CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care AdolescentCora C. Breuner, MD, MPH, a David A.and Levine, MD, b YoungTHE COMMITTEE ON ADOLESCENCEAdult Tattooing, Piercing, and Scarification Tattoos, piercing, and scarification are now commonplace among abstract adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide aAdolescent Medicine Division, Department of Pediatrics, Orthopedics the pediatrician with management information. Body modification will be and Sports Medicine, Seattle Children’s Hospital, University of Washington, Seattle, Washington; and bPediatrics, Morehouse School of contrasted with nonsuicidal self-injury. When available, information also is Medicine, Atlanta, Georgia presented on societal perceptions of body modification. State laws are subject to change, and other state laws and regulations may impact the interpretation of this listing. Drs Breuner and Levine shared responsibility for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors, and “ ” approve the final manuscript as submitted. This document is copyrighted and is property of the American Tattoos, piercings, and scarification, also known as body modifications, Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy are commonly obtained by adolescents and young adults. Previous of Pediatrics. Any conflicts have been resolved through a process reports on those who obtain tattoos, piercings, and scarification have 1 approved by the Board of Directors. The American Academy of – Pediatrics has neither solicited nor accepted any commercial focused mainly on high-risk populations, including at-risk adolescents. involvement in the development of the content of this publication. Tattooing and piercing of various body parts no longer is a high-risk Clinical reports from the American Academy of Pediatrics benefit from population phenomenon, as evidenced by growing numbers of adults and expertise and resources of liaisons and internal (AAP) and external adolescents not considered at risk who have tattoos and multiple ear and reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations body piercings. The Pew Research Center reports that in 2010, 38% of or government agencies that they represent. 18 to 29 year olds had at least 1 tattoo, and 23% had piercings in locations 2 The guidance in this report does not indicate an exclusive course of other than2 an earlobe. Of those with tattoos, 72% were covered and not treatment or serve as a standard of medical care. Variations, taking visible. Scarification is the practice of intentionally irritating the skin to into account individual circumstances, may be appropriate. cause a permanent pattern of scar tissue; data are not currently available All clinical reports from the American Academy of Pediatrics on the prevalence of scarification in the United States. automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Although body modifications have become a mainstream trend, DOI: https:// doi. org/ 10. 1542/ peds. 2017- 1962 they still may be associated with medical complications and, among Address correspondence to Cora C. Breuner, MD, MPH, FAAP. E-mail: adolescents, may also co-occur with high-risk behaviors. This first [email protected] clinical report from the American Academy of Pediatrics on tattooing, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). piercing, and scarification discusses the history of these methods of body modification, educates the reader on methods used, reports on trends in associated adolescent and young adult risk behaviors, differentiates To cite: Breuner CC, Levine DA, AAP THE COMMITTEE ON between nonsuicidal self-injury (NSSI) and body modifications, and ADOLESCENCE. Adolescent and Young Adult Tattooing, Piercing, educates the reader about how to anticipate and prevent potential and Scarification. Pediatrics. 2017;140(4):e20171962 medical complications. The report analyzes the literature about societal acceptance of people with body modifications and perceptions that Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 4, October 2017:e20171962 FROM THE AMERICAN ACADEMY OF PEDIATRICS Breuner et al https://doi.org/10.1542/peds.2017-1962 October 2017 Adolescent and Young Adult Tattooing, Piercing, and Scarification 4 140 Pediatrics 2017 ROUGH GALLEY PROOF ’ ’ might potentially interfere with probability sample of adults found by navel (38%), tongue (13%), and adolescents and young adults higher tattoo rates among4 younger nipple and genital (9%) piercings. educational and career plans. Finally, versus older cohorts. Evidence on guidance is provided to pediatricians sex differences in tattooing also A survey conducted among college and, through the pediatrician, to varies, with tattoo prevalence among freshmen from Italy found that many parents and adolescents and young women ranging from 22% to 23% students undergoing tattooing and/ or piercing were unaware12 of the adults about safety and regulations and prevalence among4, 6 men ranging regarding body modification should from 19% to 26%. Among those associated health risks. Although they wish to obtain tattoos, piercings, with a tattoo, most (86%) have most (60%) students knew about or scarification. never regretted getting one, and HIV-related risks, less than half knew about possible infection HISTORY OF BODY MODIFICATION: 30% said it makes them feel sexier. TATTOOING, PIERCING, AND Other feelings attributed to having with hepatitis C (38%), hepatitis SCARIFICATION a tattoo included feeling rebellious B (34%), tetanus (34%), or about 12 (25%), attractive or strong (21%), noninfectious complications (28%). spiritual (16%), healthier (9%), more These findings have similarly been 6 reported in a sample of medical Although interest in body intelligent (8%), and athletic (5%). students who had undergone modification has increased 13 piercing. recently, history teaches us that Estimates of tattooing and piercing body modifications are not new. among adolescents range by data Scarification is the practice of Archeologists have found evidence of source and age group. One early intentionally irritating the skin to tattoos, piercings, and scarification as study among high school students cause a permanent pattern of scar far back as 2000 BC, when they were from 8 states found that 10% had tissue. Studies have been conducted largely used as a form of art or to tattoos, and 755% expressed interest among international communities identify group membership, such as in tattooing. In this sample, tattoos describing high rates of scarification, a religious group or tribe. Although were commonly obtained around the yet no studies on scarification have mostly used to describe loyalty, ninth grade, but there were reports7 been reported14,15 from the United interests, and lifestyle choices, body of tattooing as early as age 8 years. States. In the 1990s and 2000s, Among adolescent clinic samples of modification had also been used to 3 there was some renewed interest in label criminals, slaves, and convicts. youth 12 to 22 years of age, tattooing scarification as a movement to revive ranged from 10% to 23%, and body Although in the late 20th century, indigenous rituals from around the piercing (other than the earlobe)8, 9 most tattoos were on men, ranging world, embracing a more authentic16 ranged from 27% to 42%, with or spiritual body experience. from the stereotypical tattooed higher rates of tattooing and body sailors and motorcycle bikers (eg, piercing among girls versus boys and DECLINING STRENGTH OF 8, 9 ASSOCIATIONS WITH RISK BEHAVIORS The Hells Angels in the 1960s) older versus younger adolescents. to 1980s gang members, now, Harris Poll data revealed that 22% of tattoos are collections of colorful youth 18 to 24 years6 of age reported ornamentations for both women and having a tattoo, but estimates were Although in the past, body men. Surveys of the US population as high as 38% among young people modification was often associated have shown an increase in the 4,5 18 to 29 years of age on the basis2 of with adolescent high-risk behaviors, prevalence of tattoos over time. Pew Research Center findings. current data have not consistently EPIDEMIOLOGY reported this association. In a Findings are comparable among retrospective analysis from 2007 to subsequent samples of private 2008, tattoos were associated with Harris Poll data from 2016 found that university and college students, of alcohol and drug use, violence and 3 in 10 US adults had at6 least 1 tattoo, whom 23% had 10,a tattoo 11 and 51% had weapons carrying, sexual activity,17 up from 20% in 2012. Differences a body piercing. Male athletes eating disorders, and suicide. were found by geographic region, were more likely to be tattooed However, the scientific link between with tattoos being more prevalent than male nonathletes, and although tattooing and risk behaviors1 is in the West (27%) versus the East women were more likely to have less consistent today.