Tattoos, Body Piercing, and Nursing: a Photo Essay Photographs and Text by Jason P

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Tattoos, Body Piercing, and Nursing: A Photo Essay Photographs and text by Jason P. Smith

ara “Spider” Gray-Wolfstar, RN, senior vice president of Enchanted Ink and master tattoo artist (on the left in the photo at left), and Gwynn “Wolf” Wolfstar, RN, chief executive officer Tand master piercer, have owned and operated the company in Boulder, Colorado, since 1998. (The arbitrary designation “master” in this field gener- ally refersrefers to a person who “feels comfortablecomfortable enough to take on an apprentice,” according to Wolfstar.) Both nurses use their training and clinical experience to make body decorating a safe experience in an industry that doesn’t require certi- fication. Before opening Enchanted Ink, the pair worked for a telephone triage center but werewere frustrated by inadequacies that they felt compromised the quality of patient care.care. Gray-WolfstarGray-Wolfstar was apprenticingapprenticing in tattooing at the time, and she had many unresolved “heated discussions” with her tattoo master about cross-contamination and the need to adhere to universal precautions. Meanwhile Wolfstar undertook “countless hours of researchresearch on piercings,piercings, tech-techniques, biocompatible metals, and aftercare.”

Jason P. Smith is a photographer and writer who lives in Ft. Myers, FL. All photos werewere taken in September 2006. Contact author: [email protected].

Wolfstar and Gray-Wolfstar provide the safest materials and Ł environment for their clients by staying up-to-date on perti- nent issues and taking more precautions than the average studio. For example, they dust, sweep, and mop daily to keep dust and bacteria at a minimum and research the safety of the pigments used in tattoo ink. “We don’t mix inks and only use inks that list what’swhat’s in them,” WolfstarWolfstar says. “Purple, for example, can have shellfish in it—bad for people who are allergic to shellfish. WeWe buy from the United Kingdom, where it’s regulated.”

54 AJN M April 2007 M Vol. 107, No. 4 http://www.nursingcenter.com “We base everything we do on what we’ve learned in nursing,” Wolfstar says. She acknowledges that anatomy and physiology are the most obvious references, but says that microbiology guided their development of aftercare instructions and universal precautions for their studio. Issues of pharmacology (such as “which [medications] may affect the integument and healing,” explains Wolfstar) and the roles that immunology and nutrition play in healing are also considered. They also “apply growth and development principles to determine appropriate ages for certain piercings.” In dealing with clients, they call on their nursing education for “establishing trust and confidence,” especially with those łWolfstar lines up a piece of jewelry called a barbell for who are anxious. “I think all nurses can relate to Kathryn Scoggin, 18, of Boulder. With body art becoming the necessity of remaining calm and cool while more commonplace, Gray-Wolfstar and Wolfstar think the doing a procedure,” Wolfstar says. industry should have more clearly defined and enforceable “Clients tell us they come to us because we’re regulations. Enchanted Ink posts complete aftercare informa- nurses,” she continues. “There is a feeling of com- tion at its Web site (www.enchanted-ink.com), and other local fort. The clients think if something were to go body art studios direct their clients to follow those guidelines. wrong, then as RNs, we would know what to do.” One client, for example, listed an oral diabetes medication on his client consent form, which asks Ń Their nursing licenses are prominently for both allergies and medications, and revealed displayed at the entrance to the studio, that he was hyperglycemic when the nurses asked along with the phone number for the Boulder County Health Department. Here, Gray- him about his diabetes management and glucome- Wolfstar works on Joe Martinez, 35, of ter readings. They decided to postpone the tattoo- Westminster, Colorado, who has been a ing until after the client consulted his physician. client for many years. “It’s good that they’re Wolfstar muses, “Did we actually get out of nurses,” Martinez says. “I had a couple of nursing? No. We just found a new field in nursing [tattoos] before and never knew what ques- to make a part of our lives.” tions to ask. I don’t know why anyone would go where [the tattoo artist is] not trained.”

[email protected] AJN M April 2007 M Vol. 107, No. 4 55 A Brief Overview of Body Art Regulation and standardization are needed as the popularity of tattooing and body piercing increases.

urses are continually challenged to improve patient Training is essential. Unfortunately, in many states, any- Neducation, advance patient safety, apply scientific one can begin to tattoo or create an artificial opening for principles, and push for health promotion in our evolv- jewelry after purchasing the necessary equipment for ing, multicultural society. Although tattooing and body approximately $300 and hanging a business sign. No piercing may not appeal to everyone, it’s becoming knowledge of anatomy, sanitation, sterilization, infection mainstream for those between the ages of 18 and 30. control, or skin preparation and care are required. In Current estimates of prevalence range from 24% for tat- Texas, for example, nail technicians, who perform no inva- toos among 18-to-50-year-olds1 and 30% to 50% for sive procedures, must complete at least 600 educational piercings among 18-to-23-year-olds.2 Among women hours, including 320 clinical hours for procedures, but tat- ages 45 to 70, permanent makeup on or around the too artists and body piercers face no such requirements.4 eyes, lips, and eyebrows, also known as cosmetic tattoo- Reputable body artists will respect and adhere to safe ing, is also increasing in popularity. body art practices and support enforceable regulations that Making body art procedures a safe experience is an ensure high-quality client care. important concept for this industry, because state regulations Using safe products. The safety and properties of prod- vary considerably.3 Some states set very specific standards ucts, such as the pigments used in tattooing, are of con- for sanitation, sterilization, personnel, and environmental cern, not only because there is limited knowledge about matters; others require artists to be supervised by physi- the ingredients, which are placed in the skin right below the cians; and still others require body art studios only to have epidermis, but also because removing them can be prob- a business license. The age at which body art can be lematic: although removal with Q-switched laser treatment obtained also varies. For invasive body art procedures, continues to improve, green, yellow, white, and some which includes tattooing, piercing, branding, implantation, brightly colored pigments are still difficult to remove. In scarification, tongue splitting, and cosmetic tattooing, artists addition, some yellow tattoo pigments have been found to still have no federal safety standards to follow regarding contain carcinogens, and laser treatment of those inks can bloodborne pathogens. These standards should include create other carcinogens.5, 6 “sanitation, sterilization, procedures for single-use items, The complication rate with piercings ranges from 17% competency requirements for personnel, infection control, to 45%, and in some body sites the rate is even higher.7, 8 client record keeping and retention, preparation and care Many ear piercing–related complications result from the of the body art, enforcement measures, and prohibitions customer’s poor choice of shop; one study found that hav- related to the services.”3 ing a body piercing performed at a studio is much safer The Food and Drug Administration does not approve, than having one performed at a shopping mall.9 Piercings standardize, or regulate ingredients for tattoo pigments, done at stores located at shopping malls or kiosks often nor is there a national database of body art prevalence have untrained salespeople who use piercing guns to and complications. Because tattooing and body piercing insert inexpensive brass- or nickel-filled jewelry and market are invasive procedures, I believe artists should adhere to ill-advised aftercare solutions containing benzalkonium the most comprehensive model of Oregon and Kansas chloride. Biocompatible, hypoallergenic jewelry, such as body art regulations—written examination on the regula- implant-grade stainless steel or titanium or solid white or tions with mandatory continuing education. Because of the yellow gold, should be used. popularity of tattooing and body piercing, the National Contamination can occur if the piercer does not wash Institute for Occupational Safety and Health expects this her or his hands properly; does not wear protective gloves; summer to launch an educational, industry-specific Web handles the client’s hair, clothes, or the surface of the pierc- site for body artists about the dangers of bloodborne ing site; or uses unclean equipment, or if the customer fails pathogens. to perform proper aftercare. It is therefore important to Making body art safe also may mean helping customers explain and discuss aftercare instructions verbally and to make better decisions about the site for the art rather than provide them in writing before the client leaves or have encouraging the use of risky piercing sites, such as the them posted on a Web site so the client follows them con- uvula (which, if not properly cared for, can lead to respira- scientiously for as long as the piercing is in place. A pierc- tory infection, difficult intubation, and jewelry aspiration) or ing should be thought of as a skin fistula kept open by cheek (where complications can include leakage of mucus jewelry. The healing of body piercing sites depends on the and jewelry aspiration). Customers should also consider location, and clients should be aware that infections can the current debate over whether tattoos in the lumbar area occur as long as the piercing site is open. Daily cleansing interfere with epidurals. with soap and water is advised. The actual “toughening”

56 AJN M April 2007 M Vol. 107, No. 4 http://www.nursingcenter.com ŀ Wolfstar jokes with Laura Scoggin, 20, of Boulder, before piercing her nose. “I will only do a piercing that makes sense,” Wolfstar says. “I’ve learned a lot about tissue, both as a nurse and a piercer, and I take a holistic approach to what we do.” Wolfstar and Gray-Wolfstar, who have worked to get legislation passed in Colorado requiring safe and hygienic practices for performing body art procedures, contend that tattoo artists and piercers should take at least one anatomy class. “It never hurts to know what’s under that skin,” Wolfstar says. “You want a person to have a license when they cut your hair, but not when they stick a needle in you?” of the skin tissue around the piercing site can take a year or longer to occur.10 This photo essay provides another example of how nurses continue to be advo- cates of health wherever they work.—Myrna L. Armstrong, EdD, RN, FAAN, professor at Texas Tech University Health Sciences Center School of Nursing at Highland Lakes in Marble Falls.

REFERENCES 1. Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol 2006;55(3):413-21. 2. Armstrong ML, et al. Toward building a composite of college student influences with body art. Issues Compr Pediatr Nurs 2004;27(4):277-95. 3. Armstrong ML. Tattooing, body piercing, and permanent cosmetics: a historical and current view of state regulations, with continuing concerns. J Environ Health 2005;67(8): 38-43, 54, 53. 4. Texas Department of Licensing and Regulation. Cosmetology administrative rules. 16 Texas Administrative Code, section 83.106. Health and safety standards—manicure and pedi- cure services. 2006. http://www.license.state.tx.us/cosmet/ cosmetrules.htm#83106. 5. Cui Y, et al. Photodecomposition of Pigment Yellow 74, a pigment used in tattoo inks. Photochem Photobiol 2004; 80(2):175-84. 6. Vasold R, et al. Tattoo pigments are cleaved by laser light— ł Kathryn Scoggin admires her eyebrow piercing. After proce- the chemical analysis in vitro provide evidence for hazardous dures, as Wolfstar instructs the clients in aftercare (directions for compounds. Photochem Photobiol 2004;80(2):185-90. which are also given in writing), she also assesses their condi- 7. Mayers LB, et al. Prevalence of body art (body piercing and tion. “I have them stay in the chair for about 10 minutes to make tattooing) in university undergraduates and incidence of sure they’re going to be okay,” Wolfstar says. “Clients are typical- medical complications. Mayo Clin Proc 2002;77(1):29-34. ly very anxious, nervous, and excited when a body art procedure 8. Greif J, et al. Tattooing and body piercing: body art practices is about to be done. Adrenaline is produced while they’re wait- among college students. Clin Nurs Res 1999;8(4):368-85. ing for the procedure to begin. Adrenaline is short-lived, so short- 9. More DR, et al. Ear-piercing techniques as a cause of auricu- ly after the procedure, the adrenaline stops being produced. lar chondritis. Pediatr Emerg Care 1999;15(3):189-92. Once the procedure is done, endorphins take over to help rid 10. Armstrong ML, Kelly L. Tattooing, body piercing, and the body of the pain that is being felt. In our experience, if some- branding are on the rise: perspectives for school nurses. J Sch Nurs 2001;17(1):12-23. one is going to have a vasovagal syncopal episode, it usually happens within the first 10 minutes after the procedure.” M

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