Body art: the decision making process among college students.

Abstract: The authors examined the effects of gender, age, and behavioral intentions on decisions pertaining to the body art practices of 1,061 college students. Results indicate higher rates of tattooing and body piercing than previous research had estimated. Women reported participating at significantly higher rates than did males for both tattooing (p<.05) and body piercing (p<.00). Results also indicate that many students consider their body art to be a thoughtful means of self-expression. In order to effectively assist college students with reducing health risks, college health professionals need to be knowledgeable and considerate of the factors influencing decision-making.

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For thousands of years, individuals representing virtually every culture in the world have practiced various forms of body art. Tattooing and body piercing are far from the relatively new "fads" many Americans perceive them to be. The insertion of jewelry and other objects into artificially made openings in body parts such as, but not limited to, ears, eyebrows, nostrils, lips, tongues, navels, nipples, and the genitalia of both genders; and the process of inserting pigment such as ink under the skin have been common practices for centuries. Early Egyptians and Romans practiced body piercing as a rite of passage while Mayans practiced piercing in relation to their spiritual beliefs. Victorian Royalty, specifically Queen Victoria and Prince Albert, practiced body piercing as a means of sexual stimulation (Myers, 1992). Tattooing has been documented in cultures as ancient as the Maoris and Celts. Throughout history, the purpose of tattooing has been ornamental, ritualistic, and identity-oriented (Bell, 1999). Body art, in general, has been described by anthropologists (Myers, 1999; Saunders, 1989) as a means of identifying oneself as being part of a specific group, of denoting one's financial status, or possibly of beautification of the body.

Americans have traditionally held a negative view of body art. As common as ear-piercing is today, with both genders participating at high rates, this behavior was considered unacceptable for those in mainstream society in the early 1960's (Armstrong, Ekmark, & Brooks, 1995). Likewise, possession of a tattoo has been seen as one's membership in society's lower class. According to Bell (1999):

   Tattoos have long been associated with the
   exotic "other" and are therefore fodder for
   imagination and use by subcultures of all
   types. American greasers, bikers, hippies, and
   punks, have all used tattoos as part of their
   anti-mainstream adornment. American tattooed
   people have historically been military
   personnel, convicts, circus freaks, bikers, and
   other marginal people. (pg. 54)

Over the past decade, the rate of body piercing and tattooing has increased in the United States. Results of a 1989 poll indicated that 3% of the general population had at least one tattoo (Anderson, 1992). More recently Whelan (2001) reported that 10% of American adults have or have had a tattoo. Although the somewhat temporary nature of piercings makes them more difficult to track, results from the same study indicate that 2% of adults have a piercing other than an earring.

The rate of tattooing in the 1990s has been documented to be much higher in young people than among adults. A study by Armstrong and McConnell (1994a) indicated that 8.6% of high school aged youth possessed a tattoo. A larger sample of adolescents demonstrated a 10% rate of tattoo possession (Armstrong & Pace-Murphy, 1997). The rate of tattooing among college students was reported at 16% (Drews, Allison, & Probst, 2000). While these results stem from students attending a private northeastern college with a relatively small enrollment, they are consistent with the 18% tattooing rate reported by students attending a large southwest university (Forbes, 2001). More recently, college students reported a 23% rate of tattoo possession while 51% indicated having at least one body piercing, however, the high rate of piercing reported in this study is due to the inclusion of ear piercings in the results (Mayers, Judelson, Moriarty, & Rundell, 2002). Burger and Finkel (2002) reported that 18% of college students had at least one tattoo and 24% had at least one piercing.

These rates have led to a series of concerns from health educators (McCormack-Brown, Perlmutter, & McDermott, 2001; McCormack-Brown, Perlmutter, & McDermott 2000; Armstrong et al., 1995; and Armstrong & McConnell, 1994b). The concerns related to body piercing and tattooing stem from a wealth of literature indicating that physical and psychosocial health risks exist. The greatest of these concerns is related to the possibility for transmission of blood-borne pathogens. Due to the nature of the procedures for application of a tattoo or insertion of a piercing, bleeding is certain. While many researchers (Haley and Fischer, 2001; Long and Rickman, 1994; Sperry, 1991) have argued that body art practices increase the risk of transmission of diseases such as hepatitis and HIV, the CDC (2004) has stated that while there is potential for the transmission of infectious diseases, "no data exist in the United States indicating that persons with exposures to tattooing and body piercing alone are at increased risk of infection."

Concerns about infection, allergic reaction, and dental problems related to piercing and tattooing have also been expressed. The American Dental Association (2004) has officially opposed oral piercing due to evidence of dental and tissue damage. Other complications such as bacterial infection and tissue damage at the site of body piercings have been documented as well (Mayers et al., 2002; Greif, Hewitt, & Armstrong, 1999; Tweeten & Rickman, 1998; Armstrong et al., 1995). In addition to the infection-related concerns similar to those for piercing, individuals receiving a tattoo face the risk of allergic reaction to the pigments used in the process (Armstrong & Fell, 2000). Even in the presence of the identified health risks, the body piercing and tattooing industry remains relatively unregulated by most states (Braithwaite, Stephens, Sterk, & Braithwaite, 1999). Oberdorfer, Wiggers, Considine, Bowman, & Cockburn (2003) have indicated that less than 39% of those owning or managing facilities that practice skin penetration could correctly identify recommended disinfection procedures.

Concerns about psychosocial health risks have been expressed as well. Armstrong and McConnell (1994b) classify these risks as purchase risks and possession risks. Purchase risks are those tied to the decisions made prior to and at the time the procedure is conducted, such as choice of design, location of the tattoo or piercing, cost of the procedure, and age at the time of the procedure. Possession risks are related to response of others to the piercing or tattoo.

Self-expression has emerged as a powerful factor influencing the decision among adolescents and young adults to obtain tattoos and body piercings. Greif and colleagues (1999) reported that 50% of those college students surveyed with tattoos, as well as those with body piercings, stated that their primary reason for seeking their work was "self-expression." In a more recent study, Armstrong, Owen, Roberts, and Koch (2002) indicated that 56% of those with tattoos received their tattoos while in college. Again the majority of those with tattoos (55%) agreed that their tattoo was a form of self-expression. Seventy-six percent of non-tattooed subjects in this same study either agreed or strongly agreed that tattoos are a form of self-expression. When asked about barriers to tattooing, those with tattoos were less concerned about issues such as permanent marking, cost, parents, and disease than those participants without tattoos. The aforementioned research study was the first to sample college students with tattoos and those without tattoos while investigating factors that influence decision-making. However, similar studies related to body piercing are non-existent. Additionally, previous studies have not addressed college students' degree of intent regarding tattooing and/or body piercing.

METHOD

Students enrolled in a required general education course were recruited for participation in the study. Participation was voluntary and no incentives were provided. Data were collected by way of two separate survey packets; one pertaining to body piercing and the other to tattooing. After completion and collection of the informed consent documentation, the research team instructed the respondents to note that piercing of the ears was not to be considered as body piercing. Participants then completed each survey which consisted of a demographics section followed by items designed to determine their current intentions related to the body art practice in question. Based upon the respondents' intent to participate in or abstain from body art practices, they were asked to skip to one of four sections of the questionnaire. Each section was designed to collect information regarding the factors that influenced the respondents' decision making. Upon completion of the survey, participants were instructed to insert the instruments into a provided envelope, seal it, and hand it to a member of the research team. The survey instruments, as well as the research procedures, were approved by the Institutional Review Board of the University prior to data collection.

RESULTS

The tattoo and body piercing questionnaires were completed by 1,061 participants. Of those who participated in the survey, two-thirds were female (67.0%) and one-third were male (33.0%). More respondents were age 19 or younger (59.5%) than were 20 years or older (40.5%). Most identified as Caucasian (78.1%); the remaining (21.9%) identified as African American, Latino/Hispanic, Asian/Asian American, American Indian, and Arab American. Approximately 44% of the respondents were first-year students, while the remaining respondents were sophomore (24.1%), junior (17.9%), senior (12.0%), and post-baccalaureate (1.0%) status.

Respondents were asked a series of questions concerning their intent to get a tattoo and/or a body piercing. Results for males and females on these items are presented in Table 1. The majority of respondents reported that they did not have a tattoo (60.3%); however, approximately one-fifth (21.2%) of the respondents did have a tattoo. Fifty-seven percent of respondents did not have a body piercing, while approximately 30% reported having a piercing.

With regard to intent, cross tabulations revealed a significant relationship between gender and intention to get a tattoo ([X.sup.2] = 13.62; p= .018) and gender and intention to get a body piercing ([X.sup.2] = 124.96; p= .000). In both instances, females' intent to obtain body art was far greater than that of their male peers. Age was also shown to be a significant factor in relation to one's intention to get a tattoo ([X.sup.2] = 32.48; p= .000) and/or a body piercing ([X.sup.2] = 21.80; p= .000). Younger respondents (18-19 years of age) were more likely to obtain a body piercing and/or tattoo within the next 30 days to 6 months.

DISCUSSION

In this study, respondents were asked a series of questions concerning their intent to get a tattoo and/ or body piercing. Approximately one-fifth of the participants reported that they had a tattoo (21.2%). These findings are similar to previous studies indicating a range of 16-23 percent of college students reporting a tattoo (Drews et al., 2000; Forbes, 2001; Burger & Finkel, 2002; Mayers et al., 2002). A significant relationship was found between gender and the intent to get a tattoo and the intent to get a body piercing. In both cases, female students were more likely to report intention of obtaining body art than their male counterparts. Friends, identity, and image have been identified as the major influences for tattooing among career women and female college students (Armstrong et al., 2002). However, only self-expression was viewed as a significant factor affecting intention to get a tattoo among participants. According to Saunders & Armstrong (2005), tattoos allow females to exert more of their persona, and make them feel 'special, unique, and good.'

Additionally, a significant relationship was revealed between age and intention to get a tattoo, and body piercing. Younger respondents (18-19 years of age) were more likely to report intention within the next 30 days to 6 months. This finding is consistent with previous research that have seen an increase among adolescents and young adults having, and wanting to get a tattoo (Armstrong & McConnell, 1994b; Armstrong & Pace-Murphy, 1997; Drews et al., 2000; and Forbes, 2001), and/or body piercing (Mayers et al., 2002).

The current study was a convenience sample of students enrolled in multiple sections of a wellness class in a large mid-western university; therefore, the results cannot be generalized. However, the results have numerous implications for assisting health educators in an attempt to design meaningful and successful body art materials and educational programs.

Clearly, there is an increased trend among youth to engage in body art practices, and health educators are faced with numerous challenges in trying to provide education for both college and high school aged youth. Perhaps the most significant challenge is to provide nonjudgmental, clear-cut information that can assist them with considering the physical, purchase, and possession risks. Evidence has shown that a major reason for decisions being made to obtain body art is self-expression, something that we otherwise strongly encourage in youth. Therefore, a significant purpose of our educational goals should be to assist those with intentions in becoming effective decision makers by making good, healthy, personal choices regardless of whether the anticipated behavior follows.

REFERENCES

American Dental Association. (n.d.) ADA Statement on Intraoral/Perioral Piercing. Retrieved February 2004 from http://www.ada.org/prof/resources/positions/statements/piercing.asp.

Anderson, R.R. (1992). Tattooing should be regulated. New England Journal of Medicine, 326, 207.

Armstrong, M.L., Ekmark, E., & Brooks, B.B. (1995). Body piercing: Promoting informed decision making. Journal of School Nursing, 11(2), 20-25.

Armstrong, M.L. and Fell, P.R. (2000). Body art: Regulatory issues and the NEHA Body Art Model Code. Journal of Environmental Health, 62(9), 25-30.

Armstrong, M.L. and McConnell, C. (1994a). Tattooing in adolescents: More common than you think--the phenomenon and risks. Journal of School Nursing, 10(1), 26-33.

Armstrong, M.L. and McConnell, C. (1994b). Promoting informed decision-making about tattooing for adolescents. Journal of School Nursing, 10(2), 27-30.

Armstrong, M.L., Owen, D.C., Roberts, A.E., & Koch, J.R. (2002). College tattoos: More than skin deep. Dermatology Nursing, 14(5), 317-320.

Armstrong, M.L., & Pace-Murphy, K. (1997). Tattooing: Another adolescent risk behavior warranting health education. Applied Nursing Research, 10(4), 181-189.

Bell, S. (1999). Tattooed: A participant observer's exploration of meaning. Journal of American Culture, 22(2), 53-58.

Braithwaite, R.L., Stephens, T., Sterk, C., & Braithwaite, K. (1999). Risks associated with tattooing and body piercing. Journal of Public Health Policy, 20(4), 459-470.

Burger, T.D., & Finkel, D. (2002). Relationship between body modifications and very high-risk behaviors in a college population. College Student Journal, 36(2), 203-213.

Centers for Disease Control and Prevention (n.d.). Hepatitis C Epidemiology fact sheet. Retrieved February 2004 from http://www.cdc.gov/ncidod/diseases/hepatitis/c_training/edu/1/ epidem-trans-5.htm.

Drews, D.R., Allison, C.K., & Probst, J.R. (2000). Behavioral and self-concept differences on tattooed and non-tattooed college students. Psychological Reports, 86, 475-481.

Forbes, G.B. (2001). College students with tattoos and piercings: Motives, family experiences, personality factors, and perception by others. Psychological Reports, 89, 774-786.

Greif, J., Hewitt, W., & Armstrong, M.L. (1999). Tattooing and body piercing: Body art practices among college students. Clinical Nursing Research, 8(4), 368-385.

Haley, R.W. and Fischer, R.P. (2001). Commercial tattooing as a potentially important source of hepatitis C infection. Medicine, 80(2), 134-166.

Long, G.E., and Rickman, L.S. (1994). Infectious complications of tattoos. Clinical and Infectious Disease, 18(4), 610-619.

Mayers, L.B., Judelson, D.A., Moriarty, B.W., & Rundell, K.W. (2002). Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clinic Proceedings, 77, 29-34.

McCormack-Brown, K., Perlmutter, P., & McDermott, R.J. (2000). Youth and tattoos: What school health personnel should know. Journal of School Health, 70(9), 355-360.

McCormack-Brown, K., Perlmutter, P., & McDermott, R.J. (2001). Warning kids about tattoos. The Education Digest, 66(7), 55-59.

Myers, J. (1992). Nonmainstream body modification. Journal of Contemporary Ethnography, 21, 267-306.

Oberdorfer, A., Wiggers, J.H., Considine, R.J., Bowman, J., & Cockburn, J. (2003). Skin penetration operators' knowledge and attitudes towards infection control. American Journal of Health Behavior, 27(2), 125-134.

Saunders, (1989). Customizing the body: The art and culture of tattooing. Philadelphia, PA: Temple University Press.

Saunders, J.C., & Armstrong, M. (2005). Experiences and influences of women with cosmetic tattooing. Dermatology Nursing, 17(1), 23-30.

Sperry, K. (1991). Tattoos and tattooing part I: History and methodology. The American Journal of Forensic Medicine and Pathology, 124(4), 313-319.

Tweeten, S.S. and Rickman, L.S. (1998). Infectious complications of body-piercing. Clinical Infectious Diseases, 26(3), 735-740.

Whelan, D. (2001). Ink me stud. American Demographics, 23(12), 9-11.

CHES AREAS

Responsibility I--Assessing Needs for Health Education

Jeffrey Schulz, Ph.D. is Associate Academic Dean of the School of Health Promotion and Human Performance at Eastern Michigan University. Christine Karshin, Ph.D. is an Associate Professor in the School of Health Promotion and Human Performance at Eastern Michigan University. D. Kay Woodiel, Ph.D. is the Director of Diversity Programs & Community Service at Eastern Michigan University. Address all correspondence to Jeffrey Schulz, Ph.D., Eastern Michigan University, Porter 319 A, Ypsilanti, MI. 48197. PHONE: [phone] x 2698; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Descriptive Analysis of the Sample

Variable                             Total       Females     Males

Intention to get a tattoo            (n=1041)    (n=694)     (n=347)
  No intention                        60.3%       58.4%       67.7%
  Next 6 months                       14.5%       15.1%       14.1%
  Next 30 days                         2.1%        2.4%        1.4%
  Have a tattoo                       21.2%       24.1%       16.7%
Intention to get a body piercing     (n=1028)    (n=700)     (n=328)
  No intention                        57.3%       48.3%       82.3%
  Next 6 months                        8.0%        9.7%        5.2%
  Next 30 days                         1.8%        2.6%        0.3%
  Have a body piercing                29.8%       39.4%       12.2%