Warning: This story contains images and discussion of self-injury.
"I didn't realize how much it meant to me until you started asking," said Cait, her voice quivering, as she told me about the moment last December when a tattoo artist covered up her most visible collection of self-harm scars. He had pulled her in front of the mirror, the stencil already drawn on her arm, and was asking for her final approval before making it permanent. She knew that would be the last time she would see her scars.
The crisscross of purple and white scar tissue across her left shoulder is now undetectable underneath a bouquet of orchids. The length of a shirt's sleeve is no longer the first thing she looks at when buying clothing. Strangers no longer call her "emo" when she leaves her arms uncovered.
"After years and years of hiding that part of your body and all of a sudden you're proud of it. I wanted to show people," she said. "It changed my life."
That moment was a long time coming.
Cait's first method of self-harm started as a child when she began pulling her hair out during times of stress and anger. When this stopped calming her like it used to, she escalated to scratching and then, at age 11, she began cutting.
"I think the real root of the problem was that I was never taught how to deal with emotions, given any coping mechanisms," Cait said.
Cait hasn't self-harmed in almost six years, but the scars on her shoulders, hips, and thighs have lingered. They are memorials to what she has overcome and a reminder of what she calls her most embarrassing moments.
"For many who cut, the scars become a stubborn life chapter that just won't shut."
I'm no stranger to self-harm scars. As a former social worker with teenagers for almost half a decade, I've dressed the self-injury wounds of dozens of clients. A young person cutting—or, in some cases, hacking—at their own flesh during my shift became as mundane as administering their thrice daily cocktail of anti-psychotic, antidepressant, anti-whatever meds. But I never thought of the secondary battle that went beyond the immediate problem of curbing their self-harm into something less destructive.
It's hard to pinpoint how common self-harm is because it's often done in secret. Between one and four percent of American adults and 15 percent of teens are believed to have self-harmed in some way, according to one study of the Journal of the American Board of Family Medicine. A UK study estimates that 7 percent of the country's adolescents may intentionally injure themselves.
Self-harm is not exclusive to teenagers, nor is it a modern day phenomena. The first known mention of self-harm in a medical journal was in 1896 in the Anomalies and Curiosities of Medicine. Women throughout Europe were found to torture themselves with sewing needles earning the label "needle girls." Today, the word "cutting" will likely conjure up an image of emo teenagers with their side swept bangs, skinny jeans, and black hoodies who seem to wear their wrist cuts like the latest trend in bracelets.
For many who cut, the scars become a stubborn life chapter that just won't shut. Unlike other forms of self-harm—say, alcoholism or anorexia—when you cut, burn, or self-injure in some other way, it's a past that can be visible for the world to see years after you stop.
Motherboard asks why we hurt ourselves, and concludes that "the answer may lie in the intense relief we feel when it's over."
Like all the former self-harmers I spoke with for this story, Conor, 22, kept his cutting and burning well hidden. Despite a "fantastic upbringing," Conor struggled with his mental wellbeing as a child. When he became the target of bullies at school, he began self-harming as a way to cope at the age of 13.
"Pretty much all my upper body, anything that could be reachable provided it could be hidden by a t-shirt, you're fine," said Conor, of his cutting and burning areas. "I can walk around in shorts, socks, and a t-shirt and you would never know."
The photos he sent me looked like a meteor storm on his arm: White and purple scars about an inch long started at his wrists and continued to his shoulder and beyond. When Conor ran out of untouched skin on his upper body, he moved on to his ankles.
By age 18 or 19 Conor was ready to remove, cover, or reduce his scars in any way he could—oils, creams, surgery, and tattoos were all on the table. Eventually, he chose three custom tattoos for his ankles; one of them, an eight-point star representing a compass and a new direction in life.
"In the summer, when you want to wear shorts without socks, it just draws the eye away... from any white hairless areas of the leg or any overly purple scarring," he said.
If you browse through the Reddit forum for self-harm, the issue of scars comes up again and again: Are bracelets the best way to cover up? Does scar makeup work? Did your scar tissue take the tattoo ink? On RealSelf.com, a mash of Yelp and Facebook for plastic surgery procedures, more than 2,500 conversations discuss self-harm scars.
"Did I want to have my body on display as a harmed thing or did I want to display it with something I had chosen?" - Marya Hornbacher
Dr. Cengiz Açıkel, a plastic surgeon from Istanbul, Turkey, is a name that comes up often on the site. He is considered one of the go-to doctors for reducing self-harm scars through a technique of dermabrasion—a procedure like extreme exfoliation—and skin grafting.
"These [scars] are hard to explain. They are socially unacceptable and summertime is a nightmare for these people," said Açıkel.
He encountered his first self-harm patient, a former solider, early on in his 18-year practice. After that more came, including pilots, parents, executives in high-flying careers, patients from both sexes and every socioeconomic background. He has treated at least 200 people. Most are Turkish, but some are international.
A self-harm related inquiry to Açıkel's practice is normally triggered by some life event—when you date, go for a job interview, get married, have kids, etc.
"These scars become a problem at every milestone in life," said Açıkel.
A self-harm cover-up from tattoo artist Lindy Pagan at Lucky's Tattoo in New Jersey
For Marya Hornbacher, 41, that milestone was her wedding. She has five significant scars on her arm that she wanted either covered or reclaimed into something beautiful—so to match her wedding dress, Hornbacher had a tattoo of calla lilies twist around and up her arm. It covers some of the scars, but not all of them because some are so substantial they would not take the ink.
"It is something that was a decision: Did I want to have my body on display as a harmed thing or did I want to display it with something I had chosen?" she said.
Hornbacher injured her body in different ways for about two decades. It started with eating disorders, which she details in her Pulitzer Prize-nominated memoir "Wasted: A Memoir of Anorexia and Bulimia" and ended with alcoholism. In the mix, a six-month period of cutting. She was also diagnosed with bipolar disorder, and at the time, cutting "slowed down the mania" that comes with bipolarism—or, at least, "gave me the perception that the mania was slowing down."
"There are very serious moments in your life when you will go 'Gosh damnit. I wish I would not have done that,'" said Hornbacher. Now, she's reclaimed that part of her life with the calla lilly tattoo.
Although tattoos offer a way to salvage self-harm scars, it's an ironic choice. First, like self-harm scars, there's a stigma attached to having tattoos. And then there's the argument that tattoos can be a form of self-harm themselves: The payoff for many self-harmers comes with the rush of endorphins your body is programmed to release when there is an injury.
"You are basically relying on your body's own chemical-producing capacity to generate a set of drugs that change your consciousness," said Janis Whitlock, a research scientist from Cornell who studies self-harm. She referred to it as a process addiction much like pornography, shopping, or gambling. Tattooing injures the body eliciting the same rush of endorphins.
But whether a tattoo is a form of self-harm or not comes down to motivation, according to Karen Conterio, from SAFE Alternatives, an inpatient support group in Missouri. "It is not how often the person is doing it, but why they are doing it," she said.
The decision on what to do with self-harm scars can be complicated by a love hate relationship. Scars can become markers cataloging where you've been. They can also inspire strangers to come and touch them as if they were a pregnant woman's belly or prompt a random guy to mimic slitting his wrists just to piss you off. Both have happened to Laura Lejeune.
"You can look at a certain scar and you know it is from a certain chapter in my life," she said. "Going through so much and overcoming so much, to not have the scars—it's almost like you didn't overcome it."
Lejeune, 21, runs a YouTube channel on mental health from her home in Newcastle, England. She was diagnosed with body dysmorphic disorder, anxiety, and depression when she was 15. As a momentary escape, she turned to self-harm.
At first, she covered her scars with long sleeves, even on hot days. Then it progressed to bandages. She tried makeup, but it went on cakey and drew even more attention to what she was trying to hide. At one stage, laser became a serious contender to remove the scars on Lejeune's arms and thighs. At the last moment she backed away from her appointment. She decided she couldn't be without her scars.
Then, before a trip to Florida with extended family, Lejeune realized she wasn't comfortable baring her scars. She had been considering tattooing a portrait of her grandmother to cover up the scarring on her upper left arm, and with the impending trip, she decided to go for it.
She found Nick Nelson at Ascension Tattoo in Orlando, who took on the job. In addition to the design Lejeune wanted, he added a ring of red roses to cover the raised and purple scars. It became the perfect balance for Lejeune: Her scars were still there, just underneath the tattoo.
Nelson had known a few friends to go through cutting stages, but didn't realize how common it was until he started as a full time tattoo artist seven years ago. He tattoos a handful of clients each year who are there to cover up their self-harm scars. The majority of those clients tend to be in their late 20s. Earlier on they wore their scars like victory badges, but as they got older they became sick of explaining their scars again and again, according to Nelson.
It's the same for Michelle Myles from Daredevil Tattoo on New York's Lower East Side, who said clients coming in for self-harm scar cover-ups generally are embarrassed about their past. "It is something they seemed to have grown out of and they don't want it visible... so they put something positive over it," she said.
Tattooing onto scar tissue is difficult, and Lejeune had to shop around before she found Nelson to take it on. Scar tissue is unpredictable when it is injected with ink. It can behave like normal skin or the ink can begin to bleed out, creating problems if the tattoo design calls for hard lines.
"It's nerve-racking," said Nelson.
He likes clients to wait at least two years before coming in for a tattoo as the skin can still be healing. Getting a doctor to look over the scars first isn't a bad idea either, he said.
Clients who come in for self-harm cover-ups are normally quiet about their back story, and Nelson doesn't quiz them either, but he sometimes has to bite his tongue on whether or not they will go back to self-harming once they get the tattoo.
"Part of me wants to say 'Hey, we are putting some nice art on you. Don't screw this up,'" he said.
I asked Whitlock, the researcher from Cornell, why the treatment community doesn't put a bigger focus on the visibility of scars, their stigma, and their lingering impact on life after self-harm. She told me that for young people this would likely be an ineffective deterrent because of how the brain develops during teenage years. It's when the gap between the brain's prefrontal cortex that regards what information is important, and the amygdale, which is in charge of rational thought, is as wide as it will ever be.
"In general, those kind of cautionary notes about the future tend to fall on pretty deaf ears if someone is around that age and struggling with a lot of emotion," she said.
Conterio, from SAFE Alternatives, doesn't spend much time addressing the long-term impact of scars in the support group either. When the organization started in 1986, it attracted mostly women in their 20s or 30s. Now, the majority of clients are teens.
"It is so much easier to talk about what they do to themselves physically rather than the underlying issues," she said.
When the client is ready, Conterio prepares them on how to talk about their scars. It's a very circumstantial exercise with a response planned for a range of scenarios like if a child asks verses an adult, a close friend verses an acquaintance, or a family member verses a work colleague.
Michelle Bicking, a licensed clinical social worker who runs the Self Injury Awareness Network out of Hartford, Connecticut, wants to see a greater discussion about scars in treatment. Bicking, 38, is a self-harmer in remission, pulling back from cutting her face and between her toes with razors to scratching. She described a disconnect that she and her self-harm clients have to their physical person.
"It is not so much the damage, but focusing on self-love and being aware of the different aspects of a person," said Bicking. "You are a body and one cannot live without the body."
Cait, the vet nurse from Florida, still thinks about self-harming every day even though she's almost six years clean. Keeping her body physically free from scars motivates her to use the elliptical for a quick burst of endorphins instead of cutting. That incentive has increased since she got her orchid tattoo.
"The willpower of not having any marks on my body overpowers the urge to [self-harm]," said Cait. "I like tattoos, but I don't want to be covered in them."
If you are struggling with self-harm, call the 24-hour National Suicide Prevention Hotline at 1-800-273-TALK.
Follow Serena Solomon on Twitter.