PEDIATRICS Vol. 109 No. 6 June 2002, pp. 1021-1027
Tattoos and Body Piercings as Indicators of Adolescent Risk-Taking Behaviors
* Adolescent Medicine Division, Department of Pediatrics, Naval Medical Center San Diego, San Diego, California
Clinical Investigation Department, Naval Medical Center San Diego, San Diego, California
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Purpose. This study assessed tattoos and body piercings as markers of risk-taking behaviors in adolescents.
Methods. A 58-question survey, based on the 1997 Centers for Disease Control and Prevention Youth Risk Behavior Survey, was offered to all adolescent beneficiaries that came to the Adolescent Clinic. The survey contained standard Youth Risk Behavior Survey questions that inquire about eating behavior, violence, drug abuse, sexual behavior, and suicide. Questions about tattoos and body piercings were added for the purposes of this study.
Results. Participants with tattoos and/or body piercings were more likely to have engaged in risk-taking behaviors and at greater degrees of involvement than those without either. These included disordered eating behavior, gateway drug use, hard drug use, sexual activity, and suicide. Violence was associated with males having tattoos and with females having body piercings. Gateway drug use was associated with younger age of both tattooing and body piercing. Hard drug use was associated with number of body piercings. Suicide was associated with females having tattoos and younger age of both tattooing and body piercing. Tattoos and body piercings were found to be more common in females than males.
Conclusions. Tattoos and/or body piercings can alert practitioners to the possibility of other risk-taking behaviors in adolescents, leading to preventive measures, including counseling. Tattoo and body piercing discovery should be an important part of a health maintenance visit to best direct adolescent medical care.
Key Words: adolescent • tattoo • body piercing • body modification • Youth Risk Behavior Survey • risk-taking behavior • gateway drugs • sexual intercourse • violent behavior • suicide
Abbreviations: T/P, tattoo and/or body piercing
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Body modification in the form of tattooing and body piercing is becoming increasingly common and well accepted in western society. Ten percent to 13% of adolescents age 12 to 18 have tattoos, and 3% to 8% of the general population have tattoos.1–4 Body piercing at locations other than the ear lobes has also been increasing in frequency and acceptance.5,6
The majority of medical literature on tattooing and body piercing has focused on the risks and complications of these procedures. Behavioral surveys have revealed mixed results. Some have suggested increases in homosexuality, sexual risk-taking, and sadomasochism associated with body piercing.5–7 Others have not found these associations.8 Studies of tattooing have been conducted mainly in prison populations and with patients in psychiatric facilities. These studies have demonstrated increases in violent behavior, problem behavior, and criminality.9–13 However, studies among high school students, military recruits, and professional adults have not found these associations.2,3,14 One finding consistent in the studies has been the difference between persons with amateur tattoos versus professionally applied tattoos. Possession of an amateur tattoo seems to be associated with increases in dissatisfaction with the tattoo, problem behavior, and lower academic performance. However, no studies have been done to directly assess this issue.2,3,8–11 Despite the lack of clear evidence, studies among medical professionals have demonstrated negative attitudes toward patients with piercings or tattoos.1
Finding risk-taking behaviors linked more commonly to adolescents with tattoos and/or body piercings could make observation of these types of body modifications very useful in the clinical setting by providing easily accessible and recognizable clues to potential problem areas in the adolescent or young adult patient. The purpose of this study was to assess the current prevalence of risk-taking behaviors in adolescents aged 12 through 22 years old as they relate to the presence of tattoos and body piercings. Tattoos and/or body piercings may serve the adolescent medicine practitioner as a warning signal or screening device for other risk-taking behavior and lead to medical monitoring and/or counseling.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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An anonymous survey based on the 1997 Centers for Disease Control and Prevention Youth Risk Behavior Survey assessing the prevalence of risk-taking behaviors in adolescents was conducted on military beneficiaries aged 12 to 22 years old attending the Adolescent Clinic, Naval Medical Center, San Diego. The number of patients and/or their parents offered participation was 552. Of these, 484 (88%) adolescents completed the survey. The percent female was 59%, male 41%. Those who self-described as white were 40%; black-not Hispanic, 11%; Hispanic or Latino, 11%; Asian or Pacific Islander, 26%; and other, 9%. The age distribution of participants was as follows: 11% were 12 to 13 years old, 20% were 14 to 15 years old, 26% were 16 to 17 years old, 26% were 18 to 19 years old, and 17% were 20 years old or older.
All patients attending the Adolescent Clinic on selected days from December 2000 through April 2001 were approached for participation in the survey. This Adolescent Clinic receives some referrals for adolescent medicine-related issues but is mainly a primary care clinic for dependent children, ages 12 to 22, of military personnel. No military personnel participated in the survey. If patients were under 18 years of age, their parents were presented with an informational packet that included a parent cover letter and a copy of the survey. The cover letter explained the purpose of the survey and any perceived risks to the participating adolescents. Once parents had given permission for their children’s participation, a different cover letter was presented to the adolescents. Adolescents 18 years old or older were given the cover letter when they entered the clinic that explained the purpose of the survey as well as perceived risks. Adolescents wishing to participate in the study were asked to fill out the survey in the clinic in privacy. On completion participants randomly placed their surveys into a collection folder so answer sheets could not be matched with participants. There were no patient identifiers on the survey answer sheets, thus ensuring complete patient privacy.
Six indices were created for this study using 45 items from the Youth Risk Behavior Survey to assess participation in risk-taking behaviors: Disordered Eating Behavior Index (4 items, Cronbach 
= 0.54), Violence Index (4 items, Cronbach = 0.43), Gateway Drug Index (13 items, Cronbach = 0.90), Hard Drug Index (13 items, Cronbach = 0.83), Sexual Behavior Index (7 items, Cronbach = 0.90), and Suicide Index (4 items, Cronbach = 0.75). The answers to each question (item) were scored 0 to 4 with higher scores corresponding to responses associated with greater involvement or risk. The item scores were added together to give a total index score. The Eating Disorder Index reviewed weight control methods in the previous 30 days (exercise, dieting, diet pills and purging behavior). The Violence Index asked about weapon carrying and physical violence in the last year. The Gateway Drug Index included questions about age at first use and lifetime use and current use of tobacco, alcohol, and marijuana. The Hard Drug Index included questions about use of cocaine, Ecstasy, crystal methamphetamine, inhalants, and intravenous drug use. The Sexual Behavior Index questioned age of first intercourse, number of partners, and contraceptive use. The Suicide Index asked questions about suicidal ideation and attempts in the last 12 months.
The Cronbach scores for the Eating Disorder and Violence Indices were lower than the indices. Cronbach is a reliability index, often described as measuring the "internal consistency" of a rating scale. The is calculated as 1 minus a ratio of variances, where the bottom term contains the covariance among the questions. If the questions are totally uncorrelated, their covariance is zero and reduces to 1 - 1 = 0. If they measure the same thing, they are highly correlated and the covariance adds in to make close to 1. Thus, if the factor a question measures is different from the factor another question measures, they measure different things and the questionnaire is not internally consistent. If the factor being measured is the same for all questions, goes close to 1. This way, it can be said they are measuring the same thing or they are measuring quite different things, without knowing just what this common factor is. Therefore, the 2 indices with lower Cronbach scores contain questions that are not as internally consistent as the other indices. For example, in the Eating Disorder Index questions about exercise behavior may measure a factor different from the questions about purging behavior. In the Violence Index, questions about carrying a weapon may measure a factor different from the questions about physical violence.
Additional questions were added to evaluate the presence of tattoos and body piercings. Specific tattoo questions included age at first tattoo, number of tattoos, amateur versus professional tattoos, visibility of the tattoo while clothed, and symbolism of the tattoo (gang affiliation, relationships, etc). Specific piercing questions included age at first piercing, number of lifetime piercings, presence of piercings at the time of the survey, and anatomic location of piercings.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Tattooing was reported by 13.2% of the adolescents surveyed with 5.2% having >1 tattoo. Most tattooed adolescents acquired their tattoos at older ages. Twenty-nine point two percent acquired their first tattoo before age 17 and 4.6% before age 14. Most (60.3%) had 1 tattoo. Thirty-nine point seven percent of tattooed adolescents had >1 tattoo. Most (73.8%) of the tattooed adolescents reported having all of their tattoos done by a professional. One adolescent reported gang affiliation as a reason for tattooing (these data are seen in Table 1).
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Excluding the ear lobes, 26.9% of the adolescents had body piercings during their lifetime, and 11.8% had a history of multiple body piercings. The most common locations for current piercings in the sample were ear cartilage other than earlobe (13.6%), mouth/tongue (11.2%), and navel (10.7%). The least common locations were nipple (1.2%) and genitals (0.8%). Of the pierced adolescents, 54.5% had their first piercing before age 17 and 20.9% before age 14. Of the adolescents who had been pierced, 71.6% still had their piercing at the time of the survey (Table 2).
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Tattooing and body piercing were found to be more common in females than males, 16.6% versus 8.1% for tattoos and 36.7% versus 10.1% for body piercings, respectively. Tattooing and body piercing were also more common in older adolescents. Among adolescents
15 years old, 2.0% reported having a tattoo and 26.3% of adolescents >18 years old or older reported having a tattoo. Piercing at a location other than the ear lobe was reported by 13.0% adolescents 15 years old and 37.5% of adolescents >18 years old. There were no significant differences in the percentages of tattooing or body piercing between different ethnic groups (Table 3).
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As can be seen in Table 4 and Fig 1, index scores on 5 of the 6 risk-taking indices were significantly higher in participants with at least 1 tattoo or body piercing compared with those with neither. These included the Disordered Eating Behavior Index, the Gateway Drug Index, the Hard Drug Index, the Sexual Behavior Index, and the Suicide Index. This indicates greater risk-taking or greater involvement in the individual activities for those with tattoo and/or body piercing (T/P). No significant differences were found on the Violence Index between the 2 groups.
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Regression analysis was performed on these indices to determine the influence of tattoos and/or body piercing on the index scores. The presence of T/P had the greatest influence on the Gateway Drug Index score: R2 = 0.195 (P
.001; 19.5% of the index score could be attributed to tattoos or body piercings), followed by the Hard Drug Index: R2 = 0.145 (P .001), and the Sexual Behavior Index: R2 = 0.126 (P .001). The lowest influence was found with the Disordered Eating Behavior Index: R2 = 0.010 (P = .026) and the Suicide Index: R2 = 0.016 (P = .006). The significant index score differences found between those with and without T/P mentioned above were consistently found on the Gateway Drugs, Hard Drugs, and Sexual Behavior Indices when the results were separated by type of body modification present (tattoos or body piercings) and by gender. Scores for males and females with T/P analyzed separately had higher scores than those without (Table 5).
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Violence Index scores were >3 times as high in males with tattoos and >2 times as high in females with body piercings compared with those without (Table 5). Suicide Index scores were almost twice as high in females with tattoos than those without (Table 5).
In adolescents who had tattoos, 32% higher Gateway Drug Index scores were found if they had obtained their tattoos at 16 years of age or younger (Table 6). Similarly, higher scores were found in those who had body piercings if they had received them at younger ages. Scores were 44% higher if they had received body piercings at 11–13 years old (Table 6). However, if they had obtained body piercings at 10 years of age or younger, their Gateway drug score was significantly lower than all the other age groups (Table 6).
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Significantly higher Suicide Index scores were found in participants whose first tattoo was obtained between the ages of 11 to 13 (Table 6). For those with body piercings, Suicide Index scores were 2 and a half times higher if they had obtained them between the ages of 14 to 16 compared with 17 years or older, and they were 4 times higher if they had obtained them between 11 to 13 years of age (Table 6). Interestingly, and similar to the Gateway Drug scores, had they gotten their body piercings at 10 years of age or younger, the Suicide Index score was much lower than all the other age groups (Table 6).
Analysis of the number of body piercings showed significance on the Hard Drug Index. Those with 2 body piercings had scores twice as high (Hard Drug score: 4.18) as those with only 1 (Hard Drug score: 2.01). Those with 3 or more body piercings had scores more than 3 times as high (Hard Drug score: 6.33 [3 piercings] and 6.86 [4 or more piercings]) as those with only 1 (P = .047).
Participants had 6 times higher Violence Index scores if they were unsure of the professional status of the person that had given them their tattoos (Table 7).
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Significant differences in Hard Drug Index scores were found regarding personal meaning of tattoos. The highest scores were found in participants who had tattoos associated with gang affiliation followed by "no special meaning" and love/relations. However, there was only 1 respondent with a gang-related tattoo (Table 8).
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The number of tattoos had no influence on any of the risk-taking behaviors index scores. The number of tattoos participants had was not found to be significantly associated with differences in disordered eating behaviors (P = .629), violence (P = .680), gateway drug use (P = .410), hard drug use (P = .875), sexual behavior (P = .313), or suicide (P = .683).
As stated above, having a T/P was associated with a higher Sexual Behavior Index score. However, no differences in sexual behavior scores were found among those with T/P on any of the body modification parameters surveyed. Therefore, for those with T/P, the age of T/P and number and type of body modifications had no association with the degree of sexual activity of the adolescents studied.
There were many findings that were not statistically significant, but were suggestive of relations between T/P and risk-taking behaviors. Visibility of tattoos was not found to be associated with differing scores on any of the risk-taking behavior indices. However, visibility of tattoos while clothed was suggestive of greater involvement in gateway drug use (P = .051). Having tattoos that were done by amateurs was suggestive of a higher Hard Drug Index score compared with those who received their tattoos from professional tattoo artists (amateur: 10.60 vs professional: 3.27; P = .060). Tattoos related to love and relations were suggestive of lower scores on the Disordered Eating Behavior Index (P = .083).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The purpose of this study was to assess the value of screening for tattoos and/or body piercings as markers of other risk-taking behaviors in adolescents. One potential limitation of the study design was the use of a survey for self-reported data collection. Also, the sample used was from 1 location, San Diego, California. Participants were given anonymity and confidentiality in an attempt to provide a safe environment conducive to honesty when answering the survey questions.
No previous study had examined risk-taking behavior of adolescents in association with tattooing and body piercing together. Previous work done on tattooing and body piercing has examined aspects of one or the other. Much of the work has focused on possible infectious implications, including the transmission of hepatitis C and human immunodeficiency virus. The studies related to the behavioral aspects of body modification have tended to focus on already problematic groups.
The results from the present study are clear. Adolescents possessing at least 1 T/P have significantly greater risk or degrees of involvement in the areas of drug abuse, sexual activity, disordered eating behaviors, and suicide compared with their peers without T/P. The presence of tattoos and body piercings in adolescents does not necessarily indicate risk-taking behavior in particular individuals, however asking questions about these types of risk-taking behaviors should be a part of every adolescent health visit. Not possessing a T/P does not mean an adolescent is risk-free. A number of the participants in this study without T/P had experience with the risk-taking behaviors, including gateway drugs (cigarettes, alcohol, and marijuana), hard drugs (cocaine, crystal methamphetamine, and Ecstasy), and sexual intercourse. However, those with T/P were much more involved and at greater health risk.
Significant differences were found when those with and without body modifications were examined by gender. Also, when the scores of only those participants possessing body modifications were analyzed, statistically significant differences were found among the adolescents according to the differing characteristics of their body modifications. Adolescents with tattoos or body piercings had greater involvement with gateway drugs and were at greater risk for suicide had they obtained their tattoos or body piercings at younger ages. Females in general were at greater risk for suicide if they had tattoos. Also, violence was associated with males with tattoos and females with body piercings. Finally, hard drug abuse involvement increased as the number of body piercings increased.
Determining causality was not the intention of this study, finding associations that could be used as tools to pursue important health issues with adolescents was. The meaning of these findings, therefore, is open for interpretation.
For example, regarding suicide, it seems that in the current study, younger age of body modification is associated with greater risk of suicide. Those with T/P have higher Suicide Index scores than those without T/P. Thus, screening for suicidal thoughts, behaviors, and attempts should be performed during health visits for adolescents possessing body modifications. This is especially true of females with tattoos, although the reasons why females having tattoos and young age of T/P are associated with greater risk of suicidal behaviors are unclear.
Regarding gateway drug use, it seems that the younger age of both tattooing and body piercing is associated with greater participation in this area, except if the individual had obtained their body piercings at 10 years of age or younger. This youngest group had less gateway drug involvement. Similarly, lower suicide risk was found in this age group. It may be argued that children receiving body modifications at such young ages do so with the assistance of their parents. This may imply parental involvement in their lives that may serve a protective role against gateway drug use and suicide.
The survey’s violence-related questions asked about participation in physical fights, receiving medical care as a result of the fights, carrying weapons, and carrying guns. The results of this study show that males with tattoos and females with body piercings participated more in these areas than their peers without T/P. However, carrying weapons may not indicate use of weapons or physical fighting. Future research investigating other aspects of violence in association with body modifications may therefore be beneficial.
Previous studies have shown some similar results on different populations. For example a study on adolescents found tattooing to be associated with low self-esteem, delinquency, drug abuse, and participation in satanic rituals.10 However, because the adolescents studied were already in a substance abuse program or a detention center, the results may have been difficult to apply to the general population. The present study, in comparison examined a more wide-ranging population. Another study looked at the presence of tattoos in suicides and found tattoos in 21% of the total suicides.15 More cigarette smoking and more sexual partners in college men with tattoos were also found in previous research.16 In the same study, college women with tattoos were more likely to report use of drugs other than alcohol and shoplifting. However, differences in the number of sexual partners were not shown. In a study on 16- to 65-year-old patients presenting to the emergency department, more smokers than nonsmokers had tattoos.17 However, use of other gateway drugs was not examined.
Another study found that 57% of tattooed adolescents labeled themselves as "risk takers," and that 28% used alcohol, drugs, or both before the tattooing.18 In the same study, those with amateur tattoos were found to have started younger, were in lower grade levels when they started, had more tattoos, and reported lower academic grades. In the present study, academic status was not examined. Amateur markings were suggestive of greater involvement with hard drugs. These findings may show that an adolescent who went to a professional to get a tattoo is less likely to use hard drugs to the degree that those who went to a nonprofessional are. Perhaps those under the influence of hard drugs make spontaneous decisions to obtain tattoos and do so with homemade ones.
Self-reported higher academic performance and obtaining tattoos at higher school grade levels has been associated with professional tattoos.18 In the present study, those with professional tattoos were less likely to be violent than those who were unsure of the professional status of the tattoo artist. Interestingly, those who definitively knew that the tattoo artist was an amateur had violence scores as low as those who knew their artist was a professional. This may mean that adolescents who unequivocally know the professional status of their tattoo artists may make more clear and definitive decisions to obtain tattoos. Clear decision-making, and therefore, possibly higher self-confidence, may be protective against the type of violence queried in the survey.
Gang-affiliated tattoos were found associated with hard drug use. However, only 1 participant claimed to have a gang-related tattoo. Hard drug use history should be sought in all adolescents, but particular attention may need to be paid to adolescents with gang-related tattoos.
A pertinent negative in the results of the study relates to sexual activity. The only significant finding in this area was that adolescents with at least 1 T/P were more sexually active and at greater risk sexually than adolescents without T/P. For those with T/P, no differences in their sexual activity were found regarding age of first T/P, type of T/P, or number of T/Ps. Therefore, the sexual behavior of adolescents should not be judged by how many or what type of body modifications they have, but they should be screened for good reproductive health maintenance.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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The findings of this study may impact the general perception of adolescents. The results show that the presence of tattoos and body piercings in adolescents is associated with greater risk-taking behaviors of these adolescents in the areas of gateway drug use, hard drug use, sexual activity, suicide, and disordered eating behaviors. In particular, young adolescents with tattoos and body piercings are at greater risk for suicide and cigarette, alcohol, and marijuana use. Violence is found to a greater degree in males with tattoos and females with body piercings. Finally, abuse of hard drugs such as cocaine, crystal methamphetamine, and Ecstasy increases as the number of body piercings increases. The presence of tattoos and body piercings in adolescents does not necessarily indicate risk-taking behavior in particular individuals, however, the presence of such should alert parents, teachers, and health care providers of the possibility of greater health risk in adolescents with tattoos and/or body piercings, and appropriate care should be implemented.
Clear differences were found between adolescents with and without tattoos and/or body piercings. Additional investigation is warranted. Examining a larger population of adolescents with tattoos and body piercings may show significant differences in the areas that were found to be suggestive of differences in this study.
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ACKNOWLEDGMENTS |
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The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program, sponsored this report S00-115 as required by NSHSBETHINST 6000.41A.
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FOOTNOTES |
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Received for publication Jul 9, 2001; Accepted Jan 8, 2002.
Reprint requests to (S.T.C.) Adolescent Medicine Division, Department of Pediatrics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, California 92134-5000. E-mail: sean.carroll{at}haw.tamc.amedd.army.mil
Dr Carroll is currently affiliated with Adolescent Medicine Services, Tripler Army Medical Center, Honolulu, Hawaii.
Dr Roberts is currently affiliated with the Division of Adolescent Medicine, Strong Children’s Research Center, University of Rochester School of Medicine, Rochester, New York.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
TINY HEART DEVICES REDUCE DEATH RATE, BUT COST IS CONCERN
"Researchers have found that they can sharply reduce the death rate in high-risk heart attack patients with small but costly devices that are tucked under the skin of the chest, and can avert potentially fatal heart rhythms.
The devices, implantable defibrillators, sense when the heart’s rhythm is going awry and administer a small electric shock to the heart to bring its fluttering rhythm back to normal, preventing sudden death The device costs about $20,000, though, and the operation to insert it, another $10,000."
Editorial Note: Multiply this cost by at least 400,000 new patients a year. The cost of medical care is not going down, nor will it!
Kolata G. New York Times. March 20, 2002
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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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