Serap Balci  ( Department of Pediatric Nursing, Istanbul University, Florence Nightingale Nursing Faculty, Istanbul, Turkey. )
Emine Sari  ( Department of Public Health Nursing, Selçuk University, Faculty of Health Sciences, Alaeddin Keykubat Campus, Konya, Turkey. )
Birsen Mutlu  ( Department of Pediatric Nursing, Istanbul University, Florence Nightingale Nursing Faculty, Istanbul, Turkey. )

Objective: To assess the frequency of piercing and tattooing among university students and to determine the extent of risk-taking behaviour in this age group.
Method: The descriptive cross-sectional study was conducted at a university in Istanbul, Turkey, from December 2009 to February 2010. Data was obtained from students through a questionnaire. SPSS 20 was used for statistical analysis.
Result: Of the 1303 subjects, 838(64.3%) were girls. The overall mean age of the sample was 21.7±1.9 years. A total of 107 (8.2%) had piercings and 56(4.3%) had tattoos. It was seen that young people who had piercings and tattoos were significantly more likely (p<0.05) to exhibit certain types of risk behaviour including smoking, alcohol, substance abuse, extreme sports, carrying switchblades/knives,  unprotected sexuality and having multiple sex partners.
Conclusion: In the face of the steadily increasing fads of piercing and tattooing among the youth, families, teachers and health professionals need to be constantly on the alert.
Keywords: Piercing, Tattooing, Risk behaviour. (JPMA 65: 587; 2015).


Introduction

Piercing is the process of creating a hole in the skin, subcutaneous tissue or cartilage in order to be able to insert jewellery.^1,2 A tattoo is a form of body modification done by inserting indelible ink into the dermis layer of the skin to change the pigment.³
In today\'s world, piercing and tattoos have steadily become more popular, particularly among young people as a means of self-expression or being different, and new social and cultural movements continue to support the popularity of such practices.^1,4-7 In developed countries, the prevalence of body piercing is reported to be between 4.3%-51%.8⁸ Piercing and tattooing that is performed under unhygienic conditions, however, can cause certain complications. Some of these are nerve injuries, allergic reactions, infections, bleeding, aspiration, Hepatitis B, C and D, human immunodeficiency virus (HIV), syphilis and tetanus.^1,2,4,6,7,9
It has been suggested that there might be an association between risk behaviours and piercing and tattooing practices.^{2,4,6,7,10,11} It is for this reason that health professionals must be aware of the issues that are caused by piercing and tattoos, which are fads that are steadily increasing among young people today, and also of their association with risk-taking behaviour. They must provide young people, families and teachers education and guidance.^8,9,12-14
The current study was planned to assess the frequency of piercing and tattooing among university students and to determine the extent of risk-taking behaviour in this age group.


Subjects and Methods

This descriptive cross-sectional study was conducted at a university in Istanbul, Turkey, from December 2009 to February 2010. The study universe comprised 55,900 undergraduate students enrolled at the study site. The sample size was determined using the formula [n=N.t2.pq/d2(N-1)+t2.pq] for the main cluster cut-off.¹⁵ The average prevalence of piercing and tattoo (p) at a confidence interval (CI) of 95% (alpha=0.05) and a deviation (d) of 0.02 was 20% (4.5%-23% for tattoos, 27% for piercing).⁶ Acceptable sample size was thus determined to be 1484.
After obtaining permission from the university administration and written consent from the students, a questionnaire was used as the data-collection instrument. Developed on the basis of literature,^9,16 it consisted of 5 open-ended and 55 multiple-choice questions.
The data was evaluated using SPSS 20. Descriptive statistics (frequency, percentage, mean and standard deviation) and chi-square test were used to determine the association between the variables. Results were evaluated assuming a 95% CI and a significance threshold of 0.05.


Results

To meet the sample size requirements, 1484 subjects were enrolled, but 181(12%) students returned incomplete questionnaires and the final study sample stood at 1303(88%) students.
The mean age of the students was 21.69±1.55 years and there were 838(64.3%) girls. Overall, 442(34%) students had mothers who were elementary school graduates; 407(31%) had fathers with university degrees; 1049(80.5%) were part of a nuclear family type; 1133(87%) had health insurance; 449(34.5%) were living with their families; 433(33.2%) in a dormitory; 338(25.9%) with friends; and 83(6.4%) with relatives (Table-1).


Among the subjects, 107(8.2%) had piercings. The parts of the body involved were ears 59(55.1%), nose 35(32.7%), eyebrows 24(22.4%), lips 18(16.8%), navel 14(13.1%), tongue 9(8.4%), and nipples 4(3.7%). Among those who said that they had followed a role model, were 15(71.4%) named a friend. In 28(53%) cases, the families first opposed the idea and then accepted it, while 83(77.6%) said they knew the risks involved in piercing and 62(57.9%) stated that they did not think they would have it done again (Table-2).


As for the tattoos, 56(4.3%) students had them. The parts of the body involved were predominantly the shoulders 23(44.2%), back 18(34.6%), and the arms 14(26.9%). Among those who said they had followed a role model, 7(70%) named a friend, while 44(78.6%) stated that they were not interested in having it done again (Table-3).


The number of students who had both piercings and tattoos was 18 (1.38%).
There was a statistically significant association between having piercing done and the students\' risk-taking habits of smoking (p<0.001), drinking alcoholic beverages (p<0.001), addictive substance use(p<0.05), taking stimulant substances/pills (p<0.05), engaging in extreme sports (p<0.001), getting into fights and frequently sustaining injuries (p<0.05), carrying sticks/switchblades/gas sprays (p<0.001), suffering frequent bouts of depression and engaging in unprotected sex (p<0.001) (Table-4).


There was a significant association between getting tattoos and the students\' risk-taking habits of smoking (p<0.01), taking alcohol (p<0.01), addictive substance use (p<0.01), use of stimulant substances/pills (p<0.01), engaging in extreme sports (p<0.01), carrying sticks/switchblades/gas sprays (p<0.01), engaging in unprotected sex (p<0.01), and frequently changing sexual partners (p<0.05) (Table-5).




Discussion

The practice of piercing is steadily becoming more widespread in Western societies.^11,12,14 Studies have indicated differing prevalence rates of 26.1%,10 32%,¹⁷ 53%,¹⁶ 56%,6 63%,¹³ and 33%,¹⁸ for piercing, and 13.2%,¹⁰ 22%,¹⁷ 23%,¹⁶ 73%,¹³ 24.5%,¹⁸ for tattooing among the young population. The rates found in the present study, however, were lower: 8.2% for piercing, and 4.3% for tattoos.
An observation of the parts of the body which the students had pierced showed that the majority had their piercings in the ear cartilage (55.1%), on the nose (32.7%) and eyebrows (22.4%) and that tattoos were mostly found on the shoulders (44.2%), back (34.6%) and arms (26.9%). Other studies too have reported similar results,^12,16,19 indicating that piercing is predominantly done in the facial area (e.g., ears, eyebrows, nose, tongue, lips) and that tattoos are mostly seen on the back, shoulders, arms and legs.^12,16,19,20
In this study, the students\' friends were the primary persons they modelled themselves after in deciding to get a piercing (70%) or tattoo (50%). A study stated that friends were an important factor in the decision to have piercing or tattoos done.¹⁷ A study with 536 university students, found that 98% of the students had at least one friend with piercings.⁹
Particularly in adolescence, friends/peers are very important for young people. While friendships help young people in their search to understand and better express themselves and also provide benefits in terms of developing positive feelings of self-esteem and empathy, they can at the same time have adverse effects in terms of stimulating young people to adopt risk-taking behaviours.²¹ This is why families need to be careful about the friends their children make and why it is important that they guide them in the right direction.
Half of the young people in the study group admitted that they had not told their families that they would be getting body piercing (50%) or tattoos (50.5%). Most of the students said that their families first objected to the piercing, but that they had finally resigned themselves to accepting it in the end; young people who got tattoos said that their families were completely against it. This might be because tattoos are more permanent compared to piercing. In addition, the reason why half of the young people did not share their intention with their family members may have stemmed from the fact that these were university students and therefore were adults.
Most of the young people in the study said that they had gotten their piercing (85%) and tattoos (80.4%) at a reliable establishment. One study reported that 73.8% of the young people had gotten their tattoos from trained professionals, but that 18% said that they had gone to non-professionals; 7.7% said they were not sure about whether or not they had been served by professionals.¹⁰ Another study reported that young people have piercing and tattoos done with sterile or new needles.¹² A study²² on adolescents reported that the subjects had their piercings and tattoos executed by professionals, and another study found that 88% of the students had piercings and tattoos done by professionals and that these persons complied with the universal precautions.¹³ One study reported that 53.6% of the students had their piercings and tattoos done at professional establishments and also that sterile and disposable instruments were used in the procedures in the case of 70.6%.¹⁸ These findings are a positive indication that young people generally contact reliable establishments to get their piercings and tattoos. It must not be forgotten, however, that young people who do not have their piercings and tattoos performed under suitable conditions are at risk.
The present study showed that the students who experienced problems after piercing generally suffered from infection/bleeding, difficulty in hearing, localized loss of sensation, rash, echymosis (Table-2); while students who complained of problems after getting their tattoos generally experienced infection, bleeding, pain, allergies and similar complications (Table-3).
A study has reported post-piercing complications such as septic arthritis, glomerulonephritis, endocarditis, Hepatitis B-C, jewellery aspiration, speech disorders, dental injuries, and sometimes occurrences of osteomyelitis, bacteraemia, and toxic shock syndrome.⁶ Another study found prevalence of problems such as skin irritations, infections, bleeding, allergies, swelling and other side effects following piercing and tattooing;¹¹ Infective endocarditis and dental problems, particularly in tongue piercings, have been reported¹⁴ and the development of complications such as infection, scar tissue, allergic reactions, HIV, Hepatitis B-C, tetanus and tuberculosis in young people with piercings have also been noted in literature.⁹
Complications after tattooing are reported as, among others, infections (e.g., bullae, rashes, pain) and skin irritations (rashes, dry skin, sensitivity).^8,11,13
The complications observed in the young people in the present study were similar to the complications reported in literature. The fact that more serious problems were not seen in the study group (Hepatitis B-C, HIV, osteomyelitis, etc.) may have been because the students chose less risky body parts such as the vicinity of the ear for their piercings, and also because they had applied to reliable establishments for both the piercing and tattooing procedures.
It was observed that most of the students in the study who had gotten piercings or tattoos were thinking of having more done (Tables-2-3). A study found that 63% of the students had the intention of getting another piercing and that 64% were thinking of getting another tattoo.¹⁷ Under the circumstances, it is imperative that young people receive education about the risks of piercing and tattooing and that the importance of having these performed by professionally trained people under sterile conditions is impressed upon them. Under the circumstances, it is imperative that young people receive education about the risks of both piercing and tattooing and if they decide to have these done, the importance of having these performed by professionally trained people under sterile conditions should be impressed upon them. It is also of importance that professionals who perform these procedures are educated in infection control and universal precautions.
It has been seen that young people with piercings and tattoos are more likely to exhibit certain types of risk behaviour and that this association is significant (p<0.05) (Tables-4-5).
Studies have reported that the prevalence of unprotected sex, smoking, drinking and the use of stimulant substances and pills was more prevalent among young people with tattoos and piercings.^4,17 One study reported that harmful behaviour such as eating disorders, substance/drug abuse, unprotected sex and suicide attempts were more frequently seen among youth with piercings and tattoos and that the association between these practices and risk behaviour was significant.¹⁰ Another study pointed at a more frequent and significant incidence of sexual intercourse, running away from home, suicide attempts, smoking, drinking and drug use among young people with piercings and tattoos; the same study, however, found no association between these practices and acts of violence.⁵
One research reported that among the risk behaviour exhibited by young people with piercings and tattoos, the use of alcohol and drugs has been seen to be 3.1 times more prevalent than other behaviour.¹²
One study stated that more than half of the students (53%) were using alcohol, 39% took drugs, and 40% had from 1-5, 24% from 6-10, and 26% had 11 or more sexual partners.¹³
One study reported that there was evidence pointing to an association between risk behaviours and piercing and tattoos among the youth. It is asserted that tattoos and piercings may be considered markers for such risk behaviour as unprotected sexual intercourse, alcohol and drug use, eating disorders and suicide.¹⁴
Our results were generally similar to those of prior studies, supporting the observation that risk behaviour is more frequently seen in young people with piercings and tattoos. It is for this reason that it is important that young people with piercings and tattoos are watched closely and that support should be provided to youth at risk.


Conclusion

An effort should be made to reduce the frequency of piercing and tattooing and awareness should be raised among the community and among teachers and parents about the health problems that these practices may be responsible for. Young people who have piercings and tattoos should be informed about the health issues that such practices may cause and should be directed to youth centres where they can be tracked in terms of risk-taking behaviour. Whenever necessary, they should be provided assistance in learning to cope with their own risk-taking behaviour.


Acknowledgements

We are grateful to Sevim Savaser, Saniye Cimen and university students for their support.

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