The Semicolon Tattoo

For millennia, tattoos have been used to decorate human skin as an outward symbol of underlying personal and cultural significance (1). Today, one such symbol comes in the form of a semicolon inked not in the fibers of any paper but rather in the skin of the patient who might be sitting across from you. It is a clinically significant clue that providers will need to understand in order to keep pace with a generation of patients who are interconnected within digitally driven cultural movements that are giving voice to those who may have been previously silent.

Amy Bleuel, a college student inspired by the loss of her father to suicide and her own long-standing battle with depression, started Project Semicolon in 2013, primarily in an effort to help destigmatize mental illness (2). The semicolon tattoo has since been further popularized in the Netflix series 13 Reasons Why, and it is estimated that photos of semicolon tattoos have now been shared online millions of times (2). The underlying symbolism behind the semicolon tattoo is succinctly described in that it "represents a sentence the author could've ended but chose not to" (3). In more concrete terms, the semicolon tattoo is a statement indicating that a person once thought of ending his or her life but instead decided to continue living. Ultimately, it is a symbol of hope that the wearer is the author of his or her own life and is empowered to dictate how to continue his or her story.

The semicolon tattoo can be clinically relevant information, hence why it is important for providers to be aware of this cultural phenomenon. For example, if a semicolon tattoo is appreciated in a patient who denies any history of suicidal ideation, inquiring about the tattoo could lead to further discussion of suicidality, which may be therapeutically productive. Perhaps the patient may have had suicidal ideation in the past but still harbors substantial shame, prohibiting more open discussion of the topic. Perhaps the tattoo is in support of a loved one with mental illness, ultimately shaping underlying schemas regarding psychiatric disorders in a manner that may prove to be either instrumental or possibly counterproductive within the therapeutic relationship. Regardless, inquiring about the tattoo may be a more acceptable bridge into these areas of exploration previously veiled in resistance.

In the years since its inception, the semicolon tattoo has served not only to help destigmatize mental illness within popular culture but to bring clarity to those who wear it as an outward declaration of an ongoing quest to overcome inner pain. Despite the far-reaching positive influence that her movement has created, Amy Bleuel succumbed to her struggles on March 24, 2018, at the age of 31. Although her story now ends with a period, her legacy lives on, still punctuated by a semicolon.