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TATTOOING
& BODY PIERCING Examining the Public Health Implications of These Risky Behaviors Tattooing and body piercing have emerged as popular practices among teens and young adults in the general population. Both practices are legal activities, though largely unregulated by state and local health authorities (see chart, next page). As of January 1998, 13 states and the District of Columbia regulated tattooing establishments, while only four states (Maine, Ohio, Oregon and Wisconsin) had regulatory authority over body-piercing establishments. The number of tattoos and body piercings is difficult to quantify, both within and outside of prisons. Estimates from the Association of Professional Piercers indicate that a typical piercing establishment will complete approximately 3,000 annually, while the Alliance of Professional Tattooists indicate that 15 to 20 percent of the national teen and young adult population has tattoos. Although tattooing is considered by some youths to be a sign of assertiveness, studies have shown that tattooing often is associated with low self-esteem, delinquency and drug use. It is well-documented that sharing dirty syringes spreads HIV, and tattooing with dirty needles has been linked to the spread of hepatitis C, which is carried in the blood. There also is concern that tattooing, which involves putting tiny bits of ink beneath the skin, can spread HIV. With the proliferation of tattooing and body piercing, the direction of HIV intervention and prevention activities is rapidly shifting from documentation of risk reduction practices to measuring intervention outcomes. Cause for Concern A recent survey found that prison inmates are nearly six times more likely than the general population to have AIDS. The Centers for Disease Control and Prevention reported that 5,279 inmates had AIDS in 1994, the last year for which figures are available. This represented 5.2 cases per 1,000 inmates, while among all Americans over 18, the rate was 0.9 per 1,000. By the end of 1994, the number of AIDS deaths among inmates (during incarceration) reached 4,558. While the number of deaths is striking, there is little research to document seroconversion during incarceration. Thus, it is not possible to definitively say that HIV has or has not been transmitted via tattooing and body piercing in prison. The use of illegal drugs behind bars and the use of injection drug paraphernalia is present in most U.S. prisons. Syringes that are stashed away in the prisons and used by hundreds of inmates (without knowledge of whether the "works" were bleach-cleaned) is clearly a public health threat. A 1996 survey of 4,875 Canadian inmates found that 11 percent had used illegal drugs behind bars, 45 percent had been tattooed, and 17 percent had their bodies pierced. Tattooing and body piercing are viewed as prohibitive activities in most U.S. correctional institutions with few exceptions. Given the ban on tattooing, inmates hoard needles and ink and share contaminated equipment. Moreover, risks are exacerbated by inmates' often limited understanding of "sharing." In reality, sharing includes not only passing needles among people, but also using needles and syringes that have been used by unknown persons and perhaps not properly cleaned; sharing injection solutions (as in "backloading" and "frontloading"); and sharing containers, cotton and other paraphernalia. When needles are not available, pieces of pens and light-bulbs are sometimes used by inmates to inject drugs, tattoo and body pierce. Tattooing often is done with guitar strings and other expedient materials. In tattooing, sharing of the needle (or needle substitute), ink and string used to transmit the ink may pose risks for HIV transmission. In 1996, investigators conducted focus groups and one-on-one interviews with inmates in four correctional institutions. At one juvenile boot camp facility, they reported that tattooing was a prevalent source of possible blood contact, and showed a higher prevalence than drug injection, with 12 of 25 inmates reporting having gotten a tattoo and only three of them having it done professionally. Nineteen knew that tattooing could transmit the AIDS virus, but it could not be determined from the survey whether this knowledge was acquired before or after the tattooing took place. Three of the inmates also reported participating in the high-risk behavior of becoming blood brothers with someone else, an old Indian ritual that involves two people cutting themselves on the hand or wrist and rubbing the cuts together. At a detention center facility, more females (71 percent) than males (47 percent) reported having tattoos, but all of them knew that HIV could be transmitted through tattoo needles. Many reported having homemade versus professional tattoos and several reported that they had become blood brothers or sisters with someone. A Public Health Challenge The public health challenge posed by body piercing and tattooing in prison will require increased collaboration between correctional and public health policy-makers. Such collaboration should facilitate discussions on a wide range of policy alternatives from bold harm reduction policies to health education models using peer educators. Since 1985, U.S. prisons and jails have increasingly incorporated HIV/AIDS education programs into their inmate orientation and pre-release activities. Nevertheless, community health officials suggest that many inmates are released carrying infectious diseases with them, hence posing a public health threat to the community at-large. As a harm reduction measure, the Correctional Service of Canada is considering allowing tattoo artists in prisons in a bid to curb the spread of disease among inmates. The need exists for increased scientific research to document the status of tattooing and body piercing behavior in U.S. correctional facilities. Concomitantly, there is a need for more state health departments to develop regulatory mandates for tattooing and body piercing establishments. Such policy directives could serve as guidelines for correctional systems considering harm reduction programs related to tattooing and body piercing. While custody and security issues are paramount, the role of protecting the health of those outside correctional facilities is associated with health education and disease prevention programs in place in correctional facilities. After all, the vast majority of those incarcerated return to their communities after serving their sentences. Returning to communities with infectious diseases represents both a public health threat and a public health challenge. REFERENCES Braithwaite, R., T. Hammett and R. Mayberry. 1996. Prisons and AIDS. San Francisco: Jossey-Bass. CDC. 1996. HIV/AIDS education and prevention programs for adults in prisons and jails and juvenile confinement facilities. Morbidity and Mortality Weekly. (April). Farrow, J.A., R.H. Schwartz and J. Vanderleeuw. 1991. Tattooing behavior in adolescence. American Journal of Diseases of Children. Mahon, N. 1994. Let's Talk About Sex and Drugs: HIV Transmission and Prevention Behind Bars. Abstract PD 0521 presented at the 10th International Conference on AIDS, Yokohama. Montagna, B. Personal communication, Jan. 15, 1998. Munro, M. 1997. Tattoo service urged to curb convict diseases. Vancouver Sun [online]. Available http://www.hempbc.com/cgi/me/dis/v97.n302.a14.(October). Turnbull, P.J., G.V. Stimson and G. Stilwell. 1994. Drug use in prisons. Horsham, West Sussex, United Kingdom: AIDS Education and Research Trust. Vidra, D. Personal communication, Jan. 15, 1998. By Ronald L. Braithwaite, Ph.D Adapted by Ph.D , Ph.D and M.P.H. Ronald L. Braithwaite, Ph.D., is interim chair and associate professor
at the Rollins School of Public Health of Emory University |