup\u003e]. https://www.dol.gov/general/topic/health-plans/womens\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003e A type of training offered by ART, a training organization mentioned in several interviews.\u003c/span\u003e \u003c/li\u003e\u003cli\u003e \u003cspan\u003e There is up to \u003cspan\u003e$\u003c/span\u003e1,000 dollars in discounts offered for artists already with experience working on scarred skin.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 2","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Therapeutic Tattooing, Tattoo, Body Modification, Cancer Survivorship, Psycho-oncology","lastPublishedDoi":"10.21203/rs.3.rs-4570179/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4570179/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eMany cancer treatments can lead to a disrupted body image and identity. One intervention to address these outcomes is therapeutic tattooing. However, despite the wide dissemination of this practice for cancer survivors (CSs), current research on it is lacking. This study aimed to identify tattoo artists\u0026rsquo; (TAs\u0026rsquo;) perspectives on the types, impacts, barriers and facilitators of therapeutic tattooing for CSs and the impact of doing this work on themselves.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwenty-two international TAs who tattoo CSs were interviewed and resultant transcripts were analysed thematically.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe following themes emerged: \u003cem\u003eEmotional Management of Artists, Emotional Transformation of CSs, Stigma and its effects on CSs, Artist Barriers, CS Barriers, Artist Facilitators, and CS Facilitators.\u003c/em\u003e The findings also identify a typology of cancer survivorship therapeutic tattoos.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis is the first study to identify barriers/facilitators of therapeutic tattooing, a typology of cancer survivorship therapeutic tattoos, TAs\u0026rsquo; perspectives on therapeutic tattooing, and potential negative outcomes from this practice. The findings indicate that therapeutic tattooing can be both beneficial and harmful for CSs and TAs, that there is a need for better therapeutic tattooing training for TAs and healthcare providers (HPs), increased awareness of therapeutic tattoos, a reduction in barriers to the practice and greater collaboration between HPs and TAs.\u003c/p\u003e\u003ch2\u003eImplications for Cancer Survivors:\u003c/h2\u003e \u003cp\u003eFindings from this study have major policy implications for healthcare systems, non-profit organizations, and regulatory bodies, which could serve to empower cancer survivors to make more informed decisions about their bodies and support enhanced training and accreditation of this practice.\u003c/p\u003e","manuscriptTitle":"“Art is just something that makes people heal” - A Qualitative Investigation of Tattoo Artists’ Perspectives on Cancer Survivorship Therapeutic Tattoos","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-13 01:55:07","doi":"10.21203/rs.3.rs-4570179/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-06T17:25:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-26T04:35:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97701075734323738218419029672848623648","date":"2024-06-21T03:06:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-20T20:08:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-14T04:20:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-14T04:19:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2024-06-12T12:22:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa92824a-1029-4ea4-a379-989065e5f6f3","owner":[],"postedDate":"July 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T15:59:25+00:00","versionOfRecord":{"articleIdentity":"rs-4570179","link":"https://doi.org/10.1007/s11764-024-01682-4","journal":{"identity":"journal-of-cancer-survivorship","isVorOnly":false,"title":"Journal of Cancer Survivorship"},"publishedOn":"2024-09-28 15:56:59","publishedOnDateReadable":"September 28th, 2024"},"versionCreatedAt":"2024-07-13 01:55:07","video":"","vorDoi":"10.1007/s11764-024-01682-4","vorDoiUrl":"https://doi.org/10.1007/s11764-024-01682-4","workflowStages":[]},"version":"v1","identity":"rs-4570179","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4570179","identity":"rs-4570179","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}