BackgroundTattoos are a personal expression of oneself. They may be decorative, religious, cultural, or informative or serve other purposes. Although tattoos may be temporary or permanent, the authors will use the term “tattoo” to refer to permanent tattoos. Traditionally in pharmacy and health professions, tattoos have been viewed as unprofessional.1Westerfield H.V. Stafford A.B. Speroni K.G. Daniel M.G. Patients’ perceptions of patient care providers with tattoos and/or body piercings., 2Search K.R. Tolle S.L. McCombs G.B. Arndt A. A study of visible tattoos in entry-level dental hygiene education programs., 3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. Practitioners have been reminded of this through workplace policies related to personal conduct and dress codes. The profession demands competent and professional pharmacists; however, the conversation regarding professionalism would not be comprehensive or complete without an exploration and critique of tattoo restriction through policy.The profession of pharmacy is becoming more diverse, which has created the need to examine the inclusivity of professionalism standards and policies founded on exclusionary Eurocentric ideology. The 2019 National Pharmacist Workforce Study found the percentage of Black pharmacists increased from 2.3% to 4.9% and the percentage of nonwhite pharmacists increased from 12.9% to 21.8%.4Witry M.J. Arya V. Bakken B.K. et al.National pharmacist workforce study (NPWS): description of 2019 survey methods and assessment of nonresponse bias. Tattoos are cultural norms among groups that are deemed underrepresented in the pharmacy field by the American Association of Colleges of Pharmacy.5Yanchick V.A. Baldwin J.N. Bootman J.L. Carter R.A. Crabtree B.L. Maine L.L. Report of the 2013–2014 Argus commission: diversity and inclusion in pharmacy education. Indigenous folk have used tattoos for cultural expression for centuries.6Williams B.M. Wright C. Leigh K.H. Armstrong B. Kelley S. Tattoos in nursing: do we practice what we preach?.,7Native American tattoos: identity and spirituality in contemporary America. Polynesian tribal tattoos are normative for Native Hawai’ian and Pacific Islander folk. The word “tattoo” is derived from a Tahitian word “to mark.”8Pesapane F. Nazzaro G. Gianotti R. Coggi A. A short history of tattoo. For example, Oriini Kaipara, a news anchor in New Zealand, has traditional Māori facial tattoos that “remind her of her power and identity as a Māori woman.”9Māori journalist becomes first person with facial markings to present primetime news.Even with cultural considerations, tattoos may play a role in cultural norms although the theme or content of the tattoo is not culturally related. In Black American culture, tattoos are culturally normative and appropriate, encompassing themes of individually meaningful life events such as loss, conversion, realization, and major change. Religion and spiritual themes are also commonplace among tattooed Black Americans.10Underneath the surface: African American religion and tattoo culture [Dissertation]. In addition, there is a rich Latino tattoo culture that includes themes such as family, religion, and nationality.11Tattoos are part of Latino tradition.Although tattoos are culturally normative to these underrepresented groups in pharmacy, they are also becoming commonplace for Americans in general. A 2012 poll of more than 2000 subjects in the United States revealed 21% of respondents had one or more tattoos.12Harris Interactive
One in five U.S. adults now has a tattoo. Tattoos are also more common among young people where 30% of subjects aged 25-29 years and 38% of subjects aged 30-39 years had one or more tattoo.12Harris Interactive
One in five U.S. adults now has a tattoo. Tattoos are a reality of our pharmacist workforce that has created a need for discourse regarding their restriction. The restriction of tattoos via policy sends the message that tattoos are not welcome in our profession. This message is personal to those with cultural norms involving tattoos and may come across as “your culture is not welcome in our profession.” Restrictive policies related to tattoos can feel targeted, exclusionary, and discriminatory for underrepresented minorities in the profession in which tattoos are part of the cultural norm.Origins of tattoo biasThe source of the concern and perceptions revolving around visible tattoos deserves to be discussed and critiqued. The history of tattoos long predates western civilization; however, Europeans have created a stigmatizing narrative surrounding tattoos. According to Schmid13Tattoos – an historical essay. of the University of Zürich, tattoos have historically been used by non-European cultures for religious protection, storytelling, fashion, and other practical reasons. Tattooed persons across the globe during the 18th century colonialism were brought back to Europe in the form of artwork or in person and were displayed for the public. Schmid13Tattoos – an historical essay. also says, “With time, the focus moved towards satisfying the fascination and enormous interest of the broad masses in Europe; the imported ‘wild creatures’ from far away reflected the triumph over Europe’s colonies and a proof of domination.” When used in European cultures, tattoos have historically served as a tool for criminal punishment, identification of undesirable persons, and a permanent display of social standing.13Tattoos – an historical essay.Because the Eurocentric tattoo non-normative ideology has a negative perception of tattoos, they are often used as a proxy for poor character, low intelligence, etc. These attributes become further justified to those who wish to limit visible tattoos because they perceive them as a decision—the person “chose” to get a tattoo.14Broussard K.A. Harton H.C. Tattoo or taboo? Tattoo stigma and negative attitudes toward tattooed individuals. As a result, policy has been created to restrict visible tattoos, deter tattooed persons, and promote assimilation. Despite the problematic disregard of cultural norms, this rationale lacks empathy—a trait and skill deemed essential for minimally competent pharmacists by the Accreditation Council for Pharmacy Education.15American College of Physician Executives
Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree. According to a review article by psychologists Broussard and Harton,14Broussard K.A. Harton H.C. Tattoo or taboo? Tattoo stigma and negative attitudes toward tattooed individuals. this rationale of tattoos as a choice is also used to disparage patients who use tobacco and have developed lung cancer, patients with alcohol use disorder who develop liver disease, and patients with obesity-associated morbidity. The result of this approach is stigma that leads to discrimination.14Broussard K.A. Harton H.C. Tattoo or taboo? Tattoo stigma and negative attitudes toward tattooed individuals. Despite this, individuals with and without tattoos have been assessed to be similar in terms of intelligence, honesty, and other traits by which society determines one’s character.16Swami V. Gaughan H. Tran U.S. Kuhlmann T. Stieger S. Voracek M. Are tattooed adults really more aggressive and rebellious than those without tattoos?.,17Swami V. Pietschnig J. Bertl B. Nader I.W. Stieger S. Voracek M. Personality differences between tattooed and non-tattooed individuals. This further dismantles the ideology that tattooed persons are of low moral character.Perceptions of tattoos in health care and other professions

There is limited literature on the public’s perception of pharmacists with tattoos. However, there are publications related to perceptions of tattoos on health care and other professionals including nurses, radiologists, and dental hygienists.

A study by Westerfield et al.1Westerfield H.V. Stafford A.B. Speroni K.G. Daniel M.G. Patients’ perceptions of patient care providers with tattoos and/or body piercings. surveyed 150 adults to explore patient’s perspectives of health care providers with tattoos. The study used 4 images of 2 health care providers: 1 white male with and without a visible arm tattoo and 1 white female with and without a visible arm tattoo. For the male provider, whether he had a visible tattoo or not, there was no difference in the patient’s perception of him being caring, confident, reliable attentive, cooperative, professional, efficient, and approachable.1Westerfield H.V. Stafford A.B. Speroni K.G. Daniel M.G. Patients’ perceptions of patient care providers with tattoos and/or body piercings. The same was found for the female provider, except patients felt that the tattooed female provider was less professional than the nontattooed counterpart (P1Westerfield H.V. Stafford A.B. Speroni K.G. Daniel M.G. Patients’ perceptions of patient care providers with tattoos and/or body piercings. Limitations to this study include most respondents were white (77%) and older than the age of 46 years (72%), both providers were white, and it was conducted at a rural mid-Atlantic hospital.1Westerfield H.V. Stafford A.B. Speroni K.G. Daniel M.G. Patients’ perceptions of patient care providers with tattoos and/or body piercings. This affects the generalizability of the study to health care providers of other races or ethnicities and perceptions of tattoos on health care providers in urban settings where tattoos may be more prevalent and socially accepted.To contrast, a study was done in an emergency department (ED) in Pennsylvania where patients interacted with a male or female ED physician who wore an arm tattoo, a piercing, both, or none.18Cohen M. Jeanmonod D. Stankewicz H. Habeeb K. Berrios M. Jeanmonod R. An observational study of patients’ attitudes to tattoos and piercings on their physicians: the ART study. In 924 interactions, patients rated the physician on competence, professionalism, caring, approachability, trustworthiness, and reliability.18Cohen M. Jeanmonod D. Stankewicz H. Habeeb K. Berrios M. Jeanmonod R. An observational study of patients’ attitudes to tattoos and piercings on their physicians: the ART study. None of these ratings were affected by the physician having a tattoo. Anecdotally, the physicians received positive comments during this study. Limitations to this study include the use of a convenience sample, a lack of racial and ethnic diversity among physicians, small physician sample size of 6, and a survey that was only provided in English. These factors limit the generalizability to other institutions. However, the authors concluded there were no differences in perception of patient care by patients who were treated by physicians with visible body art.18Cohen M. Jeanmonod D. Stankewicz H. Habeeb K. Berrios M. Jeanmonod R. An observational study of patients’ attitudes to tattoos and piercings on their physicians: the ART study. After the study concluded, Motluk interviewed Dr Rebecca Jeanmonod, one of the physician participants, who said, “It’s not the patients who have a problem with it [at least in emergency rooms]. It’s more something we impose on one another.”19Is it unprofessional for doctors to have tattoos or facial piercings?. Thus, we feel workplace policies should not restrict visible tattoos.A study by Gildon et al.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. surveyed radiologists on their perceptions of other radiologists having visible tattoos at work. Of a sample of 943 radiologists, 39.7% reported having a tattoo. Radiologists without tattoos had less favorable views of visible tattoos on peers.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. Radiologists with nonvisible tattoos had lower visible tattoo acceptance scores than those with visible tattoos aligning to workplace norms despite having a tattoo themself.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. The context of the tattoo had an impact on perceived acceptability with medical related tattoos being more acceptable versus other tattoos. This study sample had a majority of female respondents (77.8%), urban employment (69.2%), and predominantly worked in the South region (40.4%) followed by the Midwest (33.6%) with a mean age of 46 years.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. In addition, of those who responded 63.3% reported that their institution has a formal tattoo policy and 20.5% did not know whether their institution had a tattoo policy.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. Almost 53% of respondents reported their facility requires tattoos to be covered and 14.9% did not know whether their institution required tattoos to be covered.3Gildon B. Baldwin J. White R. Perceptions of visible body art among radiographers. The geographic locations, demographics, and already implemented policies regarding tattoos may have affected social acceptance of tattoos among the radiologists surveyed. One must balance their thoughts on personal freedom versus patient perceptions and satisfaction. Markey20

Markey L. Repairing the rusty needle: recognizing first amendment protection for tattoos. Kans J Law Public Policy;21(2):310–328.

details the progression of the history of tattoos and concludes that tattoos are in fact protected as freedom of expression. We feel that having a tattoo does not affect the professionalism or competence of the health care providers given that professionalism in many definitions refers to the attitudes, behaviors, and values of health care providers.21ASHP
ASHP statement on professionalism., 22Dubbai H. Adelstein B.A. Taylor S. Shulruf B. Definition of professionalism and tools for assessing professionalism in pharmacy practice: a systematic review., 23Patel P.M. Vaidya V. Osundina F. Comoe D.A. Determining patient preferences of community pharmacy attributes: a systematic review.Biases against tattoos may present themselves in health program administrative roles. A survey was administered to dental hygiene program directors (PDs) to assess perceptions of tattoos on candidates of the dental hygiene program.2Search K.R. Tolle S.L. McCombs G.B. Arndt A. A study of visible tattoos in entry-level dental hygiene education programs. PDs felt hygienists with visible tattoos would be perceived as less professional.2Search K.R. Tolle S.L. McCombs G.B. Arndt A. A study of visible tattoos in entry-level dental hygiene education programs. Most programs surveyed (97%) had dress code policies requiring tattoos be covered. This study is limited in that only PDs were surveyed compared with dental office staff responsible for hiring hygienists, and 56% of those surveyed were older than the age of 56 years,2Search K.R. Tolle S.L. McCombs G.B. Arndt A. A study of visible tattoos in entry-level dental hygiene education programs. in which biases against visible tattoos may be present.24Consumer perceptions of visible tattoos on service personnel. The personal perceptions of PDs may influence school dress code policies, which may encompass policies regarding visible tattoos.Learners’ perceptions of tattooed professionalsThere is scant literature in the United States regarding student perceptions of faculty or medical personnel with visible tattoos; however, in Poland, university students from nonmedical (N = 199) and medical background (N = 477) were receptive, 86% and 76%, respectively, to visible tattoos on medical staff.25Paprocka-Lipińska A. Majeranowski A. Drozd-Garbacewicz M. Mazanek M. Hebdzińska M. Styszko J. Can medical staff have visible tattoos? A survey study among students. Professions in which visible tattoos were least accepted by survey respondents included clinical psychologists (63.3% acceptance), physicians (65.4%), nurses (66.3%), and dentists (67.8%). This study specifically evaluated whether respondents felt pharmacists can have visible tattoos. Most respondents (71.3%) felt that pharmacists can have visible tattoos and 8.4% did not think pharmacists should have visible tattoos.25Paprocka-Lipińska A. Majeranowski A. Drozd-Garbacewicz M. Mazanek M. Hebdzińska M. Styszko J. Can medical staff have visible tattoos? A survey study among students. This study found that those who had tattoos were much more receptive (92%) to health professionals having visible tattoos than their nontattooed counterparts. This study is limited in that it was conducted in Poland, which may have differing views on tattoos compared with the United States. In addition, most respondents were female, 77% among medical university and 83% among nonmedical university, and the age demographic was not discussed. Thus, these findings may not be generalizable to the United States population.In addition, Wiseman26Perceptions of a tattooed college instructor. conducted a study involving 128 undergraduate college students in New Jersey to assess perceptions of a tattooed college instructor. These students were recruited from an introductory psychology class. Students read a summary of the college instructor written by a peer coworker from the same department. The instructor was a white female who was posed and photographed with no tattoo, a cross tattoo, a wire tattoo, or both cross and wire tattoo.26Perceptions of a tattooed college instructor. A tattoo of a cross is often a symbol of Christianity, whereas a tattoo of barbed wire often symbolizes strength or overcoming hardship. Some may perceive a wire tattoo as intimidating. Students all received the same summary with one of the 4 photographs and were asked to rate the instructor based on a 7-point scale. The tattooed professor rated higher than the nontattooed professor in “motivates students effectively,” “is imaginative about assignments in a good way,” and “I would recommend this teacher to other students.”26Perceptions of a tattooed college instructor. This demonstrates that the presence of tattoos does not always correlate to negative perceptions. Limitations include that the only model was a white female, which excludes other demographics and limits the generalizability of this study to other populations.Overcoming exclusionary policiesSome institutions such as Mayo Clinic are ahead of the curve with allowing visible tattoos as long as they do not show violence, profanity, or sexually explicit content.27Modern healthcare
Mayo Clinic allows a tasteful show of tattoos. Williams et al.6Williams B.M. Wright C. Leigh K.H. Armstrong B. Kelley S. Tattoos in nursing: do we practice what we preach?. asks, “Do we have a double standard by not allowing nursing students to display their tattoos, while teaching tolerance of patients’ diverse lifestyle choices?” By allowing health professionals and staff to have visible tattoos, this sets an example for learners to provide nonjudgmental patient care to all by destigmatizing tattoos. We recommend reconsidering policies that suggest covering tattoos in workplaces to promote inclusivity as mentioned in Naughton et al.28Naughton C.A. Schweiger T.A. Angelo L.B. Lea Bonner C. Dhing C.W. Farley J.F. Expanding dress code requirements in the doctor of pharmacy program.Core components to professionalism in pharmacy are defined as “competence, inclusivity, ethics, accountability, integrity, and trust.”21ASHP
ASHP statement on professionalism. Similarly, patients prefer a pharmacist who is “friendly, helpful, trustworthy, professional, competent, caring, knowledgeable, responsive, and approachable.”23Patel P.M. Vaidya V. Osundina F. Comoe D.A. Determining patient preferences of community pharmacy attributes: a systematic review. These characteristics are independent of a pharmacist having visible tattoos or not.

The authors question whether we as pharmacists are the ones limiting our definitions of professionalism with personal or historical biases regarding restrictive dress code policies. It is critical that policies regarding visible tattoos are re-evaluated through the lens of evolving professional landscape, destigmatizing marginalized groups, and practicing inclusivity. This can be done by reviewing policies regarding visible tattoos to revise this restriction to create an inclusive work environment.

Article InfoPublication History

Published online: June 29, 2022

Accepted: June 26, 2022

Received: April 22, 2022

Publication stageIn Press Journal Pre-ProofFootnotes

Disclosure: The authors declare no relevant conflicts of interest or financial relationships.

Identification

DOI: https://doi.org/10.1016/j.japh.2022.06.012

Copyright

© 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

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