A REPORT FROM THE COUNCIL ON HEALTH AND DISEASE PREVENTION KRISTIANIAGADE 12 [email protected] DK-2100 COPENHAGEN WWW.VIDENSRAAD.DK TATTOOS — HEALTH, RISKS AND CULTURE WITH AN INTRODUCTION TO THE ’SEAMLESS PREVENTION’ STRATEGY JØRGEN SERUP JEPPE TROLLE LINNET OLE OLSEN BY NIELS HARRIT BO MØHL HENRIK WESTH A REPORT FROM THE COUNCIL ON HEALTH AND DISEASE PREVENTION KRISTIANIAGADE 12 [email protected] DK-2100 COPENHAGEN WWW.VIDENSRAAD.DK TATTOOS — HEALTH, RISKS AND CULTURE WITH AN INTRODUCTION TO THE ’SEAMLESS PREVENTION’ STRATEGY JØRGEN SERUP JEPPE TROLLE LINNET OLE OLSEN BY NIELS HARRIT BO MØHL HENRIK WESTH TATTOOS – HEALTH, RISKS AND CULTURE TATTOOS – HEALTH, RISKS AND CULTURE With an introduction to the ’seamless prevention’ strategy Prepared by Jørgen Serup Niels Harrit Jeppe Trolle Linnet Bo Møhl Ole Olsen Henrik Westh Translated from Danish by Larry Morlan Technical editor Peter Gjerndrup Aagaard ISBN 978-87-998156-3-0 Photos All photos were provided by Jørgen Serup unless otherwise stated. Design B14 Year of publication 2015 First edition Report references Serup J, Harrit N, Linnet JT, Møhl B, Olsen O, Westh H. Tattoos – health, risks and culture. With introduction of the ”seamless prevention” strategy. Copenhagen: The Council on Health and Disease Prevention. 2015:1-156. The report may be freely downloaded at www.vidensraad.dk THE COUNCIL ON HEALTH AND DISEASE PREVENTION WAS FOUNDED BY AND TATTOOS – HEALTH, RISKS AND CULTURE PREFACE 4 TATTOOS IN DENMARK FROM A EUROPEAN PERSPECTIVE 5 THE COMPOSITION OF THE WORKGROUP 6 METHODS AND THE STRUCTURE OF THE REPORT 7 1 INTRODUCTION AND BACKGROUND 9 2 THE CURRENT PREVALENCE AND PATTERNS OF TATTOOS 18 3 THE PSYCHOLOGY AND SOCIAL DYNAMICS OF TATTOOS 25 4 TYPES OF TATTOOS 47 5 LIGHT, COLOURS AND TATTOOS 53 6 DISCOMFORT IN CONNECTION WITH TATTOOS 62 7 CLINICAL COMPLICATIONS IN CONNECTION WITH TATTOOS 69 8 TATTOO INK 91 9 REGULATORY CONDITIONS FOR TATTOOING AND TATTOO PIGMENTS 110 10 REMOVAL OF TATTOOS 121 11 ‘SEAMLESS PREVENTION’ - A NEW PREVENTION STRATEGY 130 12 KNOWLEDGE DEFICIT 147 The Council on Health and Disease Prevention’s website includes a number of relevant appendixes (in Danish) and links to websites on tattoos. You can see more at www.vidensraad.dk TATTOOS – HEALTH, RISKS AND CULTURE PREFACE It has become more common to get a tattoo. regarding the health effects of tattoo ink, as well Once tattoos were reserved for special subgroups, as the risks involved in the tattooing situation. We such as seamen and motorcycle gang members will also investigate whether the control systems (bikers), but now getting tattoos is prevalent in regarding tattoos are sufficient. other segments of the population. A tattoo sends a signal about identity, belonging to a group and/ This report is intended for healthcare professionals, or decoration. who are involved with patients with tattoos and their consequences, as well as the general public in order There are many myths about tattoos, and there are to provide more thorough information about the many unanswered questions. Most people have advantages and, especially, the disadvantages of heard about individual side effects, regretting tat- getting tattoos. It is also hoped that the report can toos, dangerous tattoo ink, contaminated needles be used both nationally and internationally in order and the risk of hepatitis. But are there adverse side to develop a legal and supervisory means of im- effects from the various pigments that are injected proving tattoo safety. Therefore, the report has been into the skin and exactly how widespread are these translated into English in a slightly revised form. adverse effects? Do poisons accumulate, which cannot be expelled from the body? And are there safer ways to decorate your body? Morten Grønbæk Chair of the Council on Health and Disease The Council on Health and Disease Prevention Prevention has decided to investigate the scientific literature 4 TATTOOS – HEALTH, RISKS AND CULTURE TATTOOS IN DENMARK FROM A EUROPEAN PERSPECTIVE Approximately 600,000 people in Denmark have of obtaining measurable effects on the known tattoos, and in Europe the number of tattooed problems, which include allergies in coloured people is estimated to be about 100 million. tattoos, agglomeration problems in black tattoos, Tattoos probably represent the most extensive sun-related discomfort and, not least, the psycho- exposure of people to chemical substances and social problems, including regret. The content of microparticles and nanoparticles of our time. The carcinogens in the ink gives, de facto, no measur- ingredients of tattoo ink are largely unknown and able clinical cancer. These conditions mean that bacterial contamination of new ink products is not regulation of chemical constituent substances in uncommon. Concurrently with the tattoo trend, tattoo ink, as, for example, expressed in Council of the medical and sociocultural complications and Europe Resolution ResAP (2008)1, regardless of potential risks have become obvious, and there is a the fact that tattoo ink, obviously, cannot contain need for a joint prevention effort in Europe. absolutely anything all without restriction, has not proven to function in the prevention of complica- Denmark and other European countries, as well tions related to tattoos. as the EU, are now actively involved in regulating the area, which would be most appropriate to be Innovation is needed when it comes to preven- based on a joint strategy for large regions, such as tion. This report introduces an integrated strate- Europe. The countries’ requirements for tattoos gy,’seamless prevention’, in which all parts of the are insufficient and dissimilar in sharp contrast tattooing process that present a risk are included to the EU requirements that exist for medical and subjected to pragmatic action. The action products and injections for humans. It is difficult to focuses on the customer-tattooist relationship, regulate and control tattoos because, among other which is the focal point of risks related to tattooing. reasons, the area is anchored in popular cultural Influencing this relationship and the conditions ownership, and is many-faceted and fragmented. during the tattooing process, and through a dialogue with the players and professionalising This report examines and analyses the tattoo them, provide the greatest prospects for making phenomenon from a health perspective, primar- real progress regarding prevention. As is the case ily based on Danish conditions, but also from a for other types of prevention that have significance European perspective. Lack of knowledge is, with for the effect, the strategy of ‘seamless prevention’ the exception of infections, the greatest obstacle must be consistent in a large geographical area, to the launching of efficient prevention activities and ideally it should be at a European level that is of a more technical nature with the prospect supported by European health authorities. 5 TATTOOS – HEALTH, RISKS AND CULTURE THE COMPOSITION OF THE WORKGROUP The chair of the workgroup is designated by the › Ole Olsen, MSc, CEO, Medico Chemical chairmanship of the Council on Health and Dis- Lab ApS. ease Prevention, while the members of the work- group are designated jointly by the chair of the › Henrik Westh, Professor, Chief Physician, workgroup and the chairmanship of the Council on MD, Department of Clinical Microbiology, Health and Disease Prevention. They are selected Hvidovre Hospital, and Institute for Clinical on the basis of their professional competences Medicine, University of Copenhagen within the topics that the report contains: Peter Gjerndrup Aagaard, Consultant, MSc, of the › Jørgen Serup (chair), Professor, Chief Phy- Council on Health and Disease Prevention’s secre- sician, MD, Department of Dermatology/ tariat has been the project manager and technical Tattoo Clinic, Bispebjerg University Hospital, editor for the workgroup. University of Copenhagen. Declarations of legal capacity for the members › Niels Harrit, PhD, Associate Professor of the workgroup may be obtained by contacting Emeritus, Institute of Chemistry, University of the Council on Health and Disease Prevention’s Copenhagen. secretariat. › Jeppe Trolle Linnet, Anthropologist, PhD, The workgroup wishes to thank: Lecturer at Aalborg University and Aarhus Eva Jacobsen, MSc in chemistry and mathematics, University. CEO Linnet Research. Head of Section of the Chemical and Microbio- logical Laboratory of Life Science at the Techno- › Bo Møhl, Professor, Special Psychologist in logical Institute for participating in the preparation Psychiatry, Master of Arts, Master of Psy- of the chapter on chemical substances in tattoo ink. chology, Psychiatric Centre Copenhagen, Aalborg University. 6 TATTOOS – HEALTH, RISKS AND CULTURE METHODS AND THE STRUCTURE OF THE REPORT The starting point for identifying literature that groups over time, while Chapter 2 presents the provides the basis for this report is the generally current pattern of the incidence in Denmark today. available databases of scientific literature within the Chapter 3 delves deeper in the psychological and different professional areas, as well as published social mechanisms that motivate people to get analyses and reports etc. of what is also available. tattoos, as well as people’s opinions about and The sources are stated in the references indicat- impressions of people who have tattoos. Chapters ed. The report contains the references that are 4 and 5, respectively, provide a short review of the relevant to clarifying the topic.