Tattooing: Another Adolescent Risk Behavior Warranting

Health Education
Myrna L. Armstrong and Kathleen Pace Murphy

A cross-sectional, convenient sample of adolescents (N = 2101) from 8 states were queried

regarding interest in tattooing. Permanent markings and blood-borne diseases were reasons
respondents refrain from tattooing, yet 55% (n = 1159) expressed an interest in tattooing. Tattooed
adolescents in the sample (10%, n = 213) responded with their experiences. Tattooing was
frequently done around the 9th grade and as early as 8 years of age; over half (56%, n = 120)
report academic grades of As and Bs. Potential health risks and definite psychosocial findings of
purchase and possession risks were evident, building on data from a similar 1994 study by
Armstrong and McConnell. Health providers and educators should initiate applicable health
education and become community adolescent advocates regarding this risk-taking behavior.
Findings indicate that adolescents who want a tattoo will obtain one, regardless of money,
regulations, or risks. Adolescents view the tattoos as objects of self-identity and body art, whereas
adults perceive the markings as deviant behavior. Informed decision-making could be promoted in
health education by incorporating information about the possibility of blood-borne diseases,
permanent markings, and themselves as growing and changing people.
Copyright © 1997 by W.B. Saunders Company

DOLESCENCE is filled with psychosocial
A pressures, biological turmoil, and struggles
for independence. Adolescents are challenged to
describe who they are and what they want to
become. Often, they are preoccupied with them-
selves, their appearance, and the opinions of others;
they obtain many ideas from peers, role models,
and the media. Interestingly, adolescents tend to
accept these opinions and the associated actions
readily, without questioning the decision; any expo-
sure to potential danger or injury, risk-taking, is
often done to satisfy an immediate need or goal.
Yet, risk-taking is a beneficial, natural, healthy
part of adolescent transition. It represents an element of
maturity, of reaching out and trying new roles,
without the responsibilities of adulthood. It can
also be harmful when associated with impulsive
energies, feelings of invincibility, lack of foresee-
ing potential adverse effects, need for thrill-seeking,
or even apathy (Armstrong & Gabriel, 1994b; Busen,
1991). Examples of the current documented risk-
taking behaviors and results include motor vehicle
accidents, drug, alcohol, and cigarette use, sexually
transmitted diseases, and pregnancy. Today, tattoo-
ing is on the rise with at least 7 million adults
already tattooed (Armstrong, Stuppy, Gabriel, &
Anderson, 1996). Prevalence and popularity of
tattooing have also been demonstrated among ado-
lescents (Armstrong & Gabriel, 1994; Armstrong &
McConnell, 1994b).
BACKGROUND
Tattooing and Health Risks
The most common health risks of tattooing (see
Sidebar) are infections and allergic reactions (Ander-
son, 1992; Long & Rickman, 1994). Transmission
of blood-borne diseases also are possible because
From the School of Nursing, Texas Tech University Health
Sciences Center, Lubbock, TX.
Myrna L. Armstrong, EdD, RN, FAAN, Professor, School of
Nursing, Texas Tech University Health Sciences Center,
Lubbock, TX; Kathleen Pace Murphy, PhD, RN, CRRN,
Assistant Professor, School of Nursing, Texas Tech University
Health Sciences Center, Lubbock, TX.
This study was funded by the Research Committee of Texas
Teeh University Health Sciences Center School of Nursing.
The authors gratefully acknowledge Roberta K. Brady
BSN, RN; Shelley Elliott, BSN, RN, CSN; Rosemary Foley M.
Ed, RN, CNS; Rosanne E. Mclnaney, BSN, MPH, RN," Breeky
Rameas MS, RN; Kathryn Schwabl, MS, MPH, RN, Chris Seyl,
MN, ARNP; and Donna Zaiger, BSN, RN, CSN for their
faciliative efforts during this study and Elizabeth H. Winslow,
PhD, RN for her thoughO~ulreview of an earlier manuscript.
Address reprint requests to Myrna L. Armstrong, EdD, RN,
FAAN, School of Nursing, Texas Tech University Health
Sciences Center, 3601 4th St, Lubbock, TX 79430.
Copyright © 1997 by W.B. Saunders Company
0897-1897/97/1004-000455.00/0

Applied NursingResearch,Vol. 10, No. 4 (November), 1997: pp 181-189 181

182
SIDEBAR
Although it is easy to look around crowded
beaches and malls to observe the popularity
and prevalence of tattooing, few statistics
document the incidence of tattooing in the
United States. One report is a "1990 unpub-
lished market survey of 10,000 randomly
selected American households in which 3%
of all respondents and 5% of male respon-
dents had a tattoo" (Anderson, 1992; Tope,
1995, p 791). Other indicators are increased
sales of tattoo pigments and tattoo equip-
ment. Specific tattooing businesses are diffi-
cult to count because of their movement
between home-based services and store-
fronts.
Most tattooing is done by studio artists,
who call themselves professionals, or by an
amateur. Regardless, several problems sur-
rounding the tattooing procedure potentate
health risks. The major areas of concerns
include the artist, pigment, equipment, and
environment. Studio tattoo artists are unli-
censed, the ingredients of the pigments are
not FDA approved nor standardized, hygiene
procedures for equipment are inconsistent,
and sanitary inspections of studios are infre-
quent. Studio tattooing is performed with
"an electrically powered, vertical vibrating
instrument resembling a dentist drill which
injects the tattoo pigment 50 to 3,000 times
per minute up to, or into the dermis at a depth
of 1/64 to 1/16th of an inch" (Armstrong &
Gabriel, 1994c, p 27). From one to fourteen
needles may be used during the invasive
procedure. Costs for a 2 in. × 2 in. tattoo
range from $35 to $50; costs for removal of
the same size tattoo range from $1,000 to
$1,500. Following tattooing, improper skin
care can produce short-term reddened skin
responses and the ingredients of red and
yellow pigments can initiate allergic reac-
tions. The transmission of blood-borne dis-
eases is a possibility.
small to moderate amounts of bleeding occur
during tattooing. A large incidence of hepatitis B
(13 cases) resulted in New York City banning tattoo
ARMSTRONG AND MURPHY
SIDEBAR (Cont'd.)
Seven states prohibit studio tattooing for
anyone, whereas 20 states forbid tattooing in
studios on individuals under 18 years of age
(Tope, 1995). Yet, the regulations and the
enforcement of this industry remain problem-
atic (Armstrong, Stuppy, Gabriel, & Ander-
son, 1996). Health department personnel
typically only inspect tattoo studios when
complaints are received. Many dissatisfied
customers do not notify the tattoo artists
when problems occur; they tend to go to
another tattoo artist for advice or "rework-
ing" of the tattoo.
Amateur tattooing is considered more dan-
gerous than studio tattooing because it is
frequently done in unhygienic conditions
and environments with various household
instruments. Often, the amateur tattoos are
"self-inflicted or created by a friend/rela-
tives using pencils, pens, straight pins,
needles, and pigments such as charcoal, soot,
mascara, or carbon" (Armstrong & McCon-
nell, 1994b, p 27). Greater psychosocial
risks are present because many amateur
tattoos are crude, simplistic markings placed
on exposed body locations. Adolescents are
the largest group with amateur tattoos and
popular opinion generally associates the tat-
toos with gang membership. Many amateur
tattoos are also on people following incarcera-
tion in county, state and/or federal prison
facilities.
artists in 1961; no similar large scale cases have
since been reported. Additionally, "transmission of
HIV by tattooing is possible," but no documented
cases of human immunodeficiency virus (HIV) or
acquired immune defciency syndrome (AIDS)
have been located (Long & Rickman, 1994, p 616).
Risks With Adolescent Tattooing
For almost 30 years, physicians in England have
voiced concerns about amateur tattooing and the
associate problems of embarrassment, shame, and
social disgrace (Balakrishnan & Papini, 1991;
Mercer & Davies, 1991; Thomson & McDonald,
TATTOOING: ADOLESCENT, HEALTH EDUCATION
1983). All of these physicians recommend health
education about tattooing.
In the United States, there are a few descriptive
medical articles about adolescent tattooing. Fried
(1983) suggested adolescent tattooing expressed
"aggression, sexuality, and rebellion" (p 239),
whereas Litt (1994) suggested gang association in
amateur tattooing. Farrow, Schwartz, and Vander-
leeuw, (1991) identified "an impulsive personality
style, deviant behavior, and drug abuse" (p. 187) as
common characteristics. Health education was
recommended; however, no specific programs were
cited.
In the nursing literature, Thomson and McDon-
ald (1984) described the self-infliction of tattoos
and the psycho-emotive distress of adolescents in
England. Only one study in the United States has
been conducted on adolescent tattooing. Armstrong
and McConnell (1994b) queried 642 adolescents in
six Texas high schools. Among the nontattooed
adolescents (n - 537), over a third (33%, n = 177)
were interested in tattooing. The percentage of
tattooed adolescents (n = 105) was 8.6%. Many
reported academic grades of As and Bs (69%,
n = 72). The number of those with studio or
amateur tattoos was almost equal. The average age
for the first tattoo was 14 years of age with the
earliest tattooing reported at 10 years of age. Over
half (57%, n = 60) had one tattoo, whereas 40%
(n - 42) had two or more tattoos.
Three areas of risk were investigated by
Armstrong and McConnell (1994b), namely the
psychosocial risks of purchase (vulnerability with
the procedure), possession (problems encountered
while having the tattoo), as well as health risks
(potential diseases, allergies, or infections after
tattooing). Purchase and possession risks were
documented in this study "as evidenced by
whimsical decision making, the young age at
tattooing, the short time-frame for decisions, the
visual messages in their tattoo designs, the exposed
body locations, and the lack of support by parents,
siblings, and the public" (Armstrong & McCon-
nell, 1994b, p 123). No health risks were
documented, but the potential of blood-borne
diseases existed as many (70%, n = 73) report
some bleeding during their tattooing procedure.
A second study was undertaken to examine
various regions in the United States and build on
the previous level of knowledge attained regarding
nontattooed and tattooed adolescents. No national
183
studies about tattooing in adolescents, nor tattooing
interest were found. The purposes of this explor-
atory study were two-fold, (a) to examine adoles-
cent interest in tattooing, and (b) to identify the
characteristics and associated purchase, possession,
and health risks of tattooed adolescents.
METHODS
Little is known about the tattooed adolescent so a
descriptive design similar to the ~ s t r o n g and
McConnell (1994b) study was used in this quantita-
tive study to describe the present situation, deter-
mine the frequency of its occurrence, and generate
knowledge. Information from this type of study can
build a larger knowledge base for further studies on
the risk-taking behavior of tattooed adolescents.
Instrument
A 72-item self-reporting, anonymous, scannable
bubble form survey tool was used. The survey was
based on a review of literature, personal interviews
with tattoo artists, data from three pilot studies, and
three previously published studies (Armstrong &
McConnell, 1994b; Armstrong et al., 1996). Face
and content validity were established and re-
established by expert panels before the initiation of
the three pilot studies. Using the SMOG formula,
the reading level of the survey was at the 7th grade
level.
An introduction to the survey provided the
study's purpose, risks, benefits, and a statement
regarding the adolescent's voluntary participation.
The survey tool was divided into two parts. The
first section was designed for all respondents and
included five demographic and general questions
about tattooing. The second part was specifically
designed for adolescents with tattoos; it contained
35 questions featuring multiple choices about
tattooing and health risks, as well as "yes and no"
questions about the purchase experience. Another
20 questions were open-ended regarding their
feelings about their tattoos and the responses from
others.
Additionally, 12 Likert scale questions asked
about the purpose(s) of the tattoo. Choices on the
four point scale ranged from strongly disagreed (1)
to strongly agreed (4). Reliability for this Likert
scale was 0.90, using Cronbach's Alpha (Arm-
strong & McConnell, 1994b; Armstrong et al.,
1996). At the end of the survey tool was a comment
sheet so respondents could write remarks or ask
184
questions of the investigators. If this comment sheet
was used, the subjects were asked to tear it off from
the general survey tool to assure confidentiality.
Consent
The Institutional Review Board determined the
study to be of minimal risk and approved it as an
exempt study. Before data collection, each school
reviewed the survey; it was determined to be of
minimal risk and "educationally focused research
in which the school would retain the obligation to
guard their students' interests as their parents
would" (Dellinger, 1983, p 357). Adolescents
indicated their voluntary assent to participate in the
study by completing the survey form and returning
it to the school nurse to be mailed back to the
investigators.
Procedure
School nurses were recruited through a variety of
school health networks and asked to facilitate
distribution of the survey. Letters were also
requested from the specific school administrators to
acknowledge the school's participation. These were
obtained for Institutional Review Board records.
Seven sites received 500 surveys by mutual
agreement of the school nurse and investigators; at
the eighth site, 150 surveys were sent on specific
request. Survey distribution instructions included
information to maintain the respondent's anonym-
ity and confidentiality. The school nurse, the
classroom teacher, and the accessibility of students
in the 7th grade through the 12th grade all entered
into the decisions of how classrooms were chosen
for survey distribution. Data collection was com-
pleted during class time, often in health education
classes. Surveys were distributed to each student in
the classroom unless the adolescent did not want to
participate; no one refrained. Respondents placed
their surveys into a large envelope. Any completed
comment sheets were placed in a separate enve-
lope. Both were then sealed and directly sent to the
investigator.
From the 3,650 surveys that were distributed to 8
school sites, 2,212 (61%) were returned to the
investigators. Reasons for not distributing the other
39% (n = 1,438) included lack of time to get to
numerous classrooms and special school circum-
stances, such as unexpected student testing and
crowded curriculum requirements.
On return of the surveys, 111 surveys (5%) were
ARMSTRONG AND MURPHY
rendered not usable because of insufficient data.
Surveys were retained for data analysis if over 75%
of the questions were completed.
RESULTS
Subjects
Usable data were collected from 2,101 adoles-
cents (53% [n = 1,113] girls and 47% In = 9881
boys) from 8 junior or senior high schools across
the United States (California, Illinois, Kansas,
Massachusetts, North Carolina, Ohio, Pennsylva-
nia, and Washington). Ethnic representation in-
cluded White (77%, n = 1,618), Hispanic Ameri-
can (8%, n = 168), Asian American (7%, n = 147),
African American (5%, n = 105), and others (3%,
n = 63). Time taken to complete the study varied
with the type of respondent; for those without
tattoos, it took less than 5 minutes. For the tattooed
adolescent, the length of time was 15 to 20 minutes,
depending on the amount of information provided.
All subjects were asked their interest in tattooing
and reasons for refraining from tattooing. A major-
ity of the subjects (55%, n = 1,156) were interested
in tattoos. Reasons for not obtaining a tattoo
included permanent markings (23%, n = 483);
AIDS/HIV or other diseases (18%, n = 378); paren-
tal disapproval (16%, n = 336); and pain (12%,
n = 252). Cost was not a deterrent (3%, n = 64).
Over one-fifth of the respondents (22%, n = 462)
stated there was no reason keeping them from
getting a tattoo.
After these questions, subjects without tattoos
(N = 1888, 90%) were thanked for their participa-
tion and exited from the survey while the remaining
tattooed subjects (N = 213, 10%) completed the
rest of the questions. Several adolescents without
tattoos (4%, n = 76) tried to continue into the next
section with specific questions about tattooing.
They usually stopped by the sixth question as they
did not have the applicable information to continue.
Tattooed Adolescents
The 213 tattooed adolescents (55% [n = 117] of
girls and 45% [n = 96] of boys) provided informa-
tion about their decisions and experiences before,
during, and after the tattooing. Ethnic representa-
tion of the tattooed subjects were 61% Whites
(n = 129), 21% Hispanic Americans (n = 45), and
10% others (n = 21); Asian Americans remained
the same (8%, n = 18). Over half of the subjects
(61%, n = 129) had one tattoo whereas 39%
TATTOOING: ADOLESCENT, HEALTH EDUCATION 185

(n = 84) had two or more tattoos. Some of the Table 2. Possession Risk Experiences
subjects (10%, n = 21) documented as many as six. of Tattooed Adolescents (n = 213)
Purchase Experience. The adolescent's pur- Situation Yes (%) n
chase experiences with tattooing are summarized
Personal responses
on Table 1. The mean age of their first tattoo was 14 Personal pleasure at tattooing 83 177
years (SD = 2.5) with most (87%, n = 185) Personal pleasure with tattoo now 81 173
obtaining their tattoos from 12 to 17 years of age. Concealed body area chosen 51 108
Over half of the tattooed adolescents (52%, Tattoo helpful, unique, & special 50 107
Tattoo not helpful 30 64
n = 111) had obtained their first tattoo during
Positive responses
grades 7 to 9, whereas another third (35%, n = 75) Friends 63 134
obtained their first tattoo during the 10th or l l t h Significant friends 45 96
grade. Siblings 22 47
Self-reported letter grades revealed tattooed ado- General public 11 23
Mother 10 21
lescents with As and Bs (56%, n = 119) at the time
Father 9 13
of tattooing; these grades remained for the majority
of the sample (59%, n = 126). Several remarks
(11%, n = 23) were received on the comment
Numerous reasons were reported for obtaining
sheets expressing their thoughts about the associa-
the tattoo such as "just wanted one" (44%, n = 94),
tion of grades and tattoos, for example, "grades
wanted to be independent/express oneself (23%,
have nothing to do with tattoos."
n = 49), and "for the heck of it" (16%, n = 34).
Over half (52%, n = 111) of the tattooed adoles-
Less than one third of the parents (28%, n = 60)
cents took a "few minutes" for their tattooing
were aware of the tattooing intention and 17%
decision and over one third reported major changes
(n = 36) signed consent forms; now, 62% (n = 132)
and stress in their lives (39%, n = 83) at the time of
of the parents know about the tattoo. Eight subjects
tattooing. Respondents had 309 tattoos; some of the
reported their parents also going to the studio when
designs included: initials/names (n = 55), crosses
they obtained the tattoo.
(n = 45), animals (n = 40), free-hand designs
The majority of tattooed adolescents (57%,
(n = 40), flowers (n = 35), cartoon/clowns
n = 121) labeled themselves "risk takers" at the
(n = 27), and hearts (n = 24).
time of tattooing and this remains a consistent
belief (58%, n = 124). Often, friends or a group of
Table 1. Purchase Risk Experiences of Tattooed people (70%, n = 149) were with them before
Adolescents (n = 213) tattooing. During their tattooing, other friends
(37%, n = 79) were also tattooed. Alcohol, drugs,
Situation Yes (%) n
or both, were used by some tattooed adolescents
Knew placement for body 87 185 (28%, n = 60) before the tattooing. Only 7%
Age 12-17 at tattooing 87 185
Pleased at time of tattooing 83 177
(n = 15) believed their friends applied pressure to
Knew design wanted 72 153 obtain the tattoo.
Had friends or group of people with him/her 70 149 Possession Experiences. Questions were asked
Parental knowledge of tattoo, now 62 132 about their personal response to the tattoo as well as
Describe themselves as a "risk-taker" 57 121 reactions from friends and family (Table 2). Many
Academic grades of As & Bs 56 119
Took " f e w minutes" for decision 52 111
report initial pleasure with their tattoo (83%,
Watched another tattoo procedure 51 108 n = 177) and continuing pleasure (81%, n = 173).
Reason for tattoo "just wanted one" 44 94 Body sites were equally distributed between
Changes & stress at time of tattooing 39 83 concealed (51%, n = 108) and exposed areas
Friends tattooed at same time 37 79
(49%, n = 105). When asked to describe how their
Experienced moderate-large amount of pain 35 75
Parental knowledge of tattooing, at time 28 60
tattoos were helpful, 50% (n = 107) replied "it
Used alcohol, drugs, or both, before tattooing 28 60 made me feel special and unique." The tattoo was
Comparison shopping of artists 27 58 not helpful to other respondents (30%, n = 64);
Parental consent for tattooing 17 36 they cited disappointment, embarrassment, and low
Reason for tattoo "for the heck of it" 16 34 self-esteem. Many chose not to answer these
Believed pushed into decision by friends 7 15
questions (56%, n = 119). Family support for the
186 ARMSTRONG AND MURPHY

tattoo (siblings, 22%, n = 47; mother, 10%, n = 21; Table 4, Differences Between Adolescents
and father, 9%, n = 19) was low in comparison to (N = 213) with Amateur and Studio Tattoos
positive responses from their friends (63%, n = 134) Tattoos
and significant friends (45%, n = 96). Amateur Studio
Health Experiences. Repeated needle injec- (n = 94) n (n = 119) n
tions of a foreign substance could predispose Youngest reporting (years) 8 10
subjects to health risks. Red and yellow pigments Number of tattoos (%)
were selected by 47% (n = 100) of the tattooed 1 49 46 68 81
adolescents, but only a small group of them (14%, 2 or more 40 38 30 36
Grade level (%)
n - - 3 0 ) reported short-term irritations, such as
Elementary 9 8 8 10
redness, dryness, or tender skin following tattoo- 7th 21 20 11 13
ing. No blood-borne diseases were reported but 8th 26 24 9 11
68% (n = 145) cite small to large amounts of bleeding 9th 21 20 13 15
during the procedure so the potential exists. 10th 14 13 24 29
1 lth 8 8 28 33
Purpose of the Tattoo. Twelve statements were
12th 1 1 7 8
presented as possible purposes of the tattoo; no Academic grades (%)
additional write-in comments were received. The As 14 13 38 45
most agreed-upon statement related to personal Bs 35 33 34 40
identity, "be myself, I don't need to impress people Cs 36 34 17 20
Ds 16 15 11 13
anymore" (81%, n = 173). Most of the respondents
Pleased, at time of tattooing (%) 70 66 93 111
disagreed or rejected the other statements (Table 3). Still like the tattoo (%) 75 71 82 98
Cronbach's Alpha for reliability of this scale Would do it again (%) 70 66 70 83
was .90. Parents still don't know (%) 41 39 36 43
Studio Versus Amateur Tattooing. Of the total
group of tattooed adolescents, 42% (n = 119)
obtained studio tattoos whereas 54% (n = 94)
reported amateur tattoos. Six percent reported
Table 3. Reported Purpose for Tattooing "other" in how the tattooing was done but
in Adolescents (n = 213) provided no further explanation. The differences
between those who obtained studio tattoos and
Strongly Strongly
Agreed/ Disagreed/ amateur tattoo are noted on Table 4. Those with
Item Agreed (%) Disagreed (%) n amateur markings started younger, were in lower
Be myself, I don't need to grade levels when they started (grades 7 to 9, 68%),
impress anyone anymore. 81 173 had more tattoos, and reported lower academic
Improve my social position. 92 196 grades (Bs and Cs, 70%). Those with studio tattoos
Do what another person
obtained them in higher grade levels (grades 9 to
expected. 89 190
Do what friends suggested. 88 187 • 11, 65%) and reported higher academic grades (As
Do what someone in my group and Bs, 72%). Straight pins or sewing needles,
strongly urged me to do. 88 187 pens, pencils, or other homemade devices (45%,
Make new personal associations n = 42) were used for the tattooing; many were
and friendships. 87 185
done in the home (66%, n = 62). Few gang-related
Help me be more acceptable to
my friends. 86 183 tattoos were reported (5%, n = 5), yet several
Do what people who love me (n = 13) describe tattooed dots on their hands and
say is important. 85 181 face (the configuration of the dot can explain a
Help me separate from my other certain gang).
life experiences. 85 181
Help me obtain more status and
Enforcement of Tattooing Regulations. State
prestige. 84 179 tattooing regulations (Tope, 1995) were compared
Help me feel better about with the respondent's location. Rate was deter-
myself. 79 168 mined by dividing the total amount of state par-
Help people judge me for who I ticipants into the amount of tattooed individuals in
really am. 64 134
the state study. Massachusetts, which prohibits all
TATTOOING: ADOLESCENT, HEALTH EDUCATION
tattooing, in this study had a 6% rate of tattooing,
with 17% of those adolescents obtaining parental
consent. Illinois and North Carolina prohibit
tattooing of minors. Study data indicate rates of
10% and 6% respectively, with low rates (15% and
30%) of parental consent. California permits
tattooing of minors with parental consent. Respon-
dents from this state had the highest tattooing rate
(14%), with 5% obtaining parental consent.
DISCUSSION AND IMPLICATIONS
This research expands on earlier work by Arm-
strong and McConnell (1994b) and queried adoles-
cents (N = 2101) regarding their interest in tattoo-
ing and major reasons to refrain from tattooing.
Respondents from this study were located in 8
states across the country as compared with the
Armstrong and McConnell (1994b) study con-
ducted in one state. Two findings were of interest
regarding both groups of nontattooed adolescents.
First, they agreed on the same reasons for refrain-
ing from tattoos, namely permanent markings and
the concern of AIDS and other diseases. Secondly,
tattooing interest in this study was 55% compared
to 33% in the Armstrong and McConnell study
(1994b), conducted 2 years previously. This tattoo
interest could be attributed to regional differences
as well as increased role models and coverage
about tattoos in the media.
Those with tattoos were asked about their experi-
ences and decisions surrounding the tattooing. Data
from the tattooed adolescents were similar to the
Armstrong and McConnell study (1994b). The
similarities include the academic grades, the single
and multiple tattooing, the bleeding during the
procedure, the exposed body locations, the major
changes and stress, and the responses from families
and friends. Only a small group of respondents
reported alcohol or drug use. Both groups were in
strong agreement about the purpose of their tattoo,
"be myself, I don't need to impress anyone any-
more." Profiles of those with amateur and studio
tattoos were also the same.
Several experiences occurred with greater fre-
quency in this study than in the Armstrong and
McConnell study (1994b). The percentage of tat-
tooed adolescents in the samples rose from 8.6% to
10%. There was an increased number of girls (55%
from 35%), more impulsiveness in the decision for
tattooing (52% from 41%), an increase of risk
187
takers (57% from 45%), and an earlier age ratio
(ages 12 to 17 from 14 to 18 years of age) when the
tattoos were obtained.
Potential health risks were present and definite
psychosocial findings of purchase and possession
risks occurred. This builds on the data of the
Armstrong mad McConnell study (1994b), and is
evident by "the whimsical and short decision-
making for the tattoos, the early age of tattooing,
the exposed body locations, the visual messages of
the tattoos, and the lack of support by parents and
siblings" (p. 123). Findings indicate that adoles-
cents who want a tattoo will obtain one, regardless
of money, regulations or risks. Older adolescents
have cars and money to obtain studio tattoos
whereas younger adolescents create their own
marks or asks friends to tattoo them. Additionally,
when laser therapy for tattoo removal is perfected,
cost-effective, and accessible, tattooing will in-
crease because it will be easier to "undo" the tattoo
(Anderson, 1992; Armstrong et al., 1996).
Proactive development of credible health educa-
tion for all three educational levels of schools
(elementary grades, junior high, and senior high)
becomes important, the mean age (14) in tattooing
and the young age of one respondent who started
tattooing at 8 years of age. Yet, developing educa-
tion for adolescents is challenging, especially when
many adolescents believe they have a "right to
have a tattoo" (Armstrong & McConnell, 1994a, p
28). Careful incorporation of the two major areas
that cause the nontattooed respondents the most
concern with tattooing would be important to
address within health education. Keller, Duerst, and
Zimmerrnan (1996) promote incorporation of some
fear in health education; they believe it can be
constructive when there is a action plan so learners
move toward different health behaviors. Thus,
informed decision-making could be promoted in
health education by incorporating information about
the possibility of blood-borne diseases, permanent
markings, and themselves as growing and changing
people. Hopefully this will produce dissuasion, or
at least minimize risks, by encouraging specific
questions if they insist on tattooing (Armstrong &
McConnell, 1994a). Following these studies, a
bilingual brochure and health education video were
developed, field tested, and initiated for nurses and
health educators in schools to talk about tattooing.
As noted in the subjective data provided by the
188
respondents, the view points of the adolescent and
adults about tattooing differed, in both studies.
Adolescents view the tattoos as objects of self-
identity and body art whereas adults perceive the
markings as deviant behavior. Irwin (1987) be-
lieves that adolescents often realize that certain
actions are risky, yet still engage in the behavior
because of the perceived associated psychosocial
value. From the adolescent's perspective, they were
very positive about their tattoos with the majority
describing how the tattoo(s) were helpful in "feel-
ing special and unique." Yet, parental response for
the tattoos was consistently low, around the 10%
range. Some respondents describe dlsappointment,
embarrassment, and low-self-esteem experiences
when others viewed their tattoo(s). This is unfortu-
nate at a time when adolescents are concerned
about themselves, their image, and their appear-
ance.
This profile of the tattooed adolescent is some-
what different than the descriptions found in the
American medical literature (Burma, 1959; Farrow
et al., 1991; Fried, 1983; Litt, 1994). Although the
"risk-taker" and impulsive decision making charac-
teristics were consistent, a large group of these
tattooed adolescents were academically successful
A and B students indicating an overall wider
distribution for this risk-raking behavior than previ-
ously thought. Few tattooed adolescents in both
studies mention gang affiliation or gang-related
tattoos.
Adolescence can be a vulnerable time for health
compromising risk taking. Today, many adolescent
risk-taking behaviors stem from various prevent-
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able social and environmental situations that emu-
late from adult risk-taking practices (Tonkin, 1987).
The influence of risk-taking with tattooing can be
noted with factors, such as interest, prevalence of
tattooing, impulsive decision making and the age of
tattooing. Many times those who are risk takers are
often unaware of the consequences of the behavior
they have chosen. Greater multiple risk-taking
situations were present with those obtaining ama-
teur tattoos as their risk-taking behavior began
earlier in their teenage years (Irwin & Millstein,
1986). Gender distribution is also interesting as
more than half of the tattooed adolescents were
girls. This supports the Keyes and Block (1984)
befief that greater risk-taking behaviors are present
in adolescent girls because of their earlier matura-
tion.
Is tattooing among adolescents just a "trend,"
another fad that will go away? For tattooed adoles-
cents, psychosocial and health risks are compound-
ing adolescence, a time already filled with psycho-
social pressures. Tattooing in adolescents is
increasing and needs to be added to the "growing
lists of previously ignored, important public educa-
tional issues" (Armstrong et al., 1996, p 415).
Incorporating questions in national and state adoles-
cent health risk surveys will maintain surveillance
about tattooing so further quantitative information
can be obtained. Additionally, two primary health
elements for community adolescent advocacy are
equally important; including applicable health edu-
cation projects and furthering consumer adolescent
advocacy roles to implement effective local and
state tattoo licensing regulations.
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