Photographed by Melissa Mutiara Pandika

Photographed by Melissa Mutiara Pandika

Pediatrician Pierre-Joseph Marie-Rose, MD, performs laser tattoo removal on a patient at S.F. General Hospital’s Children’s Health Center. Dr. Marie-Rose runs another tattoo removal clinic, Second Chance, at the Central American Resource Center in the Mission.

July 2012

SFGH Pediatrician Helps Patients Start Over Through Tattoo Removal

By Melissa Mutiara Pandika

Since February, Mayco has been seeing Dr. Pierre-Joseph Marie-Rose, MD, at San Francisco General Hospital (SFGH) for laser treatment to remove the tattoo on his forearm. Mayco decided to rid himself of his skin display under pressure from his mother, and because it had made him a target of gang violence in his Excelsior neighborhood. Gang-affiliated youth in the area, thinking that the tattoo signified his connection with another gang, viewed him as an outsider straying into their turf.

A 23-year-old immigrant from Guatemala, Mayco, who said he wasn’t in a gang, got the tattoo to cover a knife scar without realizing how much it would endanger him. He found out about SFGH’s Children’s Health Center tattoo removal program from a friend. “I’m feeling good because I think [the tattoo] is getting lighter,” he said. “I can feel better now. After I got it, I was worried on the street.”

Dr. Marie-Rose sees 16 to 20 patients a week at SFGH’s tattoo removal clinic; about the same number of youth and young adults visit the Second Chance Tattoo Removal Program which the doctor also runs. Upwards of 80 percent of the SFGH patients, and more than 50 percent of those visiting Second Chance – which is located at the Central American Resource Center (CARECEN) at César Chavez and Mission streets – have a gang affiliation, according to Dr. Marie-Rose. Both programs aim to assist youth in leaving street life by removing visible tattoos that pose a threat to their personal safety, and can represent an obstacle to securing employment.

In addition to tattoo removal, Second Chance offers case management services, with a goal of working with youth in an engaging, age-appropriate, culturally sensitive way, and providing individual attention and referrals to suitable resources. Second Chance offers mental health services, and tries to engage patients in youth-centered activities, such as field trips and after-school programs, as alternatives to negative street activity. Eligible patients work with a case manager to formulate goals and a plan for achieving them. For example, case managers check in frequently with clients who want to meet their probation requirements to ensure that they adhere to their curfews and make all 211 appointments.

Dr. Marie-Rose was drawn to the idea of tattoo removal as a means of violence prevention and intervention in the mid-1990s, at the height of vicious Sureño gang infighting in San Francisco. “Bodies were literally piling up,” said Dr. Marie-Rose. “It was really disturbing, and those of us working with adolescents and interested in trying to make an impact on the violence we were seeing in the community were at a loss. I think we all thought that education was the answer, but we end up with well-educated clients and no change in behavior. We wanted something more tangible.”

Around that time, Dr. Marie-Rose met Adriana Alvarado, of the Alameda County Public Health Department, and trauma surgeon Lisa Benton, MD, who had begun Project New Start, a tattoo removal clinic at Oakland’s Highland Hospital. After observing them operating their clinic, Dr. Marie-Rose, working with SFGH, San Francisco Department of Public Health (DPH), and Real Alternatives Program (RAP), which provides comprehensive services for Mission youth, made plans to start a tattoo removal program in San Francisco. He co-founded Second Chance in 1998.

 In 2009, after taking a four-year hiatus from tattoo removal to serve as the medical director at juvenile hall, Dr. Marie-Rose returned to Second Chance and started working at SFGH. Concerned that the budget crisis could potentially cut funding for the program, he applied for a Hearts Grant from the SFGH Foundation. “I’m a front line kind of guy,” he said. “I have no experience in writing grants, but I let the program sell itself.” Although he had applied for funding for a three year period, the foundation, enthused by his proposal, decided to fund it indefinitely. Ultimately, DPH, which has supported the program from its inception, spared Second Chance from funding cuts. Dr. Marie-Rose used the surplus funding to start a tattoo removal program at SFGH.

SFGH tattoo clinic’s location on the edge of the Mission and Potrero Hill, historically regarded as neutral territory for gangs, allows it to serve youth on both sides of the gang line. Second Chance is in the heart of Norteño gang territory, rendering it unsafe for youth affiliated with the rival Sureño gang, said Dr. Marie-Rose. City budget constraints cut funding for a Safe Passage program that provided van transportation to and from Second Chance for Sureño-affiliated youth.

The SFGH program was previously housed at St. Peter’s Church on Alabama Street, and then moved to César Chavez and Mission streets. The church location provided a buffering element, since many gang-affiliated youth are Catholic, Dr. Marie-Rose explained. Dr. Marie-Rose hopes that re-establishing a tattoo removal clinic at SFGH makes tattoo removal ­services more accessible, regardless of one’s affiliation, although CARECEN director of social services, Vanessa Bohm, notes that CARECEN has historically worked with both gangs. The presence of hospital security adds another level of safety. And “providing violence initiatives in a healthcare setting directly responds to the public health need,” said Dr. Rhea Boyd, MD, a second-year resident in SFGH’s Pediatric Leadership for the Underserved (PLUS) program, who is working at the tattoo removal clinic as part of her child health advocacy project. “It is about safety, but it is also about the best ways we can respond to major causes of pain and trauma in our youth.”

The SFGH Teen Trauma Recovery Program’s Wrap-Around Project and the Community Response Network (CRN) provide support for the SFGH tattoo removal program. The Wrap-Around Project aims to break the cycle of violence in vulnerable communities by addressing root causes and risk factors with culturally competent case management. CRN combines efforts across nonprofit agencies to establish a network of Safe Havens for at-risk youth. Wrap-Around case managers, many of whom have had prior gang affiliations and/or done active community work, as well as CRN workers, do street-level outreach, recommending Dr. Marie-Rose’s program to youth they identify as potentially on the brink of making a lifestyle change. They’re also on-hand in hospital waiting areas to de-escalate any conflicts that break out between patients.

Patients receive laser treatments every six to eight weeks. With each treatment, the laser shears chemical bonds within the ink, producing progressively smaller fragments of ink. Once the fragments are small enough, the patient’s immune system eliminates them. After two to three years of treatment, the tattoo disappears without a trace.

Technological improvements have led to improved outcomes. Previously, effective tattoo removal required precision. These days the wait to be seen easily exceeds the less than a minute the procedure takes. Tattoo removal is available for free to anyone aged 25 and below at SFGH. Services are free to individuals of all ages at Second Chance, though older patients are asked to make a donation.

The clinic has an informal, mellow atmosphere. Foregoing the white doctor’s coat in favor of jeans and a t-shirt, Dr. Marie-Rose jokes with patients and staff members over hip-hop and old school rhythm and blues tunes played from his iPhone. Yet harsh realities underlie the relaxed environment. “We are inflicting pain on people,” said Dr. Marie-Rose, who plays music both to create a casual environment, but also to distract patients from the pain of the laser, and drown out the loud, popping noise it produces, which some patients find disconcerting. Although he tailors the laser setting to each patient’s pain threshold, he increases it with each session. Otherwise, the tattoos take much longer to remove, a problem for patients whose often unstable lives prevent them staying in the program for more than a few years.

“We’re also bringing [patients] together when not that long ago they were at each other’s throats or may have killed each other’s friends or relatives,” added Dr. Marie-Rose. “At that level it’s profoundly intense.” Despite patients having made the decision to leave lives of violence, there’s still the potential for fights to break out between affiliates of rival gangs in waiting areas. “Some of those old allegiances die hard,” he explained. “Also, just because you’ve decided to make a change doesn’t mean that you’ve learned new ways to react to old situations. It’s a process, and we don’t want to make any assumptions.”

Although Dr. Marie-Rose engages his patients in casual conversation, he chooses his words carefully. A patient, viewing him as an authority figure, could take a facetious comment to heart, resulting in potentially dangerous consequences. Working with youth who might not share one’s values requires extreme awareness and responsibility. “At the end of the day, you and I have no idea what it means to kill somebody to prove a point or to end somebody’s life as a matter of honor, misguided or not,” he said. “You just don’t want to take anything for granted. It’s about being responsible and educating yourself.”

Individuals often get inked in order to be a part of something larger than themselves, explained Dr. Marie-Rose. Social tattoos have experienced a surge in popularity since the 1990s, when they entered mainstream fashion and pop culture. By bearing a tattoo, individuals identify themselves with a hip, trendy subset of society. Many adolescents get tattoos without fully appreciating their permanence and potential effects on future career prospects, added Dr. Boyd. Others get tattooed to commemorate a significant relationship, while some young girls feel pressured into getting tattooed by people who may be trying to exploit them, in which case the tattoo becomes a branding symbol.

Gang tattoos, like gang culture, emerged from correctional facilities, where the incarcerated have few means of displaying group membership. Imprisoned gang members have, however, devised various tattooing methods. One of Dr. Marie-Rose’s clients got tattooed in prison with ink made from ground up chess pieces and dishwashing soap. While the significance of social tattoos is often intended for public broadcast, gang tattoos are usually apparent only to other gang members. Their meanings can span a broad spectrum, often communicating affiliation and allegiance, honoring fallen comrades, or vanquished adversaries.

According to Dr. Marie-Rose, many of his patients with social tattoos remove them as part of a transition from adolescence to adulthood. They may have outgrown their tattoos or taken on a new family role, such as parenthood. In many cases, their tattoos represent a barrier to the lives they’re trying to pursue. For those whose tattoos signify a relationship, especially an abusive or exploitative one, removing a tattoo can be part of an emotional healing process, said Dr. Boyd.

One of Dr. Marie-Rose’s patients, 21-year-old Adrian, wanted to remove his tattoos so that he could enter the military, which prohibits tattoos on certain areas of the body. He associated his tattoos, some of which he got for free, and one of which he obtained while under the influence, with being a “stupid kid.” “[Removing them] is repentance in a way…for all the stupid things I ever did, stupid [people] I’ve hung out with, stupid things I took, stupid things in general,” he said. He ultimately may get the tattoos redone, due to their personal significance, just not as recklessly as the originals. “I want to…remove a past and just start a different, new one,” he said. In the military, he hopes to climb the ranks, eventually becoming a combat medic treating gunshot victims. “I want to actually help people,” he said. “You see how everything’s all bad out here, and…why not just be one of those people that helps?”

“The main reason we started the program is if you are in fact gang affiliated and you want to exit that lifestyle, then part of that is going to involve not carrying those tattoos around,” said Dr. Marie-Rose. To rival gang members, the tattoo is a target for violence not only against the wearer, but also their entire gang and/or faction, known as a “set.” Although Mayco said he wasn’t in a gang, his tattoos nonetheless drew attention from gang members, who asked where he was from. He recalled an incident when a gang member approached him while he was walking with a friend. “I said, ‘I don’t want [trouble]’…. He kept on pushing me…. He had a knife, and I ran.”

 Removing their tattoos can open up employment and military service opportunities, as well as social and cultural acceptance. “Let’s face it, you know people are going to treat you differently if they fear you, and these tattoos have profound potential to elicit fear from lay people who don’t know a lot about gangs or gang culture,” said Dr. Marie-Rose. Even if a young person no longer poses a threat, others may still perceive them as threatening.

Dr. Marie Rose doesn’t necessarily advocate for gang members to leave their gangs. Rather, he provides a tattoo removal service for those who have already made the choice to improve their lives, supporting them in their decision and helping them appreciate their actions’ impact. For many gang-affiliated youth, their gang is their family. “I think it’s pretentious to take a stance on this stuff,” he said. “You don’t know that kid. You don’t know where they’re coming from. You don’t know the factors leading them to think, ‘I’m better off in this gang.’ You don’t have an intimate knowledge of the dynamic of that social group. It is simply irresponsible to advocate removing a support system from a young person’s already unstable life without having an alternative in place. The outcome can be worse than what you set out to change.”

Second Chance and the SFGH tattoo removal program guide patients through the larger process of leaving a life of violence, of which tattoo removal is an integral part. But like any process, success isn’t guaranteed, Dr. Marie-Rose pointed out. His patients continue to live in the same communities, beleaguered with the same problems. Patients’ victims might still harbor strong emotions toward them, and be unwilling to accept that their adversary has changed. Some of Dr. Marie-Rose’s patients have been killed; others have removed all of their tattoos except those indicating their gang affiliation. “For a lot of these young people, it’s the first time they committed to a process that requires a leap of faith, where they don’t get instant gratification or any guarantees, but you have good reason to believe if you work hard enough, something good will come of it,” said Dr. Marie-Rose. The choice to remove a tattoo represents an important step in patients’ maturation process, exposing them to an environment that, though safe, still lies beyond their comfort zone.

According to preliminary data, the average age of Dr. Marie-Rose’s SFGH patients is 20 years old; Second Chance patients tend to be much older. Almost half of SFGH’s patient population is Hispanic, with the other 50 percent divided among Caucasian, African-American, Native American, and Asian races. There’s a roughly even split between genders, with slightly more males than females, and the former are more likely to have gang-related tattoos. While most patients live in the Mission, the programs draw from nearly all parts of the City. Southside neighborhoods enrollment remains low, although Dr. Marie-Rose said that he’s met with a Southeast CRN representative, and wants to refocus on attracting more patients from the area.

Dr. Marie-Rose thinks the tattoo removal programs draw patients partly because they’ve been in the same location for several years, and have partnered with community-based organizations, such as CARECEN, CRN, Wrap-Around, RAP, and Homies Organizing the Mission to Empower Youth (HOMEY) — which offers case management and other programs for underserved youth — that do active street-level outreach. He’s also tried to create environments that respect patients by treating them as individuals, rather than making generalized assumptions about them as a group. The programs’ priority, as well as their greatest success, is to retain patients. Patients that don’t return for several months, usually do so for good reason. Some get arrested, or pregnant.

Although no formal follow-up process exists for tattoo removal patients, Dr. Marie-Rose, frequently runs into his patients, and has never had a negative interaction with any of them. In fact, some of his encounters have been “profoundly positive,” he said. “I felt like a parent. I’m so proud of them.” His son’s daycare provider is a former patient. Other patients have gone on to take leadership positions in community-based organizations doing similar work.

Dr. Marie-Rose has a vested interest in violence intervention, especially among youth in vulnerable communities. He was constantly bullied growing up, which led to behavioral issues and run-ins with the law. He’s witnessed violence, lost friends to violence, and been a victim of violent crime. While serving as the medical director at juvenile hall, he grew weary and frustrated with his patients being constantly exposed to violence, sometimes dying, the vast majority as victims of violence. “It’s something I can’t abide by,” he said.

A second-generation Potrero Hill native, Dr. Marie-Rose considers himself fortunate to “live in the community (he) serves.” His Potrero Hill roots began in 1955, when his father, celebrated artist Henri Marie-Rose, settled in the neighborhood with his mother, Marjorie Raitt, who was trained at the Sorbonne and Académie Julian. As a youth, Dr. Marie-Rose attended the Head Start preschool literacy program adjacent to the Potrero Hill Neighborhood House (Nabe), and participated in the Nabe’s Cub Scout and summer camp programs. Nabe founder Enola Maxwell, photographer Bob Hayes, and former View publisher Ruth Passen helped Dr. Marie-Rose grow up. “Enola’s leadership and commitment to our community was evident in everything she said and did,” said Dr. Marie-Rose. He also recalled how Hayes – who was a jack of all trades, cooking, cleaning and making repairs – taught him photography, including how to develop his own film in the Nabe’s darkroom. “Through the years, he was always so happy to see me and catch up,” he said. “I can still hear him saying, ‘Wow!’ He was very proud of me.” Passen was a mother figure to Dr. Marie-Rose. “What always impressed me about Ruth was her energy level and enthusiasm, which she consistently focused on serving our community,” he said. “All three of these people watched me grow up and to an extent, raised me, and they will always represent, to me, the backbone of the Nabe, a Potrero Hill institution dedicated to community service above all else. I feel privileged to know or have known them.”

Dr. Marie-Rose hopes to eventually have the tattoo removal programs augment and support each other, rather than operate in parallel. He also wants to expand young adult services at SFGH, so that he can continue treating patients who enter the program into their 20s, and help gang-affiliated youth gain the necessary maturity to make positive changes in their lives.

Dr. Marie-Rose is also collaborating with Howard Pinderhughes, PhD, an associate professor at the University of California, San Francisco School of Nursing, to collect data on the motivations behind patients getting and removing their tattoos. They want to improve their understanding of how people decide to change their lives and where tattoo removal fits into that process, which could help create a model of behavioral change indicating where patients are in the process of improving their lives and what interventions are needed to help them on this path. The model could potentially be applied not only to violence, but also obesity, substance abuse, and other health issues.

“We feel that tattoo removal may be a part of the process [of behavioral change] for youth that are exposed to trauma, but we are eager to see what the data shows,” said Dr. Boyd, who is aiding Drs. Marie-Rose and Pinderhughes in their research efforts. “The idea of behavior modification is huge, and everyone is talking about it. If we can identify important steps in the process, that would be a big accomplishment.” Unlike Second Chance, SFGH doesn’t offer case management services, although entry into the SFGH system allows Dr. Mare-Rose to refer them either to himself or to other hospital physicians, as well as organizations like Wrap-Around and CRN. “This is a great place,” said Adrian of the SFGH tattoo removal program. “And besides that, this is a great place for people that don’t have money.” Mayco agreed. “I like coming here,” he said.

 “It’s humbling and validating. I feel privileged,” said Dr. Marie-Rose. “I get out what I put in. It’s a labor of love. It doesn’t matter what’s happening, I will do what I can to keep it going.”

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