Chapter 1: the Problem………………………………………………………

Home , Ampallang, Apadravya, Body modification, Dydoe, Frenulum, Genital piercing

UNIVERSITY OF CINCINNATI

Date:______

I, ______, hereby submit this work as part of the requirements for the degree of: in:

It is entitled:

This work and its defense approved by:

Chair: ______

A Content Analysis of On-Line Information on Body Piercing and Body Modification

A thesis submitted to the

Division of Graduate Studies and Research University of Cincinnati

in partial fulfillment of the requirements for the degree of

Master of Science

In the Division of Human Services of the College of Education, Criminal Justice & Human Services

2008

Rebecca Lehman B.A., University of Cincinnati, 2002

Abstract

AN ABSTRACT OF THE THESIS FOR MASTER OF SCIENCE DEGREE IN HEALTH PROMOTION AND EDUCATION, PRESENTED ON 10 JULY 2008, AT THE UNIVERSITY OF CINCINNATI, OHIO.

TITLE: A Content Analysis of On-Line Information on Body Piercing and Body Modification

MASTERS COMMITTEE MEMBERS Dr. Keith King (Chair) and Dr. Amy Bernard

This study was a content analysis of websites of 75 US-based body piercing establishments affiliated with the Association of Professional Piercers. The purpose of the study was to investigate the information available on the websites about studio cleanliness, safety precautions, potential complications from body piercings, body piercers‟ professional experience and affiliations, recommended aftercare, recommended resources on body modification, and the body modification procedures available.

The gathered information was unique in body modification research in that the information came from within the industry, as opposed to clients of the industry. Body piercing establishments provided much information that promoted safe piercing practices and minimization of risk of negative complications. The study found that the examined establishments demonstrated frequent practice of stretching body piercings and providing surface piercings and some practice of procedures that use dermal/biopsy punches, subdermal implants, and intentional scarification.

iii iv Acknowledgements

Countless thanks are due to the following people:

Dr. King & Dr. Bernard, for their work as committee chair and member, respectively.

Meg & Ned, for their patience, continued support, and wealth of insight.

Miss Faye, for her constant support, humor, and encouragement.

Dawn, for her patience and invaluable support - both emotional and financial.

Karie, Denise, & Un, for their feedback, insights, and help laughing through the frustrations of this project.

Jesse, for grudgingly understanding the importance of “weekends off” and frequent bouts of cheerleading.

v Table of Contents

Page Abstract iii Acknowledgements iv List of Tables vii Chapter 1: The Problem……………………………………………………….. 1 Statement of the Problem……………………...... 4 Research Questions…………………………………………………...... 5 Delimitations……………………………………………………………… 6 Limitations………………………………………………………………… 6 Assumptions……………………………………………………………… 6 Operational Definitions………………………………………………...... 6 Chapter 2: Review of Literature………………………………………………. 7 Body Piercing in Cultural Context…………………………………….... 7 Prevalence of Body Piercing………………………………………….... 8 Risks and Complications of Body Piercing…………………………… 10 General Complications…………………………………………... 10 Prevalence of Complications……………………………………. 13 Perception of Risk……………………………………………...... 14 Recommendations to Decrease Complications……………………… 15 Role of Body Piercers…………………………………………………… 18 Emerging Body Modification Procedures…………………………...... 19 Stretching…………………………………………………………. 19 Punch and Taper…………………………………………………. 19 Scalpelled Piercings……………………………………………… 20 Tongue Splitting………………………………………………….. 20 Frenectomies……………………………………………………... 20 Microdermal Implant……………………………………………... 20 Transdermal Implant……………………………………………... 21 Subdermal Implant……………………………………………….. 21 Intentional Scarification………………………………………….. 21 Internet as a Source of Health Information…………………………… 22 Gaps in the Literature…………………………………………………… 22 Summary…………………………………………………………………. 23 Chapter 3: Methods……………………………………………………………. 25 Participants……………………………………………………………….. 25 Instrumentation…………………………………………………………... 26 Procedures……………………………………………………………….. 28 Data Analysis…………………………………………………………….. 30 Chapter 4: Results and Discussion…………………………………………... 32 Units of Analysis…………………………………………………………. 32 Body Piercing Establishment and Website Characteristics…………. 33 Information on Cleanliness and Safety Precautions…………………. 35 Hygiene During Body Piercing………………………………….. 35 Sterilization Equipment………………………………………….. 38 Licensure………………………………………………………….. 40 Age Policies………………………………………………………. 40 Identification Policies…………………………………………….. 41 Other Policies…………………………………………………….. 42 Jewelry Used in Initial Body Piercings…………………………. 42

vi Information about Body Piercers………………………………………. 44 Early Professional Development……………………………….. 45 Health Related Training and Certification……………………... 45 Continuing Education……………………………………………. 47 Years of Experience……………………………………………… 47 Reported Affiliation……………………………………………….. 49 Information about Potential Complications and Adverse Effects…… 49 Potential Complications and Adverse Effects During the Procedure………………………………………………….. 49 Potential Complications and Adverse Effects After the Procedure………………………………………………….. 53 Potential Psychosocial Complications and Adverse Effects… 60 Information on Aftercare………………………………………………… 61 What to Expect During Normal Healing……………………….. 63 General Aftercare………………………………………………… 63 Salt Water/Saline Soaks………………………………………… 67 Cleaning with Soap………………………………………………. 69 Oral Piercing Aftercare…………………………………………... 70 Genital Piercing Aftercare……………………………………….. 73 Recommended Resources……………………………………………... 75 On-Line Resources………………………………………………. 75 Print Resources…………………………………………………... 80 Video Resources…………………………………………………. 80 Procedures Available……………………………………………………. 80 Other Information of Note………………………………………………. 83 Availability of Information……………………………………………….. 86 Discussion………………………………………………………………... 88 Chapter 5: Conclusions and Recommendations…………………………. 99 Conclusions……………………………………………………………. 101 Discussion……………………………………………………………… 108 Recommendations…………………………………………………….. 112 Recommendations for Practice………………………………. 112 Recommendations for Improving this Research……………. 113 Recommendations for Future Research…………………….. 114 References…………………………………………………………………….. 117 Appendices……………………………………………………………………. 121 Appendix A: Body Modification Content Rating Form…………….. 121 Appendix B: Panel of Experts Information…………………………. 123 Appendix C: Tables…………………………………………………... 124

vii List of Tables

Table 1.1 Site-Specific Complications of Body Piercings……………………….. 12 Table 4.1 Information on Hygiene, Cleanliness, Safety Precautions…………... 37 Table 4.2 Information on Body Piercers………………………………………...... 46 Table 4.3 Years of Experience Reported in Body Piercer On-Line Biographies……………………………………………………………...... 48 Table 4.4 Information on Potential Complications and Adverse Effects……….. 50 Table 4.5 Potential Post-Procedural Complications and Adverse Effects and Frequency of Reporting…………………………………………………. 54 Table 4.6 Information on Aftercare………………………………………………… 62 Table 4.7 Recommended On-Line Resources…………………………………… 76 Table 4.8 Availability of Body Modification Procedures…………………………. 82 Table 4.9 Other Information of Note……………………………………………….. 84 Table 4.10 Availability of Information………………………………………………... 87 Table C1 Body Piercing Establishment Hours of Operation……………………. 124 Table C2 Aftercare Guidelines and Frequency of Recommendation………….. 126 Table C3 Oral Piercing Aftercare Guidelines and Frequency of Recommendation………………………………………………………… 128 Table C4 Estimated Healing Time by Body Piercing and Frequency of Estimation…………………………………………………………………. 130

viii Chapter One

The Problem

Body piercing is a procedure which involves creating an opening in the surface of the skin and placing jewelry in it. The procedure is usually quick and performed without anesthesia. Body piercing has a long history throughout most cultures and has experienced a recent surge in popularity in Western culture, particularly among adolescents and young adults.

According to nationally representative data collected in 2004, 14% of the U.S. population had ever had a body piercing (excluding earlobe piercings). While only 2% of those born before 1963 had ever had a body piercing, 32% of those born between 1975 and 1986 had a body piercing (Laumann & Derrick, 2006). Seventy-four percent of those who had ever had a body piercing obtained their first body piercing before age 24. One- quarter to one-half of university undergraduate students reported they had ever had a body piercing (Armstong, Roberts, Owen, & Koch, 2004; Burger & Finkel, 2002; King &

Vidourek, 2007; Mayers, Judelson, Moriarty, & Rundell, 2002).

The above data demonstrated that body piercing in the US was more common among younger individuals. Roberts, Auinger, and Ryan (2004) asserted that the steady increase in rates of adolescents who reported having a body piercing demonstrated the growing popularity of body piercing among adolescents. Their data collected in 1996 found that 4.3% of adolescents reported having a body piercing. More recent studies found that between 27% and 69% of adolescents had ever had a body piercing (Carroll, et al., 2002; Deschesnes, Demers, & Finès, 2006; Gold, Schorzman, Murray, Downs, &

Tolentine, 2005; Braithwaite, Robillard, Woodring, Stephens, & Arriola, 2001). All but one study of adolescent body piercing found that girls were significantly more likely than boys to have a body piercing.

1 The Problem - 2

Body piercing could potentially result in a variety of negative health consequences and adverse effects for the pierced individual. These potential complications included bruising and bleeding at the piercing site, migration of jewelry, allergic reaction to jewelry, nerve damage, scarring and formation of keloids, localized infection, systemic infection, tetanus, and infection with bloodborne pathogens such as hepatitis and HIV (Meltzer, 2005; Samantha, Tweeten, & Rickman, 1998; Stirn, 2003).

Rates of reported complications varied, but were disturbingly high. In their national data set on body piercing, Laumann and Derick (2006) found that 23% of participants with body piercings reported complications, which most frequently occurred later than three weeks after obtaining the body piercing. Huxley and Grogan (2005) found that 19% of participants with body piercings had experienced health problems associated with the body piercing. Mayers et al. (2002) found a similar rate among university undergraduate students, where 17% of those with body piercings reported medical complications. Two other studies of university undergraduates found much higher rates of medical complications: Armstrong, Roberts, Owen, and Koch (2004) found that 69% reported complications; Greif, Hewitt, and Armstrong found that 70% reported complications. Skin irritation and infection at the piercing site were the most commonly reported complications in these two studies.

Despite the frequency of complications of body piercings, researchers found that the risk of complications played only a small role in decision-making around body piercing. King and Vidourek (2007) found that while the majority of those who had obtained a body piercing considered the risk of infection and scarring before obtaining their most recent piercing (81% and 70%, respectively), less than half considered the risk of allergic reaction and HIV infection. They found that only one in five participants considered the risk of Hepatitis B and C and Tetanus. Huxley and Grogan (2005) found that 39% of those with body piercings had not considered potential health risks before

The Problem - 3 the piercing procedure was performed. As possible complications of body piercing, 68% of participants in the study identified infection, 10% identified contraction of infectious diseases, and only 1% identified allergic reaction.

Body piercers played a key role in the risk of complications. Bruising, bleeding, migration, nerve and tissue damage, and allergic reaction to jewelry were largely due to the placement of the piercing and quality of jewelry selected by the body piercer. The

Health and Safety Executive (2003) noted there were two occasions when infections could occur: at the time of obtaining the body piercing and during the healing period.

Infections during the former were due to poor infection control practices by the body piercer. Infections during the latter were due to poor hygiene at and excessive touching of the piercing site.

Several strategies have been recommended in the professional literature to reduce the risk of health complications. These strategies have largely targeted three groups: 1) the body piercing industry; 2) medical professionals such as doctors and nurses; 3) community and university based health educators. At the time of this study, no evaluations had been conducted to assess the efficacy of these strategies. The recommendations were based on general medical knowledge and previous recommendations and regulations enacted with tattooing. Body piercers, despite having been the key figures in the body piercing industry, had not been involved in research.

The role of body piercers in reducing complications was important because most people who had body piercings reported obtaining piercings from “professional” body piercers (Deschesnes, Demers, & Finès, 2006; Huxley & Grogan, 2005; Laumann &

Derick, 2006). Also, body piercers were viewed as being among the top sources of information about body piercings (Gold et al., 2005). Caliendo, Armstrong, and Roberts

(2005) found that when individuals with intimate body piercings had complications they commonly sought advice from body piercers rather than from medical professionals.

The Problem - 4

Body piercers were also knowledgeable of additional procedures such as body modifications. Body modification involves the voluntary modification in the appearance of the body by piercing, cutting, tattooing, or inserting implants under the surface of the skin. Such examples include tongue splitting, branding, scarification, and microdermal, subdermal, and transdermal implants.

The Internet was a growing source of information and health information for adolescents and college students (American College Health Association, 2006; Brown,

Teufel, & Burch, 2007). There were several Internet websites and on-line communities related to body piercing and body modification. Web searches for body piercing establishments result in hundreds of websites. Most body piercers who were members of the Association of Professional Piercers (the leading professional association in this field) had websites about their body piercing establishment and work.

Statement of the Problem

There are many issues pointing to a need for health promotion and education around body piercing, including: 1) the growing popularity and relative frequency of body piercing; 2) the substantial risk of complications from body piercing; 3) the lack of consideration of risk when obtaining a body piercing. The field of health promotion and education is lacking a core set of information from which to develop educational materials and programs. Previous researchers have identified the prevalence of piercing and complications and medical professionals are able to identify key risks for infection.

Researchers in health information have identified the internet as a common source of health information for the public. To date, no research has been published about information available on-line about body modification and its associated risks.

The Problem - 5 complications from body piercings, the body piercers‟ professional experience and affiliations, aftercare, recommended resources on body modification, and procedures available. The study also examined the extent to which these topics were covered in the websites posted by body piercing establishments.

Research Questions

The research questions of the study are:

1. What information do body piercing establishments post on their websites about

the cleanliness of the body piercing establishment, the safety precautions used

during the piercing process at the establishment, potential complications of body

piercings, and the professional experience and/or affiliations of the body piercers

employed at the establishment?

2. To what extent do body piercing establishments post information on their

websites about the cleanliness of the body piercing establishment, the safety

precautions used during the piercing process at the establishment, potential

complications of body piercings, and the professional experience and/or

affiliations of the body piercers employed at the establishment?

3. What information do body piercing establishments post on their websites about

aftercare?

4. To what extent do body piercing establishments post information on their website

about aftercare?

5. What resources do body piercing establishments recommend for information on

body modification, as noted on their websites?

6. What body modification procedures are available at body piercing establishments

according to their websites?

The Problem - 6

Delimitations

This study was delimited to websites posted by professional body piercers who were affiliated with the Association of Professional Piercers (APP) and whose websites were listed as US-based and linked through the “Find an APP Piercer” search page on the APP website at the time of the study.

Limitations

The study was limited by the researcher‟s ability to navigate all pages of the websites.

Assumptions

The study was based on the assumption that researcher thoroughly searched and corrected recorded information from each website examined.

Operational Definitions

1. Aftercare – the set of procedures used to maximize a body modification‟s

chances of healing without health complications, including but not limited to: how

to clean the modification; what to clean it with; how often to clean it.

2. Body piercing – any opening in the surface of the skin made to place jewelry in.

For the purposes of this study, this includes all body piercings performed by the

participants, including soft-lobe piercings.

3. Body piercing establishment – a location where body piercings are performed by

body piercer(s) for profit.

4. Body modification – voluntary modification in the appearance of the skin of the

body by piercing, cutting, tattooing, or inserting implants under the surface.

5. Body modification procedures – any procedure performed in order to intentionally

modify the appearance of the skin by piercing, cutting, tattooing, or inserting

implants under the surface. For the purpose of this study, these are limited to

procedures performed by non-medical professionals at body piercing

establishments.

Chapter Two

Review of Literature

The purpose of this study was to investigate the information available on websites of body piercing establishments. The present study examined websites to identify the information provided about studio cleanliness, safety precautions, potential complications from body piercings, the body piercers‟ professional experience and affiliations, aftercare, recommended resources on body modification, and procedures available. The study also examined the extent to which these topics were covered in the websites posted by body piercing establishments.

Body Piercing in Cultural Context

Body piercing is a procedure which involves creating an opening in the surface of the skin and placing jewelry in it. The procedure is usually quick and performed with no anesthesia. Body piercing has been practiced in many cultures throughout known history, including in the Aztec, Mayan, Egyptian, Greco-Roman, Persian and Babylonian empires and tribes of Central Africa, the Middle East, and South America (Stewart, 2000; Stirn,

7 Literature Review - 8

2003). In more recent Western culture, the trend of ear piercing spread during the sixteenth century from women in Spain to women in France and England. Similarly, a trend of nipple piercing spread from Louis the XIV‟s France to England. In the late 1970s, piercing was associated with the punk movement, starting in London and New York.

Body modification through tattooing and body piercing appears to have been present throughout recorded and pre-historic cultures. In societies where body modification was not socially acceptable, body piercing and tattooing practices went “underground” and those with modifications chose easily covered locations.

From its modern emergence in the punk movement, body piercing has spread to more mainstream popularity and acceptance, especially among adolescents. In modern

Western culture, many music and television celebrities popular with adolescents are commonly shown with pierced navels, eyebrows, lips, and areas of the ears other than the earlobe. Three-fourths of adolescents – both pierced and not pierced – reported liking body piercings on others (Gold, Schorzman, Murray, Downs, & Tolentino, 2005).

Because of the role body piercing has begun to play in adolescent identity formation,

McGuinness (2006) argues that body art such as tattooing and piercing have recently become an adolescent “rite of passage”. Personal aesthetics, self-expression, and rebellion are commonly stated reasons for getting body piercings among adolescents and college students (Deschesnes, Demers, & Finès, 2006; Gold et al., 2005; Greif,

Hewitt, & Armstrong, 1999).

Prevalence of Body Piercing

Laumann and Derrick (2006) conducted a national study on tattoos and body piercings and found that 14% of the population has body piercings (defined as non-soft- lobe piercing) and an additional 9% had considered or planned on obtaining a future body piercing. Reflecting body piercing as a growing trend among adolescents and young adults, they found that while only 2% of those born before 1963 had ever had

Literature Review - 9 body piercing, 13% of those born between 1964 and 1974 had and 32% of those born between 1975 and 1986 had. They also reported that 74% of those with body piercings obtained their first before age 24. Laumann and Derrick provided the only known population-based probability sample of body piercing among adults.

A few studies have examined at the prevalence of body piercing among US university students. King and Vidourek found that 35% of students at a large state university had ever had a body piercing (defined as non-soft-lobe piercing). Armstrong,

Roberts, Owen, and Koch (2004) found that 45% of students at a large state university had ever had a body piercing (defined as non-soft-lobe piercing). Thirty-two percent of students had a current body piercing. Mayers, Judelson, Moriarty, and Rundell (2002) found that 51% of undergraduate students at Pace University in Pleasantville, NY, had ever had a body piercing (defined as any piercing on men and non-soft-lobe piercing on women). Of the 315 body piercings among the sample, 39 (12%) had been removed.

King and Vidourek, Armstrong, et al., and Mayers, et al. found that female participants were significantly more likely to be pierced than male participants. Burger and Finkel

(2002) found that 24% of undergraduate students at a small Midwestern university had ever had a body piercing (defined as non-soft-lobe piercing).

Several studies have examined the prevalence of body piercing among North

American adolescents. In their survey of 2,180 12-18 year old high school students in

Quebec, Canada, Deschesnes, et al. (2006) found that 27.3% of students reported having a body piercing (defined as non-soft-lobe piercing). Forty four percent of girls reported having a body piercing, compared to 10.6% of boys reported having one. Boys were significantly more likely than girls to be pierced before age 12 (29.4% and 13.1%, respectively). Roberts and colleagues (2004) reported on data collected in 1996 from a nationally representative US survey of 13-18 year old high school students. They found that 4.3% of students reported having a body piercing (defined as non-ear piercing), with

Literature Review - 10 girls more likely than boys to report having a body piercing (7.1% and 1.5%, respectively). Roberts, et al. believe that the low percentages in 1996 compared to the higher percentages reported in later studies demonstrated the growing popularity of body piercing among adolescents.

Unlike the larger studies above, other research into adolescents and body piercing have been conducted with smaller samples of specific adolescent groups. Gold and colleagues (2005) surveyed 12-21 year old patients at an urban, hospital-based adolescent clinic. They found that 43% of participants age 12-17 and 59% aged 18-21 reported having a body piercing (defined as any piercing for boys and non-soft-lobe piercing for girls). In contrast to other studies, Gold, et al. found that girls were less likely to be pierced than boys (46% and 54%, respectively). In a study of 12-22 year old military beneficiaries who attended the Adolescent Clinic at the Naval Medical Center in

San Diego, CA, Caroll and colleagues (2002) found that 27% of participants reported they had ever had a body piercing (defined as non-soft-lobe piercing) and 20% had a body piercing at the time of the survey. Nine percent obtained their first piercing at or before the age of ten, 11.9% while 11-13 years old, 33.6% while 14-16 years old, and

45.5% while they were 17 years old or older. Braithwaite, et al. (2001) surveyed adolescent detainees age 11 to 18 and found that 69% reported having a body piercing

(defined as any piercing). Girls had more piercings on average than boys (3.6 and 2.0, respectively). Carroll and Anderson (2002) surveyed 15 to 18 year old girls in a nonresidential educational program for at-risk girls. Thirty-six-point-seven percent of participants reported having a body piercing (defined as non-soft-lobe piercing).

Risks and Complications of Body Piercing

General complications. Body piercing can result in a variety of negative health consequences for the individual who is pierced. These complications include: bruising and bleeding at the piercing site; migration of jewelry, wherein during the healing

Literature Review - 11 process the jewelry is pushed closer to the surface of the skin, leaving a scar in the path it takes; allergic reaction to jewelry, especially common with jewelry containing nickel; nerve damage, caused by the needle damaging a nerve during the body piercing procedure; scarring and formation of keloids (hypertrophic scarring); infection at the piercing site; systemic infections, including staphylococcus and tetanus; infection with bloodborne pathogens, including Hepatitis and HIV (Meltzer, 2005; Samantha, Tweeten,

& Rickman, 1998; Stirn, 2003).

Armstrong (2005) noted the importance of body piercers being trained and educated regarding the prevention of piercing complications. Many of the potential complications are largely due to the placement of the piercing, quality of jewelry selected by the body piercer, and cleanliness of procedure.

The piercer or piercing establishment also play a key role in the development of infection. The Health and Safety Executive (2003) noted that there are two occasions where infection can occur, the first of which is under the control of the piercer. Infection can occur at the time of piercing due to poor hygiene in terms of disinfection of equipment disinfection between customers, poor surface cleaning, used and clean instruments coming into contact with one another, poor piercer hygiene, and poor state of cleanliness of the premises. The second occasion where infection can occur is during aftercare of the new piercing, which is under the control of the pierced individual.

Infection can occur during aftercare due to poor hygiene/cleaning of the piercing site and excessive touching of the piercing site and/or jewelry.

Whether due to conditions during the piercing procedure or due to individuals‟ compliance with aftercare procedures, certain piercings carry specific risks. Armstrong

(2006), Meltzer (2005), Stirn (2003), and Stewart (2000) provided detailed lists or charts of site-specific complications. Their findings have been combined and summarized in

Table 1.

Literature Review - 12

Table 1.1 Site-Specific Complications of Body Piercings Piercing Site Potential Complications Ear Pseudomonas chondritis; nonmenstrual toxic shock syndrome; keloid formation; embedded earrings; traumatic tear Tongue High risk of infection due to prevalence of bacteria; obstruction of airway due to aspirated jewelry; dental abrasions and fractures; gingival trauma; increased salivation; damaged cheek tissue; permanent numbness; loss of taste; speech impediments Nose Jewelry swallowing or aspiration; perichondritis and necrosis of nasal wall; septal hematoma formation Navel Discoloration, persistent discharge, and increased risk of infection and keloids due to friction from clothing Nipples Inflammation, infection, and abscess of milk ducts (granulomatous/nonpeuperal mastitis); infection of breast implants; breastfeeding impairment Male Genitals Prostatitis; testicular infection; paraphimosis; priapism; urethral damage; increased risk of contracting STIs Female Genitals Strictures; fibrosis; nerve damage to clitoris; increased risk of contracting STIs Note: The above complications have been cited in the following research articles: Armstrong (2006); Meltzer (2005); Stirn (2003); and Stewart (2000).

Literature Review - 13

Prevalence of complications. The bulk of literature found in literature searches on body piercing in MedLine, CINAHL, and Academic Search Premier involved case studies of individuals with acute health complications that resulted from or involved a body piercing. A survey reported in BBC News (2002) found that 95% of general practitioners in two northern England cities had treated patients with a complication resulting from a piercing. Several studies examined the prevalence of complications in samples of individuals with body piercings.

In their national data set on US body piercing, Laumann and Derick (2006) found that 23% of participants with body piercings reported complications. Four percent of respondents experienced medical problems due to the piercing during the first three weeks after obtaining it while 3% experienced problems that started during the first three weeks and continued beyond three weeks. Fifteen percent experienced medical problems due to the piercing later than three weeks after obtaining the piercing. Navel piercings were reported as the most problematic of all reported body piercings. Twenty- three percent of those who reported having a tongue piercing reported chipped or broken teeth due to the piercing. Huxley and Grogan‟s (2005) research echoed the complication rates reported by Laumann and Derick. They found that 19% of participants with body piercings had experienced health problems associated with the piercing.

Studies researching the prevalence and medical complications of body piercing and tattoos in undergraduate university students have reported similar results as the general population studies reported above. King and Vidourek (2007) found that 18% of participants reported complications with their most recent body piercing. According to

Mayers et al., (2002), the reported incidence of medical complications was 17% among students with body piercings. Nine percent reported bacterial infection of the piercing site, 4.5% reported bleeding, and 3% reported suffering local trauma.

Literature Review - 14

Gold et al. (2005) also found similar rates of medical complications of body piercing among urban adolescents. Twelve percent of participants with body piercings reported complications. More specifically 10% experienced an infection at the piercing site, 2% experienced bleeding, and 1% experienced an allergic reaction. Thirty-three percent of all participants, both pierced and non-pierced, reported knowing someone who had had a medical or health problem related to body piercing. The most commonly reported complications were infections (74%), bleeding (30%), and allergic reactions

(26%). One participant reported knowing someone who experienced tetanus as a result of a body piercing.

Two studies in university students reported much higher rates of complications than the four studies above. Armstrong and colleagues (2004) found that 69% of students with body piercings reported complications, including skin irritation (42%), infection at the piercing site (23%), and allergic reaction to the jewelry (3%). Greif and colleagues (1999) found that 70% of students with body piercings experienced health problems associated with their piercing, including infections at the piercing site (45%), skin irritation (39%), and hepatitis (0.5%).

Perception of Risk. Two sets of researchers found that despite the potential complications of body piercings, the risk of complications played only a small role in decision-making around body piercing.

In their research with college students at a large state university, King and

Vidourek (2007) found that college students varied in their considerations of both obtaining body piercings and risks associated with body piercings. Before obtaining their last piercing, 31% of participants spent less than one week considering the piercing,

41% spent one to four weeks, and 41% spent greater than four weeks. King and

Vidourek found gender differences in consideration of complications. Females were more likely than males to consider the risks of infection (85% vs. 59%), scarring (75% vs.

Literature Review - 15

45%), and allergic reaction (47% vs. 23%). Males were more likely than females to consider the risks of HIV infection (38% vs. 29%) and tuberculosis (13% vs. 9%). A small and relatively equal percentage of males and females considered the risks of Hepatitis B

(19% and 21%, respectively), Hepatitis C (23% and 20%), and tetanus (19% and 21%).

According to Huxley and Grogan (2005), 39% percent of participants with body piercings reported that they had not considered potential health risks before the piercing procedure was performed. While 68% of participants with body piercings identified

“infection” as a possible complication of body piercing, only 10% identified contraction of infectious diseases and 1% identified allergic reaction as potential complications.

Location of the body piercing establishment (28%) was the most influential factor affecting choice of body piercing professional, followed by recommendation (19%) and reputation of the professional (14%). Cleanliness of establishment was not cited by any participants in an open-ended questions as a as a factor influencing choice of piercing professional.

Recommendations to Decrease Complications

Several articles comment on strategies to reduce the risk of health complications from body piercing. These can be divided into recommendations for industry regulations, medical professionals, and health education.

A few articles call for regulation and standardization of the body piercing industry as a strategy to reduce complications. Griffith and Tengnah (2005) called for regulating piercing premises for infection control, proper disposal of waste products, and strict enforcement of age and consent laws. Armstrong (2005) advocated for the same as well as for a system of documentation of complications from piercing for public and consumer health reasons. Stirn (2003) argues that health authorities and piercers need to establish uniform and obligatory regulations in the areas of training and education, as well as hygiene enforcement.

Literature Review - 16

Open, non-judgmental communication from physicians and nurses is the most recommended strategy for medical professionals (Gold, et al., 2005; McGuinness, 2006;

Schnirring, 2003; Stirn, 2003). Stirn (2003) also argued that medical professionals need to stay up-to-date with research in piercing prevalence and complications in order to be able to competently and non-judgmentally give advice and treat complications. Gold, et al. (2005) recommended such information be added to “the list of items addressed at adolescent and preadolescent well visits.” McGuiness (2006) asserted that medical professionals to discourage adolescents from self-piercing and that medical professionals should draw on adolescents‟ concern about image and appearance when discussing piercing and tattooing risks. Greif, et al. (1999) argue another strategy for reducing complications from body piercing: they call on medical professionals to investigate, be knowledgeable of, and advocate for tattooing and piercing legislation and regulation.

Many of the suggestions for medical professionals lie in the area of health education. Several articles address the need for general health promotion and education performed by health educators as opposed to (or along with) medical professionals.

Deschesnes, et al. (2006) argued that “health education measures aimed at adolescents need to be put in place in order to prevent undesired consequences” in those seeking body piercings. These researchers also stated that health education measures need to be non-judgmental and based in scientific knowledge. Such measures need to educate about potential complications and “precautions that should be taken in order to make an informed and safe decision.” Greif, et al. (1999) called for health promotion materials aimed at potential body piercing clients distributed by piercers in conjunction with school- based health education that provides “a balanced appraisal of the risks of the procedures.” They also recommend using websites to educate about the possible dangers of piercings. Braithwaite, et al. (2001) recommended that health education

Literature Review - 17 about body piercing should be combined with other HIV and substance use risk reduction messages.

The Association of Professional Piercers (APP) was formed in 1994 (APP, 2007).

It initially began as a political action group and grew into a self-described international health and safety organization. The organization is “a united group of piercing professionals which freely share information to help fellow members, piercers, healthcare professionals, health inspectors, and the public to get the best and most up- to-date information about body piercing” (APP, 2007).

The APP has many tactics to improve the professionalism of the industry and to promote public health. To become a member of the organization, a body piercer and the establishment in which they work has to uphold a stringent set of safety and hygiene standards (APP, 2007). The APP standards are equal to or more stringent than state and local standards. If met, these safety and hygiene standards minimize risk of transmission of bloodborne pathogens and infection caused by the body piercing procedure. The APP also provides education support and conferences where body piercers can improve their technique. Improved technique can in turn minimize complications from the piercing procedure such as bruising, bleeding, and nerve damage.

The APP also provides information through its website and members about safe piercing practices. This information encourages piercing-seeking individuals to make healthy decisions and choose clean piercing establishments. The APP provides a pamphlet that gives detailed instructions on how to assess a body piercer and their establishment in terms of safety and cleanliness (APP, 2004). This pamphlet also gives points of information about aftercare. They also have developed a “Piercee‟s Bill of

Rights” which empowers piercing-seeking individuals to demand safe and clean piercing practices (APP, no date). These items are the only professionally produced health

Literature Review - 18 education materials found to date. They are available for purchase by any individual or organization, not just APP members. The APP does not provide details on the materials‟ effectiveness or any research into their effectiveness.

Role of Body Piercers

The majority of people who have had body piercings report obtaining them from a piercer they identify as a professional and/or in a piercing establishment. In their national data set, Laumann and Derick (2006) found that 68% of those who reported they had ever had a body piercing obtained them only in a professional parlor or shop (19.4% had self-pierced at least one piercing; 12.5% had been pierced by someone outside of a professional parlor or shop). Ninety percent of participants in another study reported obtaining their body piercing from a professional (Huxley & Grogan, 2005). Similarly,

89.9% of high school students in Quebec reported obtaining their first body piercing from a professional body piercer (Deschesnes, et al., 2006).

Along with being the leading source of body piercings, body piercers are a common source of information. Three-fourths of urban adolescents endorsed professional body piercing shops as a top source of information about body piercings

(Gold et al., 2005). Caliendo, Armstrong, and Roberts (2005) reported that when participants with intimate body piercings had complications they commonly sought non- medical advice from a body piercer.

As mentioned above, body piercers control one of the major risk areas for infectious complications with body piercing (Health and Safety Executive, 2003). Their compliance with sterile procedures and establishment hygiene is crucial to the minimization of the spread of infectious diseases. Their selection of quality jewelry and accurate placement of the piercing is crucial to minimization of allergic reaction, scarring, and jewelry rejection.

Literature Review - 19

Emerging Body Modification Procedures

From the main page of the popular body modification website BMEzine.com, many procedures can be found that are performed by body modification artists that go beyond the traditional definition of body piercing. These procedures include using dermal punches, scalpels, and a variety of jewelry that vary from the traditional hoops or barbells used in body piercing.

Literature searches through CINAHL, MedLine, and Alt-HealthWatch returned no articles that discuss the procedure, risks, or prevalence of the below body modifications.

Because there is no professional literature on the procedures, the procedural details below come from the BME Encyclopedia on BMEzine.com.

Stretching. Stretching is a procedure that increases the diameter of a body piercing (BME Encyclopedia, 2006f). The procedure is typically done repeatedly over time and started after the initial healing of the body piercing. The procedure is done through several methods. Some of these include: using a tapered probe to rapidly stretch the diameter of the body piercing and immediate placement of jewelry that fits the desired diameter; wearing heavy jewelry in the piercing which gradually stretched the diameter by the constant pull of its weight; periodically wrapping one to several layers of tape around the jewelry currently being worn (typically with Teflon tape).

This procedure can be done in nearly every body piercing site. Though the procedure can be done on any body piercing, the BMEzine.com site most frequently features stretching in soft-tissue lobes, the area between the lower lip and chin, nostrils, and nipples.

Punch and taper. This procedure was developed to increase the chance of viability of body piercings on flat surfaces of the body, such as the chest, stomach, wrists, or back (BME Encyclopedia, 2006c). It is performed using dermal punches and a tapered or blunt probe. The dermal punches are used to create openings perpendicular

Literature Review - 20 to the skin‟s surface and the probe is used to separate the dermis from the connective tissue below it. The openings and the path made between them with the probe are made to fit the jewelry that is to be placed in the tissue.

Scalpelled piercings. Body piercings are scalpelled for two primary reasons (BME

Encyclopedia, 2006d). An initial body piercing can be scalpelled in order to accommodate large jewelry in the body piercing site. For example, a tongue piercing can be done with a scalpel to create an opening that was 6 millimeters or larger. Also, a scalpel can be used on a pre-existing body piercing site to rapidly enlarge the opening.

Commonly, this is done in sites where the individual was already stretching the diameter of the body piercing to accommodate larger jewelry.

Tongue splitting. According to the BME Encyclopedia (2006i), tongue splitting is

“the central bifurcation of the tongue, so as to achieve a „forked tongue.‟” The procedure can be performed in several ways, including: a laser surgery procedure performed by an oral surgeon; tying a tight loop with sutures or dental floss from a fully healed tongue piercing to the tip of the tongue parallel to the split along the center of the tongue and taking several weeks to complete; scalpelling along the center of the tongue, the resulting cut may be left to heal as is, cauterized, or sutured.

Frenectomies. Two locations where connective tissue were removed, usually by scalpel, were the tongue frenum and the penile frenum (BME Encyclopedia, 2006a; BME

Encyclopedia, 2006h).

Microdermal implant. Microdermal implants are also called surface anchors or dermal anchors (BME Encyclopedia, 2006b). They are “a flat plate which [sat] beneath the skin with a single exit for a barbell post giving the visual effect of jewelry (a bead, spike, etc.) that appears to be screwed right into the body”. The procedure to implant a microdermal implant involves creating an opening with a needle or dermal punch then

Literature Review - 21 separating the dermis from the connective tissue below it. The jewelry is placed in the opening created by the separation process.

Transdermal implant. Transdermal, or percutaneous, implants are deeply-placed jewelry that is intended to be permanent. BME Encyclopedia (2006j) describes the procedure to obtain a transdermal implant:

“1. The location where the transdermal passes through the skin is marked, as well as an incision point (usually an inch or two away).

“2. The incision is opened with a scalpel and a dermal elevator (often a septum elevator) is used to create a pocket to slide in the implant.

“3. Using a dermal punch or scalpel, and using the elevator as a backing (so underlying tissue isn't damaged), the hole that the implant will pass through is made.

“4. Through the first incision, the base of the transdermal is slid in, until its post passes through the hole. If the implant is two parts, the top half is screwed on.

“5. The initial incision is closed with sutures or suture tape.” (BME Encyclopedia, 2006j)

Subdermal implant. Subdermal implants involve the placement of three- dimensional objects under the dermis (BME Encyclopedia, 2006g). Subdermal implants are usually made of Teflon or silicone, but any biocompatible material (including implant- grade steel, titanium, high-karat gold, and nylon) can be used. To place the implant, an incision is made with a scalpel and the dermis is separated from the connective tissue below with a dermal separator. The implant is placed in the space created between the dermis and connective tissue and the initial incision is sutured.

Intentional scarification. Intentional scarification involves using a variety of methods to break the surface of the skin in attempt to apply scars in a controlled manner

(BME Encyclopedia, 2006e). Procedures involve such methods as: branding with a heated object in the shape of the desired design (“strike branding”); cutting the outline of

Literature Review - 22 the design with a scalpel and removing the skin between the outlines (“skin removal scarification”); using electro-surgical units to pass a high-frequency current through the skin to cauterize the desired skin surface (“electrosurgery branding” or “Hyfrecator branding”); using a tattoo gun with no ink to create detailed scars (“tattoo gun scarification” or “etching”); using the rotating abrasive tip of a dremel to grind away layers of skin (“dremel scarification” or “abrasive scarification”)

Internet as a Source of Health Information

In their research on early adolescent health literacy, Brown, Teufel, and Birch

(2007) found that nearly 10% of boys and 7% of girls reported that they had learned the most about health from the internet over school, parents, nurses, or other sources. The older the participant, the more likely they were to use internet for information: 8% of 9- year-old participants, 15% of 11-year-olds, and 19% of 13-year-olds reported they would first turn to the internet if they had an important question about health. Participants‟ confidence in the quality of information increased with age, as well.

The American College Health Association (2006) found that 70% of college students had obtained health information through the internet. The prevalence of the internet as a health information source was second only to parents (73%). However, only

22% of participants reported that the health information on the internet was “believable.”

Gaps in the Literature

While key sources for infection were developed by the Health and Safety

Executive (2003) and seem to be generally accepted, and while research has been conducted into reported rates of body piercing and reported rates of complications as reported by individuals who had been pierced, there are considerable gaps in knowledge around body piercing and body modification in general.

The recommendations reported in the last section were made based on general medical knowledge and previous recommendations and regulations enacted with

Literature Review - 23 tattooing. No research was found on the effectiveness of these recommendations for body piercing nor was any research found on specific health promotion or education measures taken within the medical community or general public.

The transition of this knowledge into health promotion and education materials or programs for the general public was not found. Nor had any health promotion and education materials or programs about body piercing been reported or evaluated.

Griffith and Tengnah (2005) mentioned body modification performed by body piercers that have not been studied in terms of prevalence or complications, which included branding, tongue splitting, genital beading, and cutting/scarification. The website BMEzine.com (2006), which focuses on body piercing, tattooing, implants, scarification, suspension, and other forms of body modification, shows emerging trends in the areas of body surface piercing (piercing on flat portions of skin with a specific style of jewelry) and microdermals (or “single-point piercings”). The health risks and health education needs of these have yet to be studied.

Despite the multiple roles of body piercers as professionals who perform and give information about body piercings, research about or involving the participation of professional piercers has not been found. Research into body piercing to this point has been limited to those who have obtained piercings.

Summary

Body piercing has a long history and growing popularity in modern Western culture. Body piercing is particularly popular among adolescents and college students.

One-quarter to one-half of college students have ever had a body piercing. Nearly one- third of the US population age 21-32 has ever had a body piercing.

Literature Review - 24 transmission of infectious agents. Reports of health complications vary widely in the research from 12% among urban adolescents to 70% in undergraduate university students. Nationwide, the prevalence of reported complications is 23%. Despite the risk of potential health complications, only 61% of those who obtained body piercings considered the risks before the piercing procedure was performed and cleanliness of the establishment did not weigh in their choice of piercing professional.

Researchers have proposed a variety of methods to reduce the rate of complications with body piercings. These recommendations span the fields of industry regulation, medical professionals interacting with pierced and pre-pierced individuals, and health education. No research has been done in assessing the effectiveness of these recommendations.

In general, there is a lack of published research regarding body piercing. Most published research addresses prevalence, association of body art with high-risk behavior, and health complications of body piercing. Despite their roles as providers of body piercings and information about body piercing, no research has been published that involves the participation of body piercers. Research on body modification published thus far has been limited to the areas of tattooing and body piercing.

The growing popularity of body piercing combined with the substantial risk of complications from body piercing and the lack of consideration of risk when obtaining a body piercing points to a growing need for research that would be useful to health education regarding body piercing.

Chapter Three

Methods

Units of Analysis

The units of analysis were websites posted by body piercing establishments.

These websites were limited to the 75 websites of US-based piercing establishments linked at the time through the Association of Professional Piercers‟ (APP) “Locate an

APP Piercer” search page on the APP homepage (APP, 2008). Websites of individuals and piercing establishments associated with the APP were chosen due to the role the

APP plays in the field of body piercing.

25 Methods - 26

The APP is an international nonprofit professional organization with almost 240 members in seven countries. It requires standards of personal experience and environmental care for membership, including cleanliness standards, business licensure,

CPR certification, first aid certification, and bloodborne pathogens training. The APP hosts the annual APP Conference, attended by members and non-members for professional networking and skill-building workshops. It also publishes the quarterly industry journal The Point and multiple health education brochures, as well as a procedural manual of body piercing techniques.

Instrumentation

A body piercing website rating form was developed based on the research questions, information from the literature, and feedback from a panel of experts. The form, titled “Body modification content rating form,” can be found in Appendix A. The form contains fifteen areas that were assessed for each website. The first seven areas were background information on the body piercing establishment and website surveyed.

The remaining eight areas referred to specific components of the website and the established research questions.

The six areas of background information recorded were: 1) establishment (name of the establishment); 2) date of review (the date the website was reviewed by the researcher); 3) website URL; 4) date of the most recent update to the website; 5) the city and state in which the establishment is located; 6) the “hit count” of the website (a record of how many times the site has been visited); establishment days & hours (time which the establishment is open for business). This information was gathered for the purpose of maintaining a clear record of sites surveyed so as not to repeatedly visit sites, to have a record of when and from where the information was gathered, and – for the 4th, 6th, and

7th questions – general interest of the researcher.

Methods - 27

The eight areas that addressed the research questions were: 1) information on cleanliness (of the establishment); 2) information on safety precautions used during the piercing process; 3) information on potential complications and adverse effects (of body piercing procedures); 4) body piercer experience/affiliations; 5) information on aftercare;

6) recommendations for further information on body modifications; 7) procedures available; 8) and other information of note. The information found on the websites was recorded verbatim on the rating form.

Under seven of the eight main areas listed above, there were subcategories.

These subcategories were developed by review of literature, information posted on the

APP website, and feedback from the panel of experts. These were designed to help sort information gathered from the websites.

Under the area “information on cleanliness,” there were five subcategories: sterilization information; information on spore testing of sterilization equipment; surface disinfection of piercing room; whether the establishment had any licenses for operation

(city, county, or state licensing); and “other” for information gathered that didn‟t fall in the above categories. Under the area “information on safety precautions used during piercing process,” there were four subcategories: piercing set-up technique; age and consent policies; jewelry selection (process by which they selected jewelry and/or variety of jewelry available in terms of sizes, materials used); and “other.” Under the area

“information on potential complications and adverse effects,” there were four subcategories: information on potential complications that could arise during or due to the piercing procedure; and information on potential complications that could arise after the procedure; psycho-social effects; and “other.” Under the area “body piercer experience/affiliations,” there were six subcategories for information on: the piercers‟ apprenticeships; the piercers‟ professional experience; professional organizations with which the piercers were affiliated; any first aid and/or bloodborne pathogens certification

Methods - 28 the piercers had obtained; and “other.” Under the area “information on aftercare,” there were four subcategories: general aftercare information provided; site-specific piercing aftercare information (e.g. oral piercings, surface piercings, genital piercings); information for follow-up with piercer (e.g. when/how to contact, follow-up visits needed); and “other.” Under the area “recommendations for further information on body modifications,” there were three subcategories: on-line resources (including any links to outside organizations, other establishments, or on-line communities); print; and “other.”

Under the area “procedures available,” there were ten subcategories: body piercings; stretching; surface piercings; dermal punch procedures; scalpelled procedures; microdermals/dermal anchors; transdermal implants; subdermal implants; scarification; and “other.” Information for this category was culled from the website through text, price listings, photo portfolios, and other means, as information on some of the modifications was not readily available or highly publicized given their rarity and questionable legality.

Face and content validity of the instrument were established by a panel of experts that consisted of experts in the fields of health education research and the field of body piercing. The panel included two associate professors from a large state university, one of whom had previous research experience in the topic of body piercing.

The panel also included two professional body piercers. Both professional body piercers had completed apprenticeships, maintained certificates in first aid and bloodborne pathogens, were involved professionally in the field, and had over ten years of professional body piercing experience each.

Procedures

Following the approval of the researcher‟s graduate thesis committee and establishment of face and content validity of the instrument, the researcher completed a content analysis of all websites of US-based piercing establishments that were linked at

Methods - 29 the time through the “Locate an APP Piercer” search page on the APP homepage. Each website was searched by the researcher for the information sought in the instrument.

The researcher accessed each website through the “Locate an APP Piercer” search page on the APP homepage. If the link was not operating, the researcher used an on-line search engine to seek a current URL for the website using the name of the establishment. The new website was verified by the stated city and state location of the shop on the APP member list.

Once at the website of the body piercing establishment, the researcher completed the rating form for that website. Only one form was completed for each website regardless of how many links were provided to it from the APP page (for example, in instances where multiple body piercers were affiliated with the APP from one body piercing establishment that runs one website for the whole establishment). The form was completed digitally, recording verbatim through copy-and-paste method what was posted on the website.

The primary investigator recorded the name of the establishment, the date the website was searched, and the URL of the website in the corresponding places on the rating form. If the date of the most recent update to the website was available on the website, this date was recorded in the appropriate place on the rating form. If the date of the most recent update to the website or the hit count was not available on the website, the comment “n/a” (for “not available”) was recorded in the appropriate place on the rating form. If the location of the establishment was listed on the website, it was recorded on the form by city and state. If there were multiple locations of the business, the number of locations was recorded and all cities and states in which the locations were in were recorded. If the location of the establishment was not listed on the website, the location was recorded as listed on the APP website followed by a parenthetical note “not posted on site.”

Methods - 30

The primary investigator read all text on the website and followed all provided links. Text and links that contained information related to the research questions were copied and pasted directly into the rating form. Information about the procedures available at the piercing establishment were culled from posted lists of procedures provided, price lists for procedures, and review of photographs posted in on-line copies of body piercers‟ portfolios. If a procedure was demonstrated to be provided, the word

“yes” was placed after the name of the procedure on the rating form. If there was strong evidence that a procedure had been provided but could not be confirmed, the word

“probably” was recorded after the name of the procedure on the rating form. For example, large-sized piercings on ear cartilage were most commonly achieved through using a dermal punch procedure, though the possibility that the piercing could have been stretched could not be completely ruled out. Therefore, when such piercings were found in the photo portfolio but no other evidence that the establishment was providing dermal punch procedures could be found, the word “probably” was placed after the name of the procedure on the rating form.

Information that might have been relevant to health education but that did not fall under the areas developed for the research questions were copied and pasted into the twelfth area of the instrument, “other information of note.”

After completing an instrument for a website, a copy was stored on the hard-drive of a computer in a secure location. A back-up copy was stored in on an external memory device also kept in a secure location. Also, a copy of the form was printed and the print copy was stored in a secure location.

This research process was completed on a census of all websites of that were stated to be US-based body piercing establishments linked through the “Find an APP

Piercer” search page.

Methods - 31

Data Analysis

Once a census survey of all body piercing establishments stated to be US-based linked through the “Find an APP Piercer” search page was completed, the primary investigator conducted a content analysis of all information gathered in the instrument.

The researcher reviewed all information found through the websites under each area of the instrument and identified common themes found throughout. The researcher recorded major themes and the frequency with which body piercing establishments provided information about these themes. In so doing, frequencies and percentages were computed to determine the extent to which certain types of information were displayed on the websites. Descriptive statistics were used to answer research questions. In addition, under each theme, the researcher used quotes from the websites which served to reinforce the identified theme present.

The themes and frequency with which each theme was found in the websites was recorded in chapter four of this thesis.

Chapter Four

Results and Discussion

Units of Analysis

The units of analysis were 75 websites posted by body piercing establishments that were linked as US-based establishments through the Association of Professional

Piercers‟ (APP) “Locate an APP Piercer” search page and were surveyed by the primary investigator between 29 April, 2008, and 4 May, 2008. The websites were found through their link on the “Locate an APP Piercer” page; any website whose link on that page did not work was found using an on-line search engine with a search for the name of the

32 Results - 33 body piercing establishment given on the APP search page. The new website was in turn verified by confirming the location and name of the body piercing establishment as reported on the APP search page.

Body Piercing Establishment and Website Characteristics

Seventy-five websites were examined, representing 75 body piercing establishments. The 75 establishments represented at least 99 locations offering body piercing services. Sixty-one websites (81%) listed only one location for their establishment. Eight websites (11%) listed two locations run by the body piercing establishment, two (3%) listed three locations, and four (5%) listed four locations.

Of the 75 websites, two (3%) had no information available relevant to the study.

One of these two had only a main page with a message that the shop would be closed during the APP conference. The other of these two had a main page for the establishment and a link to information on piercing – the linked page contained only a photo of the outside of the establishment.

Seventy-two websites (96%) reported the city and state of the locations run by the body piercing establishment. The city and state of three establishments that did not report their locations were obtained from information on the APP website. The 75 body piercing establishments had locations in 29 states in the continental US. The west and east coasts were well represented, as was the Midwest, the eastern portion of the south, and the western portion of the west. The establishments had locations in 76 cities.

Of the 75 websites examined, nine (12%) had hit counters and six (8%) listed the date of their most recent update. Hit counters varied widely in their hit counts and reported recording hits in different ways. The lowest hit count was 1,038 visitors recorded since February 2007. The highest was 572,740 hits, with no date given for when the site began recording hits. Three websites (4%) reported the date from which their hit counts began being recorded. One website reported that it recorded only unique

Results - 34 visitors (i.e. multiple visits from the same computer would only count as one hit); all others did not report whether they recorded only unique visitors or all hits to the website.

Given the wide variance in hit counts, the paucity of hit counters, and variety of methods with which the hits could be recorded, no mean hit count was calculated. The least recently updated site reported its latest update as 11 February, 2007. The most recently updated site reported its latest update as 27 April, 2008, four days before it was surveyed. All other updates occurred between 28 December, 2007, and 17 April, 2008.

Of the 75 websites examined, 55 (73%) listed information on the days and times the locations were open. All 55 of these websites listed the days the establishment was open and times the establishment opened; 53 (71%) listed the times the establishment closed. In instances where one establishment had multiple locations, the days and times of each location‟s hours of operation were recorded. For analysis purposes, the earliest time one of their locations opened was recorded as the opening time of the establishment and the latest time one of their locations closed was recorded as the closing time of the establishment.

Of the 55 establishments that reported the days of the week they were in operation, all 55 (100%) were open for business on Wednesdays, Thursdays, and

Fridays. Fifty-four (99%) were open on Saturdays and 53 (98%) on Tuesdays. Forty-six

(84%) were in full operation and one was open “by appointment only” on Mondays.

Forty-two (76%) were in full operation and one was open “by appointment only” on

Sundays.

Most establishments (67-76%) opened at noon on the days they were open.

Closing times varied widely. The first table in Appendix C lists the opening and closing times of establishments.

Results - 35

Information on Cleanliness and Safety Precautions

Of the 73 websites that provided information relevant to the study, 59 (80%) provided information on the hygiene procedures, sterilization procedures or tools, licensing, health and safety related policies, or jewelry used in the piercing process.

Main themes found are summarized in Table 4.1

Hygiene during body piercing. Forty-one of the websites (56%) examined posted information about hygiene of the piercing area and/or process. Nine (12%) provided specific language stating that the establishment met and/or exceeded the minimum safety standards of the APP.

Fifteen establishments (21%) described that the body piercer(s) at the establishment followed universal precautions to prevent the transmission of disease.

Words such as “universal precautions,” “aseptic technique,” and “sterile technique” were used. Three websites (4%) provided articles about sterilization and infection control, including one article written in 1998 that adapted CDC infection control guidelines for use in the body piercing industry. Five websites (7%) posted detailed explanations of the sterilization room and process by which they sterilized and maintained sterility of instruments used in the body piercing process. One website included a photo-and-text slide show that went through the entire piercing process, emphasizing aseptic technique throughout. Another posted the steps staff members followed for all cleaning procedures, including the cleaning of new jewelry and changing of the sharps container that holds used needles.

Twenty-five websites (34%) used specific language stating that they exclusively use single-use needles. Most went on to describe that after the needle was used on a client it was immediately disposed of in a sharps container and that the client would see this procedure. Although single-use needles came pre-sterilized, six of the 25 websites

Results - 36 stated that they sterilized the single-use needles in the establishment before they were used on a client.

Twenty-three websites (32%) used specific language stating that that all non- disposable equipment used in the body piercing process was sterilized between every use. Only some of these specified that jewelry was part of the equipment used in the process. Fifteen websites (21%) specifically stated that the body jewelry used in the body piercing process was sterilized at the establishment before use. Others may have meant to imply that jewelry was part of the equipment used and thereby implicitly stated that it was sterilized before use in the body piercing process. Two websites (3%) stated that everything they used in the body piercing process was single-use. Though everything was single-use, the websites stated that they sterilized the equipment at the establishment before use. They also disposed of everything in front of the client.

Eleven websites (15%) described that the equipment being sterilized was sterilized in pouches made for the sterilization process. Of these, four described using integrator strips in the sterilization pouches. A piercing establishment in Pasadena, CA, described the strips:

These are small strips that are foiled in the back. On the front, is a small shiny

line that has a pass or fail section posted and a button on the right side that holds

chemicals within… After the sterilization cycle is complete, the integrator shiny

line that started out white in color is now a Grey [sic] or a black color. If the line

is Grey all the way through, then everything is definitely sterilized properly.

Because the integrator strip and the button of chemicals measure the amount of

steam, heat, pressure, and time released in the cycle, the chemicals will not be

pushed along the white line into the pass area if anything is remotely wrong with

the cycle.

Results - 37

Table 4.1

Information on Hygiene, Cleanliness, Safety Precautions

Posted Information N %

Hygiene of the body piercing area and/or process 41 56

Policies regarding piercing minors 35 48

Use only APP-approved materials in initial body piercings 31 42

Participate in spore testing of sterilization equipment 28 38

Exclusively use single-use needles 25 34

Kind of sterilization equipment used at establishment 24 33

All non-disposable equipment sterilized between each use 23 32

Provide information on styles of jewelry used in initial body piercings 23 32

Require valid photo ID before performing body piercings 20 27

Body jewelry sterilized before use 15 21

Body piercer(s) followed universal precautions 15 21

Disinfectant process of body piercing room/area 13 18

Participate in governmental or business licensure 12 16

Equipment sterilized in sterilization pouches 11 15

Body piercer(s) wore gloves throughout process 11 15

Do not pierce individuals under influence of alcohol, drugs 6 8

N = 73 websites

Results - 38

Two of these establishments posted that their staff initialed and dated the integrator strips before putting them in the sterilization pouch. The other two posted that the client initials the strips before putting them in the sterilization pouch, which was sterilized while the client waited and then the client confirmed their initials before the body piercing process began.

Eleven websites (15%) stated that the body piercers wore gloves throughout the entire body piercing process, with eight (11%) stating that the gloves were frequently changed throughout the process. Two (3%) specifically stated that they offer latex-free options – one (1%) stating that the entire establishment used no latex and the other stating that non-latex gloves were used upon request.

Thirteen websites (18%) described the disinfectant process they used in the body piercing room. All of these, at a minimum, cleaned all surfaces of the room related to the body piercing process between every client with a disinfectant.

Sterilization equipment. Twenty-eight websites (38%) posted information about the sterilization equipment they use and/or how frequently they test the equipment for effectiveness. Twenty-four websites (33%) posted what kind of sterilization equipment they use at their establishment(s). Twenty-one (29%) reported having an autoclave steam sterilizer. According to a body-piercing establishment in Concord, CA, “autoclaves achieve sterilization through the use of intense steam-heat and pressure over an extended period of time.”

Eight websites (11%) posted that they have a Statim sterilizer. Five of these eight have a Statim along with an autoclave; three have only a Statim. A body piercing establishment with locations in Pasadena and West Hollywood, CA, described the typical use of the statim:

Before every piercing we gather all of the materials used in the procedure

(including new needles, jewelry, gauze, and cotton swabs, etc.) and we run them

Results - 39

though… the Statim2000 by Scican [which] allows us to sterilize while you wait.

Using vacuum pulse technology, the Statim2000 runs a full sterilization cycle in

only 6 minutes.

While the statim does not use sterilization pouches, two establishments described using integrator strips, which the client initialed before the sterilization process was started.

Six establishments (6%) described using an ultrasonic cleaner in conjunction with the autoclave sterilizer. A body piercing establishment with locations in Pasadena and

West Hollywood, CA, explained that an ultrasonic machine works by “creat[ing] tiny implosions on the tool‟s surface by sending sound waves through an ultrasonic cleaning liquid. These implosions help remove any surface contaminants before the tools move on to the next step in the sterilization process.” In all of the establishments that stated they use an ultrasonic cleaner, the next step after completion of the ultrasonic process is being rinsed, dried, then placed in a sterilization pouch and being autoclaved.

Spore testing is a process by which sterilization equipment is tested for its effectiveness. A body piercing establishment in Concord, CA, described the process:

Spore testing (biological sterilizer monitoring) works on the scientific theory that if

the sterilization equipment kills the viable non-pathogenic microorganisms

contained on each test strip, then it is capable of killing the weaker, yet

dangerous blood borne pathogens, such as human immunodeficiency virus (HIV)

and hepatitis B (HBV), that may be present on the instrumentation being

sterilized. The spores used, Geobacillus, stearothermophilus and Bacillus

atrophaeus, are harmless to humans, however they are difficult to kill via

sterilization.

Such bacteria are present on a test strip which is sent to the body piercing establishment by the company that runs their spore tests. The strip is included in a normal sterilization cycle, and then mailed to the company, who then tries to culture bacteria from the test

Results - 40 strip. If no bacteria are found to be present, the sterilization equipment is deemed to be in effective working order. The company sends results to the body piercing establishment that they can keep for their records or post in the establishment.

Twenty-eight establishments (38%) posted specific language describing their participation in spore testing of their sterilization equipment. Thirteen (46%) reported they have their equipment spore tested on a weekly basis. Two (7%) reported that they have their equipment spore tested two times per month and one reported that they do so every two weeks. Six (21%) reported that they have their equipment spore tested once a month. Seven others (25%) reported that they participate in spore testing but did not give the frequency with which their equipment was spore tested. Eight (11%) establishments gave the name (or had scanned results sheets with the name) of the company that performs their spore testing. Three reported using North Bay Bioscience, two reported using a university program, and three reported using other private companies.

Licensure. Twelve establishments (16%) posted information about participation in governmental or business licensure. Seven websites (10%) stated that they are certified or licensed to operate through their state health department. Two stated they are certified or licensed through their county board of health and one through its city‟s

Environmental Health Department. Three were members of their local Better Business

Bureau and one of these belonged to its local Chamber of Commerce.

Age policies. Thirty-five establishments (48%) posted information about their policies regarding providing body piercings to minors. Four establishments (5%) stated that they do not provide any body piercings to minors. Thirty-one establishments (42%) stated that they provide some body piercing services to minors. All 31 of these detailed their policies for parental consent. A typical example of a policy, from a body piercing establishment in New York City, follows:

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Without exception, a parent or legal guardian must be present with a minor to

sign our release form.

Each party must have a valid photo ID. Acceptable photo ID must include

one of the following: a driver‟s license, passport, state-issued identification card

or military ID. A valid school photo ID and birth certificate with state seal is

acceptable for minors younger than driving age. Photocopies of any ID are not

acceptable.

If the parent‟s last name and/or address is different from the minors, there

must be legal documentation to prove the relationship (birth certificate, divorce

papers, adoption papers, marriage certificate).

Court papers were required to prove a relationship with a legal guardian.

Two establishments (3%) required a parent or guardian to bring a birth certificate along with their and the minor‟s valid identification. One establishment (1%) required both parents to be present and provide valid identification for themselves and the minor (in cases of divorce or death of a parent, legal documentation of the situation was required).

Several websites also stated that legally emancipated minors must bring valid photo ID and original court documents demonstrating the emancipation.

Of the thirty establishments who stated they provide services to minors, five

(17%) specified that they will only provide services to those age 16 and older. Of the thirty establishments, sixteen (53%) specified which body piercings they would provide.

Most specified that they would not provide body piercings below the neck with exception of the navel, regardless of parental consent. Many also specified they would not provide surface piercings on minors regardless of parental consent, and several specified they would not provide earlobe piercings larger than 10gauge.

Identification policies. Twenty body piercing establishments (27%) stated on their website that individuals seeking a body piercing must present valid photo ID in

Results - 42 order to obtain a body piercing. Two (3%) specified that individuals must present a valid photo ID every time they seek to obtain a body piercing, regardless of whether they‟ve previously obtained body piercings at that establishment. Valid ID was typically defined as non-expired driver‟s license, state-issued ID, passport, or military ID.

Other policies. There were six policies or requests of clients not described above that were listed by two or more establishments on their website. Six body piercing establishments (8%) stated that clients must not be under the influence of drugs or alcohol at the time they are seeking to obtain a body piercing. Four establishments (5%) posted policies about the presence of children in the piercing area. One stated no children were allowed in the piercing area, one forbade children under 16 years, one forbade children under 14 years, and one forbade children under 12 years. Two establishments (3%) stated that they reserve the right to refuse services at any time.

Six establishments (8%) requested that clients eat several hours prior to obtaining the body piercing. Four establishments (5%) requested that clients avoid blood-thinners, such as aspirin, for up to 24 hours before obtaining a body piercing.

Three establishments (4%) requested that clients do not come if they are feeling ill.

Jewelry used in initial body piercings. Thirty-eight body piercing establishments

(52%) posted information about the jewelry they use in initial body piercings.

Thirty-one establishments (42%) provided information on their websites demonstrating they only use jewelry made of implant grade quality materials in initial body piercings1.

Body jewelry used in most initial body piercings involves either ends being threaded onto a post or a bead being held in place by tension from a metal ring. In this context, 23 websites (32%) provided information about the type of jewelry they use.

1 The APP lists the following materials as ones that are appropriate for initial piercings: implant grade stainless steel and titanium, gold (14K or higher), platinum, Tygon, and PTFE (Teflon) (APP, 2004).

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Regarding body jewelry that involves ends being threaded onto a post, 23 websites

(32%) stated that they only use internally threaded body jewelry in their establishment(s).

A body piercing establishment located in Boise, ID, explained their choice:

Internally threaded means that the bar is the “female” (no visible threads) and the

bead is the “male” (a threaded post extending from the bead). The bead threads

INTO the bar.

Externally threaded is the opposite. The bar has visible threads at the

end and threads into the bead.

Each time you take an externally threaded piece of jewelry in and out of

your piercing you are “dragging” those threads through your piercing… External

threads may tear new tissue (leading to scarring), trap bacteria, and release

polishing compounds into the piercing.

Two-thirds of the websites that stated that they exclusively use internally threaded body jewelry explained a similar rationale. Many also addressed the issue that externally threaded body jewelry usually costs less than internally threaded and stated that externally threaded body jewelry is usually made of metals that don‟t meet APP standards for materials.

Regarding body jewelry where a bead is held in place by tension from a metal ring, three websites stated that they only use body jewelry with rounded ends on the ends of the metal ring that hold the bead in place. A body piercing establishment located in Atlanta, GA, explained their choice, using photos of three different types of rings:

This first ring [has non-rounded ends of the ring] and the ball does not fit

appropriately. Notice the large gap between the ball and ring. If the gap in this

type of ring were to shift into a piercing the ends can pinch or otherwise cause

Results - 44

discomfort to the wearer. The large gap will harbor dead skin and bacteria,

increasing infection risk.

This second ring has slightly less gap then [sic] the one above, although

collection of dead skin and bacteria would still be evident…

[In] this captive ring [with rounded ends]… the ball and ring fit smoothly

without significant gaps. The ring is round and the ends smooth and uniform…

This has proven an ideal piece for long term wear in a healed piercing.

Seven websites (10%) explained what “polish” is in terms of body jewelry and described the standard to which they adhere. A body piercing establishment with locations in three cities in Oregon stated “the finish of high quality jewelry should have a mirror-like sheen and be free of nicks, scratches, and polishing compounds.” Other establishments explained that nicks and scratches could irritate a body piercing and impede the healing of an initial body piercing. Polishing compounds could irritate a body piercing and introduce harmful chemicals into the wearer‟s body.

Three websites (4%) contained extensive text on body jewelry, covering technical information on the materials and processes with which body jewelry is made and/or how to fit body jewelry appropriately.

Information about Body Piercers

Fifty-four websites (74%) posted information about the body piercers who worked at their establishment or other staff who worked in areas related to body piercing at their establishment (for example, an apprentice to the body piercer or a counterperson in the body piercing area). Three biographies (or “bios”) that did not contain information related to the individuals‟ work experience or training were not recorded. Pages about an individual that contained no text but had scanned photos of pertinent certificates (for example, training completed, certifications, APP conference attendance) were recorded.

In total, biographies of 117 body piercers were recorded. Information from these

Results - 45 biographies included early professional development, health related training and certification, continuing education, years of experience, and affiliation with the APP, which is summarized in Table 4.2.

Early professional development. Nine of the individuals (7%) described early experimentation with body piercing. This included non-professional piercing of self and friends, typically during adolescence. Thirty-three individuals (28%) referenced participating in an apprenticeship. Apprenticeship was described as industry-specific training of a few months to several years under a professional body piercer. Five of the

33 individuals who referenced participating in an apprenticeship were still participating in their apprenticeship.

Twenty individuals (17%) attended trainings from one or more training establishments that taught basic to advanced body piercing and body modification skills.

Nine of these individuals (45%) attended training at The Gauntlet, a former training establishment that was well-known in the early 1990s for its groundbreaking work in body piercing and body modification. Eight (40%) attended trainings led by Fakir

Musafar, the “father of the modern primitives movement.” Seven (35%) attended trainings at Professional Piercing Information Systems, a company which provides courses on body piercing and body modification technique as well as bloodborne pathogens and disease transmission prevention trainings.

Seven individuals (6%) referenced previous or current experience as a counterperson at a body piercing establishment, five of whom were still currently working the counter and were in their apprenticing process.

Health related training and certification. Fifty-seven individuals (49%) referenced having received or maintaining current certification in bloodborne pathogens. Fifty individuals (43%) referenced having received or maintaining current certification in CPR.

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Table 4.2

Information on Body Piercers

Posted Information N %

Referenced membership in APP 103 88

Provided information on years of experience 75 64

Have received and/or maintain current certification in bloodborne pathogens 57 49

Have received and/or maintain current certification in CPR 50 43

Have received and/or maintain current certification in first aid 49 42

Attend APP conferences 37 32

Participated in an apprenticeship 33 28

Attended trainings taught at industry-specific education centers 20 17

Still participating in an apprenticeship 5 4

N = 117

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Forty-nine individuals (42%) referenced having received or maintaining current certification in first aid. Six individuals (5%) referenced receiving training from Health

Educators, Inc., a company that specialized in body modification industry-specific bloodborne pathogens, disease transmission prevention, and wound maintenance and healing training.

Continuing education. Thirty-seven individuals (32%) referenced attending APP conferences. Many of these included scans or written details of the seminars and trainings they attended while at the conferences.

Thirteen individuals (11%) referenced having or working towards post-secondary degrees. Two of the body piercers were registered nurses and one was currently pursuing her nursing degree. One was a licensed EMT. Three body piercers had master degrees, one in Somatic and Cultural Studies, one in Medical Anthropology, and one in Fine Arts.

Years of experience. Seventy-five individuals (64%) included information on their years of experience in the field of body piercing. Years of experience were calculated from when the individual began performing body piercings in a professional or semi- professional environment or when they began a body piercing apprenticeship. The years of experience reported are summarized in Table 4.3. The mean years worked was 9.64 years. Over half (42, 56%) of those who listed their years of experience had worked ten years or longer. Two individuals not included in calculations because their exact length of time piercing was not available also stated that they had been working as body piercers “since the early „90s.” All individuals who reported three years of experience or less also reported that they were still in an apprenticeship.

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Table 4.3

Years of Experience Reported in Body

Piercer On-Line Biographies

Years No. %

1 year 5 4

2 years 2 2

3 years 1 1

4 years 2 2

5 years 3 3

6 years 3 3

7 years 6 5

8 years 4 3

9 years 5 4

10 years 6 5

11 years 6 5

12 years 8 7

13 years 7 6

14 years 5 4

15 years 6 5

16 years 2 2

17 years 1 1

20 years 1 1

“Since the early 1990s” 2 2

N = 117

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Reported affiliation with the Association of Professional Piercers. Fourteen of the websites that offered bios of the body piercing staff (26%) did not reference membership in or affiliation with the APP in the staff member‟s bio or on the page of the bio, though two of these sites (4%) did include a reference to attending APP conferences.

Forty of the websites (74%) included reference to membership in or affiliation with the

APP in the member‟s bio or on the page of the bio. Five of these 40 (13%) provided explanations of what the APP is and does. Three additional websites whose bio information did not fulfill the analytical requirements to be recorded above offered information about the body piercing staff being members of the APP, two of which included explanations of what the APP is and does.

Information about Potential Complications and Adverse Effects

Thirty-four websites (47%) provided information about complications related to body piercings. Information was categorized into complications that can occur during the body piercing procedure, ones that can occur after the procedure, and psycho-social complications. The general themes found are summarized in Table 4.4.

Potential complications and adverse effects during the procedure. Thirteen websites (18%) provided information on complications that can occur during the procedure. With all but one of these – pain during the body piercing procedure – the websites described the potential complication and described how the risk for it was minimized at their establishment.

Nine establishments (12%) described the many complications that can result from the use of a piercing gun during the body piercing process. With varying degrees of detail, all nine discussed the issues described in the excerpt below, which is from the website of a Columbus, OH, based body piercing establishment. The text was a reply to the “frequently asked question” of “Do you perform any piercings with a piercing gun?”:

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Table 4.4

Information on Potential Complications and Adverse Effects

Posted Information N %

Potential post-procedural complications of body piercings 30 41

Occurring during the body piercing procedure 13 18

Risk of contracting bloodborne pathogens 9 12

Potential complications resulting from use of a piercing gun 9 12

Breast-feeding and nipple piercings 6 8

Pain during the body piercing process 5 7

Anesthetics for body piercing process 3 4

Potential psychosocial complications 2 3

N = 73

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There are several reasons why we do not use ear piercing guns for any type of

piercing.

First, there is no way to sterilize piercing guns. Most guns are made of

plastic and will melt under the extreme heat and pressure of an autoclave… and

chemical sterilization has not been proven to kill all blood borne pathogens; this

is extremely dangerous since fluid microspray (microscopic particles of tissue,

blood and other body fluids) might be present on the gun after a piercing.

Second, guns are considerably more painful than a piercing needle

because guns use the blunt end of the jewelry to do the piercing – actually

tearing the skin, traumatizing the area, and complicating healing.

Third, since both the instrument and the jewelry were designed for

earlobes, they are not compatible with other areas of the body, increasing the

risk of infection and further complicating the healing process.

Fourth, standard piercing gun studs are usually made of a poor quality

metal that can cause additional complications.

Lastly, the jewelry is poorly designed in that the backing traps and

collects waste, hair, and debris, holding it against or close to the piercing. This is

far from an ideal healing environment.

One website (1%) addressed the use of single-use piercing guns, also advising against them because of the pain and blunt trauma during the piercing process and the complications of healing due to tissue trauma, poor quality metal, and poor jewelry design.

The potential of the risk of contracting bloodborne diseases could be inferred from more than half of the websites based on their explanations of the aseptic or sterile process they use. Nine (12%) specifically and explicitly addressed the risk. In eight of the nine cases, it was discussed in the context of how to choose a body piercing

Results - 52 establishment (i.e. risk is greater if they don‟t use aseptic procedure). HIV and hepatitis

B were the most commonly referenced pathogens. One website stated that the risk of contracting bloodborne diseases was increased if the body piercer and/or the individual getting pierced were under the influence of drugs or alcohol.

Five websites (7%) addressed the issue of pain during the body piercing process.

All of the websites acknowledged and normalized pain as a potential adverse effect of the body piercing process. In answering the “frequently asked question” of “Will my piercing hurt?” a Saginaw, MI, based establishment posted, “most of the time you feel a quick, sharp, poke, then a little throb aftwards. But it fully depends on you and how your mental state is at the time. If you [sic] ready to accept your piercing you will be accepting terms with yourself and your experience.” Two of the 5 websites that addressed pain also addressed the use of anesthetics. A body piercing establishment located in Minneapolis, MN, explained its policy:

We do not use, or suggest, anesthetics because injectable and topical

anesthetics can be deadly in the hands of someone who does not know how to

use them. Only properly licensed medical professionals can legally administer

injectable and topical anesthetics.

In addition, a properly performed piercing by a knowledgeable,

professional hurts far less than such an injection.

A Cambden Town, UK, based establishment with locations in San Francisco, CA, also stated that the injection of anesthetics may be more painful than a properly performed body piercing. This establishment gave two more reasons why they do not provide anesthetics: “Creams and gels are not sterile and so may cross contaminate the area; freezing sprays may cause frostbite encouraging blistering and sores.”

One website stated that the establishment would provide anesthetics, though it did not discuss pain during the body piercing process. A body piercing establishment

Results - 53 located in Blacksburg, VA, posted on its website “we use numbing medicine for all clients at no extra charge.”

Three other potential complications or adverse reactions were described on one website each. A Cambden Town, UK, based establishment with locations in San

Francisco, CA, stated that individuals with seafood allergies will likely have an allergic reaction to iodine, which it stated is used in many skin preparations. The website stated

“if you have an allergy to seafood a different skin prep must be considered.” A body piercing establishment located in East Lansing, MI, stated that it would not pierce the navel of any individuals who have “had an apodectomy [sic] or tummy tuck surgery” due to decreased blood flow to the body piercing site due to scar tissue from the surgery.

The same establishment also stated “not under any circumstance will we re-pierce any previously pierced area of the body more than twice, even if the area is completely healed,” again due to decreased blood flow to the body piercing site due to scar tissue.

Potential complications and adverse effects after the procedure. Thirty websites

(41%) described potential complications and adverse effects that could arise after the body piercing process was completed. The potential complications and adverse effects described on at least two websites are listed in Table 4.5 and discussed below.

Infection at the piercing site was the most commonly referenced potential complication. A body piercing establishment located in Austin, TX, described the typical list of symptoms: “redness and swelling; a sensation of heat at the piercing site; pain, especially throbbing or spreading pain; unusual discharge; unusual smell from the piercing site; fever accompanied by symptoms above.” Ten websites (14%) stated that infections are usually the result of failure to adhere to aftercare instructions. In particular, failure to keep unclean objects (for example, hands, telephones, linens) away from the piercing site, exposing the site to body fluids, or submerging the piercing in standing water were commonly cited potential causes of infection.

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Table 4.5

Potential Post-Procedural Complications and Adverse Effects and Frequency of Reporting

Potential complication/adverse effect posted on website N %

Infection of the piercing site 18 25

Scarring at the piercing site 12 16

Irritation at the piercing site 10 14

Migration/Rejection of body jewelry 10 14

Allergic reaction 8 11

Discolored tongue (with tongue piercing only) 8 11

Hypertrophic scarring (keloid) 5 7

Damage to teeth, gums (with oral piercings only) 5 7

Abscess 4 5

Follicular cysts 4 5

Constriction 2 3

N = 73

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Ten websites (14%) stated it was important to leave the body jewelry in place while treating the infection. A body piercing establishment located in Denver, CO, explained:

In the event that an infection is suspected, quality jewelry or an inert alternative

should be left in place to allow for drainage of the infection. Should the jewelry

be removed, the surface cells can close up sealing the infection inside the

piercing channel, resulting in an abscess.

Five websites (7%) also stated that clients concerned about a potential infection should visit their body piercer and/or seek medical treatment. A body piercer would be able to help them determine whether there was an infection or whether the piercing site was irritated. Also, these stated that an increase in certain aftercare behavior, especially warm salt water soaks or compresses, could help early infections clear up without medical intervention.

Development of scar tissue at the piercing site was the second most commonly cited post-procedural complication. Twelve websites (16%) addressed the issue of scarring in two main contexts: development of large amounts of scar tissue (such as with hypertrophic scarring); scars at the piercing site after the piercing has healed and body jewelry is removed. For the former issue, the websites stated that development of scar tissue is typically due to irritation, friction, infection, or poor jewelry placement. The websites provided recommendations to minimize scarring from each of these sources: body piercings that become irritated or experience a lot of friction needed to have the source of irritation or friction resolved in order to minimize the development of scar tissue; infection could be prevented by adhering to recommended aftercare behavior; poor jewelry placement could be resolved by changing the jewelry to a more appropriate piece of body jewelry or by removing the body jewelry, waiting for the wound to heal, and having the body piercing redone. Healed body piercings from which the body jewelry

Results - 56 was removed were likely to have a small amount of scar tissue at the exit points of the body jewelry. The websites stated that the appearance of this scar tissue would dissipate some over time and could be more quickly minimized by daily gentle tissue massage. The twelve websites that addressed scarring acknowledged that scarring is a likely potential adverse effect of body piercings and that individuals seeking body piercings should be aware of and consider this before obtaining any body piercings.

Ten websites (14%) posted information about the potential complication of irritation. A body piercing establishment located in Philadelphia, PA, explained irritation:

More often than not, what you think is an infection is really irritation, caused by

anything that puts pressure on the jewelry or holds it in an unnatural position. If

your piercing is red, swollen right around the hole, peeling, excreting white or

yellow fluid or blood, or appears to have a solid lump or bubble of discolored skin

around it, it is probably irritated. This is a sign that you are subjecting it to

excessive abuse.

Common causes are: wearing restrictive clothing over the piercing

(navels and nipples); sleeping on it (navels and ear cartilage); holding the phone

against it (ear lobes and cartilage); sex too soon (genitals); getting hit or pulled

on; or playing with it.

Other websites cited exposure to harsh cleaners, exposure to beauty or cleaning products, overcleaning, and using too strong a salt water solution as possible causes of irritation.

The course of action recommended by most to resolve irritation was seeking out the source of the irritation and minimizing it. In cases of mechanical irritation, such as described in the excerpt above, the source needed to be found and removed (e.g. not wear certain articles of clothing, change sleeping position). In cases of chemical irritation, the irritating chemical needed to be kept away from the body piercing site (e.g.

Results - 57 change cleaners, use appropriate saline mixture, cover during shower or hairstyling to protect against other products).

Migration or rejection of jewelry was listed as a potential complication by ten websites (14%). According to a body piercing establishment located in North Olmstead,

OH:

Rejection is usually caused by „back pressure‟ often caused by using straight

bars, or simply the body refusing to accept the piercing. Rings can get knocked

around quite a bit and that irritation can also cause rejection. In fact, any piercing,

[if] it received enough trauma, can be rejected. Infection and allergy/sensitivity

are also types of irritation and can lead to rejection. Some piercing [sic] will

„migrate‟ to a more comfortable setting with being rejected.

Rejection can occur at any point in the life of a piercing – either during initial healing or after being healed for several years. Once a piercing has begun migrating or rejecting, a line of scar tissue would be left by the jewelry as it was slowly moving out of the original piercing site. Two websites (3%) gave instructions to contact a body piercer to discuss the situation if a body piercing began to migrate or reject.

Allergy or sensitivity to body jewelry and/or cleaning products was a potential complication cited by ten websites (14%). A body piercing establishment located in

Philadelphia, PA, explained:

It is always possible for living bodies to react to foreign substances introduced

into them. Some people are extremely sensitive to certain jewelry materials or to

cleaning solutions. Allergic reactions often appear as rashes, excessive clear

fluid discharge, discharge, redness, itching, or the skin pulling away from the

jewelry. They usually show up immediately. When using implant grade body

jewelry and recommended cleaning solutions, they are rare.

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The websites that discussed allergic reaction recommended making sure to use high quality, implant grade body jewelry to minimize risk of allergic reaction to jewelry. They also stated that if a cleaning product was suspected as the source of allergic reaction, cessation of use of the product was recommended.

Several websites noted that infections, irritation, and allergic reaction present themselves in similar ways, making it difficult for many clients to know what they are dealing with. These websites recommended that clients speak with a body piercer, preferably in person, to discuss any abnormalities with their body piercing.

Three potential complications or adverse effects were provided about oral piercings. Eight websites (11%) posted that individuals may experience a discolored tongue, typically a white or off-white color. All eight stated that this is due to too frequently cleaning the mouth with mouthwash; one also stated that using inappropriate mouthwash can cause this as well. Five websites (7%) stated that oral piercings can cause damage to the enamel of the teeth and to the gums. The websites stated the risk of this can be minimized by not playing with the jewelry, wearing jewelry of appropriate length, chewing food carefully so as to avoid biting the jewelry, and by being careful not to catch lip piercing jewelry on the front teeth if opening the mouth widely. Eight websites (11%) advised that clients who have high blood pressure should consult with their physician about using salt water or saline solutions to rinse oral piercings.

Four websites (5%) discussed the potential complication of abscess. These were all in the context of discussing infections. They recommend that risk for abscess can be minimized by carefully and consistently adhering to given aftercare behavior and, in the case of an infection, leaving high quality body jewelry in the piercing so as to allow drainage of the infection. Medical treatment was advised.

Four websites (5%) discussed follicular cysts. A body piercing establishment located in Vienna, WV, explained that follicular cysts “are an obstruction (usually a hair

Results - 59 or skin cells) inside the piercing which causes fluid to become trapped, resulting in a fluid filled bump.” Follicular cysts were described as being red, tender bump near the exit(s) of a body piercing which may release a clear or yellowish liquid, which may contain a small amount of blood. The websites recommended clients check that their jewelry is properly fitted to prevent recurrences. Follicular cysts could be relieved through warm sea salt soaks or gentle cleaning. One website recommended continued aftercare to prevent recurrences.

Six websites (8%) addressed an apparently common concern over a potential adverse effect of nipple piercings preventing or causing problems with nursing. All six said that breastfeeding was still possible while or after having nipple piercings. “There has not been a single documented case that we are aware of, where a woman who wished to breastfeed could not as a result of having had a nipple piercing,” stated the website of an establishment that has four locations in Indianapolis, IN. All six websites stated that nipple piercings needed to be well healed before beginning breastfeeding.

Five of these six recommended removing the jewelry for feedings because they pose a choking hazard for the nursing infant. These five websites also noted that some milk may come through the openings of the nipple piercings.

Two websites (3%) addressed concerns around body piercings and pregnancy, labor, and delivery. While several websites stated that women should not be pierced during pregnancy or while trying to become pregnant, only two websites went into detail about adverse effects of pregnancy and labor on body piercings. A body piercing establishment located in Atlanta, GA, stated that “a small percentage of women find that their piercings are rejected from the body [especially navel piercings]… Our clients and friends have worn body jewelry through labor and delivery of all kinds over the last decade.” A body piercing establishment located in Taylor, MI, provided the following information about genital piercings and labor and delivery:

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Piercings which are in danger of tearing when the vaginal opening widens should

be removed. Horizontal hood piercings may stretch uncomfortably or tear with

the jewelry in place… Properly placed labia piercings should be able to stay in

throughout the pregnancy, labor, and delivery, but it‟s best to get professional

advice.

This establishment recommended discussing the issue with the doctor or midwife prior to delivery. Both body piercing establishments stated they can help clients in this situation with the removal and replacement of jewelry.

Two websites (3%) discussed the potential complication of constriction, which occurs when the jewelry has too small a diameter, is too thick in gauge, or where the piercing was placed inappropriately by the body piercer who provided the body piercing.

According to a body piercing establishment in Eureka, CA, “a darkening of the skin between the entrances [of the body jewelry] indicates that the piercing is constricted by the jewelry.” Constriction can typically be resolved through changing to more appropriate body jewelry.

Potential psychosocial complications and adverse effects. Only two potential psychosocial complications or adverse effects were described on the websites examined.

A body piercing establishment located in Saginaw, MI, addressed individuals seeking heavier body modifications, including dermal punch, ear scalpelling, scarification, tongue splits, and genital subdermal implants: “Plan on [these modifications] being permanent, leaving marks for life, and, can be problematic, so ask and find out all you can. Fully understand and accept what you are about to get into.” They strongly suggested individuals seeking heavier modifications speak with individuals who have already received these modifications in order to get a full perspective on the effects of body modifications.

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A body piercing establishment located in Philadelphia, PA, addressed individuals seeking facial piercings:

If you‟re considering a facial piercing, you‟ve obviously decided to go public with

your perforated identity. Because however small your jewelry, there‟s just no

hiding a facial piercing during the first few months of healing.… This section is for

those who are ready to be visibly marked. And whose jobs and/or parents don‟t

mind…

While most facial piercings heal very quickly and easily, an infection or

scarring in the middle of your face can be rather unsightly. So get the

information ahead of time, and think before you act. And don‟t underestimate

how much one piece of jewelry can change others‟ perceptions of you. Having

facial piercings puts you on the frontlines of the public‟s reaction to body piercing.

Whether it counts for or against you, your business is on the table. Just consider

what doors you are opening or closing with the one little ring.

The establishment recommended that individuals seeking facial piercings should consider how the desired piercing will affect their physical and social lifestyle before obtaining the piercing.

Information on Aftercare

Forty-five websites (62%) posted information about aftercare, generally describing it as behavior that will help the body piercing heal. Five websites (7%) specified that aftercare is not meant in and of itself to heal or treat a wound, but to keep the piercing clean to allow ideal conditions for the body to heal itself. Aftercare information is divided into what to expect during healing, general aftercare, salt water/saline soaks, cleaning, oral piercing aftercare, and genital piercing aftercare. The general themes found are summarized on Table 4.6.

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Table 4.6

Information on Aftercare

Posted Information N %

General aftercare guidelines for body piercings 45 62

Aftercare guidelines for oral piercings 31 42

Salt water/saline soaks 29 40

Adverse effects of body piercing to anticipate in healing process 24 33

Cleaning with soap 23 32

Aftercare guidelines for genital piercings 16 22

N = 73

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What to expect during normal healing. Twenty-four websites (33%) provided information about what adverse effects of body piercing are normal during the healing process.

Twenty-three (32%) discussed “crusties” – whitish/yellow fluid secreted from the piercing that tends to dry around the ends of the body jewelry and at the openings of the body piercing. According to a Columbus, OH, based body piercing establishment, crusties include “blood plasma, lymph, and dead cells.” They stated “this is not pus, but indicates a healing piercing.”

Seventeen websites (23%) stated that discoloration – redness around the openings of the body piercing lasting a few days to a few weeks and/or bruising – was normal. Fifteen websites (21%) stated that swelling of the piercing site lasting a few hours to a few days was normal. They provided guidelines in their aftercare for dealing with swelling. Fourteen websites (19%) stated that a small amount of bleeding from the openings of the body piercing for a few hours to a few days was normal. Fourteen websites (19%) stated that tenderness at and around the body piercing site lasting a few hours to a few days was normal. Fourteen (19%) stated that itching and/or tightening of tissue around the body piercing was normal, typically not starting until a few days after the body piercing was obtained. Five websites (7%) described that a healed piercing may develop an accumulation of malodorous white secretions (similar to smegma) if not cleaned regularly.

General aftercare. Forty-five websites (62%) provided information about general aftercare of body piercings. A tenth of these (n=7, 11%) reposted or provided links to the current APP body piercing aftercare guidelines as their only aftercare information.

One website posted links to APP aftercare along with its own aftercare guidelines. While most of the guidelines from the APP would match the general guidelines described below, the number of websites who linked/reposted the APP guidelines is not counted in

Results - 64 the numbers provided for how many websites promote a specific behavior because the websites did not post original material. Guidelines that were posted on two or more websites are recorded in the second table of Appendix C.

Seven websites (10%) used specific language stating they provide aftercare information at the time of obtaining a body piercing, generally before the body piercing is performed and in oral and written forms.

Touching of the body piercing with unclean hands, submersion in standing water, contact with body fluids, and exposure to dirty objects were cited as leading cause of infections. All of these behaviors potentially introduced foreign bacteria into the piercing.

The use of alcohol-based cleaning products (rubbing alcohol, witch hazel), hydrogen peroxide, antibiotic ointments/creams, and wound care/surgical scrub (iodine,

Betadine, Hibiclens) were strongly discouraged. To a lesser extent, use of “ear care” solutions was discouraged. The excerpt below, from the website of a body piercing establishment located in Philadelphia, PA, describes the commonly given reasons for this:

Alcohol is far too harsh. It irritates and dries out the skin and can delay

healing…and may not be as effective on germs (when used topically) as

previously thought.

Peroxide does kill many bacteria, but it also destroys the healthy skin

around the piercing. Used long enough, it can eat away at the skin and actually

keep your piercing from healing.

Antibiotic ointments [such as] Neosporin, Bacitracin and triple antibiotic

ointments… have large amounts of petroleum jelly in them, which keeps oxygen

out of the piercing and creates the perfect warm moist environment for bacteria

to breed. The greasy barrier also keeps water and cleaning solutions from

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effectively reaching your piercing, making it impossible to clean. Read the label:

“Do not use on puncture wounds.”

Betadine/Hibiclens… may be used for first aid or surgical wound care, but

for long term care they are actually too strong and may delay healing. Betadine

may be useful to clear up an infection, but when used too often it can actually kill

healthy skin cells…

[Ear care solution] has proven to be problematic for many people. It is

not as effective a cleanser as antimicrobial soaps and does not penetrate or

remove oil and discharge in the piercing. Most [ear care] products have a very

short shelf life of a month or less… It seems some manufacturers may be using

formulas which are not compatible with human tissue…

For these reasons, most establishments advised against using the products listed above and instead advised using the aftercare guidelines for salt water/saline soaks and cleaning with soap.

Contrary to popular belief about the need to rotate ear piercings, body piercing establishments specifically recommended not moving body jewelry. These establishments stated movement of body jewelry can irritate the body piercing, cause crusted discharge to tear tissue, and introduce foreign bacteria into the body piercing.

These behaviors generally encourage the development of scar tissue, increase the risk of infection, and delay the healing process.

Changing or temporarily removing body jewelry was discouraged for the same reasons. Also, websites that recommended leaving jewelry in place at all times noted that, upon the removal of jewelry, both new and well-healed body piercings could tighten up in minutes, making reinsertion of the body jewelry difficult or impossible. If jewelry was removed and reinsertion becomes difficult, use of a taper by a body piercer might

Results - 66 be required in order to put the body jewelry back in place. This process was described as generally non-problematic, but can cause irritation to the body piercing.

Websites recommended that any behavior that moved the body jewelry from its initial placement and/or subjected it to repeated motion should be avoided in order to minimize irritation. This included avoiding sleeping on the piercing, wearing restrictive clothing, or using restrictive bandages. The websites stated that by minimizing irritation in these ways, one also minimized risk of migration or rejection of the body jewelry.

Thirteen websites (18%) provided estimated healing times for a variety of body piercings. In giving these estimated healing times, nine of these websites stated that the healing times are estimates only and that any individual may heal their body piercing in more or less time than states. A body piercing establishment located in Philadelphia, PA, gave a typical explanation of estimated healing times:

Below are approximate healing times for well-cared-for piercings for most people.

Keep in mind that your piercing may heal more quickly or take even longer.

Since most piercings have periods of both doing well and “acting up”, do not

assume that the disappearance of discharge means you are healed. Continue

suggested aftercare for at least the amount of time listed below for your piercing.

After this amount of time, if your piercing no long has discharge or “bad days”

and has not done so for at least a month, it may be healed. If you pay attention

to what your body is doing over time, you will know when it is done.

At the end of the healing time, cleaning twice daily is no longer required,

although cleaning once daily is still suggested. At this point, jewelry can safely

be changed, but should not be left out of any piercing. Even once the hole

becomes permanent, it can still shrink and make jewelry reinsertion more difficult.

Estimated healing times are listed in Table C4. As demonstrated in this table, estimated healing times for varied somewhat by piercing and within each body piercing.

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For example, three establishments stated that nostril piercings have an estimated healing time of two to three months and two establishments stated that nostril piercings have an estimated healing time of six months to a year. Earlobe piercings, by contrast, had a much closer range of estimated healing times – eight establishments said six to eight weeks, two said two to three months. In general, genital piercings that did not go through deep tissue and oral piercings had the shortest estimated healing times.

Surface piercings had the longest healing times.

After providing aftercare guidelines, seven websites included a disclaimer that stated that the guidelines were not medical advice. Rather, the guidelines were general advice for promoting healing and were based on professional experience and observation.

One website also provided aftercare guidelines for brandings.

Salt water/saline soaks. Twenty-nine websites (40%) provided information about using salt water/saline soaks as part of aftercare. Twenty-eight (97%) of these provided general aftercare guidelines, as well.

Twenty-five of the 29 websites (86%) provided directions for making salt water solutions. They all recommended using non-iodized salt, generally recommending sea salt and occasionally recommending kosher salts. Twenty (27%) gave directions to mix a quarter teaspoon of salt with eight ounces of water, preferably distilled or purified water.

Two gave instructions to mix an eighth of a teaspoon of salt with eight ounces of water.

Two gave a range of one-quarter to one-eighth of a teaspoon salt with eight ounces of water. An outlier was a website that recommended a range of solutions, from one teaspoon of salt per eight ounces of water to one teaspoon of salt per gallon of water.

Fifteen of the twenty-five (60%) specifically stated that stronger solutions were not better, as they could irritate the body piercing.

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According to the website recommendations, the solution should be made with warm to hot (“as hot as you can tolerate”) water. Once the solution was prepared, it was applied to the body piercing. Ideally, the solution was in a cup which was placed over the piercing (creating a seal with the rim of the cup) or the piercing was dipped into the solution. Fifteen websites (60%) stated that if it was not possible to soak the piercing directly in the solution, cotton balls, gauze pads, or paper towels could be soaked in the solution and applied to the body piercing. If this method was used, it was recommended that the balls/pads/towels be changed frequently.

Six websites (24%) recommended using a moistened q-tip to remove crusted discharge from the body piercing site and the body jewelry just before or while soaking the body piercing in the salt solution. Fourteen websites (56%) recommended rinsing the area around the body piercing with clean water after completing the soak. Most of these recommended drying the area with a clean paper towel or gauze pad.

Nineteen of the 25 (76%) gave a time frame for which to soak the piercing.

These varied widely from “a few minutes” to 20 minutes. Most (n=13, 68%) recommended between five and fifteen minutes.

Twenty-four of the websites (96%) gave a frequency with which to perform salt water soaks. These varied between four times per day to “a few times a week.” Thirteen

(52%) recommended between two and four times per day; twenty-three (92%) recommended between one and four times per day.

Eleven of the websites (44%) discussed premixed saline solutions for use during or between salt water soaks. There were two ways in which premixed solutions could be used: saline could be purchased and used as described above for soaking the piercing; and saline sprays or mists could be used to regularly irrigate the body piercing. Several websites that discussed saline sprays or mists stated that these did not fully replace salt

Results - 69 water soaks. Rather, they should be used in conjunction with a reduced amount of salt water soaks.

Various reasons were cited for why to perform the soaks. Eight (32%) stated that warm salt water soaks help soften and draw out discharge and impurities from the body piercing. Eight (32%) stated that warm salt water soaks promote blood circulation at the body piercing site. Six (24%) stated that salt water soaks sooth and prevent irritation of the body piercing site. Five (20%) stated that salt water soaks promote air circulation at the body piercing site.

Cleaning with soap. Twenty-three websites (32%) provided information on cleaning a body piercing with soap as a part of the aftercare process. All of these had provided general aftercare guidelines as well as the soap cleaning guidelines.

Seventeen of these websites (53%) specifically recommended anti-microbial and/or anti-bacterial soap, typically the brands Provon or Satin. These are gentle anti- microbial soaps that are free of dyes and perfumes. Two websites (9%) specified avoiding soaps containing the antibiotic triclosan. Eight websites (35%) recommended

“natural” and “cruelty-free” soaps, such as Dr. Bronner‟s or castille. Only one of these eight advocated the exclusive use of natural soaps. One website, of a body piercing establishment located in Colorado, did not recommend soap citing of the specific climate of the state.

Thirteen websites (57%) posted that the cleaning should be performed in the shower. Six of these recommended cleaning at the end of the shower so as to remove and prevent later exposure to any cleaning products used in normal showering (e.g. shampoo, body soap). Fourteen websites (61%) stated that the individual should wash their hands with anti-microbial soap before performing the cleaning. Twelve (52%) recommended soaking (e.g. salt water soak) or rinsing (e.g. in the shower) the area of the body piercing before cleaning to soften and/or remove crusted discharge.

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Eighteen websites (78%) stated that the individual should create a lather with soap and apply it to the area of the body piercing and exposed body jewelry. Seven

(30%) specified to not apply lather to the inside of the piercing. Seven (30%) specified to apply lather to the inside of the piercing by rotating the body jewelry through the piercing (two of these specified to not rotate lather into the body piercing the first seven to ten days after obtaining the body piercing and one specified not to rotate lather into the body piercing during the first several cleanings).

After the lather sat on and/or in the piercing for thirty seconds to two minutes, the individual should rinse all of the soap off of and/or out of the body piercing. Nine websites (39%) specified that the individual may rotate the body jewelry through the piercing during rinsing in order to ensure all soap is rinsed off (one advised to be careful of irritation, though). Two of the websites that specified that the body jewelry should not be rotated during the lathering process also specified that the body jewelry should not be rotated during rinsing. Ten websites (43%) stated that the piercing should be dried with disposable paper towels or clean gauze to avoid exposure to bacteria and chemical residues which may be present in reusable cloth towels.

Fifteen websites (65%) gave a frequency with which to perform the cleaning. Six

(26%) stated to clean the body piercing with soap two times per day; five (22%) stated to clean one time per day; four (17%) stated to clean one to two times per day. Fourteen

(61%) stated that it was important to not “over-clean” the body piercing (clean with soap too frequently) because doing so may irritate the body piercing.

Oral piercing aftercare. Thirty-one websites (42%) posted information on oral piercing aftercare, three of which simply reposted or linked to the APP oral piercing aftercare guidelines. Guidelines that were posted on two or more websites are recorded in Table C3.

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Accompanying most oral piercing aftercare guidelines was commentary that individuals may experience similar adverse effects as with any body piercing: swelling, slight bleeding, tenderness, and bruising. In oral piercings the typical white-yellow discharge made during the healing process is in a moist environment, so it does not

“crust” inside the mouth.

The primary recommended aftercare behavior is regular cleaning through rinsing the mouth. Twenty-seven of the websites (87%) specifically recommended using alcohol-free mouthwashes such as the brands Biotene or Tech2000; five of these recommended diluting the alcohol-free mouthwash. Alcohol-based mouthwashes were to be avoided because alcohol was too harsh a cleaning product and could cause irritation and drying, thus impeding the healing process. Twenty websites (65%) recommended using salt water/saline rinses. The salt water/saline solution was to be made using the instructions given for general salt water/saline solution used in body piercing aftercare – generally ¼ teaspoon to eight ounces of water. Three websites

(10%) stated that alcohol-based mouthwashes diluted with preferably distilled water could be used. Diluted alcohol-based mouthwashes were recommended in the context of an individual not being able to access or use alcohol-free mouthwash.

There were varied recommendations for frequency of rinsing and with which products to rinse. Twenty websites (65%) recommended rinsing after eating, drinking anything other than water, or smoking. Fifteen of these recommended rinsing with alcohol-free mouthwash; three recommended salt water/saline solution; two recommended distilled or purified water. Six of the websites that recommended rinsing with alcohol-free mouthwash after eating, drinking, or smoking stated that individuals should not rinse with alcohol-free mouthwash more than four to five times per day to avoid irritating or drying the oral piercing. Two of these six websites as well as four other websites recommended that post-eating/drinking/smoking mouthwash rinses should be

Results - 72 accompanied with twice daily sea salt/saline rinses. Two other websites recommended that post-eating/drinking/smoking mouthwash rinses should be accompanied by three to five times daily sea salt/saline rinses. One website that recommended post- eating/drinking/smoking salt water/saline rinses and one website that didn‟t recommended these rinses both recommended twice daily mouthwash rinses.

Maintenance of general oral hygiene through regular brushing was discussed by fifteen websites (48%). Six websites (19%) reminded individuals to brush their teeth two to three times per day. One website recommended brushing teeth after eating or drinking any fluids other than water in conjunction with a mouthwash rinse. Three websites recommending regular brushing as well as six other websites (total of nine websites, 29%) recommended gently brushing the jewelry. This helped remove plaque build-up that could cause irritation and increase risk of infection of the oral piercing.

Three websites (10%) recommended avoiding potential irritation caused by toothpaste – two of these recommended avoiding toothpaste with baking soda or peroxide and one of these recommended avoiding toothpaste altogether by brushing with water only.

Many of the aftercare guidelines were recommended in order to prevent introduction of foreign bacteria to the oral piercing. This was intended to reduce risk of infection. Behaviors that were recommended because they prevented introduction of foreign bacteria included: avoiding oral contact with body fluids by avoiding tongue kissing, oral sex, or sharing eating/drinking utensils; using a new toothbrush or cleaning the old toothbrush in a dishwasher; avoiding introducing unclean objects into the mouth, such as fingers, pen caps, and glasses; regularly cleaning the mouth through rinsing and brushing.

Many of the aftercare guidelines were recommended in order to prevent irritation of the oral piercing. Irritation was stated to delay healing and increase risk of infection and development of scar tissue. Behaviors that were recommended because they may

Results - 73 prevent irritation included: using alcohol-free mouthwash; avoiding spicy, salty, acidic, and/or hot food and beverages during initial days of healing; avoiding excessive talking during initial days of healing; avoiding playing with jewelry; avoiding chewing gum; avoiding sucking and straws; gently brushing jewelry as part of brushing process; avoiding toothpaste with baking soda or peroxide.

Three of the recommended aftercare behaviors were recommended in order to avoid damage to teeth or gums. Five of the twenty websites that recommended the avoidance of playing with the jewelry/piercing stated that this behavior is a leading cause of tooth and gum damage. Chewing food slowly and carefully while paying attention to jewelry/piercing placement, avoiding opening the mouth wide if one has a lip piercing

(the jewelry may catch the edge of front teeth), and downsizing the jewelry once swelling had subsided were all recommended in order to minimize risk of tooth and/or gum damage.

Genital piercing aftercare. Sixteen websites (22%) provided aftercare information specifically for genital piercings. Recommended aftercare for genital piercings closely followed general aftercare for body piercings. Extra attention was paid to the issues of avoiding contact with body fluids, avoiding mechanical irritation, and increased bleeding at the piercing site.

Accompanying most genital piercing aftercare guidelines was commentary that individuals may experience similar adverse effects as with any body piercing: swelling, bleeding, tenderness, bruising, and discharge that may dry in a clear or white/yellow crust around the openings of the piercing and/or on the jewelry. Six websites specifically stated that genital piercings may be expected to bleed more than other body piercings, particularly piercings of the penile shaft or glans. These websites provided information on bandaging the piercing with gauze or using panty-liners for one to several days in order to prevent getting blood on clothing.

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The most commonly provided recommendation regarding the aftercare of genital piercings was to avoid contact with body fluids. This was recommended in order to prevent infection of the genital piercing. A body piercing establishment located in Buffalo,

NY, explained: “This piercing is and [sic] open channel to your blood stream which increases the likelihood of contracting a STD if engaging in unprotected sex. Even if you are in a monogamous relationship large amounts of bacteria are transferred during sexual activity.” Most (n=14, 88%) specified that barriers should be used during oral or genital contact. Recommended barriers included condoms, dental dams, and Tegaderm style bandages. Five websites (31%) stated that men with penile piercings (especially frenum or Prince Albert piercings) might find condoms that have a larger reservoir tips more comfortable and less likely to break than regular condoms. Four websites (25%) recommended avoiding condoms that contain spermicide, as the chemicals in this product may irritate genital piercings.

Other behaviors were recommended in order to reduce risk of infection due to exposure to foreign bacteria. Six websites (38%) recommended cleaning genital piercings with soap or salt water/saline soaks immediately following sexual contact.

Three websites (19%) recommended that any hands that would touch on or near the genital piercing needed to be washed before doing so.

Several recommendations were given to reduce irritation of genital piercings.

Two websites (13%) stated that individuals should refrain from sexual activity for two weeks after obtaining a genital piercing. Seven websites (44%) stated that it wasn‟t necessary to fully refrain from sexual activity, but care should be taken to avoid abuse or trauma to fresh genital piercings. These websites emphasized being gentle with the genital piercing and avoiding any behaviors that caused pain, tugging, or tearing at the genital piercing site. Four websites (25%) recommended performing a sea salt/saline soak before engaging in sexual activity in order to remove any crusted discharge. If left

Results - 75 in place, this crusted discharge could irritate or tear skin in and around the genital piercing.

Recommended Resources

Over half of the websites (n=42, 58%) surveyed provided links and information for further resources on body piercing and/or body modification. Forty-two (58%) provided links to websites related to body piercing and/or body modification. Two (3%) provided information on print resources. One (1%) provided information on instructional

DVDs.

On-line resources. One hundred and one websites were linked to from the websites surveyed. The categories of websites are summarized on Table 4.7.

Four websites linked to (4%) were categorized as “industry” websites. Links to the Association of Professional Piercers were provided on 33 websites (45%).

Professional Piercing Information Systems, a company that sells sterilization and body modification equipment as well as provides industry-specific courses on technique and bloodborne pathogens, was linked to by four websites (5%). Links to Health Educators,

Inc., a company that provides industry-specific courses on bloodborne pathogens and disease transmission prevention, were provided on three websites (4%). Links to the websites of Fakir Musafar, “the founder of the modern primitive movement” and long- standing teacher of body modification procedures and rituals, were provided on two websites (3%).

Forty-one of the websites linked to (41%) were identified as websites for body piercing establishments. Only three of these were linked to by multiple websites. Four of the websites examined (5%) provided links to Rings of Desire, a body piercing establishment in New Orleans, LA, that has been closed since March, 2006. Three of the websites examined (4%) provided links to Infinite Body Piercing, a body piercing establishment in Philadelphia, PA. Two of the websites examined (3%) provided links to

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Table 4.7

Recommended On-Line Resources

Posted Information N %

Body piercing establishments 41 41

Jewelry manufacturers 18 18

“Other” 16 16

Own social networking page 13 13

Body piercing industry websites 4 4

Governmental/business organizations 4 4

Jewelry retailers 4 4

On-line body modification communities 3 3

Suspension organizations 3 3

Aftercare products 1 1

N = 101

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23rd Street Body Piercing, a body piercing establishment in Oklahoma City, OK. The remaining 38 websites to which links were provided were linked to by only one website examined. These websites represent body piercing establishments and tattooing establishments that offer body piercing located throughout the US, Canada, and

Australia.

Eighteen websites to which links were provided (18%) were categorized as jewelry manufacturers. These are establishments whose primary purpose was the development, manufacturing, distributing, and sale of jewelry designed for body piercings and/or body modifications. Unless otherwise noted, these manufacturers primarily manufactured metal body jewelry. Nine of the websites examined (12%) provided links to Anatometal, a jewelry manufacturer based out of Santa Cruz, CA.

Eight of the websites examined (11%) provided links to Industrial Strength, an international jewelry manufacturer based out of Carlsbad, CA. Four websites (5%) each provided links to Body Vision, Neometal, and Tawapa jewelry manufacturers based out of Los Angeles, Silverdale, WA, and San Francisco, respectively. Tawapa manufactures body jewelry only out of organic materials, including amber, animal bone, water buffalo horn, and various hardwoods. Three websites (4%) each provided links to Glasswear

Studios, a jewelry manufacturer based out of Ashland, OR. Glasswear manufactures body jewelry exclusively out of glass, including softer glass such as soda lime and barium crystal and harder glass such as borosilicate (Pyrex) and fused quartz. Five websites of jewelry manufacturers had links provided to them on two each of the websites examined (3%). All of these manufacturers were based out of the US. These included a manufacturer who exclusively manufactures jewelry out of glass, another who exclusively manufactures jewelry out of soft silicone, and another who exclusively manufactures jewelry out of organic materials who also sells antique tribal body jewelry.

Eight websites of US-based jewelry manufacturers had links provided to them on only

Results - 78 one (1%) each of the websites examined. Seven of these were based out of the US and one was based out of Brighton, England. One of these manufacturers makes high-end metal and organic body jewelry.

Four of the websites to which links were provided (4%) were categorized as

“jewelry retailers,” all of which primarily conducted business on-line. Three of the four on-line retailers sold body jewelry as well as a limited amount of non-body piercing jewelry and clothing. The fourth sold a wide variety of body modification related merchandise, including clothing, books, stickers, and tattoo machines. The four retailers were US-based.

Only one of the websites examined (1%) provided links to aftercare products. It provided links to five products: Biotene (an alcohol-free pro-biotic mouthwash); Emu oil;

H2Ocean (pre-packaged sterile saline); TECH 2000 (an alcohol-free anti-bacterial mouthwash); and Satin (a medical grade liquid anti-bacterial soap).

Links were provided to four websites (4%) of organizations categorized as

“governmental/business.” These organizations were linked to by one website (1%) each.

These organizations are: the Florida Department of Health; the Greater Redding

Chamber of Commerce; the Occupational and Safety Health Administration; and the

Texas Department of Health.

Three on-line body modification communities were linked to by the websites examined. Body Modification Ezine (BMEzine) had links provided to it by 19 of the websites examined (26%). Tribalectic on-line body modification community had links provided to it by seven of the websites examined (10%). The Church of Body

Modification had links provided to it by two of the websites examined (3%).

Thirteen links (13%) were provided to body piercing establishments‟ own pages on internet-based social networking sites. Twelve establishments (16%) provided links

Results - 79 to their own MySpace.com page. One establishment (1%) provided a link to its own

Friendster.com page.

Three of the websites examined (4%) provided links to the websites of organizations dedicated to the body modification ritual of suspension. Suspension is a ritual by which individuals suspend their body from specially made hooks that are placed through temporary piercings. Two of the websites examined (3%) provided links to

Suspension.org, a clearinghouse of information about suspension that also maintains a list of suspension groups world-wide. Two of the websites examined (3%) provided links to the Constructs of Ritual Evolution suspension group based out of Costa Mesa, CA.

One of the websites examined (1%) provided a link to ihung, a suspension group based out of Columbus, OH.

Sixteen websites that had links provided to (16%) them were categorized as

“other.” Thirteen of these links were active; three were inactive. Two had links provided to them on two each of the websites surveyed: 3D Body Art, showcasing the body modification work of Steve Haworth; the One Project, which annually hosts a three-day festival dedicated to ritual. Each of the following active websites were linked to by only one each of the websites surveyed: Bod-Mod.com (“Anthropological, Cultural, and

Ethnographic Studies Place”); Fakir Rants (archive of columns by Fakir Musafar, published on BMEzine.com); Human Anatomy Online; Gauntlet Enterprises (former world-renowned body piercing training establishment); The Lizardman (a man who completed a full-body modification with green tattooing, implants, and split tongue);

ModBase (software for body modification establishments); the MySpace page

StopBodyArtDiscrimination; Piel Tattoo and Piercing Magazine (online version); Piercing

FAQ (an archive of information related to body piercing); and Scar Wars (an annual convention about scarification). Links were provided to three websites that are no longer active but were still deemed by the researcher to be noteworthy. One of the websites

Results - 80 examined provided an inactive link to Piercing Mildred, a former on-line game where participants could electronically pierce, tattoo, or otherwise modify a character and earn play money for further body modification procedures for their character. One of the websites examined provided an inactive link to Bodyart Web Directory, a former archive of information related to body modification. One of the websites surveyed provided an inactive link to a tattoos page at the National Geographic website.

Print resources. Two of the websites examined (3%) provided information on print resources. Infinite Body Piercing, a body piercing establishment in Philadelphia,

PA, provided information on its own print resources, including Starting Point: A Primer of

Modern Body Piercing, The Infinite Guide to Stretching, and Aftercare. Infinite Body

Piercing also provided a long list of books from its own library that were available for sale, most of which were body modification related. Nomad, a body piercing establishment in

Bend, OR, provided details on the following books: A Brief History of the Evolution of

Body Adornment in Western Culture: Ancient Origins and Today by Blake Perlingieri;

Spirit + Flesh by Fakir Musafar; The Quest for Human Beauty by Julian Robinson; Body

Play, Volume 1 by Fakir Musafar; and Tribal Arts magazine Feature, Summer/Autumn

2001 by Jonathan Fogel.

Video resources. One of the websites examined (1%) provided information on

DVD resources. Nomad, a body piercing establishment in Bend, OR, offers for sale two

DVDs: Nomad Extreme Tribal DVD; and Nomad Advanced Male Genital Freehand

Technique DVD. The website stated “these DVDs are strongly recommended for advanced piercers with five or more years of professional experience.”

Procedures Available

The availability of procedures was determined by examining on-line portfolios, price lists, website photos, and text about procedures. Using this process, of the 73 websites that had information related to the study 71 (97%) demonstrated that they

Results - 81 provided body piercing. The availability of body modification procedures is summarized on Table 4.8.

Sixty establishments (82%) demonstrated that they provided stretching services.

Fifty-two establishments (71%) demonstrated that they provided surface piercing. Of these, one also demonstrated that it provided surface-to-surface (or “surface weaving”) piercings, where a single piece of jewelry is place in two or more surface piercings.

Seven establishments (10%) demonstrated that they provided dermal punch procedures. An additional nine establishments (12%) included photos in their online portfolios that included ear cartilage modifications that were very likely created by dermal punch procedure. This means that a fifth (22%) of establishments might offer procedures that involve the use of dermal punches. Seven establishments (10%) demonstrated that they provided scalpelled procedures. One additional establishment

(1%) included photos in their online portfolio that included modifications that were very likely created through a scalpelled procedure. Scarifications performed by scalpel were not included in this count.

Fifteen establishments (21%) demonstrated that they provided microdermals/dermal anchors. Two establishments (3%) demonstrated that they provided subdermal implants. None demonstrated that they provided transdermal implants, though one included photos in its online portfolio of what was likely a transdermal implant.

Thirteen establishments (18%) demonstrated that they provided scarification.

Five of these provided branding scarification only. Five provided both branding and scalpel scarification. Two provided scalpel scarification only. One provided scalpel, branding, and electrocautery scarification.

Nine establishments (12%) demonstrated that they offer or support the body modification ritual of suspension, where individuals suspend their body from specially

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Table 4.8

Availability of Body Modification Procedures

Procedure N %

Body piercing 71 97

Stretching 60 82

Surface piercing 52 71

Microdermals/dermal anchors 15 21

Scarification 13 18

Suspension ritual 9 12

Dermal punch procedures (suspected) 9 12

Dermal punch procedures (confirmed) 7 10

Scalpelled procedures (confirmed) 7 10

Temporary corset ritual 5 7

Subdermal implants 2 3

Scalpelled procedures (suspected) 1 1

N = 73

Results - 83 made hooks that are placed through temporary piercings. Five (7%) demonstrated that they provided the body modification ritual of temporary corsets. This is a ritual where several temporary piercings are made, have captive bead rings placed in them, and ribbons or strings are threaded through the rings to give the appearance of a laced-up corset. Two establishments (3%) demonstrated that they provided the body modification ritual of play piercing, where an individual is pierced with typically small gauge needles which are left in place for a short period of time. One establishment demonstrated that it offered the body modification ritual of cheek skewering, where one long skewer is pierced through both cheeks. One establishment demonstrated that it offered or supported kavadi ritual, a traditionally Hindu ritual in which a frame with long weighted skewers is held to the body while the individual walks or dances and the skewers pierce into the skin of the back and chest. One establishment demonstrated that it provided the body modification ritual of flesh pulls, where a specially made hook (or hooks) is placed in temporary a piercing and the individual uses their own strength and/or weight to put pressure on the hook by pulling against another person, people, or inanimate object.

One establishment demonstrated that it offered a body piercing called “pocketing”

(sometimes called “anti-piercing”), where the ends of the piercing are under the surface of the skin and the middle portion of the jewelry is above the surface.

Other Information of Note

Twenty-one websites (29%) provided information that was not anticipated by the survey instrument and was recorded in the “other” category. These mainly included articles posted on the websites about body modification and information to consider when making body modification related decisions. The general themes found are summarized in Table 4.9.

Seven websites (10%) provided information about what to look for when choosing a body piercing establishment and/or body piercer. Five of these were longer

Results - 84

Table 4.9

Other Information of Note

Posted Information N %

Body modification procedures/techniques 10 14

Information on what to look for when choosing body piercing establishment 7 10

On-line forums 7 10

Process of becoming a body piercer 3 4

Body piercing etiquette 2 3

N = 73

Results - 85 articles; two were answers to “frequently asked questions.” The information provided emphasized the importance of carefully choosing a body piercing establishment and/or body piercer in order to minimize risks during the piercing process. These risks included contraction of bloodborne pathogens, complications due to improper placement of the body piercing, improper or poor quality jewelry, or infection due to poor body piercer hygiene. The information provided emphasized researching the studio cleanliness, sterilization processes, aseptic technique (or lack thereof), jewelry selection, portfolio of work, training and certifications, affiliations, aftercare information, and/or bedside manner of the body piercer.

Ten websites (14%) provided information about body modification procedures.

Five websites (7%) provided information that explained the process of stretching body piercings. Four websites (5%) provided explanations of freehand technique and stated that that was process they used in performing body piercings. A body piercing establishment located in Salt Lake City, UT, explained the process and their rationale for using it:

At [our establishment] we use Freehand Technique, meaning that we do not use

clamps or forceps during your piercing… By taking the clamps out of the

procedure, you recieve [sic] a much safer and much less painful piercing. There

is less truama [sic] to the tissue, which often means less swelling and a faster

healing period.

Two websites (3%) provided detailed information on the process and potential adverse effects associated with surface piercings. One website (1%) provided detailed information about branding scarification.

Seven websites (10%) provided online forums for individuals to participate in.

Three of these were electronic guest books where individuals who had been pierced at the establishment were encouraged to post about their experience. Two of these were

Results - 86 discussion forums in which the public and the body piercers of the establishment participated. Two had electronic forms for submitting questions about body piercing to the body piercer at the establishment.

Three websites (4%) provided information about the process of becoming a professional body piercer. One website (1%) provided their establishment‟s detailed curriculum for apprentices. One website (1%) provided general information on the basic concepts of body piercer apprenticeships. One website (1%) included a brief article on learning how “to pierce well” (emphasis in original).

Two websites (3%) provided information on body piercing etiquette. These covered information on how to behave in the body piercing area, the importance of asking questions and following the body piercer‟s suggestions, and tipping body piercers for their services.

Three websites (4%) provided lengthy articles related to body piercing. One website provided an article titled “Health standards and guidelines for body and ear piercing” that was attributed to Alberta Health and Wellness. One website provided a state-by-state listing of body piercing related legislation and bills in the United States up through the year 2000. One website provided an article titled “Parental Guidance,” attributed Michael Rooney and published in Pain magazine. The article discussed rationale for not piercing minors and ethical issues for body piercers around parents making decisions about their minors getting body piercings.

Availability of Information

Throughout the process of recording data from the websites on the coding instrument, the researcher kept records of the URL (unique resource locator, or website address) the information came from and how far from the homepage information was found. Any time material was copied from a website into the survey instrument, the URL

Results - 87

Table 4.10

Availability of Information

Links taken to get to information N %

0 56 8.7

1 256 39.6

2 224 34.7

3 110 17

N = 646

Results - 88 was also copied into the form above the text. The researcher also kept track of how many links away from the homepage the text was found. The URL provided through the

APP “Locate an APP piercer” search page was considered the homepage the website.

Any information found on the homepage was coded as the number zero (0) next to the

URL on the survey instrument. If the researcher followed a link on the homepage and found material on the new page that was copied into the survey instrument, the information found on that page was coded as the number one (1) next to the URL. If the researcher followed a link on that page that was also not available on the homepage and found material on the new page that was copied into the survey instrument, the information found on that page was coded as the number two (2) next to the URL.

At the completion of data collection, all coded numbers were tabulated and the availability of information was calculated by percentage. Over four-fifths of information was found within two links of the homepage. Results indicated that 8.7% of information recorded on the instrument was gathered from the homepages of the websites. In addition, 39.6% and 34.7% of information recorded on the instrument was gathered from the first and second links from the homepage, respectively. The remaining 17.0% of information was recorded on the third link from the homepage. No information was found further than three linked pages from the homepage.

The format of the majority of websites was what made information highly accessible within a few links. Most pages had a format where the menu for all major pages was on the top and/or sides of the homepage and each page to which it linked.

Discussion

Seventy-five websites were examined, representing 75 body piercing establishments with 99 locations in 76 cities in 29 states of the continental US. Seventy- two of these websites contained information relevant to the study. These websites were selected for the sample because they were listed as US-based body piercing

Results - 89 establishments through the Association for Professional Piercer‟s “Find an APP Piercer” search page.

Well over half of the websites provided information on cleanliness and safety precautions. This information was broken into the themes of: hygiene during body piercing; sterilization equipment; licensure; age policies; identification policies; other policies; and jewelry used in initial body piercings.

Fifty-six percent posted information about hygiene during the body piercing area of the establishment and/or process. Nearly one-quarter of these stated that they met or exceeded the minimum safety standards of the APP. A fifth described using universal precautions to prevent the transmission of disease. A third of the establishments stated that they use single-use needles in the body piercing process, preventing transmission of bloodborne pathogens and other diseases. Fifteen percent stated that the body piercers wore gloves during the entire body piercing process, over a third of which stated that the gloves were frequently changed. Eighteen percent described the process by which the body piercing area was cleaned and disinfected between clients.

Thirty-two percent of websites stated that all non-disposable equipment used in the body piercing process was sterilized between every use. A fifth of websites stated that body jewelry used in the body piercing process was sterilized before use. Fifteen percent described the process by which they sterilized equipment, a quarter of which described a process by which the client could check to make sure the equipment was properly sterilized.

Over a third of the establishments provided information about the sterilization equipment they use and/or how frequently they test the equipment for effectiveness.

Thirty-eight percent of establishments stated they participated in spore testing, which tested their sterilization equipment for effectiveness, on a mostly weekly basis.

Results - 90

Sixteen percent of the establishments posted information about participation in governmental or business licensure. Nearly half of the websites surveyed posted information about their policies regarding providing body piercings to minors. Of the

40% of establishments who reported they will provide body piercings to minors, all had a similar policy: valid documentation must demonstrate the identity of the parent/legal guardian, the minor, and the relationship between the two. Establishments limited the kinds of body piercings they would provide to minors regardless of parental consent.

Twenty-seven percent of websites stated that individuals must present valid photo ID in order to obtain a body piercing.

Six other policies or requests of clients were listed on websites. Six establishments stated that clients must not be under the influence of drugs or alcohol at the time they are seeking to obtain a body piercing. Four establishments posted policies forbidding children under certain ages from the body piercing area. Two establishments stated that they reserve the right to refuse services at any time. Six establishments requested that clients eat several hours prior to obtaining a body piercing. Four establishments requested that clients avoid blood-thinners for up to 24 hours before obtaining a body piercing. Three requested that clients do not come if they are feeling ill.

Just over half of the websites surveyed contained information about jewelry used in initial body piercings. This information included the materials the jewelry was made of and/or style of jewelry used. Four materials were considered safe for initial piercings by the APP: implant grade quality metals (stainless steel, titanium); 14K or higher gold; tygon, and PTFE. Thirty-one establishments provided information on their websites demonstrating that they only use jewelry made of these materials in initial body piercings.

Body jewelry used in most initial body piercings involved either jewelry where ends are threaded onto a post or jewelry where a bead is held in place by tension from a metal ring. A third of establishments stated that they only use internally threaded body

Results - 91 jewelry, meaning that the threads into which the ends fix are inside the post of the jewelry, not exposed. A tenth of websites explained that they only use jewelry with a high quality polish, meaning the jewelry is free of nicks, scratches, and polishing compounds.

Three-fourths of the websites provided information about the body piercers who worked at their establishment. Information was recorded on 117 body piercers, including early professional development, health related training and certification, continuing education, years of experience, and affiliation with the APP.

Twenty-eight percent of piercers referenced participating in an apprenticeship, which was described as industry-specific training of a few months to several years under a professional body piercer. Four percent were still participating in their apprenticeship.

Seventeen percent of piercers developed their body piercing and body modification skills through attending industry-specific training. Almost half of the piercers referenced having received or maintaining current certification in bloodborne pathogens. Nearly all of these referenced having received or maintaining current certification in CPR and first aid, respectively.

Two-thirds of piercers included information on their years of experience as a body piercer. The mean years worked was 9.64 years. Over half of those who listed their experience had worked ten years or longer. Most of the individuals with three years of experience or less clearly stated they were still in their apprenticeship.

Three-quarters of the websites that included information on the body piercers employed at the establishment referenced membership in the APP in either the text of the body piercer‟s biography or on the page where the biography was located. Five of these included information about what the APP is and does.

Information about potential complications and adverse effects was found on nearly half of the websites. Potential complications and adverse effects discussed

Results - 92 included those that could occur during the body piercing process, those that could occur after the body piercing process, and those that were psycho-social in nature.

Potential complications and adverse effects that could occur during the body piercing process were discussed on thirteen websites. All but one – pain experienced during the procedure – were discussed in the context of how the risk for the potential complication was minimized at the establishment.

The most frequently discussed process-based complication were the risks associated with using a piercing gun for body piercings (including lobes). Use of piercing guns was discouraged for many reasons: most piercing guns cannot be sterilized; the gun piercing process causes microspray of tissue, blood, and body fluid that is rarely successfully removed from the piercing gun between clients; piercing guns are more painful than a piercing needle; piercing guns cause trauma to the tissue being pierced, complicating the healing process; most jewelry used with piercing guns is made of poor quality metal and the design complicates the healing process.

The risk of contracting bloodborne pathogens during the body piercing process was discussed by a tenth of the websites, typically in the context of how to choose a body piercing establishment (i.e. the risk is greater at an establishment that does not use aseptic procedure). HIV and hepatitis B were the most commonly referenced pathogens.

Seven percent of the websites addressed the issue of pain during the body piercing process, acknowledging and normalizing pain as a potential adverse effect of the body piercing process. Two websites addressed the issue of using anesthetics to minimize pain during the body piercing process. They would not provide them for many reasons, including: only properly licensed medical professionals can administer many forms of anesthetic; injections of anesthetics may hurt more than a properly performed body piercing; cream/gel anesthetics may not be sterile, thus containing a risk for cross-

Results - 93 contamination; freezing/cooling techniques may cause tissue damage, thus complication healing.

Forty-one percent of websites described potential complications and adverse effects that could arise after the body piercing process was completed. These include: infection of the piercing site; scarring at the piercing site; irritation at the piercing site; migration/rejection of jewelry; allergic reaction to metal or cleaning products; discolored tongue due to over cleaning oral piercings; damage to teeth and gums from oral piercings; abscess; follicular cysts; and constriction of tissue by too-small jewelry.

In nearly every case, the websites describing the potential complications stated that the risk for most of these complications was typically minimized by properly following aftercare guidelines. Most important of these was minimizing contact with the body piercing site of unclean items and body fluids. Minimizing movement at the piercing site and movement of the body jewelry also minimized risk for these complications.

Several websites noted that infections, irritation, and allergic reaction present themselves in similar ways, making it difficult for clients to know what complication they are experiencing. These websites recommended that clients speak with a body piercer, preferably in person, to discuss any abnormalities and receive strong advice on how to resolve the complication.

An apparently common concern over a potential adverse effect – that nipple rings would limit breastfeeding ability – was discussed by eight percent of the websites. All said that breastfeeding was still possible after or while having nipple piercings. All recommended that the piercings be well healed before beginning breastfeeding and all but one recommended removing jewelry for feedings as it posed a choking hazard to the nursing infant.

Only two psychosocial complications were described on the websites surveyed.

One establishment recommended that individuals seeking heavy modifications such as

Results - 94 dermal punch, ear scalpelling, scarification, tongue splits, and genital subdermal implants discuss the permanent and potentially life-changing nature of these with individuals who already had them. Another establishment encouraged individuals to give great thought to the social and work-related impact of facial piercings.

Sixty-two percent of the websites posted information about aftercare, generally describing it as behavior that would help the body piercing heal. Information on general body piercing aftercare, oral piercing aftercare, and genital piercing aftercare was found, as well as what one should expect during the healing process.

A third of the websites provided information about what to expect during the healing process. These included: whitish/yellow fluid secreted from the body piercing that tends to dry around the ends of the body jewelry and openings of the body piercing; redness and/or bruising around the openings of the body piercing; swelling; bleeding from the openings of the body piercing; tenderness at and around the body piercing site; and itching and/or tightening of the tissue around the body piercing.

General aftercare of body piercings was discussed by 62% of the websites, 16% of which reposted or posted links to the APP guidelines. A tenth of establishments specifically stated on their websites that they provide oral and/or written aftercare instructions at the time of performing the body piercing.

Aftercare guidelines were designed to limit exposure of the body piercing to external bacteria, clean the body piercing site, and encourage the body‟s ability to heal the wound of the body piercing. Some of the most commonly given guidelines included: do not touch the body piercing with unclean hands (own or others‟); do not submerge the body piercing in standing bodies of water; do not use alcohol (rubbing, witch hazel), hydrogen peroxide, antiseptic/antibiotic creams, or iodine/Betadine on the piercing site; leave the body jewelry in place; and avoid contact with body fluids. Maintenance of general health through diet, regular sleep, and exercise, as well as the use of

Results - 95 multivitamins and/or vitamin C and/or zinc was recommended by nearly half of those providing aftercare instructions. Avoidance of behaviors that caused chemical or mechanical irritation of the piercing site was also commonly recommended. Use of regular salt water/saline soaks and cleaning with antibacterial soap were also frequently recommended.

Oral piercing aftercare was discussed by 42% of the websites. In their basic rationale, the guidelines were closely aligned with regular body piercing aftercare: minimize exposure to sources of foreign bacteria; regularly clean the piercing site; minimize chemical and mechanical stress. The first of these was achieved by avoiding contact with other people‟s body fluids by avoiding tongue kissing, oral sex, and shared utensils, getting a new toothbrush, and keeping objects (pencils, pen caps, fingers, eyeglasses) out of one‟s mouth. The second of these was achieved through regular rinsing with alcohol-free mouthwash and/or salt water/saline and good general oral hygiene practices. The third of these was achieved by not playing with jewelry, avoiding irritating foods, avoiding chewing gum, and avoiding harsh or irritating cleaners.

Individuals are also advised to anticipate swelling with oral piercings. Swelling could be minimized by holding ice in the mouth, using anti-inflammatories, and sleeping with one‟s head elevated.

Genital piercing aftercare guidelines were provided by 22% of the websites.

These guidelines closely followed those for general body piercings, with extra attention paid to the issues of avoiding contact with body fluids, avoiding mechanical irritation, and increased bleeding at the piercing site. The first two of these were discussed primarily in the context of sexual activity.

Only 3% of websites stated that individuals with genital piercings need to abstain from sexual activity during initial healing (two weeks). Others stated that it wasn‟t necessary to fully refrain from sexual activity, but that care should be taken to avoid

Results - 96 abuse or trauma to fresh genital piercings. Recommended behaviors to avoid irritation included avoiding behaviors that cause pain, tugging, or tearing at the piercing site and performing a salt water/saline soak before engaging in sexual activity.

Avoidance of contact with body fluids involved using barrier methods of protection during sexual activity. Dental dams were recommended for oral sex and condoms for penetrative acts. Cleaning of hands before touching the piercing site and cleaning of the piercing site after sexual activity were both recommended to prevent risk of infection.

Over half of the websites surveyed provided links and information for further resources on body piercing and/or body modification: 58% provided links to websites related to the topic; 3% provided information on print resources; and 1% provided information on instructional DVDs.

One hundred and one websites were linked to from the websites surveyed.

These were divided into ten categories: industry-related; body modification establishments; jewelry manufacturers; jewelry retailers; aftercare products; governmental/business; on-line body modification communities; social networking; suspension; and other. Industry-related websites included the APP website as well as organizations that provide body piercing and body modification related training. Forty- one body piercing establishments were linked to, mostly each establishment was linked to on only one website. Eighteen jewelry manufacturers were linked to, the most popular of which were the large implant-grade metal jewelry manufacturers Anatometal and

Industrial Strength. Four jewelry retailers were linked to, all US and internet-based.

Links to five aftercare products were provided on one website. Governmental and business organizations, to which four links were provided, included state departments of health, a chamber of commerce, and the Occupational and Safety Health Administration.

Three on-line body modification communities were linked to, the most popular by far of

Results - 97 these was Body Modification Ezine which had 19 websites provide links to it. Twelve establishments provided links to their own MySpace.com page and one provided a link to its Friendster.com page. Links were provided to websites of organizations dedicated to suspension, which is a ritual by which individuals suspend their body from specially made hooks that are placed through temporary piercings. Sixteen websites that had links provided to them were categorized as “other” and included topics such as 3D body art, ritual-based festivals, general piercing information, and a now-defunct game that involved electronically piercing, tattooing, or otherwise modifying an on-line character.

Of the websites that had information related to the study, 98% demonstrated that they provided body piercings through their portfolio, price list, website photos, or text about procedures. Eighty-two percent demonstrated that they provided stretching services. Seventy-one percent demonstrated that they provided surface piercing.

Dermal punch procedures were clearly provided by 10% of the establishments and potentially provided by an additional 12%. A tenth of the establishments demonstrated that they provided scalpelled procedures (scarifications performed by scalpel not included). A fifth demonstrated that they provided microdermals/dermal anchors.

Eighteen percent of the establishments demonstrated that they provided scarification by branding, scalpelling, or electrocautery. Twelve percent demonstrated that they offer or support the body modification ritual of suspension. Other body modification rituals that were demonstrated on the websites surveyed included corsetry (rings in temporary piercings that have ribbons laced through them), play piercing (small gauge needles pierced and briefly left in place), cheek skewering, kavadi, and flesh pulls (hooks in temporary piercings against which the person pulls).

Twenty-nine percent of the websites provided information that was not anticipated by the survey and was recorded in the “other” section of the instrument.

These mainly included articles posted on the websites about body modification and

Results - 98 information to consider when making body modification related decisions: Seven websites provided information about what to look for when choosing a body piercing establishment/body piercer; ten provided information on procedures such as stretching and freehand piercing technique; three provided information the process of becoming a professional body piercer; two provided information on body piercing etiquette. Seven websites included on-line forums in which individuals could participate.

Chapter Five

Conclusions and Recommendations

Body piercing has a long history and growing popularity in modern Western culture. Body piercing is particularly popular among adolescents and college students.

One-quarter to one-half of college students have ever had a body piercing. Nearly one- third of the US population age 21-32 has ever had a body piercing.

Body piercings carry a variety of potential health complications. There is some variation by body piercing site, but all body piercings carry the risk of bruising, bleeding, tissue trauma, keloid formation, allergic reaction to jewelry, bacterial infection, and transmission of infectious agents. Reports of health complications vary widely in the research from 12% among urban adolescents to 70% in undergraduate university students. Nationwide, the prevalence of reported complications is 23%. Despite the risk of potential health complications, only 61% of those who obtained body piercings considered the risks before the piercing procedure was performed and cleanliness of the establishment did not weigh in their choice of piercing professional.

99 Recommendations - 100

Researchers and medical professionals have identified the prevalence of body piercing, potential complications, and key risks for infection. Researchers have also identified the internet as a common source of health information for the public. At the time of this project, no research had been published about information available on-line about body modification and its associated risks.

The purpose of this study was to investigate the information available on websites of body piercing establishments. The study examined websites to study the information provided about studio cleanliness, safety precautions, potential complications from body piercings, the body piercers‟ professional experience and affiliations, aftercare, recommended resources on body modification, and procedures available. The study reported the extent to which these topics were covered in the websites posted by body piercing establishments. It also noted other information provided on body piercing establishments‟ websites not anticipated by the research questions.

The first chapter of this thesis outlined information that demonstrated the need for this research and the parameters within which the research was conducted. The second chapter of this thesis outlined the body of knowledge about body piercing and body modification at the time of the study, including frequency of body piercing, potential complications of body piercing and their associated factors, and emerging body modifications. The third chapter of this thesis described the process by which the research was conducted, including a description of the instrument through which information was gathered. The fourth chapter of this thesis detailed all major data

Recommendations - 101 gathered from the research, including information about the websites examined and the establishments they represent, information on body piercing processes, cleanliness, potential complications, and aftercare, as well as additional resources recommended for information on body piercing and modification. This chapter provides a discussion of the findings and offers specific recommendations for practitioners and researchers.

Conclusions

The study was a census study of all websites of body piercing establishments listed as US-based establishments through the Association of Professional Piercers

“Find an APP Piercer” search page. Seventy-five websites were examined, representing

75 body piercing establishments with 99 locations in 76 cities in 29 states of the continental US. Information posted on the following topics and the extent to which information on the topics were recorded and analyzed: cleanliness of the body piercing establishment; safety precautions used during the piercing process at the establishment; potential complications of body piercings; professional experience and/or affiliations of the body piercer(s) employed at the establishment; recommended aftercare for body piercings; and recommended on-line, print, and video resources on body piercing and body modification. Using a variety of methods, including reviewing on-line photo portfolios, general text, and pricelists, the body modification procedures available at the examined body piercing establishments were recorded.

Body piercing establishments were found to generally be open every day of the week. Of those that provided business hours, all were open Tuesdays through

Saturdays, 84% were open on Mondays, and 76% were open on Sundays. The vast majority of establishments opened at or around noon on the days they were open; closing times varied widely.

Well over half of the websites provided information on cleanliness and safety precautions. This included information on hygiene during the body piercing process,

Recommendations - 102 sterilization equipment, licensure, jewelry used in initial body piercings, and age, identification, and other policies.

Fifty-six percent posted information about hygiene during the body piercing area of the establishment and/or process, nearly one-quarter of which stated that they met or exceeded the minimum safety standards of the APP. One-fifth to 1/3 described using prevention practices such as universal precautions to prevent the transmission of disease, single-use needles in the body piercing process, and use of gloves during the entire body piercing process.

Thirty-two percent stated that all non-disposable equipment used in the body piercing process was sterilized between every use. Fifteen percent described the process by which they sterilized equipment, a quarter of which described a process by which the client could check to make sure the equipment was properly sterilized. Over a third (38%) of the establishments provided information about the sterilization equipment they use and/or how frequently they test the equipment for effectiveness. Sterilization equipment was tested for effectiveness by a process called spore testing, in which a test strip containing live non-pathogenic spores was sterilized by the equipment and then tested for living cultures by an independent laboratory. Thirty-eight percent of the establishments stated they participated in spore testing, most commonly on a weekly basis.

Twelve establishments (16%) posted information about participation in governmental or business licensure. Ten establishments (14%) were certified or licensed to operate through their state, county, or city departments of health. Three (4%) were members of their local Better Business Bureau, one of which also belonged to its local Chamber of Commerce.

Forty-seven percent of the websites examined posted information about their policies regarding providing body piercings to minors. Of the 40% of establishments

Recommendations - 103 who reported they will provide body piercings to minors, all had a similar policy: valid documentation must demonstrate the identity of the parent/legal guardian, the identity of the minor, and the relationship between the two. Establishments limited the kinds of body piercings they would provide to minors regardless of parental consent: most would not provide body piercings below the neck with the exception of navels; many would also not provide surface piercings or earlobe piercings larger than 10 gauge.

Twenty body piercing establishments stated that individuals must present valid photo ID in order to obtain a body piercing. Valid ID was typically defined as non- expired driver‟s license, state-issued ID, passport, or military ID.

Fifty-two percent of the websites examined contained information about jewelry used in initial body piercings. This information included the materials the jewelry was made of and/or style of jewelry used. Four materials are considered safe for initial piercings by the APP: implant grade quality metals (stainless steel, titanium); 14K or higher gold; tygon, and PTFE. Forty-two percent of the establishments provided information on their websites demonstrating that they only use jewelry made of these materials in initial body piercings. Body jewelry used in most initial body piercings involved either jewelry where ends are threaded onto a post or jewelry where a bead is held in place by tension from a metal ring. Thirty-two percent of establishments stated that they only use internally threaded body jewelry, meaning that the threads into which the ends fix are inside the post of the jewelry, not exposed. This style was recommended because it minimized tissue damage during insertion and was typically made of higher quality materials. Seven websites (10%) explained that they only use jewelry with a high quality polish, meaning the jewelry is free of nicks, scratches, and polishing compounds. The higher quality the polish of body jewelry, the less likely was jewelry-caused irritation in a body piercing.

Recommendations - 104

Three-quarters of the websites provided information about the body piercers who worked at their establishment. Information was recorded on 117 body piercers on topics including early professional development, health related training and certification, continuing education, years of experience, and affiliation with the APP.

Thirty-three individuals (28%) referenced participating in an apprenticeship, which was described as industry-specific training of a few months to several years under a professional body piercer. Five of these thirty-three were still participating in their apprenticeship. Twenty individuals (17%) developed their body piercing and body modification skills through attending industry-specific training offered by specialized training companies.

Forty-eight percent of the body piercers referenced having received or maintaining current certification in bloodborne pathogens. Forty-three percent and 42% referenced having received or maintaining current certification in CPR and first aid, respectively. Thirty-seven individuals (32%) referenced attending APP conferences.

Sixty-four percent included information on their years of experience as a body piercer. The mean years worked was 9.64 years. Over half (56%) of those who listed their years of experience had worked ten years or longer. Most of the individuals with three years of experience or less (63%) clearly stated they were still in their apprenticeship.

Information about potential complications and adverse effects was found on thirty-four websites (47%). Potential complications and adverse effects discussed included those that could occur during the body piercing process, those that could occur after the body piercing process, and those that were psycho-social in nature.

Potential complications and adverse effects that could occur during the body piercing process were discussed on 18% of the websites. The most frequently discussed process-based complication was the risk associated with using a piercing gun

Recommendations - 105 for body piercings (including lobes). The risk of contracting bloodborne pathogens during the body piercing process was discussed by nine websites (12%), typically in the context of how to choose a body piercing establishment (i.e. the risk is greater at an establishment that does not use aseptic procedure). HIV and hepatitis B were the most commonly referenced pathogens. Five websites (7%) addressed the issue of pain during the body piercing process, acknowledging and normalizing pain as a potential adverse effect of the body piercing process.

Forty-one percent of the websites described potential complications and adverse effects that could arise after the body piercing process was completed. These included: infection of the piercing site; scarring at the piercing site; irritation at the piercing site; migration/rejection of jewelry; allergic reaction to metal or cleaning products; discolored tongue due to over cleaning oral piercings; damage to teeth and gums from oral piercings; abscess; follicular cysts; and constriction of tissue by too-small jewelry.

In nearly every case, the websites describing the potential complications stated that the risk for most of these complications was typically minimized by properly following aftercare guidelines. Most important of these was minimizing contact of unclean items and body fluids with the body piercing site. Minimizing movement at the piercing site and movement of the body jewelry also minimized risk for these complications.

Only two psychosocial complications were described on the websites examined.

One establishment recommended that individuals seeking heavy modifications such as

Recommendations - 106 dermal punch, ear scalpelling, scarification, tongue splits, and genital subdermal implants discuss the permanent and potentially life-changing nature of these with individuals who already had them. Another establishment encouraged individuals to give great thought to the social and work-related impact of facial piercings.

Forty-five websites (62%) posted information about aftercare, generally describing it as behavior that will help the body piercing heal. Information on general body piercing aftercare, oral piercing aftercare, and genital piercing aftercare was found, as well as what one should expect during the healing process.

A third of the websites provided information about what to expect during the healing process. This included: whitish/yellow fluid secreted from the body piercing that tends to dry into a crust around the ends of the body jewelry and openings of the body piercing; redness and/or bruising around the openings of the body piercing; swelling; bleeding from the openings of the body piercing; tenderness at and around the body piercing site; and itching and/or tightening of the tissue around the body piercing.

General aftercare of body piercings was discussed by 62% of the websites.

Recommendations - 107 thirds of websites recommended the use of regular salt water/saline soaks and cleaning with antibacterial soap.

Oral piercing aftercare was discussed by thirty-one websites 42% of the websites.

In their basic rationale, the guidelines were closely aligned with regular body piercing aftercare: minimize exposure to sources of foreign bacteria; regularly clean the piercing site; minimize chemical and mechanical stress. The first of these was achieved by avoiding contact with other people‟s body fluids by avoiding tongue kissing, oral sex, and shared utensils, getting a new toothbrush, and keeping objects (pen caps, fingers, eyeglasses) out of one‟s mouth. The second of these was achieved through regular rinsing with alcohol-free mouthwash and/or salt water/saline and good general oral hygiene practices. The third of this was achieved by not playing with jewelry, avoiding irritating foods, avoiding chewing gum, and avoiding harsh or irritating cleaners.

Individuals are also advised to anticipate swelling with oral piercings. Swelling could be minimized by holding ice in the mouth, using anti-inflammatories, and sleeping with the head elevated.

Genital piercing aftercare guidelines were provided by 22% of the websites.

Over half of the websites examined provided links and information for further resources on body piercing and/or body modification: 58% provided links to websites related to the topic; 3% provided information on print resources; and 1% provided information on instructional DVDs. One hundred and one websites were linked to from the websites examined. These were divided into ten categories: industry-related; body modification establishments; jewelry manufacturers; jewelry retailers; aftercare products;

Recommendations - 108 governmental/business; on-line body modification communities; social networking; suspension; and other.

Of the 73 websites that had information related to the study, information on the body piercing and body modification procedures available at the establishment was found on 71 (97%). Eighty-two percent of the establishments demonstrated that they provide stretching services. Seventy-one percent demonstrated that they provided surface piercing. Dermal punch procedures were clearly provided by 10% of the establishments and potentially provided by an additional 12% of the establishments.

Twenty-one percent of the establishments demonstrated that they provided microdermals/dermal anchors. Eighteen percent demonstrated that they provide scarification by branding, scalpelling, or electrocautery. Twelve percent demonstrated that they offer or support the body modification ritual of suspension. Ten percent of the establishments demonstrated that they provided scalpelled procedures (not including scarifications performed by scalpel). Other body modification rituals that were demonstrated on the websites examined included corsetry, play piercing, cheek skewering, kavadi, and flesh pulls.

Information that was not anticipated by the study was found on 29% of the websites examined. These mainly included articles posted on the websites about body modification and information to consider when making body modification related decisions. Seven websites (10%) included on-line forums in which individuals could participate.

Discussion

This content analysis of 75 body piercing establishment websites provides detailed information about body piercing from the body piercing industry. The study was the first to examine practitioners and establishments within the industry for body piercing and modification information, as opposed to individuals who have patronized

Recommendations - 109 establishments within the industry. The findings thus provide a more thorough understanding of the information on body piercing websites and in turn have implications for interpreting previous research and for future health promotion practice and research.

One area where this research culled out new information that affects previous and future research is in the discussion of complications. Previous researchers identified bruising, bleeding, swelling and/or other signs of local trauma as negative complications of body piercings (Armstrong, 2006; Meltzer, 2005; Stirn, 2003; Stewart,

2000). These outcomes were described by body piercing establishments as normal parts of the body piercing and/or healing process. This would imply that while bruising, bleeding, swelling, and other signs of local trauma are adverse effects of the body piercing process, they are to be anticipated and as such are not unexpected negative complications.

Previous research into the prevalence of complications such as infection and allergic reaction has relied on self-reporting by the pierced individual (Armstrong, et al.,

2004; Gold, 2005; Greif, et al., 1999; Huxley & Grogan, 2005; King & Vidourek, 2007;

Laumann & Derick, 2006; Mayers, et al., 2002). The current study found that body piercing establishments stated on their websites that it can be difficult for pierced individuals to distinguish between infection, irritation, and allergic reaction. These establishments recommended that individuals consult with a body piercer or a medical professional for proper diagnosis and treatment recommendations. Relying on pierced individuals to self-report negative complications such as infection and allergic reaction is problematic because they may be ill equipped to distinguish what they are experiencing.

The literature on body piercing thus far focused largely on the role body piercers and body piercing establishments play in minimizing risks of negative complications during the body piercing procedure (Armstrong, 2005; Griffith & Tengnah, 2005; Stirn,

2003). Several recommendations were given in the literature to minimize risk, primarily

Recommendations - 110 on minimizing risk of transmission of bloodborne pathogens. The establishments examined in the current study largely demonstrated that they are meeting these recommendations and many communicated how and why they did so. Of the 73 websites that provided information relevant to the study, 59 (80%) provided information on the hygiene procedures, sterilization procedures or tools, licensing, health and safety related policies, or jewelry used in the piercing process. Thirteen websites (18%) provided information specifically about complications that can occur during the procedure.

As well as focusing on the ways they minimized risk to clients, the body piercing establishments in the current study focused on ways the clients could minimize their own risk of post-procedure complications. Thirty websites (41%) described potential complications and adverse effects that could arise after the body piercing process was completed, emphasizing ways to minimize risk for these complications. In the discussion of complications, emphasis was placed on adhering to aftercare guidelines as a means for minimizing risk. The emphasis on post-procedural complications may reflect the findings of Laumann and Derick (2006), who discovered that reported complications from body piercings most frequently occurred later than three weeks after obtaining the body piercing.

Many establishments demonstrated their commitment to adolescent safety through their parental consent guidelines and rationales for limiting the body piercings they would provide to minors. Several establishments also reinforced messages about minimizing risk during the body piercing process in offering tips for clients to evaluate body piercing establishments.

Huxley and Grogan (2005) found that location of the body piercing establishment, recommendation by friends, and professional reputation were the three greatest factors in choosing a body piercer and that cleanliness of establishment was not a factor for any.

Recommendations - 111

Huxley and Grogan (2005) and King and Vidourek (2007) explored the degree to which individuals considered risks of complications before obtaining body piercings, which varied widely depending on the potential complication. The current study found that, to a limited extent, body piercing establishments encouraged potential clients to consider risks in many ways before obtaining body piercings. Thirteen websites (18%) discussed potential complications that could result from the piercing procedure, discussing all of these (except pain) in the context of how they minimized the risk of the potential complication. A tenth of the websites examined included information on how to choose a body piercing establishment that provided safe body piercings. Four-fifths of the websites examined provided information on the safety standards they adhere to, creating norm of safe piercing practice that clients should look for and expect. This norm encouraged individuals seeking body piercings to consider cleanliness of establishment first among factors in choosing a body piercing establishment.

The previous literature on body piercing has included no information on aftercare of body piercings. Complications of body piercings most frequently arise during the aftercare period (Laumann & Derick, 2006). The current study found that the examined establishments place an emphasis on aftercare as a means of minimizing post- procedural complications. Twenty-four websites (33%) provided information about what adverse effects of body piercing are normal during the healing process (e.g. swelling, bruising, discoloration, discharge). Forty-five websites (62%) provided information about general aftercare of body piercings. The lack of previously published information on aftercare, coupled with the potential importance of aftercare in preventing potential complications, makes this newly recorded information on aftercare key in the promotion of behaviors that minimize risk of body piercing complications.

The previous literature has focused on the clients of the body piercing industry; the researcher found no studies that noted involvement of or sought information from

Recommendations - 112 body piercing practitioners. The current study found that the practitioners at the websites examined posted openly about their credentials and experience. Three- quarters of the websites examined included information about the individuals employed at the body piercing establishment. Information was recorded on 117 body piercers on topics such as professional development, health related training and certification, continuing education, and years of experience.

Throughout many articles in the existing literature, recommendations are given for open, non-judgmental communication between physicians and nurses and their patients about body piercing (Gold, et al 2005; McGuinness, 2006; Schnirring, 2003;

Stirn, 2003). Other articles called for a need for informed health education about body piercing (Braithwaite, et al., 2001; Deschesnes, et al., 2006; Greif, et al., 1999).

Professionals in all of these circumstances need current and accurate information from which to base their discussions and education. The information gathered in this study can provide a base from which to work until further study supports or disproves these results. The data contained in this research is unique in that it is founded on the experience of professionals within the field of body modification. Information that could not be found elsewhere in the literature that could prove useful includes: detailed aftercare guidelines; body modifications other than body piercing; and recommended resources for information on body piercing and modification.

Recommendations

Recommendations for practice. The information gathered in this study can be of great value to health education and medical practitioners and researchers. While the veracity of the information gathered can only be tentatively accepted, a foundation has been laid for improved research and improved health education that involves information from within the body piercing/modification industry.

Recommendations - 113

There are several key areas of note for health promotion and education. First among these is the safety and hygiene practices at APP body piercing establishments and the rationale for these practices. The experience and education of APP body piercers and recommended certifications in bloodborne pathogens, CPR, and first aid are also important to be aware of. A major advancement from this study are recommended aftercare guidelines and the rationale for these guidelines, which can be useful both in terms of educating piercing seeking individuals as well as providing support to pierced individuals. Review of resources that are recommended by APP member establishments could be helpful in the development of health promotion strategies. Awareness of emerging non-traditional body modifications – such as stretching, surface piercing, dermal anchors, and scarification, as well as body modification rituals such as suspension, play piercing, and pulling – will be key for future efforts in health promotion around body modification.

Recommendations for improving this research. There were several limitations to this research that could be improved upon with a different research design. First the sample was very limited – a census study of body piercing establishments that were listed as US-based members of the APP were included. The results of this research are not able to be generalized to any groups nor the body piercing industry as a whole.

Second, the method through which information was obtained – via websites – can be problematic. Available information is limited to what the establishments decided to place on their website. Considering that the establishments established their websites for commercial reasons (as denoted by the “.com” suffix on the URL) as opposed to education reasons, their decisions on which information to post may be based more on business than on client education. While it was illuminating to review the extent to which topics were posted on as a limited gauge of what is valued or notable within the sample, general information on each desired topic was not available for all establishments. Many

Recommendations - 114 factors may affect what establishments post on their website about the procedures they perform, providing limited availability of information on prevalence of non-body piercing body modifications. In addition, the employees of the establishments have expertise specifically in body modification and may lack expertise in website development and publishing, limiting what information they are able to post.

Recommendations for future research. Given that this study was designed to be a content analysis, there is much future research that can be drawn from it. Every theme that was explored can benefit from further exploration in health and health education research.

This study was limited to body piercing establishments that were listed as US- based establishments through the APP on-line member search page. Membership in the APP requires demonstration of experience and knowledge, training in safety measures, as well as environmental safety requirements of the establishment. This may mean that APP-affiliated establishments have higher adherence to and promotion of key safety considerations. The APP also provides general aftercare guidelines and position statements on issues related to body piercing, which may have influenced the uniformity of messages around aftercare. This research was also a census study. All of these points lead to the non-generalizability of the results to other groups. Research into non-

APP-affiliated body piercing establishments needs to be done to illuminate the standards and ideas of the body piercing industry as a whole. In particular, areas of establishment policies, establishment hygiene, body piercer background, jewelry standards, and aftercare guidelines need to be explored.

The professional body piercer members of the panel of experts advised the researcher that the APP does not support members performing any procedures outside of providing body piercings with a needle. This would exclude procedures that use dermal punches, tapers, and scalpels, including scarification and implant procedures.

Recommendations - 115

The body piercers on the panel of experts also advised that use of dermal punches and scalpels is, at best, a legal gray area in some states and illegal in others because it causes the body piercer using them to cross the line into practicing medicine without a license. These two factors may have caused members to not demonstrate through their websites the full variety of body modification procedures they provide. Research into the true prevalence of these procedures is needed.

This study examined the websites of body piercing establishments and found a general wealth of information about body piercing and modification. How establishments‟ websites are used by the general public as well as by future and previous clients could be useful. It could also be useful to investigate how body piercers perceive their websites, how they determine which information to post, and whether/under what circumstances they recommend their website to clients.

Previous research involving the concept of “safe piercing practices” has followed a loosely-defined set of standards developed in the public health and medical sectors.

Research into the integration of those standards with those provided and outlined by professionals in the field of body piercing/modification is needed. This can then be used to develop more solid health promotion and education programming around safe body piercing/modification practices, which can be further studied.

This study raised issues around the definition of outcomes of body piercing as negative complications or anticipated adverse effects. Further research into this issue is needed, and such research needs involvement of both medical professionals and body piercing practitioners. Research into true prevalence of negative complications – particularly those difficult for non-professionals to distinguish such as irritation, infection, and allergic reaction – is needed. Awareness of the body piercing healing process – be it with undesired negative complications or anticipated adverse effects – among the

Recommendations - 116 piercing seeking public as well as medical and health education professionals needs to be explored.

A relatively consistent set of aftercare guidelines was found in this study. Further research into consistency in the industry as a whole is needed, as is medical research into the effectiveness of these aftercare guidelines. Research exploring awareness of and adherence to aftercare guidelines would also be beneficial. Awareness of these aftercare guidelines among those who work with pierced populations, particularly medical and health education professionals, would illuminate areas where further education of these professionals is needed.

Exploration of the resources recommended by the body piercing establishments in the study could be useful. Particularly notable are the on-line communities established around body piercing/modification. These can be useful tools in research as gateways into modified communities as well as looking at emerging trends in body modification. Consistency of message around safety and aftercare messages in these establishments could also make useful research.

Based on the frequency and openness with which body piercing establishments provided information on cleanliness, aftercare, and professional background, as well as the client-centered focus of the websites, it is the researcher‟s belief that professional body piercers can be great allies of health promoters and medical professionals. Based both on their involvement in body piercing/modification and their vast knowledge of body piercing/modification, further research that involves the participation of body piercers practitioners is strongly recommended.

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Appendix A

Body Modification Content Rating Form 1. Piercing establishment (Name): 2. Date of review: 3 May 2008 3. Website URL: 4. Date of most recent site update: n/a 5. Establishment location (City, State): 6. Hit count: n/a 7: Establishment days & hours: n/a 8. Information on cleanliness: URL:

Sterilization information: Information on spore testing of sterilization equipment: Surface disinfection of piercing room: City/County licensing: Other: 9. Information on safety precautions used URL: during piercing process: Piercing set-up technique: Age & consent policies: Jewelry selection: Other: 10. Information on potential complications URL: and adverse effects: During procedure: Post-procedure: Psychological: Other: 11. Body piercer experience/affiliations: URL:

Professional bio: Apprenticeship: Professional experience: Professional affiliations: First aid/bloodborne pathogens training: Other: 12. Information on aftercare: URL:

General: For specific piercing: Follow-up with piercer: Other: 13. Recommendations for further URL: information on body modifications: On-line: Print: Other:

121 Appendix A - 122

14. Procedures available: URL: Body piercing: Stretching: Surface piercings: Dermal punch procedures: Scalpelled procedures: Microdermals/dermal anchors: Transdermal implants: Subdermal implants: Scarification: Other: 15. Other information of note: URL:

Appendix B

Panel of Experts Information

The panel of experts contained four individuals, two who were professional body piercers with over a decade of experience each and two who were experienced researchers in health promotion and education. Their information follows:

Ned Dixon

Body Piercer, Beelistic Tattoo and Piercing

Cincinnati, OH

Meagan Kreiner

Body Piercer, Venus by Maria Tash

New York City, NY

Keith King, PhD, CHES

Associate Professor, Health Promotion and Education

College of Education, Criminal Justice, and Human Services

University of Cincinnati

Amy Bernard, PhD, CHES

Associate Professor, Health Promotion and Education

College of Education, Criminal Justice, and Human Services

University of Cincinnati

123

Appendix C

Tables

Table C1 Body Piercing Establishment Hours of Operation Open Closed Day Time N (%) Time N (%) Monday 10:00 3 (7%) 18:00 2 (5%) 11:00 4 (9%) 19:00 5 (12%) 12:00 34 (76%) 20:00 11 (26%) 13:00 2 (4%) 21:00 8 (19%) 14:00 2 (4%) 22:00 14 (33%) 23:00 2 (5%) 0:00 1 (2%) Tuesday 10:00 3 (6%) 18:00 3 (6%) 11:00 5 (9%) 19:00 8 (15%) 12:00 37 (70%) 20:00 10 (19%) 13:00 3 (6%) 21:00 8 (15%) 14:00 2 (4%) 22:00 18 (34%) 14:30 1 (2%) 23:00 3 (6%) 15:00 1 (2%) 0:00 1 (2%) 16:00 1 (2%) Wednesday 10:00 3 (5%) 18:00 3 (6%) 11:00 5 (9%) 19:00 8 (15%) 12:00 39 (71%) 20:00 11 (21%) 13:00 3 (5%) 21:00 9 (17%) 14:00 2 (4%) 22:00 18 (34%) 14:30 1 (2%) 23:00 3 (6%) 15:00 1 (2%) 0:00 1 (2%) 16:00 1 (2%) Thursday 10:00 3 (5%) 18:00 2 (4%) 11:00 6 (11%) 19:00 7 (13%) 12:00 38 (69%) 20:00 11 (21%) 13:00 3 (5%) 21:00 9 (17%) 14:00 2 (4%) 22:00 20 (38%) 14:30 1 (2%) 23:00 3 (6%) 15:00 1 (2%) 0:00 1 (2%)

124 Appendix C - 125

16:00 1 (2%) Friday 10:00 3 (5%) 18:00 1 (2%)6 11:00 6 (11%) 19:00 8 (15%) 12:00 38 (69%) 20:00 11 (21%) 13:00 3 (5%) 21:00 15 (28%) 14:00 2 (4%) 22:00 7 (13%) 14:30 1 (2%) 23:00 4 (8%) 15:00 1 (2%) 0:00 1 (2%) 16:00 1 (2%) 1:00 Saturday 10:00 4 (7%) 18:00 2 (4%) 11:00 6 (11%) 19:00 4 (8%) 12:00 37 (69%) 20:00 8 (15%) 13:00 3 (6%) 21:00 11 (21%) 14:00 1 (2%) 22:00 15 (29%) 14:30 1 (2%) 23:00 7 (13%) 15:00 1 (2%) 0:00 4 (8%) 16:00 1 (2%) 1:00 1 (2%) Sunday 11:00 3 (7%) 17:00 4 (10%) 12:00 28 (67%) 18:00 12 (30%) 13:00 6 (14%) 19:00 4 (10%) 14:00 5 (12%) 20:00 9 (23%) 21:00 3 (8%) 22:00 5 (13%) 23:00 2 (5%) 0:00 1 (3%) N = Number of those opening/closing that day

Appendix C - 126

Table C2

Aftercare Guidelines and Frequency of Recommendation

Guideline N %

Do not touch the body piercing with hands that are not freshly washed (own 27 60

hands or others‟)

Do not submerge the body piercing in standing bodies of water, including 26 58

swimming pools, hot-tubs, lakes, oceans, or own bathtub (unless

freshly cleaned)

Do not use alcohol on the body piercing (rubbing alcohol, witch hazel) 25 56

Do not use hydrogen peroxide on the body piercing 25 56

Leave the body jewelry in place (don‟t change jewelry without the aid of a 24 53

body piercer or remove temporarily)

Do not use antiseptic/antibiotic creams or ointments on the body piercing 23 51

Avoid contact with body fluids (own and others‟) 22 49

Do not use strong cleaning solutions on the body piercing (iodine, Betadine, 21 47

Hibiclens)

Keep beauty/cleaning products away from the body piercing 20 44

Promote general health (regular sleep, healthy diet, exercise) 17 38

Avoid over-cleaning 16 36

Avoid contact with dirty fabrics (linens, clothes) 16 36

Supplement diet with a multivitamin, zinc, and/or vitamin C 15 33

Do not wear restrictive clothing 15 33

Do not move or rotate body jewelry 13 29

With clean hands/gauze/tissue, periodically check and tighten ends of 13 29

jewelry

Use Tegaderm/Clean Seals to cover body piercing if it is known it will be 12 27

exposed to standing water

Appendix C - 127

Avoid sleeping on the body piercing 12 27

Contact the body piercer if jewelry needs to be removed or replaced for 11 24

medical purposes

Keep hair away from the body piercing 9 20

Do not use “ear care” solution (benzethonium or benzalkonium chloride 8 18

solutions)

Maintain cleanliness of phones, glasses, hats, other objects the body 8 18

piercing may come in regular contact with

Do not hang objects (e.g. charms) from the jewelry until the body piercing is 7 16

healed

Avoid Band-Aids and/or restrictive bandages 6 13

While playing sports, a bandage (eye patch, ace bandage) may be worn 6 13

over a navel piercing for protection

Reduce or eliminate intake of alcohol, drugs, caffeine, and/or aspirin 5 11

Avoid contact with pet hair, dander 5 11

Carry a clean, spare end for body jewelry 5 11

Reduce or stop smoking 4 9

Downsize jewelry (change to a shorter post) after swelling subsides in the 4 9

body piercing

Avoid tanning beds 3 7

Take non-prescription anti-inflammatories to reduce swelling 3 7

For above-neck piercings, sleep with a propped pillow to reduce overnight 3 7

swelling during initial healing

Select one cleaning product and use it exclusively 3 7

N = 45

Appendix C - 128

Table C3

Oral Piercing Aftercare Guidelines and Frequency of Recommendation

Guideline N %

Use an alcohol-free mouthwash (Biotene, Tech2000) 27 74

Anticipate swelling of the tongue with tongue piercings 23 74

Ice can help relieve swelling of the tongue 23 74

Use salt water/saline for oral rinse 20 65

Don‟t play with jewelry/piercing 20 65

Avoid oral contact with body fluids (tongue kissing, oral sex, shared utensils) 19 61

Reduce or eliminate use of tobacco 19 61

Get a new toothbrush 18 58

Downsize jewelry (change to a shorter post) after swelling subsides 18 58

Anti-inflammatories (ibuprofen) can help relieve swelling 16 52

Avoid spicy, salty, acidic, and/or hot food and beverages for the first days to 15 48

week of healing

Open mouth and/or chew with consciousness of jewelry 15 48

Avoid alcohol and/or drugs 14 45

With oral-to-surface piercings, provide oral piercing aftercare inside mouth 12 39

and traditional body piercing aftercare to the surface

Avoid chewing gum 11 35

Avoid chewing on fingernails, putting fingers in mouth 11 35

Sleeping with head elevated can reduce overnight swelling 9 29

Avoid chewing on pen caps, glasses, etc. 9 29

Brush jewelry as part of oral hygiene process 9 29

Avoid excessive talking during initial healing 8 26

Brush teeth regularly 7 23

Avoid blood-thinners 7 23

Appendix C - 129

With clean hands/gauze/tissue, periodically check and tighten ends of jewelry 6 19

Avoid caffeine 4 13

Permissible to use diluted alcohol-based mouthwash solution 3 10

Avoid straws, sucking 3 10

Avoid toothpaste with baking soda, peroxide 3 10

N = 31

Appendix C - 130

Table C4 Estimated Healing Time by Body Piercing and Frequency of Estimation Body Piercing Description Time N % Ampallang Horizontally through 4-8 months 2 15 the glans, 3-6 months 2 15 transecting or 6-8 months 1 8 passing above the 6-9+ months 1 8 urethra ~3 Months 1 8 6-8 weeks 1 8 4-6 months 1 8 Apadravya Vertically through 4-8 months 2 15 the glans, 3-6 months 2 15 transecting the 6-8 months 1 8 urethra 6-9+ months 1 8 ~3 months 1 8 6-8 weeks 1 8 Beauty Oral-to-surface 2-3 months 3 23 Mark/Marilyn/Madonna piercing above the 6-8 weeks 1 8 upper lip on either 1-2 months 1 8 side 8-10 weeks 1 8 Bridge (Earls) Horizontally through 2-3 months 3 23 the bridge of the 8-10 weeks 2 15 nose 3-5 months 1 8 1-3 months 1 8 Cartilage Through any portion 6-12 months 2 15 of the cartilaginous 3-6 months 2 15 part of the earlobe 6-8 months 1 8 2-12 months 1 8 6-9+ months 1 8 ~3 months 1 8 2-8 months 1 8 4-8 months 1 8 2-3 months 1 8 4-9 months 1 8 Cheek Oral-to-surface 3-4 months 1 8 piercing through the 4-6 weeks 1 8

Appendix C - 131

cheek Clitoral hood Vertically or 2-8 weeks 3 23 horizontally through 6-8 weeks 2 15 the clitoral hood 2-3 months 1 8 2-3+ weeks 1 8 2-6 weeks 1 8 4-8 weeks 1 8 Clitoris Horizontally through 2-4 weeks 2 15 the clitoris 6-8+ weeks 2 15 Dydoe Through the coronal 8-12 weeks 2 15 ridge of the glans 3-5 months 1 8 6-9+ months 1 8 2-3 months 1 8 6-8 weeks 1 8 Earlobes Through the non- 6-8 weeks 8 62 cartilaginous part of 2-3 months 2 15 the earlobe 1-3 months 1 8 4-6 weeks 1 8 Eyebrow Diagonally through 6-8 weeks 4 31 the ridge of the 2-3 months 3 23 eyebrow 6-12 months 1 8 1-3 months 1 8 2-4 months 1 8 4-8 weeks 1 8 4-6 weeks 1 8 Foreskin Placed so rings are 6-8+ weeks 2 15 on the end of penis when foreskin is rolled forward Fourchette Vertically where the 4-6 weeks 2 15 inner labia meet, 6-8+ weeks 1 8 between introitus and anus Frenum Horizontally through 2-3 months 4 31 skin on underside of 6-8 weeks 4 31 penile shaft 3-4+ weeks 1 8 “Genitals” All genital piercings 1-6 months 1 8

Appendix C - 132

1-3 months 1 8 6-24 weeks 1 8 Guiche Horizontally through 2-3 months 3 23 tissue between 8-10 weeks 2 15 scrotum and anus 6-8 months 1 8 3-4+ months 1 8 6-8 weeks 1 8 Labia (Inner) Horizontally through 2-4 weeks 2 15 tissue of inner labia 2-8 weeks 2 15 6-8 weeks 2 15 2-3 months 1 8 4-6+ weeks 1 8 4-8 weeks 1 8 Labia (Outer) Horizontally through 2-6 months 2 15 tissue of outer labia 6-8 weeks 2 15 3-5 months 1 8 3-4 months 1 8 2-3 months 1 8 Labret/Lip Oral-to-surface 2-3 months 5 38 piercing under the 6-8 weeks 2 15 lower lip 6-12 weeks 1 8 1.5-4+ months 1 8 1-2 months 1 8 8-10 weeks 1 8 6-10 weeks 1 8 Lip frenulum Horizontally through 3-6 weeks 1 8 (“scrumper”) gums-to-lips frenulum Lorum (“LOwer Horizontally 3-4+ months 1 8 frenUM) between penile shaft and scrotum Lowbret (“LOWer Oral-to-surface just 1-2 months 1 8 laBRET”) above the lowest portion of lower mouth/gums Navel Through protruding 6-12 months 4 31 lip of skin on upper 3-6 months 3 23

Appendix C - 133

or lower portion of 6-8 months 1 8 navel 4-12+ months 1 8 6-9 months 1 8 ~3 months 1 8 5-12 months 1 8 9-12 months 1 8 Female Nipple Vertically, 3-6 months 3 23 horizontally, or 3-5 months 2 15 diagonally through 2-6 months 2 15 base of nipple, 6-12 months 1 8 where the nipple 6-9+ months 1 8 meets the areola 1-3 months 1 8 2-4 months 1 8 2-3 months 1 8 9-12 months 1 8 Male Nipple Vertically, 3-6 months 3 23 horizontally, or 4-6 months 2 15 diagonally through 2-6 months 2 15 base of nipple, 3-5 months 1 8 where the nipple 6-9+ months 1 8 meets the areola 1-3 months 1 8 2-4 months 1 8 2-3 months 1 8 9-12 months 1 8 Nostril Through the nostril, 2-3 months 4 31 typically at the 6-12 months 2 15 horizontal crease 2-4 months 2 15 2-12 months 1 8 6-9+ months 1 8 1-3 months 1 8 3-6 months 1 8 6-10 weeks 1 8 Prince Albert Enters in the end of 6-8 weeks 3 23 the urethra and 2-6+ weeks 1 8 exits where the 4-9 weeks 1 8 glans meets the 4-6 weeks 1 8 underside of the 2-8 weeks 1 8

Appendix C - 134

penile shaft Princess Albertina Enters the urethra 6-8 weeks 1 8 and exits in membrane between the urethra and introitus Pubic Surface piercing at 3-4+ months 1 8 upper base of penis Reverse Prince Albert Enters in the end of 4-6 months 3 23 the urethra and 6-8 months 1 8 exits where the 2-8 weeks 1 8 glans meets the upper side of the penile shaft Scrotum (hafada) Horizontally through 2-3 months 4 31 surface of out layer 6-10 weeks 2 15 of scrotal tissue 3-4 months 1 8 6-8 weeks 1 8 Septum Horizontally through 2-3 months 4 31 nasal septum 6-8 weeks 4 31 1-3 months 2 15 2-6 months 1 8 4-6 weeks 1 8 4-9 months 1 8 Surface Runs parallel to the 4-12 months 2 15 surface of the skin, 8-12 months 1 8 entering and exiting 3-? Months 1 8 on the same plane Tongue Vertically through 6-8+ weeks 3 23 the mid-line of the 4-6 weeks 3 23 tongue 2-3 months 2 15 4 weeks 1 8 3-6 weeks 1 8 4-8 weeks 1 8 1 month 1 8 Tongue web, Lip Horizontally through 3-6 weeks 2 15 frenulum frenulum between 1 month 1 8

Appendix C - 135

base of tongue and bottom of mouth Transverse lobe Transverses the 3-6 months 2 15 lower earlobe Triangle Horizontally through 8-10 weeks 2 15 base of clitoral 3-6 months 2 15 hood, passing 3-4+ months 1 8 underneath the 4-6 months 1 8 clitoris Vertical lip/labret Vertically through 2-3 months 1 8 lower lip, entering below lip and exiting at top of lip N = 13

Descriptions of piercings summarized from Mass (2001).