Effects of body modification are more than just skin deep

October 16, 2017

AAP’s first ever clinical report on body modification guides pediatricians on medical precautions and counseling practices.

Like it or not, teenagers and young adults are embracing body modification, making it more commonplace and accepted than in previous generations, where tattoos and piercing were mostly seen in high-risk groups.

With increased acceptance comes increased prevalence, and parents and pediatricians should know how, where, and why teenagers are choosing body modification.

Cora Collette Breuner, MD, MPH, FAAP, a pediatrician specializing in adolescent health and chair of the American Academy of Pediatrics (AAP) Committee on Adolescence, helped craft the Academy’s first-ever guidance on body modification. She says parents and pediatricians have to be educated when it comes to knowing the rules and regulations of body modification in their state, as well as the risks and complications of such procedures, so they can guide adolescents in their decision making.

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“Our hope from the AAP and from the Committee on Adolescence is that pediatricians and other healthcare providers will learn how to guide their young adults on making a decision about body modification,” Breuner says. “An informed young adult is one who can make a decision that [he or she] hopefully can make which will not lead to a complication and definitely lead to no regret.”

Previous reports on body modifications have focused on high-risk and at-risk teenagers, but tattooing and piercing are no longer seen as activities limited to high-risk populations. More and more adults and teenagers have tattoos and body piercings, with a 2010 report estimating that 38% of persons aged 18 to 29 years had at least 1 tattoo and 23% had piercings in places other than the earlobe. The mainstream nature of piercings and tattoos today has not removed the risk associated with them, however, and pediatricians and parents should be aware of the possible medical complications and safety issues.

Body modification is increasing in popularity, according to the report, which cited a 2016 Harris poll estimating that the popularity of tattoos was up 20% since 2012. Few adults polled about their tattoos regret getting them, with most revealing that it makes them feel rebellious, strong, attractive, or spiritual. As far as popularity among teenagers goes, the report cites 1 study conducted across 8 states that found that 10% of high school students already had tattoos and 55% had an interest in getting one. Other polls place prevalence of tattoos in the 12-to-22-years age group at 10% to 23%, and body piercing in places other than the earlobe at 27% to 42%.

College students also favor body modification, with 23% having tattoos and 51% reporting body piercings, according to the report. Male athletes were more likely than nonathletes to have tattoos, and piercing was more common among women, the committee states. In terms of what types of piercings are popular, upper ear cartilage piercing (53%) was the most common visible piercing, followed by the navel (38%) and tongue (13%). About 9% of college students reported having nipple or genital piercings.

Whereas tattooing and piercing used to be associated with high-risk groups engaged in drug and alcohol use, violence, or self-harm, this is not the case today, the researchers say. However, pediatricians are still advised to conduct careful psychosocial assessments with teenagers to help decrease high-risk behaviors through targeted behavioral interventions. Body modification is not the same as nonsuicidal self-injury (NSSI), the report clarifies, which is often impulsive or compulsive and associated with mental health disorders.

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Public opinion regarding tattooing and piercing is changing as well, particularly among those aged younger than 50 years. However, societal acceptance doesn’t mean there aren’t consequences for body modification. The report reveals that employers still cite tattoos as a limitation when it comes to career potential, and adolescents should be counseled about the visibility and potential consequences later in life of their body modification choices.

The report also reveals that although most teenagers and young adults are aware of the risk of contracting human immunodeficiency virus from tattooing and/or piercing, less were aware of the risks of hepatitis and tetanus or noninfectious medical complications.

The report details the processes used for tattooing, as well as the recommended care of new tattoos. Pediatricians and parents should be aware that although the process for tattooing is generally safe, many tattoos are done by amateurs who may not follow antiseptic procedures, therefore increasing the risk of complications. In addition to infectious complications, tattoos can result in inflammation, neoplasms, and even vasculitis. Preexisting conditions such as psoriasis, systemic lupus, and sarcoidosis may activate the Koebner phenomenon, leading to new lesions at the site of the tattoo. Still, infections are the more serious complication of tattooing, and can be caused by contaminated ink or needles, or contamination or injured tissue during the healing process.

For individuals who don’t experience complications but later regret a tattoo, removal is an option, but it is both expensive and painful.

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In regard to piercing, there are also concerns about infection. Body piercing salons are unregulated in many states and ear piercing guns are generally not sterilized between uses. For this reason, some physicians may choose to perform body piercing in the clinical setting. Popular choices for body piercings include ears, cartilage, nose and septum, navel, lips, cheeks, the tongue, and dermal piercing. Attention must be paid to the location of the piercing and the appropriate jewelry type to avoid complications during the healing process.

Similar to tattooing, piercing carries a risk of infection ranging from local to severe to life threatening. Bloodborne pathogens can be transmitted, and infection can also result from poor sanitation during the piercing or healing process. Individuals with atopic dermatitis or allergic metal contact dermatitis are at increased risk of developing staphylococcal or streptococcal skin infections.

Generally, the clinical report cautions pediatricians to assess adolescents and young adults interested in body modification for NSSI syndrome, and to educate them on the possible significant consequences both for their health and future career. Teenagers and their parents should be reminded that tattoos are permanent, and that removal may not be entirely effective in addition to being painful and expensive. Education should be provided on finding safe, clean locations for tattooing and piercing, as well as the risks of possible scarring and/or medical complications. Pediatricians should also counsel teenagers and their parents about when to seek medical attention in the event of a complication, and how to care for new tattoos or piercings.

“Healthcare providers, parents, and young adults considering tattoos or piercing need to be aware that there are risks and that they should be prepared with up-to-date immunizations,” says Breuner. “They should also be knowledgeable about complications and contraindications including if they have immunodeficiency disease.”