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Health implications of body piercing and tattooing: a literature review

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Tattooing and body piercing have become increasingly popular in recent years, particularly among young adults and adolescents. Montgomery and Parks (2001) say tattoos represent attributes such as individualism, risk, sexual fantasies and uniqueness, which are important for adolescents attempting to prove their individuality.

Abstract

VOL: 99, ISSUE: 37, PAGE NO: 62

Jane Barnett, MSc, RGN, is public health nurse, Gloucestershire Health Protection Unit, Cheltenham

 

Tattooing and body piercing have become increasingly popular in recent years, particularly among young adults and adolescents. Montgomery and Parks (2001) say tattoos represent attributes such as individualism, risk, sexual fantasies and uniqueness, which are important for adolescents attempting to prove their individuality.

 

 

Jewellery and body adornment may reflect culturally defined notions of beauty for particular groups. In the UK, ear lobe piercing has been accepted for many years. The piercing of other body parts is a more recent trend.

 

 

Whatever the reasons for choosing body adornment, it can have serious health implications, which clients and health care workers should be made aware of.

 

 

Legislation in the UK
There is a general view that legislation is weak in relation to body piercing (Health and Safety Executive/Local Authorities Enforcement Liaison Committee, 2001; Carroll and Beard, 2000; Wright, 1995). In London, businesses performing electrolysis, piercing, tattooing, acupuncture, branding and any other scarification - defined as special treatments - must be licensed by the local authority (LA). However, outside London there is no legal requirement for LA inspection except if businesses carry out ear piercing or tattooing (HSE/LAELC, 2001).

 

 

Local authorities can create by-laws and may also use general enforcement powers under the Health and Safety at Work Act 1974 to ensure the safety of people visiting piercing studios. However, in theory businesses that perform body piercing, but not ear piercing or tattooing, do not have to register under existing law.

 

 

The Tattooing of Minors Act 1969 prohibits the tattooing of anyone under 18 years of age. No such limitation applies to ear or body piercing, although piercing of genitalia of children younger than 16 years is prohibited under the Sexual Offences Act 1956.

 

 

Most reputable studios have a voluntary code relating to age and to those under the influence of drugs or alcohol (Wright, 1995). In the event of new legislation, it should be recognised that more stringent controls may encourage young people to pierce or tattoo themselves, potentially increasing the health risks.

 

 

Hazards of tattooing and body piercing
There is sufficient literature to suggest that the spread of blood-borne viruses (BBV) may be a risk associated with tattooing, piercing and some complementary therapies such as acupuncture (Haley and Fischer, 2001; Montgomery and Parks, 2001; Nishioka and Gyorkos, 2001; CDR Weekly, 1998). There is particular concern about the potential for the spread of hepatitis C (Department of Health, 2002).

 

 

Other potential complications include adverse reactions to the pigment used for tattooing (Montgomery and Parks, 2001; Sperry, 1992) and granulomatous responses, melanomas and basal cell carcinomas (Wright, 1995). Several LA guidelines highlight additional health hazards from body piercing (Bournemouth Borough Council, 2001; Bury and Rochdale Metropolitan Borough Council/Bury and Rochdale Health Authority, 2000), including:

 

 

- Blood poisoning;

 

 

- Localised severe swelling and trauma around the piercing site;

 

 

- Scarring;

 

 

- Localised infection;

 

 

- Allergic reactions to metals and antiseptics;

 

 

- Severe bleeding.

 

 

These authors suggest that practitioners should make customers aware of the possible adverse effects by displaying information within their premises. The issue here is the balance between adequately informing customers of the risks associated with a procedure and the potential loss of business.

 

 

Training
There is no current requirement for tattooists or body piercers to undertake specific training. Caine (2001) observed the lack of consistency in practitioner training and commented that some viewed short courses or videos as sufficient preparation for practice.

 

 

The Management of Health and Safety at Work Regulations 1999 place a responsibility on employers to provide adequate training to ensure that employees can carry out their work safely. It is also a requirement to carry out an assessment of the risks to employees’ and customers’ health and safety, including risks of infection.

 

 

Infection control issues in studios
Several authors have carried out infection control assessments in these areas (Barnett et al, 2003; Raymond et al, 2001; Carroll and Beard, 2000). Caine (2001) observes that although environmental health officers (EHOs) can inspect for health and safety hazards, they do not necessarily know what infection control risks to look for, so a combined approach involving the EHO and infection control personnel is advantageous.

 

 

Barnett et al (2003) noted the importance of infection control personnel being accompanied by an EHO, who has legal right of entry to premises.

 

 

Infection control issues are similar for tattooing and body piercing. Table 1 summarises an audit tool used by Barnett et al (2003), based on the original tool by Millward et al (1993). This has been adapted for use in tattooing and body piercing premises.

 

 

One factor identified by Carroll and Beard (2000) and by Barnett et al (2003) is the tattooing machine, which has a lumen through which a sterile needle is threaded for each client. Between clients, the needle is disposed of and the lumened part is detached and placed in an ultrasonic machine which removes debris before sterilisation in an autoclave (HSE/LAELC, 2001). If this process is inadequate, there may be risks of cross-contamination.

 

 

An important factor in body piercing is the sterilisation of jewellery immediately prior to insertion. The sterilisation of packaged jewellery in a standard steam steriliser was identified by Barnett et al (2003) as a risk. Unless a vacuum steriliser is used, which will penetrate packaging, the jewellery may not be sterile at the point of use. Piercers were therefore advised to sterilise jewellery immediately before insertion.

 

 

Conclusions
Several authors have identified a range of skills and knowledge among tattooists and body piercers (Barnett et al, 2003; Raymond et al, 2001; Carroll and Beard, 2000). New legislation is needed to strengthen the powers of LA enforcement officers, particularly those outside London, and to overcome variations in training. Although information on the range of body adornment and advice for prospective customers are available on the internet, schools may need to make some of the health messages accessible to their pupils.

 

 

Health care workers in community settings also need to be able to direct those considering body adornment to appropriate information. Wright (1995) says they should not be seen to disapprove of body adornment.

 

 

LAs may be able to assist with the provision of educational material on the potential risks of body piercing and tattooing. Individuals should also consider their motivation for the piercing or tattoo, and the future implications for employment or personal relationships (Wright, 1995).

 

 

Bury and Rochdale Metropolitan Borough Council/Bury and Rochdale Health Authority (2000) advises prospective customers to look for elements of good practice before deciding. These include many areas identified in Table 1. Most reputable practitioners would welcome questions from potential clients - those that do not should be treated with caution.

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