Body Modification: Tattooing and Body Piercing
Monica Sifuentes, MD
A 16-year-old girl comes to your office for her annual physical examination. Although the girl was previously healthy, her mother is concerned that the girl seems irritable and unwilling recently to participate in family events. The adolescent is currently in 10th grade at a local public school, gets As and Bs in most subjects, is a member of the volleyball team, and has just begun working part-time at a movie theater. Both her parents are employed, and the girl gets along well with her 19-year-old sister, who is currently in college, and her 14-year-old brother. She has many friends in the neighborhood as well as at school.
You interview the adolescent alone and learn that she occasionally smokes marijuana, has tried cocaine on 1 occasion, and attends parties at which many people are drinking alcohol. She has been sexually active in the past but is not currently. She denies depression and describes her mood as generally happy, except when she is forced to spend what she believes is excessive time with her family instead of with friends.
On physical examination, the adolescent’s height and weight are in the 50th percentile for age. Her body mass index is 21. Vital signs are normal. You note a small tattoo at her right hip area. The girl’s mother is unaware of its presence, according to the teenager. She obtained it a few months prior while visiting her sister in college.
1. What is the epidemiology of body modification in adolescents and young adults?
2. What is the motivation for obtaining tattoos and body piercing in this age group, and is there an association with high-risk behavior?
3. What techniques are used to place tattoos and perform body piercing?
4. What are possible adverse consequences of body modification, and what should be done to manage them?
5. How can the primary care physician assist an adolescent in making a safe and healthy decision about body modification?
Body modification is the practice of permanently altering one’s appearance, and it has been practiced in many cultures worldwide for millennia. Such modification includes tattooing, body piercing, and scarification. Although much less common than tattooing and body piercing, scarification uses various techniques to intentionally irritate the skin to produce a permanent pattern of scar tissue. It is described as a more intense form of body modification and is reportedly appealing to individuals seeking a more dramatic result.
Historically, body modification, particularly tattooing, was associated primarily with the military and with disenfranchised individuals, such as criminals and gang members. Currently, however, it is considered mainstream among many individuals in US society, with people of all ages as well as socioeconomic and educational backgrounds sporting tattoos and piercings. Body art is seen in most clinical settings serving youth and young adults as well as in middle schools and high schools and on college campuses. Additionally, it is not uncommon to encounter a teenager with multiple tattoos and body piercings or to evaluate an adolescent for a possible complication of the procedure. Whether described as a rite of passage, an expression of their own individuality, or a desire to join a particular peer group, obtaining a tattoo or body piercing has become a widespread experience during adolescence and young adulthood and therefore should be added to the primary care physician’s list of issues to review with the teenager during the routine health maintenance visit.
The practice of typical body modification should be distinguished from more intense nonsuicidal self-injurious behaviors, such as cutting, scratching, burning, and hitting oneself. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes nonsuicidal self-injury disorder (NSSID) as a mental health disorder associated with self-injury that can manifest in impulsive or compulsive adolescents suffering from anxiety, depression, personality disorders, or psychotic disorders. Adolescents engaged in self-injury expect to gain relief from their negative emotions through physically hurting themselves and may use this behavior as a means of coping with personal emotional issues. Consultation with a mental health specialist is warranted for these challenging cases.
It was previously estimated that 13% to 25% of the general population in the United States had a tattoo. Because tattooing has grown in popularity and become a fast-growing retail business, however, these figures are likely a gross underestimation. Surveys conducted in outpatient clinics and on high school and college campuses confirm that more than 10% to 15% of teenagers aged 12 to 18 years have a tattoo. In a study of more than 2,000 US high school students, 55% expressed interest in obtaining a tattoo regardless of its permanence or the students’ academic success in school. Additionally, it has been reported in the literature that one-half of new tattoos are obtained by women and that many are obtained during the college years. Surveys conducted in the last 10 years reveal that approximately 20% to 25% of college students have a tattoo.
Body piercings are more common than tattoos among adolescents and young adults, and some experts speculate that this may be because the procedure is not permanent, allowing the individual to remove the jewelry at any time. In a study of college students, 45% had undergone body piercing and 22% had tattoos with and without piercings. Other studies that include younger adolescents attending an outpatient adolescent clinic report body piercing in approximately 27% and tattoo in approximately 13%. Most studies also confirm that females are more likely to obtain a piercing than males; male athletes are more likely to obtain a tattoo than their nonathlete male counterparts.
The motivation for obtaining body art also has been studied, with most of the literature confirming adolescents’ search for uniqueness and desire to enhance their independence and self-identity. For some teenagers, body art is considered a form of decoration or an opportunity to be creative; alternatively, it fulfills a desire for peer acceptance and solidifies group membership. Attainment of body art for the purpose of peer acceptance or solidifying group membership has been documented by studies demonstrating that friends or peers provide the strongest influence for youth pursuing body art. Tattoos in particular can be a means of permanently documenting a relationship with an individual or group. Despite popular belief, studies do not confirm that most adolescents obtain a tattoo or body piercing impulsively while under the influence of illicit drugs or alcohol. In fact, many older teenagers and young adults report taking considerable time to decide whether to obtain a tattoo or piercing.
The extent to which parents or guardians are involved in the adolescent’s decision to have a tattoo placed or body piercing performed is variable for many teenagers and depends on their particular relationship, whether the adolescent is a minor, and state parental consent requirements. In some cases, parents are not consulted before the procedure, although in many states the law requires parental consent and presence, and tattooing of minors is prohib-ited. Current laws are not consistently enforced, however, and in many states tattooing and body piercing have different regulations. Health professionals are therefore encouraged to become familiar with their individual state laws related to minors obtaining tattoos and piercings to counsel their patients appropriately.
Tattoos can be found on any area of the body and, depending on the talent of the artist and the desire of the client, can be simple and 1 color or quite elaborate and multicolored. Generally, amateur tattoos (ie, those performed by a nonspecialist or friend) are less intricate and are considered more risky because often they are not performed under ideal circumstances, using antiseptic techniques, or with conventional pigments and applicators. Unconventional pigments include charcoal, India ink, and mascara. Pencils, pens, sewing needles, and other sharp objects, including guitar strings, may be used to apply the dye for a self-administered or amateur tattoo.
The most common site for piercing is high on the pinna of the ear. Regular lobular ear piercings are not generally included in the context of body modification because they occur commonly at any age. Other body sites that are pierced include the tragus of the ear, eyebrows, tongue, nose, nasal septum, cheek, lip, navel, and nipples. Intimate or genital piercings also can be seen in males and females. The foreskin, penis, scrotum, clitoris, perineum, and labia are all common areas for intimate piercings. Although specific data by sex are not available, it is reported that more men than women obtain genital piercings.
Technique, Application, and Safety Standards
The process of applying a professional or commercial tattoo is relatively standardized, although different tattoo parlors may have their own individual practices. Generally, the client selects a design from flash sheets in the shop or an individualized design by the artist, and the tattoo is stenciled or drawn on clean-shaven skin. The skin is cleansed again with an antiseptic solution, and a thin layer of ointment, such as petroleum jelly, is placed on the site. Most professionals in the United States use a motorized, electric-powered tattoo gun, which is similar to a dental drill, that holds 1 or several needles in a needle bar that is dipped in ink and that punctures the skin a few millimeters deep, up to several thousand times a minute. In Europe, small amounts of ink are applied directly to the skin and the needle is used to push the ink into the skin. Regardless which method is used, the pigment reaches the level of the dermis via the solid-bore needle or needless, while blood and serosanguineous fluid are wiped away as tattoo placement continues. When the tattoo is completed or the session is finished, an antibiotic ointment is applied and a bandage is placed over the site.
The client is instructed to remove the dressing 24 hours later and keep the area moist with an antibiotic ointment. Additionally, clients are instructed to place an emollient or vitamin E oil over the healing tattoo several times a day. The area is to be cleansed with a mild soap and patted dry or blotted (not rubbed). If aftercare instructions are followed carefully, most tattoos heal in approximately 2 to 3 weeks, with superficial crusting and “shedding” of epidermis as part of the natural course of tattoo placement. Sunscreen should be worn if sun exposure cannot be avoided in the ensuing weeks. Swimming, soaking in water, and direct shower jets to the area are discouraged for several weeks.
Ideally, the application process uses inks that are poured into single-use disposable containers and sterile needles that are disposed of after each client. Although the tattoo ink pigments are considered cosmetics and are subject to US Food and Drug Administration regulation, however, neither the tattooing process itself nor the use of the inks is regulated. Additionally, certain pigments may not be approved for intradermal use and have been known to contain low concentrations of metal salts, such as lead, iron, mercury, or aluminum.
The practice of universal precautions is required by state and local regulatory agencies and advocated by specific educational groups, such as the Alliance of Professional Tattooists (APT), a nonprofit organization established in 1992 to promote standards for professional and associate tattooists and develop guidelines for consumers to evaluate the safety of individual tattooing establishments. The organization also sponsors regular educational seminars for tattoo artists on the prevention of disease transmission in tattooing. Membership in APT is voluntary and requires that the professional tattooist pay annual dues, participate in a health and safety semi-nar, and have at least 3 years of full-time experience at a consistent location. Other membership levels are available, with variable costs for annual dues and requirements for membership (eg, <3 years’ experience and/or apprenticing associates). Despite APT efforts and standards, however, specific areas of concern about the tattoo industry remain, including unlicensed tattoo artists and establishments, the presence of unregulated ingredients in the pigments, inconsistent cleaning of equipment between clients, an inability to reliably sterilize all parts of the equipment despite good efforts, and infrequent inspections of tattoo parlors by regulatory agencies.
The process of body piercing is generally less complicated than tattooing and depends, in part, on the anatomic site to be pierced. The client chooses the jewelry and body part to be pierced, the area is cleaned with a topical antiseptic, and a large hollow needle is brought through the skin. The jewelry is then brought through the hole following the needle, and the hole is sealed with a bead, bar, or metal disc. Because the procedure is relatively quick, topical anesthetics are generally not required.
Although earlobe piercing is a relatively straightforward procedure, it is commonly performed using a piercing gun at a local mall, cosmetic shop, or kiosk. Because the stud is driven through the earlobe via the gun rather than through a hollow tube manually, the tissue is torn or crushed rather than pierced. Additional concerns about the piercing gun include inconsistent and informal training of personnel, an inability to sterilize all parts of the gun between procedures, and embedded earrings and ear backs. The gun cannot be adjusted for the thickness of other tissues, so although it is a popular method for earring placement, this tool is not recommended for sites other than the earlobe.
The immediate aftercare of piercing varies by the site pierced. For example, local skin discoloration and a nonmalodorous serous exudate can occur with piercings of the nares or navel. Tongue or lip piercings have been associated with significant swelling for several days after the procedure. Additionally, a yellow-white fluid secretion can occur that, to the unfamiliar examiner, appears to mimic an infection. Clients with oral piercings are generally instructed to dissolve ice in their mouth immediately after piercing to help with pain and swelling, manage further discomfort with a nonsteroidal anti-inflammatory drug, and elevate the head when sleeping.
Healing times vary considerably depending on the anatomic site of the piercing. Generally, sites with increased vascularity and exposure (eg, face, tongue) tend to heal faster than those involving cartilage, which is poorly vascularized. Areas of the body that are subject to movement also heal more slowly. For example, healing time may be 1 to 2 months for the tongue, 1 to 1.5 months for the nasal septum, 2 to 3 months for the nostril, and 2 to 4 months for the tragus of the ear. High-ear piercings through the cartilage also may require 2 to 4 months for healing. Navel piercings have the longest healing time (up to 9–12 months) because of friction and moisture from clothing and often are associated with the most complications.
As with tattooing, not all states have regulations and safety standards in place for body piercing, and if such regulations and safety standards do exist, local governing bodies do not consistently enforce them. Universal precautions should be strictly practiced, and the adolescent should be familiar with these guidelines and know how to find a reputable piercer before obtaining body art.
Because no formal training programs exist for piercers, many learn by video or apprenticeship. Generally, practitioners in stu-dios have completed an apprenticeship and have more training than those in cosmetic shops, malls, or ear-piercing kiosks. They also are more experienced in piercing sites other than the ears and may be members of the Association of Professional Piercers (APP). Established in 1994, the APP is a nonprofit organization dedicated to the education, health, and safety of body piercing for the public. It has developed self-regulatory policies for the industry, standards for membership in the organization, and annual conferences on health and safety issues. Members must have at least 1 year of piercing experience, documented training in blood-borne pathogens and cardiopulmonary resuscitation, and certification in first aid. Members also must show photographic proof of a medical-grade autoclave in the piercing studio and send in spore test results from the autoclave. To help document this, a detailed video of the studio is required, along with copies of all aftercare education given to clients. After this process is completed, the member receives a certificate to mount in the studio.
Current legislation addressing minors and piercing is regulated by individual states; in some states, such as California, ear piercing performed with piercing guns is excluded from the definition of body piercing. Concerning minors, the APP requires that the parent or legal guardian as well as the minor show proof of identification before signing the consent form for body piercing. Additionally, nipple or genital piercings are not performed on anyone younger than 18 years.
All teenagers should be interviewed alone, after their parent or legal guardian has had an opportunity to discuss their concerns with the health professional (see Chapter 4). A visible tattoo or body piercing allows the physician to inquire about the circumstances surrounding the body art at the beginning of the interview, in contrast to body art noted in an inconspicuous area of the body during the physical examination. Whether parental consent was obtained before the procedure should be addressed directly, because this issue could be a basis for current as well as future familial conflict. The type of facility in which the tattoo or piercing was obtained should be discussed, along with whether the adolescent recalls whether universal precautions were followed. A general review of systems should be performed to exclude systemic conditions, such as viral hepatitis, as well as any other complications related to obtaining the tattoo or piercing in a nonprofessional environment. Specific questions about the area of the body that is pierced also should be reviewed (Box 65.1). For example, the teenager with a tongue piercing should be asked if he, she, or they has problems with mastication, swallowing, loss of taste or movement, or permanent numbness.
It has been reported that amateur or self-administered tattoos are associated with increased high-risk behaviors, including substance abuse at a younger age, illicit drug use, lower academic achievement, and an increased number of tattoos overall. Recent studies have shown, however, that not all adolescents and young adults with multiple tattoos or body piercing(s) engage in high-risk behavior (Box 65.2). Successful academic achievement and close family support have been reported in tattooed and nontattooed college students. Although tattoos are permanent, more than 50% of academically successful high school students with consistently good grades have reported an interest in them.
Box 65.1. What to Ask
Tattoos and Body Piercing
•When was the tattoo or body piercing placed?
•Did the teenager obtain consent from the parent or legal guardian before getting the tattoo or piercing?
•Is the adolescent satisfied with the tattoo or piercing?
•Was the tattoo or body piercing placed by a professional or by a friend, acquaintance, or relative?
•If the tattoo or body piercing was obtained in a studio, where was the studio located? Was it licensed? Was it clean, “like a medical facility”?
•Did the tattooist or piercer wash his, her, or their hands before gloving? Use new disposable gloves? Open all equipment in front of the teenager?
•For tattoos, did the tattooist remove a sterile needle and tube set from a new envelope? Did the tattooist pour fresh ink in a new disposable container?
•For body piercing, did the piercer use individually wrapped sterile needles? Did the piercer use a piercing gun?
•Did the teenager receive aftercare education, including written material?