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Tattooing and Body Piercing: Body Art Practices Among College Students
Judith Greif, Walter Hewitt and Myrna L. Armstrong
Clin Nurs Res 1999; 8; 368
DOI: 10.1177/10547739922158368
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CLINICAL
Greif
et al.NURSING
/ BODY ART
RESEARCH
PRACTICES
/ November 1999
Tattooing and body piercing are increasing, especially among college students. A
study of 766 tattooed and/or body-pierced college students in 18 universities
across the United States and one in Australia was conducted to discover the
demographic characteristics, motivational factors, and health concerns. The traditional college time of 18 to 22 years of age (69%) was when they obtained their
tattoo (73%) and/or body piercing (63%). More frequent health problems and impulsive decision making were noted for those with body piercing when compared
to those tattooed. Three cases of hepatitis were reported. Health professionals
should openly discuss body art with students, convey a nonjudgmental attitude,
and assist with informed decision-making information to either reduce risks or
dissuade. Open communication and applicable health education will be very
important.
JUDITH GREIF
WALTER HEWITT
Rutgers University Health Service
MYRNA L. ARMSTRONG
Texas Tech University Health Sciences Center
Body art, specifically tattooing and body piercing, has been practiced in almost every culture around the world, and for thousands of years. Tattoos are now being reported on archaeological findings including a 2,400-year-old Russian mummy with a
tattoo still clearly visible on her biceps (Polosmak, 1994). Royalty, especially the name of Queen Victoria, is frequently mentioned as having had a tattoo, and her consort, Prince Albert, is
Authors Note: We gratefully acknowledge the thoughtful review of Janet K.
Bundy, M.S., R.N. C.I.C., Dr.PH(c); also, services of Judy Soncrant, project
manager, and Dawn Wald, supervisor, computer services, and the late Rita Puritz, administrative assistant, Rutgers University.
CLINICAL NURSING RESEARCH, Vol. 8 No. 4, November 1999 368-385
1999 Sage Publications, Inc.
368
369
said to have had a penile piercing through his urethra (Greif &
Hewitt, 1998). Anthropologists describe body art or modification as a way of identifying oneself as being a part of a specific
group, whether a religious group, a tribe, or gang; of denoting
ones financial or marital status; or even as a way of beautifying
the body (Myers, 1992; Saunders, 1989). Many, from pirates to
Roman Centurions, have had body piercingssometimes symbolizing royalty, bravery, virility, or as a rite of passage. Yet in
Western culture, tattooing and piercing often have been considered taboo, perhaps stemming from the Bibles Old Testament citing in Leviticus 19:28 and Deuteronomy 14:1 that prohibits the marking of ones flesh in celebration of other gods.
Today, both genders are almost equally represented in
obtaining tattoos and body piercing. This description includes
both adults and adolescents from a wide range of occupations
and socioeconomic groups (Anderson, 1992; Armstrong, 1991;
Armstrong, Ekmark, & Brooks, 1995). Between 7 million and
20 million adults are reported to be tattooed. Armstrong and
Pace Murphy (1997) reported 1 in every 10 adolescents are tattooed, and Sperry provided an even higher estimate of 25% of
all 15- to 25-year-olds being tattooed (quoted in OHara, 1995).
Websters Dictionary (1993) defines the word tattoo, from the
Tahitian term, tatu, as an indelible mark or figure fixed upon
the body by the insertion of pigment under the skin or by the
production of scars (p. 1207). Today, that is often accomplished in a studio by artists using a rapid-injecting electrical
device that delivers a uniform series of punctures into the dermal layer of the skin (Greif & Hewitt, 1998). The pigment for the
tattoo is injected into the skin 50 to 3,000 times per minute up
to, or into the dermis at a depth of 1/64 to 1/16 of an inch
(Armstrong, 1991, p. 216). Although many of the ingredients in
tattoo pigments were approved as cosmetics for topical use by
the FDA in 1938, they have not been approved for invasive procedures, with some pigments containing lead, mercury, and
trace amounts of arsenic (Tope, 1995). In addition, many of
these tattoo pigments do not contain standardized ingredients.
This lack of purity and identity can prevent effective results if
the tattoo recipients change their mind about the tattoo and
want it removed (Anderson, 1992). Although almost all tattoos
can be lightened, Q-switched laser treatment truly clears only
about [70%] and some inks have proven to be resistant to laser
370
treatment, particularly dark green and yellow varieties (Armstrong, Stuppy, Gabriel, & Anderson, 1996, p. 415).
Piercing involves the insertion of a needle into various areas
of the body to create an opening through which decorative
ornaments such as jewelry may be worn (Greif & Hewitt, 1998,
p. 26). The procedure only takes a few minutes to perform and
is frequently done on body areas such as the ears, nose, eyebrows, lips, tongue, nipples, naval, and genitals. Specific jewelry (surgical-grade stainless steel or solid 14-karat yellow
gold, niobium, or titanium) is strongly recommended for insertion into the opening to avoid allergic and infectious responses.
Most body piercing is performed in tattoo studios; unfortunately it is also self-inflicted and done in temporary establishments such as flea markets, rock concerts, and college parties
as part of the entertainment. Gauntlet, an international chain
of body piercing shops in California, New York, and Paris,
reports at least 30,000 piercings each year (Michaela Grey, personal communication, June 17, 1997). Statistics on the
amount of body piercing done is difficult to determine as the
procedure lacks the permanency of tattooing; if the person
doesnt like the piercing, they can remove the jewelry and the
hole will close. Then, other than the frequent formation of scar
tissue at the site, no one knows of their previous piercing
actions.
Tattooing and body piercing are still primarily an artistconsumer regulated business (Armstrong, 1991). Many states
(N = 27) do not have any regulations for tattooing (Tope, 1995)
and few states (N = 5) have statutes for body piercing (Armstrong & Fell, in press). If there are regulations, enforcement is
of concern as most local and state health departments prioritize inspections; those with complaints are reviewed and those
with no complaints are often left alone (Armstrong & Pace Murphy, 1997). Thus, the customer must have knowledge of the
health concerns and risks for safe practice of body art.
In general, for the amount of body art that is done, there
seem to be relatively few health problems although the potenial of blood-borne disease risk still exists and the medical
literature describing the complications seems to be evolving.
The major risk is due to the small amount of bleeding present
with both procedures. Hepatitis B remains the significant concern and recently both the American and Canadian medical
371
METHODOLOGY
A descriptive and primarily quantitative design, similar to
the Armstrong and McConnell (1994) and the Armstrong and
Pace Murphy studies (1997), was used to describe the present
situation and generate knowledge.
INSTRUMENT
372
on a review of literature, personal interviews with college students with body art, data from a pilot study, and four published
studies on body art (Armstrong, 1991; Armstrong, Ekmark, &
Brooks, 1995; Armstrong & McConnell, 1994; Armstrong &
Pace Murphy, 1997). An expert panel of college health physicians, nurses, and counselors reviewed the questionnaire for
this study. Thirty questions of the survey were from the Armstrong Tattoo Survey (ATS). Face and content validity were
established for these questions and reestablished by expert panels before the initiation of the studies. Similar questions about
body piercing were incorporated, based on author experiences.
A pilot study (N = 12) was conducted to test and refine the survey tool used in this research. The pilot study helped clarify the
direction of questioning for the college student respondents.
An introduction to the survey provided the studys purpose,
benefits, and statements regarding the respondents voluntary
participation; completion of the survey implied consent to participate in the study. The survey was divided into four sections
with 31 questions about tattooing, 31 questions about body
piercing, 4 general questions related to body art, and 20 demographic questions. Demographic questions included age, race,
gender, sexual orientation, academic major, academic performance, family history and income, and attendance at religious
services. The reading level of the survey was at the 10th grade.
A variety of query formats were used such as multiple choice
and Likert scale questions. Questions inquired about motivating factors, costs, number of body art procedures, health
issues, risk behaviors, as well as parental involvement in decision making. Open-ended questions were provided so respondents could comment more extensively on their participation
with body art.
PROCEDURE
373
19 universities varied from one student body of 479, to the largest campus of 46,000 (Figure 1). The number of surveys sent to
each university depended on specific requests of the college
health personnel; a total of 1,700 surveys were sent out.
DISTRIBUTION
When college students with body art presented at the participating universities for any health services, they were asked by
the health care providers if they would like to volunteer to complete a questionnaire about their body art experiences. Students with only traditional earlobe piercings were excluded for
this study because reasons for this type of piercing tend to be
different than body piercing. All respondents were asked to
complete the general body art and demographic questions. In
the directions of the survey, tattooed and/or body-pierced
respondents were asked to complete the specific section(s) of
the survey applicable to them; that is, if they were tattooed,
they were to complete those questions. If they had a body piercing, they were asked to complete those questions. If they were
both tattooed and pierced, they were asked to complete two
sections. For the purpose and eligibility of this study, tattoos
were defined as permanent marks or designs applied to the
skin, not temporary decals (Armstrong & McConnell, 1994).
Body piercing was referred to as the penetration of the skin with
a sharp implement to create openings through which jewelry
may be worn (Greif & Hewitt, 1998). On completion of the survey, respondents placed their answers in a large envelope and
this envelope was placed in a sealed drawer for confidentiality.
To achieve an adequate sample size, data collection extended
over two full semesters. At the end of the second semester, the
surveys were sent to the authors for analysis.
RESULTS
A total of 828 surveys were returned to the investigators for a
49% response rate. Reasons for not returning the other surveys
included lack of time to distribute the surveys and the lack of
tattooed and/or pierced students that presented for health services during the time of data collection. On review, several
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375
surveys (N = 52) were disqualified due to large blocks of incomplete data. Data were analyzed using the Statistical Package for
the Social Sciences (SPSS) computer software. For those
schools with 40 or more completed surveys, specific data for
their university were later provided following data analysis. The
following is a discussion of 766 completed surveys. Qualitative
comments were reviewed and recorded separately; many of
these comments are not addressed in this analysis.
SAMPLE
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Table 1
Reasons Why Students Obtain Body Art
Tattoo (N = 561)
Self-expression
Just wanted one
To remember an event
Feel unique
Independence
296
200
121
100
62
53
35
21
17
11
189
149
81
80
48
38
21
21
Self-expression
Just wanted one
To be different
Beauty mark
NOTE: Total percentage is higher than 100 because multiple reasons could be
selected by respondents.
tattoo was $750 and another respondent paid $215 for a single
piercing, including the jewelry. Most students (76%) did not
notify their parents of the intent to obtain a tattoo or body
piercing, even when some were minors, but eventually the parents were informed (75%). Both those with tattoos and piercings cited the same major reasons for their body art as selfexpression (50%) and just wanted one (48%) (Table 1).
When asked about the purpose of their body art, 61% of the
respondents strongly agreed/agreed with the statement to be
myself, I dont need to please or impress anyone. Other statements that inquired about the purpose of the body art and the
relationship of their friends acceptance and expectations were
strongly excluded. Those with multiple body piercings, as well
as tattoos, often commented that they found them to be
addicting and I like the way they feel.
RISK-TAKING BEHAVIORS
377
24% reported daily cigarette use. Only 13% cited the use of
drugs and/or alcohol before their body art procedure.
Three demographic questions asked about sexual intercourse, the number of sexual partners, and sexual preference.
Only 5% of the participants in this study reported never having
sexual intercourse. Forty percent of the respondents reported
between 1 and 5 partners, 6 to 10 partners (24%), and 11 or
more partners (26%). The majority of students (87%) reported
heterosexual orientation, 12% reported bisexual activity, and
less than 1% reported homosexual preference.
Most students (88%) reported their first body art was done
by professional artists in a studio using sterile, disposable needles, skin disinfection, proper handwashing, and clean latex
gloves. Following the procedure, 66% of the respondents
reported receiving both written and verbal instructions regarding potential risks and aftercare.
TATTOOED COLLEGE STUDENTS
In this study, 561 college students or 73% of the respondents were tattooed; 84% of them had one or two tattoos. One
respondent was tattooed at the age of 13 and another respondent obtained his first tattoo at 40 years of age. The most tattoos one respondent reported was 20 tattoos. Decision making
concerning having tattoos seemed to range from a group of
respondents (20%) that took a few minutes to make their decision to another group that took years to decide (23%). Most of
the respondents (90%) reported continual satisfaction with
their tattoos and 82% would do it again.
Although many students (71%) reported no health problems
secondary to their tattooing, 14% had skin irritations (shortterm redness, dry skin, or tenderness) and 1% cited site infections (blister, pus, swelling, pain, or redness). Only 4% of those
with skin problems sought assistance from a health professional. One student reported contracting hepatitis after her
tattooing procedure. This respondent had obtained her first
tattoo at 16 in a professional studio with an autoclave on the
premises, an artist using a new pair of disposable latex gloves
for the tattoo, and skin disinfection done before and after the
procedure. She denies use of alcohol or drugs before her tattoo,
has never smoked cigarettes or used recreational drugs, and
378
limits alcohol use. She commented, I tested positive for antibodies twice after the tattoo and then 2 years later tested negativeI never displayed symptoms of the disease. Currently,
she ranked herself as a junior in college, would have the tattooing done again, and would not have the tattoo removed as it
makes me feel unique and individual. In her comments to the
question of What would you like to tell someone else considering body art?, she wrote check health [and] NEW NEEDLES.
COLLEGE STUDENTS WITH BODY PIERCINGS
379
380
residual, giving them freedom to feel they can proceed with the
piercing without many perceived risks (Armstrong, Ekmark, &
Brooks, 1995, p. 25). Thus, could the nature of body piercing
procedure produce more casual decision making?
A small group of impulsive decision makers with tattooing
was also reported. This finding seems to correspond with
Armstrong and McConnell (1994) and Armstrong and Pace
Murphys studies (1997) with tattooed adolescents where the
short decision making was frequently present. Could these
responses still correspond to the late adolescent developmental
activities of impulsiveness and the lack of effective decision
making when away from home?
In this study, there also was a sizable group of respondents
who took more time for deliberate decision making, especially
with tattooing; some describe making their decisions over
months and even years. The price of the body art also related to
their deliberate decision making; reported costs were not
inexpensive. This subgroup of respondents seemed to align
more with the Armstrong study (1991) examining tattooed
career-oriented women where more deliberate decision making
was observed for the body site, the artist, the studio, and the
design. This delayed decision making could correspond to the
group of the respondents (more than half ) who were enrolled in
upper division undergraduate and graduate education. The
longer amount of time taken for the tattoo decision could relate
to the permanency of the tattoo procedure as well as the
increased education level. This better decision making also
seemed to lead to the high rate of satisfaction with their body
art and the large amount of respondents that would do the procedure again.
The college students made the decision to obtain body art.
Often, the parents were not consulted on decisions for tattooing and body piercing. If they were minors, parental permission
was not sought. College health personnel were not part of their
decision making also. If there were complications from the
body art, many times the participants tried to take care of it
themselves rather than consult with health professionals.
The participants major reasons for the body art were the
same, self-expression and just wanted one. The body art procedures seemed to be deliberate, done specifically for themselves as illustrated by their strong agreement about the
381
382
Health problems can arise either during the body art procedure or from lack of proper aftercare. Repeated needle injections of a foreign substance for tattooing and bleeding can predispose subjects to bloodborne diseases as well as the
penetration of a needle or piercing gun for body piercing. Overall, for the amount of body art that is done, most of the respondents in this study reported effective, safe hygiene practices of
their tattooist and piercer with the use of sterile, disposable
needles, skin disinfection, proper handwashing, and latex
gloving for the procedure. Many seemed to observe the procedure and artists techniques before the procedure, yet some
respondents received no aftercare instructions for proper skin
treatment. This could be one reason for almost half of the
respondents with body piercing, and others with tattoos, to
have skin irritations and infections. Informed customers
should know that skin care is essential following procurement
of the body art. Specific written and verbal instructions from
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384
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Judith Greif, R.N., N.P., C., M.S., is a family nurse practitioner at the Hurtado Health Center, Rutgers University Health Service, New Brunswick, NJ.
Walter Hewitt, R.N., C., B.S.N., is the assistant clinical coordinator, Hurtado
Health Center, Rutgers University Health Service, New Brunswick, NJ.
Myrna L. Armstrong, Ed.D., R.N., F.A.A.N., is a professor in the School of
Nursing, Texas Tech University Health Sciences Center, Lubbock, TX.