Tattooing: Another Adolescent Risk Behavior Warranting

Health Education
Myrna L. Armstrong and Kathleen Pace Murphy

A cross-sectional, convenient sample of adolescents (N = 2101) from 8 states were queried

regarding interest in tattooing. Permanent markings and blood-borne diseases were reasons
respondents refrain from tattooing, yet 55% (n = 1159) expressed an interest in tattooing. Tattooed
adolescents in the sample (10%, n = 213) responded with their experiences. Tattooing was
frequently done around the 9th grade and as early as 8 years of age; over half (56%, n = 120)
report academic grades of As and Bs. Potential health risks and definite psychosocial findings of
purchase and possession risks were evident, building on data from a similar 1994 study by
Armstrong and McConnell. Health providers and educators should initiate applicable health
education and become community adolescent advocates regarding this risk-taking behavior.
Findings indicate that adolescents who want a tattoo will obtain one, regardless of money,
regulations, or risks. Adolescents view the tattoos as objects of self-identity and body art, whereas
adults perceive the markings as deviant behavior. Informed decision-making could be promoted in
health education by incorporating information about the possibility of blood-borne diseases,
permanent markings, and themselves as growing and changing people.
Copyright © 1997 by W.B. Saunders Company

DOLESCENCE is filled with psychosocial lescents (Armstrong & Gabriel, 1994; Armstrong &
A pressures, biological turmoil, and struggles McConnell, 1994b).
for independence. Adolescents are challenged to
BACKGROUND
describe who they are and what they want to
become. Often, they are preoccupied with them- Tattooing and Health Risks
selves, their appearance, and the opinions of others; The most common health risks of tattooing (see
they obtain many ideas from peers, role models, Sidebar) are infections and allergic reactions (Ander-
and the media. Interestingly, adolescents tend to son, 1992; Long & Rickman, 1994). Transmission
accept these opinions and the associated actions of blood-borne diseases also are possible because
readily, without questioning the decision; any expo-
sure to potential danger or injury, risk-taking, is
often done to satisfy an immediate need or goal. From the School of Nursing, Texas Tech University Health
Yet, risk-taking is a beneficial, natural, healthy Sciences Center, Lubbock, TX.
Myrna L. Armstrong, EdD, RN, FAAN, Professor, School of
part of adolescent transition. It represents an element of Nursing, Texas Tech University Health Sciences Center,
maturity, of reaching out and trying new roles, Lubbock, TX; Kathleen Pace Murphy, PhD, RN, CRRN,
without the responsibilities of adulthood. It can Assistant Professor, School of Nursing, Texas Tech University
also be harmful when associated with impulsive Health Sciences Center, Lubbock, TX.
This study was funded by the Research Committee of Texas
energies, feelings of invincibility, lack of foresee-
Teeh University Health Sciences Center School of Nursing.
ing potential adverse effects, need for thrill-seeking, The authors gratefully acknowledge Roberta K. Brady
or even apathy (Armstrong & Gabriel, 1994b; Busen, BSN, RN; Shelley Elliott, BSN, RN, CSN; Rosemary Foley M.
1991). Examples of the current documented risk- Ed, RN, CNS; Rosanne E. Mclnaney, BSN, MPH, RN," Breeky
Rameas MS, RN; Kathryn Schwabl, MS, MPH, RN, Chris Seyl,
taking behaviors and results include motor vehicle
MN, ARNP; and Donna Zaiger, BSN, RN, CSN for their
accidents, drug, alcohol, and cigarette use, sexually faciliative efforts during this study and Elizabeth H. Winslow,
transmitted diseases, and pregnancy. Today, tattoo- PhD, RN for her thoughO~ulreview of an earlier manuscript.
ing is on the rise with at least 7 million adults Address reprint requests to Myrna L. Armstrong, EdD, RN,
FAAN, School of Nursing, Texas Tech University Health
already tattooed (Armstrong, Stuppy, Gabriel, &
Sciences Center, 3601 4th St, Lubbock, TX 79430.
Anderson, 1996). Prevalence and popularity of Copyright © 1997 by W.B. Saunders Company
tattooing have also been demonstrated among ado- 0897-1897/97/1004-000455.00/0

Applied NursingResearch,Vol. 10, No. 4 (November), 1997: pp 181-189 181

182 ARMSTRONG AND MURPHY

SIDEBAR SIDEBAR (Cont'd.)

Although it is easy to look around crowded Seven states prohibit studio tattooing for
beaches and malls to observe the popularity anyone, whereas 20 states forbid tattooing in
and prevalence of tattooing, few statistics studios on individuals under 18 years of age
document the incidence of tattooing in the (Tope, 1995). Yet, the regulations and the
United States. One report is a "1990 unpub- enforcement of this industry remain problem-
lished market survey of 10,000 randomly atic (Armstrong, Stuppy, Gabriel, & Ander-
selected American households in which 3% son, 1996). Health department personnel
of all respondents and 5% of male respon- typically only inspect tattoo studios when
dents had a tattoo" (Anderson, 1992; Tope, complaints are received. Many dissatisfied
1995, p 791). Other indicators are increased customers do not notify the tattoo artists
sales of tattoo pigments and tattoo equip- when problems occur; they tend to go to
ment. Specific tattooing businesses are diffi- another tattoo artist for advice or "rework-
cult to count because of their movement ing" of the tattoo.
between home-based services and store- Amateur tattooing is considered more dan-
fronts. gerous than studio tattooing because it is
Most tattooing is done by studio artists, frequently done in unhygienic conditions
who call themselves professionals, or by an and environments with various household
amateur. Regardless, several problems sur- instruments. Often, the amateur tattoos are
rounding the tattooing procedure potentate "self-inflicted or created by a friend/rela-
health risks. The major areas of concerns tives using pencils, pens, straight pins,
include the artist, pigment, equipment, and needles, and pigments such as charcoal, soot,
environment. Studio tattoo artists are unli- mascara, or carbon" (Armstrong & McCon-
censed, the ingredients of the pigments are nell, 1994b, p 27). Greater psychosocial
not FDA approved nor standardized, hygiene risks are present because many amateur
procedures for equipment are inconsistent, tattoos are crude, simplistic markings placed
and sanitary inspections of studios are infre- on exposed body locations. Adolescents are
quent. Studio tattooing is performed with the largest group with amateur tattoos and
"an electrically powered, vertical vibrating popular opinion generally associates the tat-
instrument resembling a dentist drill which toos with gang membership. Many amateur
injects the tattoo pigment 50 to 3,000 times tattoos are also on people following incarcera-
per minute up to, or into the dermis at a depth tion in county, state and/or federal prison
of 1/64 to 1/16th of an inch" (Armstrong & facilities.
Gabriel, 1994c, p 27). From one to fourteen
needles may be used during the invasive
procedure. Costs for a 2 in. × 2 in. tattoo
range from $35 to $50; costs for removal of
the same size tattoo range from $1,000 to artists in 1961; no similar large scale cases have
$1,500. Following tattooing, improper skin since been reported. Additionally, "transmission of
care can produce short-term reddened skin HIV by tattooing is possible," but no documented
responses and the ingredients of red and cases of human immunodeficiency virus (HIV) or
yellow pigments can initiate allergic reac- acquired immune defciency syndrome (AIDS)
tions. The transmission of blood-borne dis- have been located (Long & Rickman, 1994, p 616).
eases is a possibility.
Risks With Adolescent Tattooing
For almost 30 years, physicians in England have
voiced concerns about amateur tattooing and the
small to moderate amounts of bleeding occur associate problems of embarrassment, shame, and
during tattooing. A large incidence of hepatitis B social disgrace (Balakrishnan & Papini, 1991;
(13 cases) resulted in New York City banning tattoo Mercer & Davies, 1991; Thomson & McDonald,
TATTOOING: ADOLESCENT, HEALTH EDUCATION 183

1983). All of these physicians recommend health studies about tattooing in adolescents, nor tattooing
education about tattooing. interest were found. The purposes of this explor-
In the United States, there are a few descriptive atory study were two-fold, (a) to examine adoles-
medical articles about adolescent tattooing. Fried cent interest in tattooing, and (b) to identify the
(1983) suggested adolescent tattooing expressed characteristics and associated purchase, possession,
"aggression, sexuality, and rebellion" (p 239), and health risks of tattooed adolescents.
whereas Litt (1994) suggested gang association in
amateur tattooing. Farrow, Schwartz, and Vander- METHODS
leeuw, (1991) identified "an impulsive personality Little is known about the tattooed adolescent so a
style, deviant behavior, and drug abuse" (p. 187) as descriptive design similar to the ~ s t r o n g and
common characteristics. Health education was McConnell (1994b) study was used in this quantita-
recommended; however, no specific programs were tive study to describe the present situation, deter-
cited. mine the frequency of its occurrence, and generate
In the nursing literature, Thomson and McDon- knowledge. Information from this type of study can
ald (1984) described the self-infliction of tattoos build a larger knowledge base for further studies on
and the psycho-emotive distress of adolescents in the risk-taking behavior of tattooed adolescents.
England. Only one study in the United States has
been conducted on adolescent tattooing. Armstrong Instrument
and McConnell (1994b) queried 642 adolescents in A 72-item self-reporting, anonymous, scannable
six Texas high schools. Among the nontattooed bubble form survey tool was used. The survey was
adolescents (n - 537), over a third (33%, n = 177) based on a review of literature, personal interviews
were interested in tattooing. The percentage of with tattoo artists, data from three pilot studies, and
tattooed adolescents (n = 105) was 8.6%. Many three previously published studies (Armstrong &
reported academic grades of As and Bs (69%, McConnell, 1994b; Armstrong et al., 1996). Face
n = 72). The number of those with studio or and content validity were established and re-
amateur tattoos was almost equal. The average age established by expert panels before the initiation of
for the first tattoo was 14 years of age with the the three pilot studies. Using the SMOG formula,
earliest tattooing reported at 10 years of age. Over the reading level of the survey was at the 7th grade
half (57%, n = 60) had one tattoo, whereas 40% level.
(n - 42) had two or more tattoos. An introduction to the survey provided the
Three areas of risk were investigated by study's purpose, risks, benefits, and a statement
Armstrong and McConnell (1994b), namely the regarding the adolescent's voluntary participation.
psychosocial risks of purchase (vulnerability with The survey tool was divided into two parts. The
the procedure), possession (problems encountered first section was designed for all respondents and
while having the tattoo), as well as health risks included five demographic and general questions
(potential diseases, allergies, or infections after about tattooing. The second part was specifically
tattooing). Purchase and possession risks were designed for adolescents with tattoos; it contained
documented in this study "as evidenced by 35 questions featuring multiple choices about
whimsical decision making, the young age at tattooing and health risks, as well as "yes and no"
tattooing, the short time-frame for decisions, the questions about the purchase experience. Another
visual messages in their tattoo designs, the exposed 20 questions were open-ended regarding their
body locations, and the lack of support by parents, feelings about their tattoos and the responses from
siblings, and the public" (Armstrong & McCon- others.
nell, 1994b, p 123). No health risks were Additionally, 12 Likert scale questions asked
documented, but the potential of blood-borne about the purpose(s) of the tattoo. Choices on the
diseases existed as many (70%, n = 73) report four point scale ranged from strongly disagreed (1)
some bleeding during their tattooing procedure. to strongly agreed (4). Reliability for this Likert
A second study was undertaken to examine scale was 0.90, using Cronbach's Alpha (Arm-
various regions in the United States and build on strong & McConnell, 1994b; Armstrong et al.,
the previous level of knowledge attained regarding 1996). At the end of the survey tool was a comment
nontattooed and tattooed adolescents. No national sheet so respondents could write remarks or ask
184 ARMSTRONG AND MURPHY

questions of the investigators. If this comment sheet rendered not usable because of insufficient data.
was used, the subjects were asked to tear it off from Surveys were retained for data analysis if over 75%
the general survey tool to assure confidentiality. of the questions were completed.

Consent RESULTS

The Institutional Review Board determined the Subjects

study to be of minimal risk and approved it as an Usable data were collected from 2,101 adoles-
exempt study. Before data collection, each school cents (53% [n = 1,113] girls and 47% In = 9881
reviewed the survey; it was determined to be of boys) from 8 junior or senior high schools across
minimal risk and "educationally focused research the United States (California, Illinois, Kansas,
in which the school would retain the obligation to Massachusetts, North Carolina, Ohio, Pennsylva-
guard their students' interests as their parents nia, and Washington). Ethnic representation in-
would" (Dellinger, 1983, p 357). Adolescents cluded White (77%, n = 1,618), Hispanic Ameri-
indicated their voluntary assent to participate in the can (8%, n = 168), Asian American (7%, n = 147),
study by completing the survey form and returning African American (5%, n = 105), and others (3%,
it to the school nurse to be mailed back to the n = 63). Time taken to complete the study varied
investigators. with the type of respondent; for those without
tattoos, it took less than 5 minutes. For the tattooed
Procedure adolescent, the length of time was 15 to 20 minutes,
School nurses were recruited through a variety of depending on the amount of information provided.
school health networks and asked to facilitate All subjects were asked their interest in tattooing
distribution of the survey. Letters were also and reasons for refraining from tattooing. A major-
requested from the specific school administrators to ity of the subjects (55%, n = 1,156) were interested
acknowledge the school's participation. These were in tattoos. Reasons for not obtaining a tattoo
obtained for Institutional Review Board records. included permanent markings (23%, n = 483);
Seven sites received 500 surveys by mutual AIDS/HIV or other diseases (18%, n = 378); paren-
agreement of the school nurse and investigators; at tal disapproval (16%, n = 336); and pain (12%,
the eighth site, 150 surveys were sent on specific n = 252). Cost was not a deterrent (3%, n = 64).
request. Survey distribution instructions included Over one-fifth of the respondents (22%, n = 462)
information to maintain the respondent's anonym- stated there was no reason keeping them from
ity and confidentiality. The school nurse, the getting a tattoo.
classroom teacher, and the accessibility of students After these questions, subjects without tattoos
in the 7th grade through the 12th grade all entered (N = 1888, 90%) were thanked for their participa-
into the decisions of how classrooms were chosen tion and exited from the survey while the remaining
for survey distribution. Data collection was com- tattooed subjects (N = 213, 10%) completed the
pleted during class time, often in health education rest of the questions. Several adolescents without
classes. Surveys were distributed to each student in tattoos (4%, n = 76) tried to continue into the next
the classroom unless the adolescent did not want to section with specific questions about tattooing.
participate; no one refrained. Respondents placed They usually stopped by the sixth question as they
their surveys into a large envelope. Any completed did not have the applicable information to continue.
comment sheets were placed in a separate enve-
lope. Both were then sealed and directly sent to the Tattooed Adolescents
investigator. The 213 tattooed adolescents (55% [n = 117] of
From the 3,650 surveys that were distributed to 8 girls and 45% [n = 96] of boys) provided informa-
school sites, 2,212 (61%) were returned to the tion about their decisions and experiences before,
investigators. Reasons for not distributing the other during, and after the tattooing. Ethnic representa-
39% (n = 1,438) included lack of time to get to tion of the tattooed subjects were 61% Whites
numerous classrooms and special school circum- (n = 129), 21% Hispanic Americans (n = 45), and
stances, such as unexpected student testing and 10% others (n = 21); Asian Americans remained
crowded curriculum requirements. the same (8%, n = 18). Over half of the subjects
On return of the surveys, 111 surveys (5%) were (61%, n = 129) had one tattoo whereas 39%
TATTOOING: ADOLESCENT, HEALTH EDUCATION 185

(n = 84) had two or more tattoos. Some of the Table 2. Possession Risk Experiences
subjects (10%, n = 21) documented as many as six. of Tattooed Adolescents (n = 213)
Purchase Experience. The adolescent's pur- Situation Yes (%) n
chase experiences with tattooing are summarized
Personal responses
on Table 1. The mean age of their first tattoo was 14 Personal pleasure at tattooing 83 177
years (SD = 2.5) with most (87%, n = 185) Personal pleasure with tattoo now 81 173
obtaining their tattoos from 12 to 17 years of age. Concealed body area chosen 51 108
Over half of the tattooed adolescents (52%, Tattoo helpful, unique, & special 50 107
Tattoo not helpful 30 64
n = 111) had obtained their first tattoo during
Positive responses
grades 7 to 9, whereas another third (35%, n = 75) Friends 63 134
obtained their first tattoo during the 10th or l l t h Significant friends 45 96
grade. Siblings 22 47
Self-reported letter grades revealed tattooed ado- General public 11 23
Mother 10 21
lescents with As and Bs (56%, n = 119) at the time
Father 9 13
of tattooing; these grades remained for the majority
of the sample (59%, n = 126). Several remarks
(11%, n = 23) were received on the comment
Numerous reasons were reported for obtaining
sheets expressing their thoughts about the associa-
the tattoo such as "just wanted one" (44%, n = 94),
tion of grades and tattoos, for example, "grades
wanted to be independent/express oneself (23%,
have nothing to do with tattoos."
n = 49), and "for the heck of it" (16%, n = 34).
Over half (52%, n = 111) of the tattooed adoles-
Less than one third of the parents (28%, n = 60)
cents took a "few minutes" for their tattooing
were aware of the tattooing intention and 17%
decision and over one third reported major changes
(n = 36) signed consent forms; now, 62% (n = 132)
and stress in their lives (39%, n = 83) at the time of
of the parents know about the tattoo. Eight subjects
tattooing. Respondents had 309 tattoos; some of the
reported their parents also going to the studio when
designs included: initials/names (n = 55), crosses
they obtained the tattoo.
(n = 45), animals (n = 40), free-hand designs
The majority of tattooed adolescents (57%,
(n = 40), flowers (n = 35), cartoon/clowns
n = 121) labeled themselves "risk takers" at the
(n = 27), and hearts (n = 24).
time of tattooing and this remains a consistent
belief (58%, n = 124). Often, friends or a group of
Table 1. Purchase Risk Experiences of Tattooed people (70%, n = 149) were with them before
Adolescents (n = 213) tattooing. During their tattooing, other friends
(37%, n = 79) were also tattooed. Alcohol, drugs,
Situation Yes (%) n
or both, were used by some tattooed adolescents
Knew placement for body 87 185 (28%, n = 60) before the tattooing. Only 7%
Age 12-17 at tattooing 87 185
Pleased at time of tattooing 83 177
(n = 15) believed their friends applied pressure to
Knew design wanted 72 153 obtain the tattoo.
Had friends or group of people with him/her 70 149 Possession Experiences. Questions were asked
Parental knowledge of tattoo, now 62 132 about their personal response to the tattoo as well as
Describe themselves as a "risk-taker" 57 121 reactions from friends and family (Table 2). Many
Academic grades of As & Bs 56 119
Took " f e w minutes" for decision 52 111
report initial pleasure with their tattoo (83%,
Watched another tattoo procedure 51 108 n = 177) and continuing pleasure (81%, n = 173).
Reason for tattoo "just wanted one" 44 94 Body sites were equally distributed between
Changes & stress at time of tattooing 39 83 concealed (51%, n = 108) and exposed areas
Friends tattooed at same time 37 79
(49%, n = 105). When asked to describe how their
Experienced moderate-large amount of pain 35 75
Parental knowledge of tattooing, at time 28 60
tattoos were helpful, 50% (n = 107) replied "it
Used alcohol, drugs, or both, before tattooing 28 60 made me feel special and unique." The tattoo was
Comparison shopping of artists 27 58 not helpful to other respondents (30%, n = 64);
Parental consent for tattooing 17 36 they cited disappointment, embarrassment, and low
Reason for tattoo "for the heck of it" 16 34 self-esteem. Many chose not to answer these
Believed pushed into decision by friends 7 15
questions (56%, n = 119). Family support for the
186 ARMSTRONG AND MURPHY

tattoo (siblings, 22%, n = 47; mother, 10%, n = 21; Table 4, Differences Between Adolescents
and father, 9%, n = 19) was low in comparison to (N = 213) with Amateur and Studio Tattoos
positive responses from their friends (63%, n = 134) Tattoos
and significant friends (45%, n = 96). Amateur Studio
Health Experiences. Repeated needle injec- (n = 94) n (n = 119) n
tions of a foreign substance could predispose Youngest reporting (years) 8 10
subjects to health risks. Red and yellow pigments Number of tattoos (%)
were selected by 47% (n = 100) of the tattooed 1 49 46 68 81
adolescents, but only a small group of them (14%, 2 or more 40 38 30 36
Grade level (%)
n - - 3 0 ) reported short-term irritations, such as
Elementary 9 8 8 10
redness, dryness, or tender skin following tattoo- 7th 21 20 11 13
ing. No blood-borne diseases were reported but 8th 26 24 9 11
68% (n = 145) cite small to large amounts of bleeding 9th 21 20 13 15
during the procedure so the potential exists. 10th 14 13 24 29
1 lth 8 8 28 33
Purpose of the Tattoo. Twelve statements were
12th 1 1 7 8
presented as possible purposes of the tattoo; no Academic grades (%)
additional write-in comments were received. The As 14 13 38 45
most agreed-upon statement related to personal Bs 35 33 34 40
identity, "be myself, I don't need to impress people Cs 36 34 17 20
Ds 16 15 11 13
anymore" (81%, n = 173). Most of the respondents
Pleased, at time of tattooing (%) 70 66 93 111
disagreed or rejected the other statements (Table 3). Still like the tattoo (%) 75 71 82 98
Cronbach's Alpha for reliability of this scale Would do it again (%) 70 66 70 83
was .90. Parents still don't know (%) 41 39 36 43
Studio Versus Amateur Tattooing. Of the total
group of tattooed adolescents, 42% (n = 119)
obtained studio tattoos whereas 54% (n = 94)
reported amateur tattoos. Six percent reported
Table 3. Reported Purpose for Tattooing "other" in how the tattooing was done but
in Adolescents (n = 213) provided no further explanation. The differences
between those who obtained studio tattoos and
Strongly Strongly
Agreed/ Disagreed/ amateur tattoo are noted on Table 4. Those with
Item Agreed (%) Disagreed (%) n amateur markings started younger, were in lower
Be myself, I don't need to grade levels when they started (grades 7 to 9, 68%),
impress anyone anymore. 81 173 had more tattoos, and reported lower academic
Improve my social position. 92 196 grades (Bs and Cs, 70%). Those with studio tattoos
Do what another person
obtained them in higher grade levels (grades 9 to
expected. 89 190
Do what friends suggested. 88 187 • 11, 65%) and reported higher academic grades (As
Do what someone in my group and Bs, 72%). Straight pins or sewing needles,
strongly urged me to do. 88 187 pens, pencils, or other homemade devices (45%,
Make new personal associations n = 42) were used for the tattooing; many were
and friendships. 87 185
done in the home (66%, n = 62). Few gang-related
Help me be more acceptable to
my friends. 86 183 tattoos were reported (5%, n = 5), yet several
Do what people who love me (n = 13) describe tattooed dots on their hands and
say is important. 85 181 face (the configuration of the dot can explain a
Help me separate from my other certain gang).
life experiences. 85 181
Help me obtain more status and
Enforcement of Tattooing Regulations. State
prestige. 84 179 tattooing regulations (Tope, 1995) were compared
Help me feel better about with the respondent's location. Rate was deter-
myself. 79 168 mined by dividing the total amount of state par-
Help people judge me for who I ticipants into the amount of tattooed individuals in
really am. 64 134
the state study. Massachusetts, which prohibits all
TATTOOING: ADOLESCENT, HEALTH EDUCATION 187

tattooing, in this study had a 6% rate of tattooing, takers (57% from 45%), and an earlier age ratio
with 17% of those adolescents obtaining parental (ages 12 to 17 from 14 to 18 years of age) when the
consent. Illinois and North Carolina prohibit tattoos were obtained.
tattooing of minors. Study data indicate rates of Potential health risks were present and definite
10% and 6% respectively, with low rates (15% and psychosocial findings of purchase and possession
30%) of parental consent. California permits risks occurred. This builds on the data of the
tattooing of minors with parental consent. Respon- Armstrong mad McConnell study (1994b), and is
dents from this state had the highest tattooing rate evident by "the whimsical and short decision-
(14%), with 5% obtaining parental consent. making for the tattoos, the early age of tattooing,
the exposed body locations, the visual messages of
DISCUSSION AND IMPLICATIONS the tattoos, and the lack of support by parents and
This research expands on earlier work by Arm- siblings" (p. 123). Findings indicate that adoles-
strong and McConnell (1994b) and queried adoles- cents who want a tattoo will obtain one, regardless
cents (N = 2101) regarding their interest in tattoo- of money, regulations or risks. Older adolescents
ing and major reasons to refrain from tattooing. have cars and money to obtain studio tattoos
Respondents from this study were located in 8 whereas younger adolescents create their own
states across the country as compared with the marks or asks friends to tattoo them. Additionally,
Armstrong and McConnell (1994b) study con- when laser therapy for tattoo removal is perfected,
ducted in one state. Two findings were of interest cost-effective, and accessible, tattooing will in-
regarding both groups of nontattooed adolescents. crease because it will be easier to "undo" the tattoo
First, they agreed on the same reasons for refrain- (Anderson, 1992; Armstrong et al., 1996).
ing from tattoos, namely permanent markings and Proactive development of credible health educa-
the concern of AIDS and other diseases. Secondly, tion for all three educational levels of schools
tattooing interest in this study was 55% compared (elementary grades, junior high, and senior high)
to 33% in the Armstrong and McConnell study becomes important, the mean age (14) in tattooing
(1994b), conducted 2 years previously. This tattoo and the young age of one respondent who started
interest could be attributed to regional differences tattooing at 8 years of age. Yet, developing educa-
as well as increased role models and coverage tion for adolescents is challenging, especially when
about tattoos in the media. many adolescents believe they have a "right to
Those with tattoos were asked about their experi- have a tattoo" (Armstrong & McConnell, 1994a, p
ences and decisions surrounding the tattooing. Data 28). Careful incorporation of the two major areas
from the tattooed adolescents were similar to the that cause the nontattooed respondents the most
Armstrong and McConnell study (1994b). The concern with tattooing would be important to
similarities include the academic grades, the single address within health education. Keller, Duerst, and
and multiple tattooing, the bleeding during the Zimmerrnan (1996) promote incorporation of some
procedure, the exposed body locations, the major fear in health education; they believe it can be
changes and stress, and the responses from families constructive when there is a action plan so learners
and friends. Only a small group of respondents move toward different health behaviors. Thus,
reported alcohol or drug use. Both groups were in informed decision-making could be promoted in
strong agreement about the purpose of their tattoo, health education by incorporating information about
"be myself, I don't need to impress anyone any- the possibility of blood-borne diseases, permanent
more." Profiles of those with amateur and studio markings, and themselves as growing and changing
tattoos were also the same. people. Hopefully this will produce dissuasion, or
Several experiences occurred with greater fre- at least minimize risks, by encouraging specific
quency in this study than in the Armstrong and questions if they insist on tattooing (Armstrong &
McConnell study (1994b). The percentage of tat- McConnell, 1994a). Following these studies, a
tooed adolescents in the samples rose from 8.6% to bilingual brochure and health education video were
10%. There was an increased number of girls (55% developed, field tested, and initiated for nurses and
from 35%), more impulsiveness in the decision for health educators in schools to talk about tattooing.
tattooing (52% from 41%), an increase of risk As noted in the subjective data provided by the
188 ARMSTRONG AND MURPHY

respondents, the view points of the adolescent and able social and environmental situations that emu-
adults about tattooing differed, in both studies. late from adult risk-taking practices (Tonkin, 1987).
Adolescents view the tattoos as objects of self- The influence of risk-taking with tattooing can be
identity and body art whereas adults perceive the noted with factors, such as interest, prevalence of
markings as deviant behavior. Irwin (1987) be- tattooing, impulsive decision making and the age of
lieves that adolescents often realize that certain tattooing. Many times those who are risk takers are
actions are risky, yet still engage in the behavior often unaware of the consequences of the behavior
because of the perceived associated psychosocial they have chosen. Greater multiple risk-taking
value. From the adolescent's perspective, they were situations were present with those obtaining ama-
very positive about their tattoos with the majority teur tattoos as their risk-taking behavior began
describing how the tattoo(s) were helpful in "feel- earlier in their teenage years (Irwin & Millstein,
ing special and unique." Yet, parental response for 1986). Gender distribution is also interesting as
the tattoos was consistently low, around the 10% more than half of the tattooed adolescents were
range. Some respondents describe dlsappointment, girls. This supports the Keyes and Block (1984)
embarrassment, and low-self-esteem experiences befief that greater risk-taking behaviors are present
when others viewed their tattoo(s). This is unfortu- in adolescent girls because of their earlier matura-
nate at a time when adolescents are concerned tion.
about themselves, their image, and their appear- Is tattooing among adolescents just a "trend,"
ance. another fad that will go away? For tattooed adoles-
This profile of the tattooed adolescent is some- cents, psychosocial and health risks are compound-
what different than the descriptions found in the ing adolescence, a time already filled with psycho-
American medical literature (Burma, 1959; Farrow social pressures. Tattooing in adolescents is
et al., 1991; Fried, 1983; Litt, 1994). Although the increasing and needs to be added to the "growing
"risk-taker" and impulsive decision making charac- lists of previously ignored, important public educa-
teristics were consistent, a large group of these tional issues" (Armstrong et al., 1996, p 415).
tattooed adolescents were academically successful Incorporating questions in national and state adoles-
A and B students indicating an overall wider cent health risk surveys will maintain surveillance
distribution for this risk-raking behavior than previ- about tattooing so further quantitative information
ously thought. Few tattooed adolescents in both can be obtained. Additionally, two primary health
studies mention gang affiliation or gang-related elements for community adolescent advocacy are
tattoos. equally important; including applicable health edu-
Adolescence can be a vulnerable time for health cation projects and furthering consumer adolescent
compromising risk taking. Today, many adolescent advocacy roles to implement effective local and
risk-taking behaviors stem from various prevent- state tattoo licensing regulations.

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