research on body modification

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• Published: 24 January 2023

Deviance as an historical artefact: a scoping review of psychological studies of body modification

• Rebecca Owens   ORCID: orcid.org/0000-0002-6630-5216 1 ,
• Steven J. Filoromo 2 , 3 ,
• Lauren A. Landgraf 4 ,
• Christopher D. Lynn 3 &
• Michael R. A. Smetana 3  

Humanities and Social Sciences Communications volume  10 , Article number:  33 ( 2023 ) Cite this article

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• Social anthropology

Body modification is a blanket term for tattooing, piercing, scarring, cutting, and other forms of bodily alteration generally associated with fashion, identity, or cultural markings. Body modifications like tattooing and piercing have become so common in industrialised regions of the world that what were once viewed as marks of abnormality are now considered normal. However, the psychological motivations for body modification practices are still being investigated regarding deviance or risky behaviours, contributing to a sense in the academic literature that body modifications are both normal and deviant. We explored this inconsistency by conducting a scoping review of the psychological literature on body modifications under the assumption that the psychological and psychiatric disciplines set the standard for related research. We searched for articles in available online databases and retained those published in psychology journals or interdisciplinary journals where at least one author is affiliated with a Psychology or Psychiatry programme ( N  = 94). We coded and tabulated the articles thematically, identifying five categories and ten subcategories. The most common category frames body modifications in general terms of risk, but other categories include health, identity, credibility/employability, and fashion/attractiveness. Trends in psychology studies seem to follow the shifting emphasis in the discipline from a clinical orientation regarding normality and abnormality to more complex social psychological approaches.

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Introduction

Body modifications in general and tattooing in particular have increased in popularity steadily over the last 50 years in England, the United States, and other industrialised countries (Burns, 2019 ; DeMello, 2000 ; Statista Research Department, 2021 ). The culture around tattooing and other body modifications in the developed and developing countries has shifted rapidly; however, attitudes can be resistant to change. Moreover, while pictures of tattoos and other body modifications populate Instagram and other visually oriented social media platforms, a recent opinion piece from The Times that enjoyed a wide circulation during the writing of this article (“Seeing tattoos makes me feel physically sick: Ubiquity of body art is born out of an existential crisis of humanity in the post-religious world” by Melanie Phillips, 2022 ) supports the notion that mainstream attitudes may lag behind cultural portrayals.

There are numerous means to permanently modify the body (Table 1 ), so this is potentially a vast literature. The contemporary history of all body modifications is beyond the scope of this article, but we recommend interested readers consult Pitts-Taylor ( 2003 ), Eubanks ( 1996 ), Vale and Juno ( 1989 ) as but a few examples. However, the body modification literature focuses primarily on tattooing, so a short history at least of tattooing may be illustrative.

Tattooing and body modifications in general are likely as old as the human species based on multiple lines of circumstantial evidence. The oldest evidence of permanent modification comes from the teeth of a Late Pleistocene hominid from Olduvai Gorge in Tanzania, Africa (12–20 k years old) (Willman et al., 2020 ), while the tattooed mummy commonly known as Ötzi is currently the oldest definitive evidence of tattooing (Deter-Wolf et al., 2016 ). Tattooing has been practiced around the world and was well-known to Europeans before colonial navigators began exploring the world’s oceans but appears to have waned in popularity with the rise of nation-states (Buss and Hodges, 2017 ). Nevertheless, when Captain James Cook encountered tattooed peoples throughout the Pacific, the facial tattooing and patterns observed were so striking that the Polynesia word tatau (meaning, “to strike”) was picked up by Cook’s sailors to describe what they had seen and in some cases experienced (Douglas, 2005 ). Missionaries and other colonial agents suppressed tattooing as non-Christian in many parts of the world, but some tattooing traditions were maintained through this period and have resurged in popularity (Buss and Hodges, 2017 ; Caplan, 1997 , 2000b ; DeMello, 2000 ).

Tattooing in Europe and North America were popular as both exotic collections of the wealthy or the souvenirs of soldiers and sailors until the invention of the electric tattoo machine (Caplan, 1997 ; Lodder, 2013 ). In the nineteenth century, Thomas Edison’s newly invented electric pen was modified by Samuel O’Reilly in the United States to patent the first electric tattooing machine. The further development of tattoo machines prompted the appearance of tattoo parlours in major cities throughout Europe and North America, where tattoos became affordable for the working classes and extremely popular (Lodder, 2013 ). As tattooing flourished among the poor and penal populations swelled, especially among urban poor, attitudes toward tattooing shifted. Criminologists began collecting the skin of deceased tattooed people, which were used to categorise and diagnose tendencies toward criminality and mental illness (Angel, 2017 ; Lodder, 2013 ). Though multiple competing models of deviance were developed, the focus in the writings of nineteenth century criminologists on “the soldier, seaman, or ‘recidivist’” belies the fact that British royal military figureheads may have played a part in reinvigorating interest in pilgrimage and souvenir tattoos that persisted beyond the era (Angel, 2017 ).

The effort to taxonomically categorise criminal tendencies was a failure in terms of identifying deviance, but it may have helped create the stigma it sought to describe, along with associations being made between tattooing and lower social classes in Europe and North America (Bradley, 2000 ; Caplan, 2000a ). The working-class popularity of tattooing waxed during the twentieth century with the two world wars, as military and non-military alike collected patriotic emblems, but popularity waned after the wars. The uniforms of working-class professions increased the visibility of tattoos, and such visible tattooing also became negatively associated with groups adjacent to the working class, like bikers and gang members (DeMello, 2000 ). These were not the first concerns and class, as fears about tattooing among minors and erotic designs appearing on women led to efforts to legally suppress tattooing in Germany in the 1910s and in the United States in the 1930s (Govenar, 2000 ; Oettermann, 2000 ). Negative associations with tattooing finally led to a complete ban in New York City in 1961 due to a purported concern over hepatitis transmission, which had a ripple effect across the United States that persisted until the ban was lifted in New York in 1997 (McCabe, 1997 ).

Pressure from city health departments all over North America led to innovations in tattooing by artists seeking to revitalise the industry. As a study of legal dynamics of tattooing in Vancouver, Canada makes clear, the pressures from health departments led to changes that, over the succeeding decades, have become local law (Jelinski, 2018 ). These innovations set the stage for what Rubin ( 1988 ) called the “second tattoo renaissance,” a resurgence in the popularity akin to the uptick after the electric tattoo machine was invented. As one of us (Lynn) observed first-hand, tattooing seemed to explode in popularity in New York City and throughout North America and Europe after New York City’s ban was lifted, though speculation and stigma about the psychology of modified individuals remains.

The mystery around tattooing and body modifications in general is not why people engage in them—the real enigma is how and why the symbolic importance of body modifications (or any cultural practice) changes societies over time or in response to sociocultural factors. Don Ed Hardy, one of the foremost tattoo artists of the second tattoo renaissance, points out that tattoos are windows into the psyche but also like “Geiger counters for people’s fears” (Vale and Juno, 1989 , p. 51), telling more about the viewer of the tattoo than the wearer. Given social and technological changes that have fuelled the body modification renaissance of the past 50 years, it is important that the granularity of our research questions and designs follow similar evolutions.

As body modifications have increased in global popularity, so too have studies of body modifications proliferated in a way that is theoretically and methodologically diverse. Despite this, we were surprised to find recent studies that seemed to take antiquated theoretical perspectives by framing research in terms of correlations with risk behaviour (e.g., Broussard and Harton, 2018 ). Why do researchers continue to revisit the notion that people with body modifications represent or are from stigmatised groups despite the overwhelming number of studies indicating that body modifications more accurately reflect prosocial rather than anti-social means of social communication (examples of significant treatments include Atkinson, 2004 ; Lingel and Boyd, 2013 ; Pitts, 2003 )? To address this question, we conducted a scoping review of the psychological literature on body modifications.

First, we established which body modifications were relevant to this review. The term “body modifications” is broad and can include everything listed in Table 1 , as well as extreme dieting, bodybuilding, cosmetic procedures (e.g., lip fillers and muscle relaxing injections) and surgeries (e.g., breast augmentation and fat removal or displacement), and even hair dying. However, for this scoping review, we opted to include only invasive, voluntary body modification processes done outside of medical contexts. To focus on discipline-specific approaches that might explain the persistence of stigmatisation in the literature, further inclusion criteria were: (1) research published in peer-reviewed psychology journals or multidisciplinary journals; (2) where papers are published in multidisciplinary journals, at least one of the authors is a psychologist or psychiatrist (deduced by affiliation); (3) papers published in English; and (4) research is empirical or theoretical (primary source, not a review). Research was excluded if these criteria were not met. Qualitative and quantitative research was eligible, and all years of publication were included in the search.

We searched the following databases on 13 April 2020 and updated on 17 May 2021: Embase Ovid, Web of Science, EBSCOhost and PubMed. The search specified tattoo* OR piercing OR scarification in the title AND feeling OR motivation OR attitude OR perception in the abstract. Further searches across these databases were conducted for “extreme modification” in the title OR in the abstract to try and identify any relevant journal articles regarding less popular forms of body modification. Search results were filtered to journal articles only and limited to relevant academic disciplines (for example, psychology, psychiatry, social sciences). We conducted a final search of Google Scholar on 7 April 2022 for any new relevant publications. Finally, ad hoc articles were found in the course of research through miscellaneous means, such as through being referenced in another article.

Through title screening, we identified 297 articles from the four databases and 21 from other sources (Fig. 1 ). We removed 54 duplicate articles identified in multiple databases. We used the inclusion/exclusion criteria for final sample determination. Articles for which study objectives or author affiliations were unclear were examined closely by all five co-authors and discussed further. For instance, several articles on body modification appear in the interdisciplinary journal Deviant Behaviour by authors from various disciplines, so only those by authors with express affiliations to psychology or psychiatry were retained. Other close-but-no cases were an article in the journal Art Therapy by an art therapist and several articles in nursing journals by nursing faculty exploring tattooing motivations and identity-formation. Art therapists are sometimes psychologically trained, so we examined the credentials of the author, and, since the degrees were in counselling and therapy but not psychology or psychiatry explicitly, the article was excluded. The nursing articles are like the psychology/psychiatry journal articles thematically in their focus on motivations and stigma, but they do not meet inclusion criteria for author affiliations. This process led to the exclusion of 171 articles, leaving 94 eligible for analysis.

PRISMA flow diagram of the scoping review process.

Our team of five co-authors met weekly over the course of a year to read and discuss coding of articles. First, we divided the articles up among our team, read 5–10 each, and identified salient themes. We then met to discuss the themes we had identified and repeated this process multiple times. Through this iterative process, we determined that the best way to assess the corpus of psychological studies of body modifications would be to categorise them based on their stated or implied study objectives. Therefore, we reshuffled the articles and divided them evenly among the five team members, and each team member categorised the articles based on the specific or apparent objectives of each article’s authors. We then met as a team and discussed the coding of each article; if the team was not in agreement, we discussed until we reached consensus on the final set of categories and subcategories and the categories to which each article should be assigned. Ad hoc articles discovered during the process were reviewed together and assigned categories by the entire team.

In addition to themes, we coded articles based the demographic focus of the study (e.g., college students, women, prisoners, etc.), what country the study took place in and whether they were in-person or online studies, the methods used, and gaps or critiques of the literature identified by the authors. After coding the articles, we reread the articles within each section in order of publication date to see what theory authors were drawing on and, a task which elicited some additional articles and shed light on temporal changes in Psychology as a discipline.

We identified 69 articles about tattooing only, 18 about tattooing and piercing, 6 about piercing only, and one article about multiple forms of body modifications, including scarification, tattooing, piercing, and other forms.

Table 2 outlines the categories that most appropriately characterise the objectives of each article. The most common sample among psychology articles examining body modifications was a general Euro-American population ( n  = 33), followed by college students ( n  = 22), women only ( n  = 9, including one that sampled women only but asked about men), prisoners or convicts ( n  = 7), patients ( n  = 6), youth ( n  = 4), specific job roles ( n  = 4), general tattooed population ( n  = 3), case studies ( n  = 2), men only ( n  = 2, one sampled men but asked about women only), and multiple populations ( n  = 2).

The most common objective among psychology articles about body modifications ( n  = 36 or 38% of total sample) was to test for underlying dysfunction or tendencies toward deviant behaviour associated with body modifications. Among those, 25% examined correlations between past behaviours or experiences and body modifications, whereas 41% examined current behaviours or sought to predict future behaviour.

The second most common objective was an effort to assess how tattooed (not body modifications in general) people are perceived, characterised, and treated by others ( n  = 31 or 32% of total sample). Within this category, we identified six sub-objectives, including perceptions for employment or when at work (32% of category), if tattooing impacts trustworthiness (12% of category), if tattooed people are worth helping (9% of category), and if tattooing influences perceived attractiveness (6% of category).

The third most common objective was a general exploration of why people engage in body modifications ( n  = 18 or 19% of total sample). Among those, five articles (27% of category) explored the possibility that tattooed people are fundamentally different from non-tattooed people.

The fourth most common objective of psychological studies of body modifications was to explore if tattoos impact health ( n  = 15 or 16% of total sample). Two articles (13% of category) concluded that tattoos help health, whereas authors of nine articles (67% of category) investigated whether tattoos indicate poor health.

The least common objective among psychological studies of body modifications was to explore them as aspects of identity ( n  = 9 or 9% of total sample). We identified one subcategory for those focused on subjective feelings of attractiveness vis-à-vis their body modifications with two articles in this subcategory (22% of category).

In this article, we provide an overview of peer-reviewed, primary source articles on voluntary, invasive body modifications published in psychology journals or journal articles that featured one or more authors whose affiliation was a Psychology or Psychiatry programme. Our search was intended to be a comprehensive assessment of sources available through online databases. The identified studies range widely in terms of study characteristics, methodologies, and locations. A notable finding was that there were few psychological/psychiatric studies of body modifications beyond those related to tattooing. Most of the body modifications outlined in Table 1 are rare, so, if the objective of the studies was to identify aberration, it might seem intuitive to study the rates and motivations for engaging in rare body modifications. However, our main finding is that psychological/psychiatric studies of tattooing have been rooted in traditional abnormal psychology and have tended to reify stigma through their research design. This is true even when the author objectives are to demonstrate that modified people are not deviant or stigmatised. There were very few psychological studies of body modifications outside of clinical or penal settings until the twenty-first century, suggesting changing perspectives in the fields of psychology and psychiatry.

Body modifications and deviance

Most psychological studies of body modifications seem to derive from the field of abnormal and clinical psychology. The earliest publications in our sample (Duncan, 1989 ; Edgerton and Dingman, 1963 ; Ferguson-Rayport et al., 1955 ; Taylor, 1974 ) are studies of prisoners and psychiatric patients that provide clues as to the shift from popular practice to stigma. Ferguson-Rayport et al. ( 1955 ) review numerous studies indicating, for instance, that tattooed people were more likely to be denied military enlistment or that tattooing was linked with homosexual behaviour in correctional institutions and reform schools. Furthermore, the authors hold “that the tattoo expresses masochistic-exhibitionistic drives and directly illustrates and encourages homosexual activity…tattoos are often compensatory in individuals poorly adjusted, especially in the sexual sphere” (Ferguson-Rayport et al., 1955 , p. 116). Such studies appear to reconstitute or extend earlier criminological efforts to taxonomically categorise potential for deviance. Edgerton and Dingman ( 1963 ), by contrast, conducted a qualitative exploration of tattooing among mental hospital patients to determine if, as suggested by anthropological studies of non-Euro-american tattoo practices, marking oneself permanently is an important aspect of identity-formation.

Though several standardised methods for assessing personality were developed in the first half of the twentieth century (Butcher, 2009 ), they do not appear to have been used in body modification research until the 1970s, when research sought to determine if tattooed prisoners and psychiatric patients were psychologically different than non-tattooed counterparts. For example, Taylor ( 1974 ) indicates significant differences between tattooed and non-tattooed individuals but does not provide any statistics to support this. By contrast, Duncan ( 1989 ) and other forensic studies (e.g., Birmingham et al., 1999 ) find negative or unhealthy behaviour associated variously with both modified and non-modified inmates.

Within the clinical psychology literature, penal or forensic studies seem to highlight body modifications as potential indicators of deviance or mental disorder, whereas studies relating to outpatient disorders (e.g., Bui et al., 2013 ; Caplan et al., 1996 ; Claes et al., 2005 ) suggest that body modifications may be sublimations of tendencies toward self-harm or other negative behaviour. Cardasis et al. ( 2008 ) notes a justification for this approach, pointing out that a primary feature of anti-social personality disorder is a need to seek immediate gratification and external stimulation to alleviate anxiety or discomfort. Buss and Hodges ( 2017 ) suggest the search for associations between body modifications and deviance is rooted in religious proscriptions against marking one’s body (see Scheinfeld, 2007 for examples) that were employed in the colonial era of empire-building to distinguish the “civilised” from “savage”. Multiple studies (e.g., Aizenman and Jensen, 2007 ; Ceylan et al., 2019 ; Stirn and Hinz, 2008 ; Stirn et al., 2011 ; Swami et al., 2015 ; Vizgaitis and Lenzenweger, 2019 ) conflate body modifications and non-suicidal self-injury or trauma and suggest that body modifications may be indicators of other anti-social tendencies.

Others (e.g., Drews et al., 2000 ) simply choose to emphasise terms like “risky” behaviour over analogous but differently valanced terms like “adventurous” or to emphasise the potential risks of tattooing (e.g., Koch, Roberts, Cannon, et al., 2005 ). Though poor-quality tattooing can certainly be dangerous (Kluger, 2015 ; Kluger and Koljonen, 2012 ), the chances of encountering tattoo-related medical complications in the current era is low, and there is some evidence to suggest that past fears over blood-borne pathogen transmission have been greater than the actual incidence of such tattoo-related medical complications (Jelinski, 2018 ; Lynn et al., 2019 ).

Body modifications and social interactions

All other psychological studies seem to wrestle with the changing status of body modifications as an emerging or “new” normal. We identified what could be called a “general” category of social psychology studies of body modifications, seeking explanations for how modified people are perceived and how people with modifications are treated (e.g., Drews et al., 2000 ; Galbarczyk et al., 2020 ; Galbarczyk and Ziomkiewicz, 2017 ; Hawkes et al., 2004 ; Martino, 2008 ; Martino and Lester, 2011 ; Miłkowska et al., 2018 ; Resenhoeft et al., 2008 ; Wohlrab et al., 2009a , 2009b ). An a priori assumption undergirding these studies is that body modifications have been historically stigmatised, and stigma may persist in interpersonal interactions.

A paradigm shift in body modification research seems to have occurred from the 1970s through the 2000s, with psychology the last to come around. This shift makes the fields of psychology and psychiatry appear to be out of step, but it is worth remembering that clinical psychology is historically grounded in the deficit-oriented biomedical model, which is focused on healing illness and diagnosing disfunction (Sheridan and Radmacher, 1992 ). Whereas body modifications as normal behaviours have long been subjects of study for allied social sciences like anthropology and sociology, social psychology was still developing as a discipline in the 1950s and 1960s (Stangor, 2014 ); social psychology research on body modifications seems to have only gotten underway beginning in the twenty-first century.

Three areas within social psychology seem particularly focused on body modifications: industrial, health, and evolutionary psychology. Industrial or occupational psychology is a subfield of social psychology concerned with human relations in work-related settings. A common theme in the concern over body modifications is how visible modifications will influence employability (e.g., Burgess and Clark, 2010 ; Dillingh et al., 2020 ; Flanagan and Lewis, 2019 ; Hauke-Forman et al., 2021 ; Tews et al., 2020 ; Thielgen et al., 2020 ; Timming et al., 2017 ; Timming, 2015 ; 2017 ; Wiseman, 2010b ). Some studies relate to particular circumstances wherein bias toward body modifications could undermine interactions beyond employment status, such as in the courtroom (e.g., Funk and Todorov, 2013 ) or classroom (Wiseman, 2010b ) or based on the specific imagery of a person’s tattoos (e.g., Timming and Perrett, 2016 ).

Among health psychologists, there is concern that the association of body modifications with abnormality might lead to people in marginal groups being in “double jeopardy” (e.g., Zestcott et al., 2017 ; Zestcott and Stone, 2019 ; Zestcott et al., 2018 ). Another line of research taking the opposite tack comes out of evolutionary psychology, arguably a subfield of social psychology (Kruglanski and Wolfgang, 2012 ). The evolutionary perspective suggests that well-healed modifications may function as external indicators of good underlying health. This hypothesis is tested by exploring how modifications are perceived by observers in terms of attractiveness and health as adaptive indicators of partner suitability (e.g., Galbarczyk et al., 2020 ; Galbarczyk and Ziomkiewicz, 2017 ; Miłkowska et al., 2018 ; Wohlrab et al., 2009a , 2009b ).

Body modifications and health

Most studies of body modifications and health do not focus on the double jeopardy of marginalised groups or evolutionary signalling theory. Most are grounded in abnormal psychology studies of the 1980s and 1990s and therefore collect data on mental/physical health and substance use even when their study objective is ostensibly about body modifications and other topics (e.g., Dillingh et al., 2020 ). Some reframe the focus on abnormality and instead use body modifications as indications of “impulsivity” or tendencies toward “sensation-seeking”, which are themselves considered risk factors for some abnormalities (e.g., Kertzman et al., 2013 ; Mortensen et al., 2019 ). One study uncritically claims that tattoos and premarital sex are “categorically deviant in a traditional sense but are typical among college students” as justification for a correlational study (Koch et al., 2005 , p. 887). Another study by the same group of authors (Koch et al., 2005 ) explores beliefs about the health and social dangers of tattoos, as though tattoos are more dangerous than current evidence suggests (cf. Jelinski, 2018 ; Lynn and Medeiros, 2017 ). Some studies note that, not only are body modifications different in how they are adopted and used, but each type of body modification also has variation. Tattooing varies by design, extent, body location and other factors that are “read” by interlocutors and observers in the explicit and implicit communication of social interactions (Geller et al., 2020 ). Furthermore, as body modifications become more popular in developing countries due to media exposure, psychological studies conducted by researchers in those countries replicate the type of mental health studies conducted previously in Europe and the United States (e.g., Geller et al., 2020 ; Kertzman et al., 2019a , 2019b ; Kertzman et al., 2013 ; Pajor et al., 2015 ).

By contrast, other psychological studies acknowledge that, among body modifications, piercing and tattooing is “becoming mainstream” (Hill et al., 2016 , p. 246) and explore body modifications from developmental psychology perspectives. Some such studies explore body modifications as means of improving self-esteem or one’s own body image (e.g., Hill et al., 2016 ; Kertzman et al., 2019a ), as a form of healing from trauma (e.g., Maxwell et al., 2020 ), or as an option for healthy lifestyles (Huxley and Grogan, 2005 ). One unique study (Thompson, 2015 ) explored associations between tattooing and “generativity”, a concept associated with prosocial behaviour.

Tattooing and identity

Beyond the importance of deviance, health, and the social roles of tattoos, researchers identified the role and materiality of body modifications in identity and personal aesthetics. We note two general trends concerning the role of body modifications specifically in emerging identities and perceptions of attractiveness. We distinguished studies of identity as those in which researchers largely ask questions that explore how those with body modifications view themselves. Within these articles, there are two further distinctions of identity, where researchers identify the underlying meanings attributed to body modifications (e.g., Mun et al., 2012 ; Tiggemann and Golder, 2006 ; Tiggemann and Hopkins, 2011 ) and modifications as identity signalling to social others (e.g., Bergh et al., 2017 ; Dillingh et al., 2020 ; Molloy and Wagstaff, 2021 ; Mun et al., 2012 ; Skegg et al., 2007 ).

Neither identity nor the meanings people attribute to their tattoos are fixed in time (Howson, 2013 ), and researchers try to convey this complexity by collecting diachronic information pertaining to the meaning of tattoos (the narrative story behind the tattoo), though the recurrent theme within these studies concerns change to meanings (e.g., Mun et al., 2012 ; Tiggemann and Golder, 2006 ; Tiggemann and Hopkins, 2011 ). For example, Mun et al. ( 2012 ) note that some tattoo meanings shift over time, reflecting life transitions, such as tattoos that commemorate past relationships or affiliations (e.g., gang imagery) (e.g., Mun et al., 2012 ). The through line of these identity-oriented articles largely point to individuals using tattoos as markers of individuality that reflect multi-faceted, densely layered meanings.

Tattoos can also be the material manifestations of certain types of communal (e.g., Edgerton and Dingman, 1963 ), ethnic (e.g., Skegg et al., 2007 ), or gender identities (e.g., Galbarczyk and Ziomkiewicz, 2017 ). Within this scoping review, several of the developmental psychology articles focus largely on tattoos as materialising and signalling identity (e.g., Dillingh et al., 2020 ; Mun et al., 2012 ; Skegg et al., 2007 ). Although many individuals use tattoos to signal identity through self-presentation (e.g., Molloy and Wagstaff, 2021 ; Mun et al., 2012 ; Tiggemann and Golder, 2006 ; Tiggemann and Hopkins, 2011 ), this requires understanding the meaning of a tattoo’s visibility (can it be seen by casual observer or only in intimate circumstances?) (Dillingh et al., 2020 ). People present themselves in myriad situations and environments in their everyday lives, requiring different “selves” to be presented accordingly; tattoos signalling identity can therefore take many forms, and psychologists suggest that people make these decisions based on life experiences, social settings, and other reasons in order to embody the identities they want to present (e.g., Dillingh et al., 2020 ; Mun et al., 2012 ; Tiggemann and Golder, 2006 ; Tiggemann and Hopkins, 2011 ).

Limitations

Our analysis unfortunately reinforces the “siloing” of academic disciplines for a subject that is in fact very interdisciplinary in nature and has been studied from numerous vantages we did not address. However, the historical trend we have noted was not apparent until we conducted this analysis, and it is important to distinguish the contributions various disciplines can make to body modification research and what strengths and weaknesses may be inherent to respective disciplinary approaches. This analysis may also suggest that psychologists and psychiatrists are alone in drawing parallels between body modification and risk behaviour or stigma, but this is also far from true. Nevertheless, forensic research conducted by psychologists, psychiatrists, and criminologists prevails among early body modification studies. Future research should include similar treatments for other relevant disciplines (e.g., anthropology, sociology, biology, criminology, nursing, dermatology, etc.).

Conclusions

The psychological studies examined in our review span the period 1955–2021. Early studies imply moral parallelisms by comparing body modification tendencies to religiosity, sexual activity, sexuality, alcohol or drug use, etc. This approach seems to derive from the legacy of nineteenth century criminology, which in turn appears based on a previous stigmatisation of irreversible body alterations among European cultures (Caplan, 1997 ). Lane ( 2014 ) makes a similar observation, suggesting that nineteenth century criminologists thought of criminals as atavistic and tattoos as indications of their reversion to primitiveness. This approach is continued in contemporary research when studying body modification in clinical populations, as well as among adolescents, seeking explanations for past behaviours and for “tells” of future tendencies (Lane, 2014 ).

In conclusion, we found no legitimate motivation for the inherent stigma towards individuals who voluntarily modify their bodies. Instead, this is an historically particular legacy of the social sciences and their various developments. Continued focus on deviance or risk regarding body modifications directly (i.e., not including intervening assessments of personality traits) seems a desperate assertion of an antiquated or atypical moral stance that now rings as somewhat absurd. Future research should continue to integrate perspectives from allied disciplines to gain a more accurate and nuanced view of the psychology of body modifications. The psychobiosocial approach taken in several twenty-first century health psychology studies—e.g., “double jeopardy” among marginalised populations or how tattoos are used by some people to help heal from past traumas—are promising research directions. The psychological study of modified people has primarily focused on tattooing, and future research should also acknowledge the variation of invasive voluntary modifications as they become more popular and available. Furthermore, technological advances are making tattoos less permanent while opening biomedicine to other forms of tattooing, which promise further shifts in how we study the psychology of body modifications. Emerging research using new methods and technology and that acknowledges how past research design reify the stigma they purport to study promises suggests a new paradigm of body modification investigations on the horizon.

Data availability

Data sharing is not applicable to this research as no data were generated or analysed.

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Owens, R., Filoromo, S.J., Landgraf, L.A. et al. Deviance as an historical artefact: a scoping review of psychological studies of body modification. Humanit Soc Sci Commun 10 , 33 (2023). https://doi.org/10.1057/s41599-023-01511-6

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• March 1, 2024 | VOL. 19, NO. 3 CURRENT ISSUE pp.2-13

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Body Modification and Personality: Intimately Intertwined?

• Andrew J. Perrin , M.D., Ph.D.

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Many psychiatric residents will encounter patients who modify their bodies. Body modification (e.g., tattooing, non-earlobe piercing) can incite many reactions in the observer and can often be a source of stereotyping. An oft-repeated mantra is that possession of significant body modifications (≥1 tattoo or multiple non-earlobe piercings) is suggestive of the presence of a personality disorder in the bearer ( 1 – 3 ). The veracity of this claim is difficult to substantiate anecdotally. Additionally, public perception of body modification continues to change ( 4 ).

Up to 20% of U.S. adults bear at least one tattoo ( 5 ). Therefore, it is unclear whether body modification has experienced some acculturation or whether possession of modifications still suggests character pathology. The body of literature examining body modification and its relation to personality is large. The present review focuses on the origins of early beliefs and how these may be challenged with more recently published literature.

The oldest examples of body modification date from the Egyptian Middle Kingdom (ca. 2000 BC). Tattooing during this era was reserved for those of high standing, and in fact, navel piercing was routinely used as a sign of royalty ( 6 ). Purposeful passage of pointed instruments through appendages was harnessed by classical Mayan civilization (ca. 250–1000 AD) in religious ceremonies. The blood released by these temporary body modifications was used to adorn penitent followers and to demonstrate the virility of holy practitioners ( 7 ).

What then caused a change from desirable to deviant? In three great voyages (1768–1780), Captain Cook, a British explorer and cartographer, made the first recorded European contact with the Hawaiian islands and in eastern Australia. He and his crew repeatedly encountered the people of Polynesia, among whom tattooing was prevalent. Tattooing in the South Pacific then served to mark cultural rites of passage, affiliation to one’s kin, and identification of one’s enemies. Indeed, the modern word “tattoo” descends from the Polynesian word “tatua,” meaning “artistic” ( 1 ). Cook’s men were amazed with these tattoos, with some even choosing to have the same tattoos inscribed on themselves. Upon their return to Europe, which at the time was largely unfamiliar with body modification, such flaunted markings instantly drew admiration. A perceived link between body modification and exotic locales then encouraged select European nobility to undergo modification as well ( 7 ).

Over the next 100 years, body modification, especially tattooing, became more and more synonymous with the mariner and the lower socioeconomic classes that seamen inhabited ( 7 ). The invention of the electric tattoo gun in the late 1800s further democratized tattooing ( 8 ), and as the prevalence of tattoos in the lower socioeconomic classes increased, the desirability of body modification in the upper socioeconomic classes decreased. From the perspective of the upper class, tattoos grew to symbolize the homogeneity of the working masses ( 7 ). Ease of tattooing allowed it to be co-opted into criminal identification schemes as well. Thus, by the early 20th century, body modification had become a mark of social deviance ( 7 ).

Perceptions in the 20th Century

In the early 20th century, both medical practitioners and psychiatrists were integral in linking body modification with presumed characterological deficits. The presence of body modifications was identified in “prostitutes and perverts” by the psychiatrist Parry in 1934 ( 9 ), and body modifications noted during indoctrination physicals of American World War II conscripts were found to be associated with higher rates of rejection for service (43.8% versus 29.9%). These rejections in tattooed conscripts were more likely to result from “neuropsychiatric reasons,” including “psychopathic personality” and “mental defect.” Such findings led Lander and Kohn ( 3 ), the examining doctors, to state that “there is thus a correlation between … tattoos and the presence of significant psychopathology,” a finding subsequently publicized in Time magazine ( 10 ).

Further studies in the 1950s and 1960s presented evidence that linked the possession of multiple tattoos to underlying disorders of personality. In a series of works examining hospitalized psychiatric and general medical patients (in aggregate: tattooed, N=111; not tattooed, N=609), Gittleson and colleagues ( 2 , 11 ) reported an elevated prevalence of personality disorders in those who were tattooed (25% of patients) compared with those who were not (8% of patients) ( 2 ). The specific personality disorder diagnoses in those tattooed was not fully delineated in early reports, but in the 1990s Inch and Huws ( 12 ) presented a series of cases that conceptualized tattooing and other body modifications as being a manifestation of borderline personality disorder.

Retrospectively, it is difficult to disentangle the relative contributions of social stigma against body modification on the one hand and objective medical reporting on the other, in the formation of a firm opinion relating body modification and personality. It is also difficult to determine how much the countercultural nature of body modification may have enriched the prevalence rates of personality disorders in the tattooed population, as tattooed persons may have already been more culturally non-conformist in nature to begin with. What is clear is that most of the previous centuries’ work was based on case series or on enriched samples of psychiatric inpatients. Limited data were collected from other, broader segments of society, especially those without documented psychiatric diagnoses.

A 2000 study reported by Rooks and colleagues ( 13 ) was one of the first to report data from a patient population broader than psychiatric inpatients alone. In a consecutive 2-day survey of all patients presenting to a community hospital emergency department, the presence of tattoos was recorded, as well as the primary reason for presentation (a tripartite outcome of injury, illness, or psychiatric/chemical dependency). Although 16% of patients reported possessing at least one tattoo, the investigators were unable to find a correlation between possession of a tattoo and the reason for presentation to the hospital ( 12 ). Although this study, due to its design, was unable to definitively disprove a link between tattoos and the presence of a personality disorder, it did provide evidence beyond the scope of the previous works of Gittleson and colleagues ( 11 ). While it may be that possession of body modifications has little to do with the reason for patient presentation for acute care, the dissonant results of these two studies focuses attention on the changing perception of body modification over 30 years.

An additional study by Hohner and colleagues ( 14 ) examined the link between the presence of borderline personality traits and body modification. In a sample of 289 women with body modifications, a group manifesting borderline personality traits was identified and then compared with the remaining women who did not manifest these same personality traits. No difference was found in the number or nature of body modifications between the two groups. While a definitive conclusion on the relation between borderline personality disorder and body modification awaits more rigorously designed studies, the work of Hohner and colleagues ( 14 ) highlights that the number and type of body modification were not useful discriminators in a modern cohort of women. When compared with the work of Inch and Huws ( 12 ), the evidence presented by Hohner and colleagues also suggests that a re-evaluation of previously held assumptions about body modification and personality may be topical.

The above studies highlight potential changes in the diagnostic implications of body modification in a more general population. Ongoing work in forensic settings has suggested that a link between specific personality traits and body modification may be relevant. Detailed study of 36 male forensic patients conducted by Cardasis ( 15 ) revealed that significantly more patients with tattoos had a diagnosis of antisocial personality disorder compared with patients without tattoos. Additionally, patients with antisocial personality disorder had a greater number of crudely or self-applied tattoos and a tendency toward having a greater percentage of their total body surface area tattooed. Unfortunately, neither this study nor other more recent works have addressed the diagnostic implications of full-arm “sleeve-type” tattoos. Future studies on this topic could be informative.

Conclusions

The last 75 years have seen significant change in the societal perception of body modification ( 16 ). While initial psychiatric and medical studies placed emphasis on the diagnostic utility of body modifications in identifying personality disorders, studies in broader groups of patients have generated some challenge to long-promulgated diagnostic links between body modification and personality disorders. At the same time, studies in the forensic setting have refined this diagnostic link in a specific population and suggested that antisocial personality disorder must be carefully ruled out in those forensic patients who possess large numbers of crudely applied or self-made tattoos or who have a large area of their body covered by tattoos. While initially seeming contradictory, these two disparate views of body modification are in fact complementary and help to make the resident’s understanding of the link between body modification and personality disorder more sophisticated than it was in the previous century. Anchoring quickly on personality dysfunction in a body modifier now seems premature, and it is advisable to consider body modification more as a signal for further inquiry ( 17 ), especially if there is a forensic history. A better understanding not only of coping style and life course, but also reasons for body modification, should help the resident to avoid the rapid application of a diagnosis that can be ultimately difficult to remove if erroneous.

Key Points/Clinical Pearls

Body modification is encountered often in psychiatric practice, and its presence can influence clinical perceptions of underlying personality structure.

Previous psychiatric literature presented a link between body modification and the presence of a personality disorder.

Recent research suggests that previous links between body modification and personality disorders may not hold in the general population but that the presence of tattoos in the forensic population requires a more thorough evaluation to rule out personality dysfunction, especially antisocial personality disorder.

The changing societal perceptions of body modification reflects the evolving nature of this area.

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• Self-harm behavior: hierarchical and network analysis 7 September 2021 | Neurology Bulletin, Vol. LIII, No. 2

Body, Gender and Beauty: Modified Bodies Between Youth Culture Designs, Constructed Identity Models and Coping Strategies

• First Online: 07 March 2021

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In the twenty-first century, the body has become a commodity and an asset, being at the mercy of social standardizations and economic interests (cf. Unterdorfer et al. 2009 ). Every day, humans (un)consciously modify and design their bodies. This indicates a worldwide phenomenon concerning (more or less) all humans. Since the postmodern era, an increasing tendency to design one’s visual appearance has been observed. There are (almost) no limits anymore for the body to become a performing object and scope of action (cf. Gugutzer 1998 ; Villa 2007 ). Cognitive processes dealing with constructions of identity/identities are becoming ever more subtle, because changed life situations are found in the globalized world. Due to major interventions of neo-capitalistic environments, existing identity models are becoming fragile, giving rise to the need to find alternative standardizations and new orientations. Social realities of young people are shaped by diversity and heterogeneity. Simultaneously they need to socialize to get around ideas of what is “normal” and what is not. These ambivalent re-quirements of customization and pluralization on the one hand and standardization on the other hand, create a big area of tension, especially for lesbians, gays, bisexuals, trans, inter and queer people.

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Ganterer, J. (2021). Body, Gender and Beauty: Modified Bodies Between Youth Culture Designs, Constructed Identity Models and Coping Strategies . In: Knapp, G., Krall, H. (eds) Youth Cultures in a Globalized World. Springer, Cham. https://doi.org/10.1007/978-3-030-65177-0_12

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Original research article, personality and willingness towards performance enhancement and body modification: a cross-sectional survey of a nationally representative sample of norwegians.

• 1 Department of Sport and Social Sciences, Norwegian School of Sport Sciences, Oslo, Norway
• 2 Department of Psychosocial Science, University of Bergen, Bergen, Norway
• 3 Human Enhancement and Body Image Lab (HEBI Lab), Addiction Research Group, University of Bergen, Bergen, Norway

We conducted an exploratory investigation of the relationship between personality and willingness towards performance enhancement and body modification in Norway. The study is based on Norwegian Monitor data from a cross-sectional survey of a nationally representative sample of 4,233 (females: 49.9%) persons aged 15 to 96 (45.92 ± 18.02) years. Data were collected using a questionnaire containing demographic questions and measures of physical appearance satisfaction, physical activity level, personality (five-factor model), and willingness towards performance enhancement (e.g., substances that improve creative thinking) and body modification (e.g., use of muscle-building substances). Data were analyzed using descriptive statistics and multiple regression analyses. We found that 62.2% and 50.1% of our sample were either willing to use or contemplating using substances that reduce memory failure and enhance physical fitness respectively. Our sample was most willing or contemplating tattooing (30.0%) and generally skeptical of the other body modification methods with willingness to use or contemplating using substances to enhance muscularity least accepted (3.9%). Higher fantasy/openness and lower agreeableness were associated with higher willingness towards both performance enhancement and body modification. Additionally, higher extraversion and lower control/conscientiousness predicted higher willingness towards body modification. Our findings corroborate previous indications that performance enhancement and body modification are now mainstream. They also underline the importance of personality traits in willingness towards these practices.

Introduction

Human enhancement and body modification.

Human enhancement refers to the improvement of human capacity, disposition and well-being through genetic, biomedical or pharmaceutical means in the absence of pathology or beyond what is necessary for sustenance or restoration of good health ( 1 – 3 ). Body modification on the other hand has been defined as permanent or semipermanent voluntary alteration of the human body that is not medically sanctioned such as plastic surgery, diet and exercise regimen, and other permanent and temporary cosmetic procedures ( 4 ).

Unlike human enhancement, there is contention regarding the definition of body modification. A distinction is made between body modification and nonmainstream body modification where the latter is defined ( 4 ) “as any permanent or semipermanent, voluntary alteration of the human body that is not medically mandated and that transgresses and challenges common assumptions and expectations of bodily presentation and/or aesthetic, and therefore may be considered extreme and/or deviant by members of mainstream Western society” ( p . 4). Thus, tattoos, piercings, and plastic surgery for example, although often voluntarily done and permanent or semipermanent and normative in certain non-Western societies (e.g., male circumcision and female genital mutilation in some African and Middle Eastern societies) are not considered nonmainstream body modification. On the other hand, eccentrically placed, egregious, or extreme tattoos/piercings such as full-body or genital tattoos/piercings are regarded nonmainstream body modification. In the present study, “body modification” is used as an umbrella term for both (mainstream) body modification and nonmainstream body modification ( 4 ).

There is also contention regarding the conceptualization of human enhancement and body modification. On the premises that human enhancement is a category of body modification, every modification is arguably an enhancement, and that “body modification” unlike “human enhancement” is a normative and less prejudicial term, it has been argued and recommended that “body modification” be used as an umbrella term for both human enhancement and body modification ( 5 ). However, we distinguish between “human enhancement” and “body modification” in the present study.

The last few decades have witnessed advances in human enhancement and body modification. The widespread use of anabolic-androgenic steroids - AAS ( 6 , 7 ) and various other human enhancement drugs ( 1 , 8 ) as well as the proliferation of various body modification methods ( 9 – 11 ) for aesthetic and ergogenic enhancement is illustrative. It is noteworthy that the explosion of social media appears to promote and reinforce this phenomenon ( 12 – 15 ).

Personality

Personality is defined as an organized and relatively stable set of psychological traits and mechanisms within an individual that influence the individual's interactions and adaptations to the physical and psychosocial environment ( 16 ). Personality is typically assessed as traits ( 17 ) defined as relatively stable cognitive, emotional and behavioral factors that establish individual identity and distinguishes people from others ( 18 ). The five-factor model (FFM) is a reliable, well-validated ( 19 ) and the foremost ( 16 , 17 ) personality taxonomy. It consists of five personality factors or traits (neuroticism, extraversion, openness, agreeableness, and conscientiousness) with each associated with certain tendencies.

Neuroticism is defined in terms of the incidence and intensity of negative emotions and affect with higher scorers having a higher tendency towards anger, anxiety, depression, impulsivity, and vulnerability. Extraversion is defined as the magnitude and intensity of energy directed into the social world. Higher scores signal higher assertiveness, friendliness, sociability, and a higher tendency to experience positive emotions. Openness (also termed creativity, culture, fantasy, intellect, and openness to experience) is defined as aesthetic, emotional, intellectual and practical aptitude with higher scores signaling a higher appreciation of and interest in art and beauty, adventure, unusual ideas and values, new and diverse experiences, and intellectual curiosity. Agreeableness is defined in terms of compassion, cooperation, modesty, sympathy and trust with higher scores indicating a higher tendency to be altruistic, compassionate, cooperative, modest and sympathetic. Conscientiousness refers to the degree of efficiency, personal organization, and dependability with higher scores indicating a higher tendency to be organized, punctual and dependable, show self-discipline, aim for achievement, and prefer planned rather than spontaneous activity. These factors or traits are expatiated in the personality psychology literature ( 16 , 17 , 19 ).

The relationship between personality, human enhancement and body modification

Personality traits have been implicated in human enhancement and body modification. The stimulation ( 20 ) theory of tattooing ( 21 ), extended to body modification, posits that body modification is an expression of high extraversion. An Austrian online survey ( 22 ) examined the link between personality and attitudes towards four human enhancement methods: pharmacological enhancement (e.g., use of psychostimulants such as modafinil to increase cognitive performance), current-based enhancement (e.g., deep brain stimulation to enhance memory and intelligence), genetic enhancement (human enhancement through genetic modification), and mind uploading (digital replication of the brain's cellular structure and upload onto an external storage medium for emulation.

In terms of the FFM, it was found that higher openness is associated with less negative attitudes towards pharmacological enhancement, genetic enhancement, and mind uploading. Additionally, it was found that attitudes towards human enhancement and body modification seems to differ by type with more negative attitudes towards pharmacological and genetic enhancement than current-based enhancement and mind uploading ( 22 ). In a similar study ( 23 ), agreeableness and conscientiousness correlated negatively with acceptance of human enhancement and body modification. Agreeableness and conscientiousness in particular correlated negatively with acceptance of genetic enhancement with conscientiousness having an additional negative correlation with deep brain stimulation. Additionally, multiple regression analysis showed that higher conscientiousness-industriousness is associated with lower acceptance of enhancement.

Prevalence and correlates of human enhancement and body modification in Norway

Previous studies have examined the prevalence, attitudes and correlates of human enhancement and body modification in Norway. Historically, data from representative samples of Norwegians aged 18 to 69 from 1968 to 1989 showed a negative attitude towards drug use, high support for prohibition of drug use, and preference for harsher punishment for drug users ( 24 ). In our 2006 survey ( 25 ) of elite athlete ( n  = 234, males: n  = 151) and general population ( n  = 428, males: n  = 275) samples aged 18 to 35 years, the athlete sample showed higher physical appearance satisfaction than the general population sample. We also found that males have higher willingness towards performance enhancement whereas females have higher willingness towards body modification. In addition, whereas vitamins, nutritional supplements and hypoxic rooms were accepted by more than 65% of both samples, there was an almost unanimous rejection of erythropoietin (EPO), anabolic steroid and amphetamine use. Moreover, the athlete sample showed more reluctance towards performance enhancement and body modification than the general population.

In another 2006 survey ( 26 ) on body modification based on a representative sample of 1,862 northern Norway women aged 18 to 35 years, liposuction was the most prevalent body modification technique (25%), followed by breast augmentation (15%), rhinoplasty (7%) and abdominoplasty (5.6%). Also, whereas most respondents with interest in abdominoplasty showed no interest in other body modification procedures, most of the women with interest in breast augmentation and rhinoplasty expressed interest in more than one procedure. In terms of demographics, younger women univariately showed higher odds of interest in breast augmentation whereas lack of exercise was univariately associated with higher odds of interest in breast augmentation, liposuction, and abdominoplasty.

In the same study ( 26 ), results of multiple logistic regression analyses showed that lower educational attainment, and physical appearance evaluation are associated with higher odds of interest in breast augmentation, rhinoplasty, liposuction, and abdominoplasty whereas lack of exercise was associated with higher odds of interest in rhinoplasty. However, higher physical appearance orientation was associated with higher odds of interest in breast augmentation, rhinoplasty, and liposuction. On personality (FFM), lower conscientiousness, emotional stability and openness were univariately associated with higher odds of interest in breast augmentation, rhinoplasty, and liposuction whereas lower extraversion and agreeableness were univariately associated with higher odds of interest in rhinoplasty, and liposuction.

Additionally, a meta-analysis ( 27 ) of 32 studies shows that in the Nordic countries, Norway has the second-highest prevalence of AAS use (2.4%) after Sweden (4.4%). There is also experimental evidence from Norway ( 28 ) showing that AAS and EPO targets/users receive lower ratings on emotional stability, openness to experience and agreeableness. Also, in an online survey ( 29 ) of 15,654 (6,151 females) persons aged 16 to 91 years in Norway, the estimated prevalence of tattooing was 20.8% (females: 23.8%, males: 17.9%), of which 13.3% had readily visible tattoos. Results of multivariate logistic regression analysis indicated that females, being older than 19 years, higher body mass index, lifetime AAS use, and higher scores on extraversion were associated with higher odds of having a tattoo.

Furthermore, in the development of the Bergen Tanning Addiction Scale ( 30 ), based on an online sample of 23,537 (15,301 females, age range: 16–88, years mean = 35.8) respondents, being female and lower educational level were associated with higher tanning addiction. In terms of personality, higher neuroticism and extraversion, and lower intellect/openness were associated with higher tanning addiction.

The present study

The present study is an exploratory investigation of the relationship between personality (FFM) and willingness towards performance enhancement (a specific form of human enhancement) and body modification in a nationally representative sample of Norwegians. Performance enhancement is operationalized in terms of use of substances that improve creative thinking, memory, physical fitness, workload/stress tolerance, physical strength and endurance, sexual ability, and emotional intelligence. Body modification is operationalized in terms of use of muscle-building substances, undergoing liposuction, facial plastic surgery, surgical operation for weight control, silicone implantation, tattooing, and substance use for youthful appearance. Since relatively little previous research could guide our expectations, instead of formulating specific hypotheses, we used an exploratory approach and formulated the following overarching research questions: 1) What is the prevalence of willingness towards performance enhancement and body modification in the Norwegian general population? 2) What is the relationship between personality traits (FFM) and willingness towards performance enhancement and body modification in the Norwegian general population?.

The study is based on the 2015 Norwegian Monitor data collected by Ipsos Social Research Institute. Data were collected using telephone interviews (introductory questions) and a cross-sectional survey design. A simple random sampling from telephone directories was employed. Ipsos Group S.A. which conducts the Norwegian Monitor is a multinational market research company with ISO9001 and ISO202252 certification, and complies with the ESOMAR International Code on Market and Social Research. The Norwegian Monitor has approval from the Norwegian Data Protection Authority. Informed consent was obtained prior to data collection, and the dataset was anonymized before submission to the authors. The present study is based on data from a nationally representative sample of 4,233 (females: 49.9%) persons in Norway aged 15 to 96 ( M  = 45.92, SD  = 18.02) years. The sample is weighted according to sex, age, and geographical region. Participant characteristics are presented in Table 1 .

Table 1 . Sample characteristics.

Data were collected using a self-completion questionnaire.

Demographics

The questionnaire included questions assessing various demographic variables such as participants’ sex, age, highest education, father's highest education, mother's highest education, income, household income, and geographical region.

Physical appearance satisfaction

Physical appearance satisfaction was assessed using the question: “How satisfied or dissatisfied are you with your physical appearance?” Response options were: do not know (0), very dissatisfied (1), slightly dissatisfied (2), neither satisfied nor dissatisfied (3), fairly satisfied (4), and very satisfied (5). We therefore used an index score (range: 0–5) with higher scores denoting higher physical appearance satisfaction.

Physical activity level

Level of physical activity was assessed using the question: “How often would you say that you engage in physical activity in the form of training or exercise?” Response options were never (0), less than once every 14 days (1), once every 14 days (2), once a week (3), twice a week (4), 3–4 times a week (5), 5–6 times a week (6), and 1 or more times per day (7). We calculated an index score (range: 0–7) with higher scores denoting higher physical activity level.

Personality (FFM)

Personality was assessed using a 20-item (BFI-20) version ( 31 ) of the Big Five Inventory - BFI-44 ( 32 ). “I see myself as someone who: is depressed, blue; is outgoing, sociable; is original, comes up with new ideas; is helpful and unselfish with others; and does a thorough job” are example items assessing emotional stability, extraversion, fantasy/openness, agreeableness, and control/conscientiousness respectively. Items are answered on a five-point scale ranging from disagree strongly (1) to strongly agree (5). An index score was calculated for each factor/trait by summing participants’ responses on the corresponding items. In the present study, Cronbach's alphas were.74 for emotional stability,.80 for extraversion,.65 for fantasy/openness,.55 for agreeableness, and.53 for control/conscientiousness.

Willingness towards performance enhancement

Seven questions were used in assessing willingness to use various kinds of performance-enhancing substances: use of substances that improve creative thinking, memory, physical fitness, workload/stress tolerance, physical strength and endurance, sexual ability, and emotional intelligence. An example item is: “In the future, legal substances may be produced that may increase performance in various areas of life. How willing would you be to take the following substances if you at the same time ran a possible risk of a decrease in life expectancy?: substances that to a significant degree increase the ability to think creatively” (creative thinking). Items are answered on a four-point scale: cannot answer (0), not willing (1), may be willing (2), and willing (3). See Table 2 . An index score was calculated by summing participants’ responses on the seven items. Total scores range between 0 and 21 with higher scores denoting more willingness to use of performance-enhancing substances. Cronbach's alpha across the seven questions was.86.

Table 2 . Willingness towards performance enhancement (use of performance-enhancing substances).

Willingness towards body modification

Willingness towards body modification was assessed using seven questions directly referring to different techniques and areas of body modification: use of muscle-building substances, undergoing liposuction, facial plastic surgery, surgical operation for weight control, silicone implantation, tattooing, and substance use for youthful appearance. An example item is: “In our society, it is possible to alter the appearance by different methods. How willing are you to use the following methods, even if they involve health risks?: take substances to get a muscular body” (muscle-building substances). Items are answered on a four-point scale: cannot answer (0), not willing (1), may be willing (2), and willing (3). See Table 3 . An index score was calculated by summing participants’ responses on the seven items. Total scores range between 0 and 21 with higher scores denoting more willingness to resort to body modification techniques. Cronbach's alpha across the seven questions was.70.

Table 3 . Willingness towards body modification.

Data analysis

We used descriptive statistics comprising frequencies and proportions as well as means and standard deviations to determine characteristics of the sample, and sample proportions in terms of willingness to use of performance-enhancing substances and body modification. Finally, we conducted multiple regression analyses to identify correlates of willingness to use performance-enhancing substances and body modification. Data analysis was conducted using SPSS version 28 (IBM Corp.).

Prevalence of willingness towards performance enhancement

Sample proportions on willingness towards use of performance-enhancing substances are presented in Table 2 . It is evident that 62.2% and 50.1% of our sample was either willing to use or contemplating using substances that reduce memory failure and enhance physical fitness respectively. Also, 26.9% of our sample was either willing to use or contemplating using substances that enhance sexual ability. Furthermore, 20.9% of our sample was either willing to use or contemplating using substances that enhance creative thinking, workload/stress tolerance, physical strength endurance, and emotional intelligence.

Prevalence of willingness towards body modification

Table 3 presents sample proportions on willingness towards body modification. As shown in Table 3 , our sample was most (30.0%) willing or contemplating tattooing. In addition, our sample was generally skeptical of the other body modification methods with willingness to use or contemplating using substances to enhance muscularity least accepted (3.9%). Except for willingness towards or contemplating liposuction (17.5%), the other methods (facial plastic surgery, surgical operation for weight control, silicone implantation, and substance use for youthful appearance) show about 10% percent willingness or contemplation.

Correlates of both willingness towards performance enhancement and body modification

The models accounted for 8.1% and 18.8% of the variances in willingness towards performance enhancement and body modification respectively. See Table 4 .

Table 4 . Multiple regression analysis of predictors of willingness towards performance enhancement and body modification.

Demographics and physical appearance

Males ( β  = −0.12, p  < .001) had higher willingness towards performance enhancement whereas females ( β  = 0.13, p  < .001) were associated with higher willingness towards body modification. Additionally, younger persons showed higher willingness towards performance enhancement ( β  = −0.19, p  < .001) and body modification ( β  = −0.30, p  < .001). Moreover, lower physical appearance satisfaction was related to higher willingness towards performance enhancement ( β  = −0.07, p   < .001) and body modification ( β  = −0.18, p  < .001).

Higher fantasy/openness as well as lower agreeableness predicted higher willingness towards performance enhancement (fantasy/openness: β  = 0.06, p  < .001; agreeableness: β  = −0.04, p  < .05) and body modification (fantasy/openness: β  = 0.05, p  < .01; agreeableness: β  = −0.09, p  < .01).

Correlates of only willingness towards body modification

Persons with lower education ( β  = −0.05, p  < .01) showed higher willingness towards body modification.

Higher extraversion ( β  = 0.09, p  < .001) and lower control/conscientiousness ( β  = −0.04, p  < .05) were associated with higher willingness towards body modification.

Prevalences of willingness towards performance enhancement and body modification

The prevalences of willingness towards performance enhancement observed in the present study are similar to the observed prevalences from our 2006 Norwegian general population survey ( 25 ). Additionally, the prevalences of unwillingness towards body modification observed in the present study are similar to the prevalences from our 2006 Norwegian general population survey ( 25 ). In contrast, we noticed in juxtaposition, disparities between the two datasets with conspicuously lower estimates on muscularity, liposuction, tattooing and youthful appearance in the present study. Importantly, the present findings on the prevalence of willingness towards performance enhancement and body modification are elucidating and corroborate previous indications ( 1 , 6 , 8 , 29 , 33 , 34 ) that these practices are now mainstream with a sizeable proportion of the population willing or contemplating engaging in these practices.

Given the skills and environmental constraints moderators of the link between intention and behaviour as delineated in the integrated behavioral model ( 35 , 36 ), it is reasonable that the actual current prevalence (20.8%) of tattooing in Norway ( 29 ) is lower juxtaposed with the prevalence of willingness towards or contemplation of getting a tattoo (30.0%) observed in the present study. Indeed, we observed that our sample is generally more accepting of performance enhancement and relatively skeptical of the other body modification methods. A plausible explanation for this observation, based on the integrated behavioral model ( 35 , 36 ) as posited above, is the relatively lower skills and environmental constraints such as self-administration moderating the relationship between intention and actual performance-enhancing substance use (e.g., pills for creative thinking and reduced memory failure) compared to the body modification techniques presented (e.g., liposuction and plastic surgery).

Demographic and physical appearance correlates of willingness towards performance enhancement and body modification

Our finding associating males with higher willingness towards performance enhancement and females with higher willingness towards body modification is consistent with our previous finding ( 25 ). It is also in line with the preponderance of literature on gender/sex differences in performance enhancement ( 6 , 7 ) and body modification ( 29 , 30 ). Additionally, our finding that younger persons show higher willingness towards performance enhancement and body modification corroborates previous findings ( 26 , 37 ) and the perspective that human enhancement is an element or fountain of contemporary youth culture and identity ( 1 , 10 , 38 ). Moreover, our finding that lower physical appearance satisfaction predicts higher willingness towards performance enhancement and body modification is tenable from an enhancement perspective. Furthermore, our finding that persons with lower education have higher willingness towards body modification is consistent with previous findings ( 26 , 30 ).

Personality and willingness towards performance enhancement and body modification

Our finding that higher fantasy/openness predicts higher willingness towards performance enhancement and body modification is consistent with previous findings from a survey of Canadian undergraduate students ( 39 ) and evidence from a recent Austrian online survey ( 22 ). This finding is reasonable given the aforementioned nomenclature (e.g., creativity, culture, fantasy, intellect), facets (aesthetic, emotional, intellectual and practical aptitude) and definition of openness in terms of appreciation of and interest in art and beauty, unusual ideas and values, new and diverse experiences, and intellectual curiosity ( 16 , 19 ). Additionally, our finding that lower agreeableness predicted higher willingness towards performance enhancement and body modification is consistent with recent evidence from an Austrian survey indicating that agreeableness correlates negatively with acceptance of human enhancement ( 23 ). It also mirrors findings from a comparison of body-modified (tattoos and piercings) and non-modified persons ( 34 , 37 ) and body piercing contemplators ( 40 ).

In line with the stimulation ( 20 ) theory of tattooing ( 21 ), and evidence that higher scores on extraversion predict higher odds of having a tattoo ( 29 ) or contemplating getting a body piercing ( 40 ), we found that higher extraversion is associated with higher willingness towards body modification. An explanation for this finding is that higher scores on excitement/sensation seeking, a facet of extraversion ( 19 ), have been associated with a higher tendency towards body modification ( 11 , 39 ). Moreover, we found that lower control/conscientiousness is associated with higher willingness towards body modification in line evidence from a survey of American college students ( 34 ). As noted previously, persons with higher scores on conscientiousness tend to exhibit high self-discipline and preference for planned instead of spontaneous behaviour. Indeed, the deliberation facet of conscientiousness denotes a tendency towards critical consideration prior to behaviour ( 19 ). In this regard, this finding is tenable due to the spontaneity associated with body modifications such as tattoos and body piercings ( 41 , 42 ).

Implications for practice and future research

Our findings have clinical, policymaking, and technological implications. Consideration of the demonstrated mainstream proliferation of these practices in policymaking may be beneficial in averting potential future complications and harms emanating from nonmedical and illicit performance enhancement and body modification in the general population. Additionally, the correlates identified in the present study need consideration in the design and deployment of targeted preventive, treatment, and harm reduction interventions. Relatedly, the present findings may be informative for medical practitioners, technology providers, and regulatory authorities in the performance enhancement and body modification industry.

Our findings also have implications for future research. Future cross-disciplinary research, including philosophical, socio-cultural and ethical perspectives on human enhancement and body modification, may elevate the field. Experimental, mixed-methods and qualitative designs may also provide deeper insight and perspectives on human enhancement and body modification. The use of longitudinal designs may also elucidate trends in human enhancement and body modification in the general population. Furthermore, the use of measures of personality traits with facets, such as the NEO-PI-R ( 19 ), may provide an opportunity for facet-level exploration of the personality correlates of human enhancement and body modification. Similarly, the low explained variance in the regression models implies that future studies examine other potential correlates or confounders of performance enhancement and body modification such as participants’ exposure to these practices, and religious, ethical and moral attitudes. We also encourage psychometric effort in the development of well-validated measures of performance enhancement and body modification.

Strengths and limitations

The present study is one of the few explorations of the prevalence and correlates of willingness towards performance enhancement and body modification in Norway. It improves on our previous study ( 25 ) by examining correlates of performance enhancement and body modification in a large nationally representative sample. It is one of the few studies to examine the association of personality traits with performance enhancement and body modification. However, the Cronbach's alpha value for openness to experience (.63) is relatively low ( 43 ) but acceptable as it is higher than the .60 cut-off score recommended for scales with few items ( 44 ) such as our personality (BFI-20) measure ( 31 ). Relatedly, the low Cronbach's alpha values for agreeableness (.55) and control/conscientiousness (.53) should be noted in the interpretation of the results on this factor.

Additionally, the two models explained only 8.0% and 18.9% of the variances in performance enhancement and body modification respectively. This implies that other unexamined variables such as participants’ familiarity with these practices, and religious, ethical and moral beliefs influence performance enhancement and body modification, and require exploration in future studies. Also, we are unable to make causal inferences due to our use of a cross-sectional survey design. Moreover, although self-reports have the advantage of eliciting data from many individuals in an ethical and relatively inexpensive manner, there is concern regarding the validity of reporting on a self-administered survey, especially when self-reports are not validated against objective criteria or data from other sources. Our personality measure also did not permit facet-level exploration of the five-factor model.

The present exploratory study provides insight into the prevalence and correlates of willingness towards performance enhancement and body modification in the Norwegian population. It particularly elucidates the link between personality and willingness towards performance enhancement and body modification in the Norwegian population. Our findings corroborate previous indications that performance enhancement and body modification are now mainstream. They also underline the importance of personality traits in willingness towards performance enhancement and body modification. Our findings may be useful in the design and deployment of targeted preventive, treatment, and harm reduction interventions. Future interdisciplinary and multi-design research is needed to further highlight the practice of performance enhancement and body modification.

Data availability statement

The datasets presented in this article are not readily available because; The dataset is collected by a commercial research and survey agency and their property. However, it can be accessed in case of the need for check or control of the analyses in the article. Requests to access the datasets should be directed to; [email protected].

Ethics statement

The studies involving human participants were reviewed and approved by the Norwegian Data Protection Authority. The patients/participants provided their written informed consent to participate in this study.

Author contributions

GB initiated the study. All authors, GB, DS and SL contributed equally to the writing of the article and approved the submitted version.

Acknowledgement

We thank the Norwegian Ministry of Culture and Equality, by the Department of Culture, Sports and Non-profit Work, for giving us access to the Monitor data base.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: human enhancement, body modification, bodily appearance, personality, big five

Citation: Breivik G, Sagoe D and Loland S (2022) Personality and willingness towards performance enhancement and body modification: A cross-sectional survey of a nationally representative sample of Norwegians. Front. Sports Act. Living 4:906634. doi: 10.3389/fspor.2022.906634

Received: 28 March 2022; Accepted: 29 November 2022; Published: 22 December 2022.

Reviewed by:

© 2022 Breivik, Sagoe and Loland. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Gunnar Breivik [email protected]

Specialty Section: This article was submitted to Movement Science and Sport Psychology, a section of the journal Frontiers in Sports and Active Living

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History of Body Modification: Tattooing, Piercing, and Scarification

Epidemiology, declining strength of associations with risk behaviors, body modification is not nssi, perceptions of community and potential employers about tattooing and piercing, permanent makeup, henna and temporary tattoos, complications, henna and black henna temporary tattoos, tattoo removal, piercing and stretching, stretching methods, regulation of tattooing and piercing, scarification, regulation of scarification, advice for pediatricians, general issues, tattoos and henna, piercings and stretching, resources for information about tattoos and body piercings, body piercings, lead authors, committee on adolescence, 2016–2017, former committee member, adolescent and young adult tattooing, piercing, and scarification.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Cora C. Breuner , David A. Levine , THE COMMITTEE ON ADOLESCENCE , Cora C. Breuner , Elizabeth M. Alderman , Robert Garofalo , Laura K. Grubb , Makia E. Powers , Krishna K. Upadhya , Stephenie B. Wallace; Adolescent and Young Adult Tattooing, Piercing, and Scarification. Pediatrics October 2017; 140 (4): e20163494. 10.1542/peds.2017-1962

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Tattoos, piercing, and scarification are now commonplace among adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide the pediatrician with management information. Body modification will be contrasted with nonsuicidal self-injury. When available, information also is presented on societal perceptions of body modification.

Tattoos, piercings, and scarification, also known as “body modifications,” are commonly obtained by adolescents and young adults. Previous reports on those who obtain tattoos, piercings, and scarification have focused mainly on high-risk populations, including at-risk adolescents. 1 Tattooing and piercing of various body parts no longer is a high-risk–population phenomenon, as evidenced by growing numbers of adults and adolescents not considered at risk who have tattoos and multiple ear and body piercings. The Pew Research Center reports that in 2010, 38% of 18 to 29 year olds had at least 1 tattoo, and 23% had piercings in locations other than an earlobe. 2 Of those with tattoos, 72% were covered and not visible. 2 Scarification is the practice of intentionally irritating the skin to cause a permanent pattern of scar tissue; data are not currently available on the prevalence of scarification in the United States.

Although body modifications have become a mainstream trend, they still may be associated with medical complications and, among adolescents, may also co-occur with high-risk behaviors. This first clinical report from the American Academy of Pediatrics on tattooing, piercing, and scarification discusses the history of these methods of body modification, educates the reader on methods used, reports on trends in associated adolescent and young adult risk behaviors, differentiates between nonsuicidal self-injury (NSSI) and body modifications, and educates the reader about how to anticipate and prevent potential medical complications. The report analyzes the literature about societal acceptance of people with body modifications and perceptions that might potentially interfere with adolescents’ and young adults’ educational and career plans. Finally, guidance is provided to pediatricians and, through the pediatrician, to parents and adolescents and young adults about safety and regulations regarding body modification should they wish to obtain tattoos, piercings, or scarification.

Although interest in body modification has increased recently, history teaches us that body modifications are not new. Archeologists have found evidence of tattoos, piercings, and scarification as far back as 2000 BC, when they were largely used as a form of art or to identify group membership, such as a religious group or tribe. Although mostly used to describe loyalty, interests, and lifestyle choices, body modification had also been used to label criminals, slaves, and convicts. 3  

Although in the late 20th century, most tattoos were on men, ranging from the stereotypical tattooed sailors and motorcycle bikers (eg, The Hells Angels in the 1960s) to 1980s gang members, now, tattoos are collections of colorful ornamentations for both women and men. Surveys of the US population have shown an increase in the prevalence of tattoos over time. 4 , 5  

Harris Poll data from 2016 found that 3 in 10 US adults had at least 1 tattoo, up from 20% in 2012. 6 Differences were found by geographic region, with tattoos being more prevalent in the West (27%) versus the East (28%), Midwest (27%), and South (32%). 6 Tattoos were also more prevalent among adults in their 30s compared with those younger and older, 6 although another national probability sample of adults found higher tattoo rates among younger versus older cohorts. 4 Evidence on sex differences in tattooing also varies, with tattoo prevalence among women ranging from 22% to 23% and prevalence among men ranging from 19% to 26%. 4 , 6 Among those with a tattoo, most (86%) have never regretted getting one, and 30% said it makes them feel sexier. Other feelings attributed to having a tattoo included feeling rebellious (25%), attractive or strong (21%), spiritual (16%), healthier (9%), more intelligent (8%), and athletic (5%). 6  

Estimates of tattooing and piercing among adolescents range by data source and age group. One early study among high school students from 8 states found that 10% had tattoos, and 55% expressed interest in tattooing. 7 In this sample, tattoos were commonly obtained around the ninth grade, but there were reports of tattooing as early as age 8 years. 7 Among adolescent clinic samples of youth 12 to 22 years of age, tattooing ranged from 10% to 23%, and body piercing (other than the earlobe) ranged from 27% to 42%, 8 , 9 with higher rates of tattooing and body piercing among girls versus boys and older versus younger adolescents. 8 , 9 Harris Poll data revealed that 22% of youth 18 to 24 years of age reported having a tattoo, 6 but estimates were as high as 38% among young people 18 to 29 years of age on the basis of Pew Research Center findings. 2  

Findings are comparable among subsequent samples of private university and college students, of whom 23% had a tattoo and 51% had a body piercing. 10 , 11 Male athletes were more likely to be tattooed than male nonathletes, and although women were more likely to have a piercing than men, there was no difference by sex for tattooing. 10 , 11 Of students with current piercings, high-ear cartilage (53%) was the most common visible piercing, followed by navel (38%), tongue (13%), and nipple and genital (9%) piercings.

A survey conducted among college freshmen from Italy found that many students undergoing tattooing and/or piercing were unaware of the associated health risks. 12 Although most (60%) students knew about HIV-related risks, less than half knew about possible infection with hepatitis C (38%), hepatitis B (34%), tetanus (34%), or about noninfectious complications (28%). 12 These findings have similarly been reported in a sample of medical students who had undergone piercing. 13  

Scarification is the practice of intentionally irritating the skin to cause a permanent pattern of scar tissue. Studies have been conducted among international communities describing high rates of scarification, yet no studies on scarification have been reported from the United States. 14 , 15 In the 1990s and 2000s, there was some renewed interest in scarification as a movement to revive indigenous rituals from around the world, embracing a more authentic or spiritual body experience. 16  

Although in the past, body modification was often associated with adolescent high-risk behaviors, current data have not consistently reported this association. In a retrospective analysis from 2007 to 2008, tattoos were associated with alcohol and drug use, violence and weapons carrying, sexual activity, eating disorders, and suicide. 17 However, the scientific link between tattooing and risk behaviors is less consistent today. 1 As with any adolescent or young adult, for those with piercings and tattoos, it is advised that the pediatrician conduct a careful adolescent psychosocial history with targeted behavioral interventions to assist in decreasing risk behaviors. 18  

It is important to be able to distinguish normal body modification from body modification that is more dramatic or intense as part of NSSI syndrome, which is described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as follows: “over the past year, the person has for at least 5 days engaged in self-injury with the anticipation that the injury will result in some bodily harm without suicidal intent.” 19  

NSSI differs from body modification because NSSI often is impulsive or compulsive and may be associated with mental health disorders, including psychotic disorders, personality disorders, and anxiety disorders. 20 Estimated prevalence rates for NSSI in 2008 for adolescents were between 14% and 24%. It can include cutting, scratching, burning, and hitting oneself. Individuals who hurt themselves report injuries to many different body parts. 21 The individual who engages in self-injury expects to get relief from a negative emotion, deal with a personal issue, or create a positive feeling. 19  

Importantly, NSSI is clinically concerning because of an association with mental health disorders, whereas body modification such as tattooing, piercing, and/or scarification does not have these associations and is more socially acceptable. 19 Intention is the most important differentiator and can be discerned with careful clinical interviewing. 18  

Public opinion of the relationship between having a tattoo and deviant behavior is changing. In 2008, among those with and without tattoos, 29% believed that people with tattoos were more likely to do something most people consider deviant, whereas 24% believed this in 2012. 6 From another survey regarding technological and social changes, 40% of respondents said that more people getting tattoos has been a change for the worse, 45% of respondents said that it has made no difference, and only 7% said this has been a change for the better. As might be expected, older Americans are far more likely to negatively view this trend; 64% of those 65 years and older and 51% of those 50 to 64 years of age said more people getting tattoos has been a change for the worse. A majority of those younger than 50 years (56%) said the tattoo trend has not made much of a difference. 22  

The age differences are larger among women than men. Of women aged 50 years and older, ∼6 in 10 (61%) said more people getting tattoos have been a change for the worse, compared with 27% of younger women. The gap is smaller among men; 51% of men aged 50 years and older said more people getting tattoos has been a change for the worse, compared with 30% of younger men. 2  

Although societal acceptance of tattoos and piercings has increased, there still may be repercussions when seeking employment or educational opportunities. In a 2014 survey of nearly 2700 people, 76% thought that tattoos and/or piercings had hurt their chances of getting a job, and 39% thought employees with tattoos and/or piercings reflect poorly on their employers. 23 One executive career coach wrote that 37% of human resource managers cite tattoos as the third physical attribute likely to limit career potential (nonear piercings and bad breath were the top 2). 24 , 25 Consequently, adolescents and young adults contemplating body modification may be well advised to make sure that the tattoo or piercing is not visible in typical work attire.

A multitude of videos on YouTube and other Internet video repositories exist for the reader to view and learn about safe and acceptable methods of tattoo placement. After selecting or designing the art to be transferred via tattoo, it is stenciled or drawn on the skin. The skin is cleansed with antiseptic, and a thin layer of ointment (such as petroleum jelly) is placed on the site. Professional tattoo artists use a motorized, electric–powered machine that holds needles and can puncture the skin up to several thousand times per minute. The needles are dipped into the ink and then puncture the skin at a depth of a few millimeters, where the pigment reaches the dermis layer. Any blood or serosanguineous fluid is wiped away during the procedure. After completion, another antiseptic is applied, and the tattoo is covered. After 24 hours, the dressing is removed and the tattoo remains open to air, and the skin is kept moist by applying antibiotic ointments, thick skin cream, or vitamin E oil several times daily. If cleansing is necessary, the skin is blotted and not rubbed. Tattoos generally take 2 weeks to heal; sun exposure should be avoided or sunscreen should be used, and swimming, direct shower jets, or soaking in water should be avoided. Clothing that might adhere to the tattoo site should not be worn. 3  

The inks of tattoos are a mixture of inorganic and synthetic organic pigments and diluents. They are considered cosmetics by the US Food and Drug Administration. Metal salts are commonly used as pigments; aluminum, cadmium, chromium, cobalt, iron, mercury, nickel, silicon, and titanium are a few of the metallic elements in tattoo pigments. 26 Although the concentration of metals in tattoo ink is low, metals are emerging as a class of human carcinogens. Cutaneous exposure over a lifetime may result in adverse events. Risk is modified by bioavailability, cellular uptake, metal interactions, protein binding, bone sequestration, and excretion. Age, sex, genetic variance, and other factors also appear to influence potential toxicity. 27  

Unfortunately, many tattoos are placed by amateurs, which makes the process much riskier. In these cases, antiseptic processes may not be followed, leading to potential skin infections and transmission of bloodborne illnesses, such as hepatitis C or HIV. Prison tattooing is usually painful because of the use of typically blunt instruments that are available. The generally poor quality and obvious visual location tends to stigmatize prisoners on release and may limit their chances of obtaining employment (see the previous section about public and employer perceptions as well). 28 The pigments are not standardized and may also contain more toxic materials as well as contamination. 27  

Permanent makeup has become an increasingly popular form of tattooing. Permanent makeup advertisers talk about the advantages of being waterproof, not smearing, time saving, and hassle free. Some people choose permanent makeup because of physical limitations, such as visual impairments or arthritis of the hands or shoulders. Cosmetic tattooing can also be an adjunctive to reconstructive surgery, such as nipple reconstruction after a mastectomy or breast reduction surgery. It is also used to cover scars, birthmarks, alopecia, and vitiligo. Cosmetic tattooing also may be attractive to patients who have allergies to conventional cosmetics. 29 The method of tattooing is similar to what is discussed previously.

The henna plant contains the pigment lawsone; in the skin, it interacts with keratin to give a reddish-brown color (sometimes known as “red henna” to distinguish from “black henna,” which is red henna mixed with paraphenylenediamine [PPD]). Red henna is commonly used in Islamic and Hindu societies, especially for celebrations such as weddings and religious ceremonies. The henna powder is mixed with a variety of materials depending on the artist and the region. They may include essential oils, such as lemon or eucalyptus, the dried powder of indigo plant leaves, lemon or beet root juice, tannin from tea leaves, dried coffee, charcoal powder, turpentine, PPD (discussed later), or even animal urine. Henna also has been used in different ways for medicinal purposes beyond the scope of this report. 30  

The paste is applied to the skin and remains for 30 minutes to 6 hours; the longer the exposure, the darker the color. At that point, there will be an orange stain, which will darken over the next 2 to 4 days. A temporary tattoo will usually last for 2 to 6 weeks, until the outer layer of skin exfoliates. 30  

The rate of complications from having tattoos placed is not known. However, with the large number of tattoos placed every day and few reports of complications from clients who receive tattoos, the rate is likely low. Most of the relevant medical literature are case reports or reports of local clusters of infection. Reported complications of tattoos are inflammation, infections (bacterial and viral), neoplasms, and rare reports of vasculitis. Inflammation is caused by sensitivity to tattoo pigments leading to focal edema, pruritus, papules, or nodules at the site. Pathologically, the reactions include lichenoid, eczematoid, sarcoidal, and pseudolymphomatous reactions as well as foreign-body granulomas. Preexisting conditions can lead to other reactions; psoriasis, systemic lupus, and sarcoidosis may demonstrate the Koebner phenomenon, leading to new lesions at the site of the tattoo. Even temporary henna tattoos have been associated with inflammatory reactions. 31  

Infections are a potentially more serious complication of tattooing. Tattooing can lead to infection caused by contaminated tattoo ink or needles; inadequate disinfection of the skin to be tattooed, resulting in resident bacterial contamination during the tattooing process; and, secondarily, during the healing process, when injured tissue causes pruritus. 32 Unfortunately, the real frequency of local infections after tattooing is unknown. Infections may be superficial pyogenic infections, deep or severe pyogenic infections, atypical mycobacterial infections, systemic or cutaneous viral infections, or (rarely) cutaneous fungal infections. Systemic viral infections from bloodborne pathogens include hepatitis C, hepatitis B, and HIV. Superficial pyogenic infections are usually related to Staphylococcus aureus or Streptococcus pyogenes , with common patterns of pustules or papulopustules along the tattoo lines. Infections are typically present 4 to 22 days after tattooing. Infections range from cellulitis and small pustules to larger abscesses that require surgical incision and drainage. Management is similar to other skin pyogenic infections. More severe pyogenic infections remain rare, but there are case reports of endocarditis, spinal abscess, erysipelas, gangrene, and amputations. 33  

There are many case reports of patients who have acquired nontuberculous mycobacteria (NTM) infections after receiving tattoos. 34 , 35 The infection usually is caused by contamination of the ink or equipment with nonsterile water. 36 Infections with Mycobacterium chelonae and Mycobacterium abscessus , which are rapidly growing bacteria, have occurred from the contamination of either inks or diluents. NTM infections range from mild inflammation with lesional rash, papules, or nodules to severe abscesses requiring extensive and multiple surgical débridements. NTM infections may require a minimum of 4 weeks of treatment with 2 or more antibiotic agents. 36 Examples of antibiotic agents that have been used, with variable success and sensitivities, are amikacin, ciprofloxacin and moxifloxacin, clarithromycin, minocycline, tigecycline, cefoxitin, imipenem, trimethoprim-sulfamethoxazole, and linezolid. 35 Antibiotic sensitivity is important in designing a treatment plan. 37 Consultation with an infectious disease expert for suspected NTM infection in a tattoo is warranted.

Another case report described Herpes compuncturum that developed 3 days after tattooing; it was concluded that this was a secondary infection in a patient in whom S aureus also was detected. Antibiotic therapy, antiviral therapy, and pain management resolved the rash. 33  

Bloodborne pathogens may occur after tattooing. Tattooing is associated with hepatitis B transmission, especially in teenagers with other high-risk behaviors. 38 Tattooing also is associated with higher rates of hepatitis C transmission. 39 HIV transmission associated with sharing tattoo needles or reusing tattoo inks has been reported. 40 If tattoos are placed in licensed parlors, infections are less likely to occur after tattooing than if they are placed by unlicensed individuals. 41  

There have been case reports of neoplasms associated with or after tattoo placement. Keratoacanthoma, squamous cell carcinoma, basal cell carcinoma, and leiomyosarcoma have been described occurring in areas of the skin with tattoo pigmentation. It is not known whether this is a coincidence or a causal effect. Tattoos placed over melanocytic nevi can make it difficult to monitor to ensure there is no malignant transformation, and both nevi and melanoma have been reported in previously tattooed skin. 31  

Rarely, there have been cases reported of acute cutaneous vasculitis in tattoo recipients occurring 10 to 14 days after placement. The following symptoms were typical: chills, arthralgia, myalgia, and purpuric rash. Treatment is similar to the treatment of other vasculitides. 33  

Researchers in one review article discuss toxicologic risks of tattoo ink, including phototoxicity, substance migration, and the possible metabolic conversion of tattoo ink ingredients. Also reviewed are the potential risks associated with cleavage products formed during laser-assisted tattoo removal. 42  

Red henna is relatively safe. From a population perspective, at least half of the population of India has been exposed to henna in their lifetimes with negligible reported immediate hypersensitivity reactions. 43 When they have occurred, it is not certain whether sensitivity is caused by the lawsone pigment, another component of the henna leaf, or the mixture of components. There is more concern for hairdressers who use henna in dyes because it may be an occupational hazard. 30 Treatment is similar to that of other hypersensitivity reactions.

The structure and redox potential of lawsone is similar to naphthalene, a potent oxidant of glucose-6-dehydrogenase (G6PD)-deficient cells. Topical application of red henna may cause hemolysis in children with G6PD deficiency. The hemolysis can be life threatening, with symptoms of pallor, lethargy, jaundice, anemia, vomiting, tachycardia, poor peripheral perfusion, and shock. 30  

Black henna contains the chemical PPD. No natural black henna exists. PPD is added to accelerate the dyeing and drying process (to 30 minutes), to strengthen and darken the color, to enhance the design, and to make the pattern last longer. These methods stain the skin black and have an appearance more like a real tattoo. Black henna is available worldwide, lasts several weeks in the skin, and offers an alternative to permanent tattoos. It is painless, and because the skin is not punctured, there is no risk of introducing local or bloodborne pathogens. However, there is a slight (2.5%) risk of allergic reactions from skin sensitization. Once sensitized, patients may experience allergic contact dermatitis from hair dyes that contain PPD. There are also reported cross-reactions to other hair dyes, dyes used in textiles, rubber chemicals, and local anesthetics. Some reported reactions were severe, requiring hospitalizations, especially in children. Most reactions were at the site, but generalization can occur. It takes several weeks for reactions to subside despite topical and sometimes oral corticosteroid therapy. 30  

The current increasing popularity of tattoos in the United States has concomitantly spurred an increased interest in tattoo removal, although tattoo removal is not new. Egyptian mummies dating to 4000 BC have evidence of attempted tattoo removal. Ancient Greek authors described the use of salt abrasion or a paste that also contained garlic and cantharidin to remove tattoos. Relationships, social status, and aesthetic tastes may change. Not all tattoos are placed intentionally; penetration of exogenous pigments can occur from road dirt from an accident, graphite in pencils, or gunpowder, and many people may want these unintentional tattoos removed. 44 Adolescents may overestimate the effectiveness of tattoo removal when having one placed and should be instructed that tattoo placement is permanent, and it is expensive and sometimes difficult to remove them. 3 Tattoo removal techniques can be categorized as mechanical, chemical, ablative, and selective. 44  

“Q-switched” lasers are the current state-of-the-art tattoo removal method. The laser wavelength is adjusted to match the absorption pattern of the different color pigments. The Q-switched laser pulse is delivered over nanoseconds with extremely rapid heating as high as 900°C (1652°F), leading to fragmentation of tattoo pigment particles. Immediately after the pulse, the epidermis appears white because the formation of gas as water in the skin is vaporized. An acute inflammatory infiltrate surrounds the pigment and debris from fragmented cells. Tattoo particles can be found in regional lymph nodes. Phagocytosis and clearance of fragmented pigment particles ensues. Free pigment is intracellular again within 4 weeks. Subsequent treatment should be performed after at least 4 weeks. One single-session laser treatment is available. Longer intervals may reduce the risk of permanent pigmentary changes to the skin. 44 , 45 It is important to have the requisite training in the use of the Q-switched laser for tattoo removal; the literature notes case reports of significant burns within tattoos after treatment, leading to scarring and poor outcomes. 46 In one case described in a report, the patient elected to have another tattoo placed to hide the burned area. 47  

Other methods that are less commonly used for tattoo removal include mechanical and chemical removal techniques. Mechanical methods include dermabrasion (which is variably effective) and excision with or without grafting (mostly for small tattoos; the predicted scar remaining would have to be acceptable to the patient). A number of chemical methods have been used with dermabrasion or as monotherapy. Imiquimod has been applied, with or without tretinoin, with mixed results. These techniques often result in hypo- or hyperpigmentation, or scarring, with varying effectiveness. 44  

Although laser removal may be the best way to remove a tattoo, the time, needed treatments, and cost should not be underestimated. One case report noted a 29 year old patient with 2 large, multicolored tattoos on his arms and chest who presented for removal. After 47 treatments, there was significant improvement. 48 There is no cost regulation of laser tattoo removal, and price per sq in per treatment can be anywhere between $49 and $300 depending on the location of the removal service. There are also standards published that involve the skin type and complexion of the individual, the colors involved, and complexity of the pattern adding up to a clinical score known as the Kirby-Desai score. A tattoo that is 15 sq in and is estimated to have 8 sessions based on this Kirby-Desai score could cost $5880, assuming a cost of $49 per sq in. 49  

A multitude of videos on YouTube and other Internet video repositories exist for the reader to view and learn about safe and acceptable methods of body piercing, some of which take the observer through the steps, including infection control practices. Most body piercing jewelry consists of rings, hoops, studs, or barbell-shaped ornaments. The size and shape of jewelry is determined by the body site pierced and personal preferences. Jewelry is not always interchangeable between piercing sites. In particular, jewelry designed for ear piercing may not be suitable for another part of the body because of the length of the post or the pressure exerted by the clasp. 50  

Most body piercing jewelry is made of metal, usually stainless steel, gold, niobium, titanium, or alloys. Gold often is combined with nickel or other metals to make alloys that have improved hardness and durability. Nickel in gold-filled or gold-plated jewelry is associated with a high prevalence of reactivity in people who are nickel sensitive. Those who are getting a piercing should pay careful attention to the studs or clasps on earrings; jewelry with a high karat rating commonly is paired with less expensive gold-plated studs or earring backs. Niobium and titanium are light-weight elemental metals that rarely produce an allergic response. Other features to consider in body piercing jewelry include the ease of removal (in case of trauma or radiographs), surface smoothness, and its capacity to withstand autoclaving and cleaning. 51 Surgical stainless steel rarely causes allergic skin reactions; however, not all stainless-steel products are nickel free. 52  

Although earrings may be sterilized before use, most piercing guns are not sterilized between procedures. Ear piercing systems using disposable, sterile cassettes are available but are not always used. 51 Because body piercing salons are unregulated in many states, some physicians may choose to perform body piercing procedures in their own office settings.

The lips, cheeks, and midline of the tongue are popular sites for oral piercings. Perforation of lingual blood vessels can cause bleeding and hematoma formation. Edema frequently develops after a tongue piercing, so a longer barbell is recommended initially. 53 Switching to a shorter barbell reduces the damage to the dentition and gingiva. Of note, beaded jewelry may become trapped between the teeth.

The ear is the most universal site for body piercing. Multiple ear piercings have gained approval, especially high piercing through the cartilage of the pinna. The nose can be pierced in the fleshy nares or through the cartilaginous septum. Septal piercings usually are performed in the inferior, fleshy part of the septum and not through cartilaginous tissue. The navel or periumbilical area is a popular self-piercing site. Navel rings and subsequent scarring are more problematic in overweight patients and in the latter stages of pregnancy as abdominal girth expands.

Wearing a curved barbell instead of a ring until the navel piercing has healed may reduce irritation and scarring. Friction from clothing with tight-fitting waistbands and subsequent skin maceration may account for the delayed healing and increased infection rates of navel piercings. Careful placement of jewelry and avoidance of rigidly fixed jewelry may minimize these problems. Before nipple and areolae piercings, men and women should be counseled about the lengthy time required for complete healing and the risk of delayed infection (see Table 1 ). Genital piercings anecdotally have been reported to enhance sexual sensitivity. Genital piercing sites in men include the penile glans, urethra, foreskin, and scrotum; sites in women include the clitoral prepuce or body, labia minora, labia majora, and perineum. 54  

Approximate Healing Times for Body Piercing Sites 51  

Dermal piercing, also known as microdermal piercing or single-point piercing, is defined as piercings placed into a flat surface of the body. The jewelry has an entry point and an exit point, but dermal piercing has just one end that can be seen on the surface of the skin. The second end is studded into the dermal layer of the skin. This variant of piercing has gained a lot of popularity because it can be placed on most flat surfaces of the body, and designs can be created by putting together multiple dermal piercings or combining with tattoos. They may be difficult to remove and may occasionally require surgical removal. 55 , 56  

No reliable estimates are available regarding people who have experienced complications related to body piercing. Importantly, adolescents and young adults with increased vulnerability to infection (eg, patients with diabetes mellitus or who are taking corticosteroids) and those taking anticoagulant medications may be at greater risk of complications from body piercing. However, multiple adverse outcomes associated with body piercing have been reported, including infection, pain, bleeding, hematoma formation, cyst formation, allergic reaction, hypertrophic scarring, and keloid formation. 51 , 57 , – 60  

Infection severity ranges from local infections (impetigo and cellulitis) to more severe infections, including osteomyelitis, toxic shock syndrome, and bacteremia. Life-threatening infections as a result of complications associated with body piercing include septic arthritis, endocarditis, and hepatitis B. With any piercing, there is the danger of infection, including hepatitis B or C virus and tetanus. 41 , 61 Body piercing as a possible vector for HIV transmission has been suggested, although no cases have been reported. 62 , 63  

A serious consequence of oral piercing is airway compromise from trauma, tongue swelling, or obstruction by jewelry. 64 Securing an adequate airway or endotracheal intubation can be challenging when a patient has a tongue barbell. 57 , 65 If lingual jewelry cannot be removed easily or expeditiously, precautions should be taken during intubation to ensure that jewelry is not loosened and aspirated or swallowed. Removal of oral and nasal jewelry also is recommended before nonemergency surgical procedures. Chipping or fracturing of teeth is the most common dental problem related to tongue barbells. 66  

Although there is a risk of infection because of the vast amounts of bacteria in the mouth, the infection rate is low. Oral rinses (eg, Listerine; Johnson and Johnson Consumer Companies Inc, New Brunswick, NJ) or the application of nonprescription cleansers (eg, Gly-Oxide Liquid Antiseptic Oral Cleanser; GlaxoSmithKline Consumer Healthcare, Philadelphia, PA) may be recommended prophylactically after an oral piercing. 67  

Ludwig angina is a rapidly spreading oral cellulitis and has been reported as a complication of tongue piercing. 68 Treatment involves maintaining an adequate airway, the administration of systemic antibiotic agents, and surgical drainage of abscesses.

Of people with ear piercings, up to 35% had one or more complication (eg, minor infection [77%], allergic reaction [43%], keloid formation [2.5%], and traumatic tearing [2.5%]). 69 Auricular perichondritis and perichondrial abscess typically occur in the first month after piercing, especially during warm-weather months. 70  

Auricular perichondritis presents as painful swelling, warmth, and redness in a portion of the auricle that often spares the earlobe. Acute tenderness on deflecting the auricular cartilage helps distinguish this deeper perichondrial infection from a superficial skin infection. Minor infections can progress to perichondritis, abscess formation, and necrosis with or without systemic symptoms. The most common pathogens (ie, Pseudomonas aeruginosa , S aureus , and S pyogenes ) often respond well to fluoroquinolone antibiotic treatment (eg, ciprofloxacin or levofloxacin). 71 , 72 Alternative options for hospitalization will depend on the pathogen and might include clindamycin, ceftazidime, and cefepime.

If an abscess is present, surgical incision and drainage often are necessary. Once an abscess develops, good cosmetic preservation of the auricular cartilage is difficult to maintain.

Prolonged wearing of heavy jewelry also may result in an elongated tract or bifid deformity of the earlobe.

People with atopic dermatitis or allergic metal contact dermatitis are at increased risk of developing minor staphylococcal or streptococcal skin infections. 73  

Superficial earlobe infections tend to have a benign course and respond well to local treatment, including warm, moist packs and application of over-the-counter, topical antibiotic ointment (eg, bacitracin [Polysporin and Neosporin; Johnson and Johnson Consumer Companies Inc, New Brunswick, NJ]). Treatment with mupirocin ointment or oral antistaphylococcal antibiotic agents may be warranted. 61 Oral antibiotic agents, such as the first-generation cephalosporins (eg, cephalexin or cefadroxil and penicillinase-resistant penicillins), are appropriate treatment options for more extensive but uncomplicated skin and soft tissue infections. Alternative antibiotic agents (ie, clindamycin or trimethoprim-sulfamethoxazole) may be more appropriate in communities that have higher rates of methicillin-resistant S aureus cases. Guidelines for the treatment of methicillin-resistant S aureus , according to the Infectious Diseases Society of America, also suggest doxycycline or linezolid might also be appropriate. 74 An earring can be replaced, or the ear can be repierced 6 to 8 weeks after resolution of local swelling and tenderness. 51  

The earlobe is a common site for hypertrophic scarring and keloid formation. In addition to aesthetic concerns, patients with keloids may have itching and tenderness. Treatment options for keloids include surgical excision, intralesional corticosteroid injections, cryosurgery, pressure dressing, radiation, and laser therapy. 75 , 76  

Contact dermatitis resulting from nickel exposure is common. Contact sensitivity to gold and localized argyria, a skin discoloration resulting from silver salts, also have been described. 77 , 78 Avoidance of the metals that trigger a reaction and the application of topical corticosteroids hasten the resolution of allergic dermatitis.

Occasionally, inflammation or infection result in such significant swelling that an earring should be removed. The pierced hole can be maintained, if desired, by inserting a ring made from a 20-gauge Teflon catheter with silicone tubing into the hole while the surrounding skin heals. 79 Similarly, a loop fashioned from nylon suture material may keep a piercing intact during the healing process.

Earrings can also become embedded in the earlobe, a complication common in persons with thick, fleshy earlobes that are pierced with spring-loaded guns. 80 Piercing guns exert high pressure on the soft tissue of the earlobe and cannot be adjusted for varying tissue thickness. Embedding may be prevented by using longer earring posts with adjustable backings. If gentle probing fails to locate an embedded earring, a small incision under local anesthesia (without epinephrine) may be necessary to locate and remove the earring or backing. Any suspected infection should be treated. 80  

Trauma to the pierced external ear is common. Lacerations to the ear may occur after falls, motor vehicle crashes, contact sports, person-to-person violence, or accidental pulling of an earring. The simplest laceration occurs when an earring is pulled through the earlobe, especially if the original earring hole was close to the periphery. All wounds should be cleaned and repaired within 12 to 24 hours. A simple earlobe tear can be sutured under local anesthesia. If the hole has closed, the earlobe can be repierced in an unscarred area after ∼3 months. 81  

Various closure techniques have been described in the literature. More complex lacerations of ear cartilage should be referred to subspecialists for repair. 82  

Pointed earring posts may cause pressure sores or postauricular skin irritation when worn during sleep. The removal of jewelry at bedtime is indicated if switching to a different earring style does not resolve the problem. Parents of infants or young children with pierced ears should be informed of the risk of aspiration and ingestion of earring parts. In such situations, earrings with a locking back or screw back are advisable. 83  

A localized infection of the earlobe may not be easily differentiated from allergic contact dermatitis unless there is purulent drainage or a high index of suspicion. 78  

Piercing the nasal cartilage can cause significant bleeding and lead to septal hematoma formation that often is accompanied by infection. Other potential complications that may result in cosmetic deformities include perichondritis and necrosis of the cartilaginous nasal wall. Infection requires aggressive treatment with antibiotic agents that have good coverage against Staphylococcus species that commonly colonize the nasal mucosa. Mupirocin is effective and offers excellent coverage against Gram-positive cocci. Fluoroquinolones have the advantage of excellent skin penetration and added coverage against Pseudomonas species. 84  

Nasal jewelry has the potential to be aspirated or swallowed. Rings placed in the nostril or septum also can migrate forward or be pulled out. As with ear piercing, the studs or backings of the jewelry may become embedded and require surgical removal. 84 Abscess formation has been reported after nipple piercing. 85  

There are case reports of cellulitis and spread of infection around a breast implant after a piercing. 86 , 87 However, little information is available about nipple piercing after breast implantation or chest wall augmentation. The effects of nipple piercings on lactation are not clear, but jewelry or scar tissue could impair latching on or block a milk duct and adversely affect an infant’s ability to breastfeed. Nipple piercings should be removed to avoid aspiration by the infant during lactation.

Jewelry inserted through the glans penis may interrupt urinary flow. Paraphimosis (ie, the inability to replace a retracted foreskin) has been associated with urethral and glans piercings in uncircumcised men. 88 The foreskin may be reduced manually after a penile nerve block. If this maneuver is unsuccessful, the prepuce can be injected with hyaluronidase to allow the edematous fluid to dissipate. 89  

Penile rings also can cause engorgement and priapism (ie, persistent erection), requiring emergency treatment to preserve erectile function. Women with genital piercings can develop bleeding, infections, allergic reactions, keloids, and scarring. 90  

It is advisable that sexually active people with genital piercings be counseled that jewelry may compromise the use of barrier contraceptive methods. Condoms may be more prone to break, and diaphragms may be more easily dislodged during sexual activity when 1 or both partners have genital piercings. Avoiding jewelry with sharp edges and using looser-fitting condoms or double condoms may help avoid some of these problems. 91  

From a unique study on urban teenagers and their knowledge of piercing complications, 92 33% of all subjects reported knowing someone who has had a medical or health problem related to body piercing; they most commonly reported infections (74%), bleeding (30%), allergic reactions (26%), and bruising and keloids (19% each) (see Table 2 ). Among those subjects with body piercings, 12% reported having had personal experiences with health problems related to the piercing, including infections, bleeding, bruising, and allergic reaction. Interestingly, those who got their piercings in a body-piercing shop were far more likely to report having had an infection (18.4%) than those who got pierced elsewhere (1.9%). 92  

Potential Complications of Body Piercings 51  

In patients with moderate- to high-risk cardiac conditions.

Adolescents were asked to estimate the percent chance of having a piercing-related health problem. The perceived risk for piercing by a professional (34%) was lower compared with a nonprofessional (73%). Neither those with a piercing nor those who had a problem with a piercing perceived risk any differently. Those who had pierced themselves perceived much less risk from piercing by a nonprofessional (50%) than those who had been pierced but not by themselves. Those with piercings of the face (nose, eyebrow, lips, and chin) tended to perceive less risk for face piercing (41.5%) compared with those without (49.7%). In the analysis of perceived risk, there were no effects of race, sex, or age. 92  

In a recent review from 2012, similar complications were confirmed, including systemic infections (such as viral hepatitis and toxic shock syndrome) and distant infections (such as endocarditis and brain abscesses). 58 It was recommended that body piercers have their clients complete a medical and social history to identify conditions that may predispose them to complications. Piercing candidates should choose a qualified practitioner to perform their piercings. 58  

One small study of children and adults with congenital heart disease found no cases of endocarditis after ear piercing, although only 6% of the patients received prophylactic antibiotic treatment. 93  

There have been recent reports of bacterial endocarditis after nipple and navel piercings in patients with surgically corrected congenital heart disease. It is important for physicians to know about planned piercings so they can consider antibiotic prophylaxis in patients with moderate- or high-risk cardiac conditions, 94 , – 96 although the American Heart Association guidelines on endocarditis prophylaxis do not specifically mention the need for antibiotic agents in people contemplating ear or body piercings. 97 , 98  

Ear stretching is a modification practiced by and originating from indigenous peoples. Tribes in various countries in Africa, Eurasia, America, and other indigenous lands have practiced the ritual of ear stretching for cultural, religious, and traditional purposes. Ear stretching is a ritual that has been practiced by people all over the world since ancient times. Bone, horn, wood, and stone were generally carved for ear stretching, but other organic materials that had the right shape naturally, from shells to teeth and claws, were also used.

Many cultures have practiced stretching, including ancient Egyptians (eg, King Tutankhamen), Buddhists from Nepal, Mursi tribal women of Ethiopia, and the African Maasai from Kenya and Tanzania. Stretching is also apparent in the Easter Island heads. Historically, the practice has been used for the purpose of tribal status, to scare enemies in war, and for beauty purposes. It has been and still is a common practice for both men and women. For men, it has been used historically to indicate the standing members of a specific tribe. The bigger the stretching, the higher the ranking the man had. As for women, ear stretching is more for decorative purposes and also signifies when a girl has reached womanhood. These practices are still important and used today by many tribes and cultures. 50  

Stretching, in the context of body piercing, is the deliberate expansion of a healed piercing for the purpose of wearing certain types of jewelry. Ear piercings are the most commonly stretched piercings, with nasal septum piercings, tongue piercings, and lip piercings and lip plates following close behind. Although all piercings can be stretched to some degree, cartilage piercings are usually more difficult to stretch and more likely to form hypertrophic scars if stretched quickly. Dermal punching is generally the preferred method for accommodating larger jewelry in cartilage piercings. 50  

Stretching should be performed in small increments to minimize the potential for damaging the healed piercing or creating scar tissue. In North America, most stretching methods go up by a single, even-sized gauge increment at a time. Stretching to 2 gauge, or 6 mm, is considered the point of no return, and the hole will not close to a standard piercing size if the “plug” is removed.

The typical jewelry worn in a large, stretched piercing is a plug, sometimes incorrectly referred to as a gauge, which refers to the sizing system used in the United States. It is solid, usually cylindrical, and may be flared out at one or both ends (saddle shaped) or kept in place by o-rings fastened around the ends. A variation on this is the flesh tunnel, which is shaped in the same way but is hollow in the middle. Claw-, talon-, and spiral-shaped pieces are also commonplace. Ear weights in varying degrees of size are also worn, commonly made from silver or bronze, although other metals, such as copper or brass, are occasionally used. However, some people are easily irritated by some metals; therefore, care should be taken when metal jewelry is worn. Ear cuffs (such as the gold ones used in South Indian provinces) or wrapped bead work (common among the Maasai of East Africa) are other options, although these are not usually seen in modern Western contexts. 50  

With both body piercing and stretching, the system of gauges and inches is used in gauge size notation, which was originally meant for wire thickness determination. A gauge number denotes a thickness on a standardized scale, which, for most purposes, starts at 20 gauge (0.03 in or 0.81 mm). This is most often used for the nose and ear post studs. Importantly, as the gauge number decreases to 0 gauge or even 00 gauge, the thickness of the piercing increases. 50  

Although no reliable estimates exist for the frequency of complications, the risk of adverse effects can still be reduced by ensuring sanitary tattoo parlors, needles, and inks; comprehensive training of artists; and strong infection-control practices. Individual states have regulated tattooing for decades to address public health concerns. States did not have any common standards until 1999, when the National Environmental Health Association published Body Art: A Comprehensive Guidebook and Model Code . 99 This was an interdisciplinary collaboration of academics, public health professionals, professional organizations, physicians, environmental health experts, and body art practitioners. The model provided detailed recommendations for and guidelines on sanitation and infection control. Artist training should include competence in sterilization procedures, anatomy, and infection control. As of 2012, 41 states each had at least one statute in place regulating tattooing. The remaining 9 states delegate authority to local-level and individual jurisdictions within those states. Even with these regulations, 72% of states do not effectively regulate sanitation, training and licensing, and infection control. Training and licensing was the least consistently regulated topic. Pediatric health care providers are recommended to learn about regulations in local states or jurisdictions. 100  

Similarly, there has been considerable debate about adolescents who are minors obtaining tattoos and parental consent requirements ( Table 3 ). At least 45 states have laws prohibiting minors from getting tattoos. Thirty-eight states have laws that prohibit both body piercing and tattooing on minors without parental permission. Each state varies on legislation of body piercing and tattooing. 101 It has been a challenge for states to keep pace with the new body art forms. Almost every state has laws addressing some aspect of body art. Nevada has no laws addressing body art; Maryland has limited laws. In New Hampshire, body piercing is not permitted on a person younger than 18 years without consent of that person’s parent or legal guardian. The consenting individual needs to be physically present at the time of piercing, provide evidence of status as parent or legal guardian, and sign a document that provides informed consent. Penalties for violators are fines, prison time, or both; most of these laws define violators as the person who performed the tattoo or piercing. Pediatric health care providers are encouraged to educate themselves about laws related to minors obtaining tattoos and piercings in their states. 101  

Body Piercing and Tattooing of Minors: Consent and Physical Presence Requirements by State 101 ,   102  

The prohibition does not apply when the tattooing is performed by a physician or licensed technician under a physician’s supervision.

Prohibition applies only to unmarried minors.

Prohibition for those younger than 14 years, consent required for ages 14–18 years.

Prohibition for those younger than 18 years, consent required for ages 18–21 years.

Prohibition for those younger than 16 years, consent required for ages 16–18 years.

Tattooing is allowed only for covering up an existing tattoo.

Scarification involves cutting, burning, or branding words or images into the skin. Although many people who have scarification have it done by amateurs, professional practitioners of this type of body modification use a variety of methods. The purpose is to create a permanent body modification. Some practitioners will also use methods that enhance scar formation, such as scraping off scabs or irritating the wound with materials such as iodine, citrus juice, or toothpaste. In some traditional cultures, ash or clay is packed into the wound to encourage hypertrophied scars. There are many methods in use, including the following: hot and cold branding (the latter with liquid nitrogen), moxibustion (placing incense on the skin and allowing it to burn until it’s extinguished in the skin), cutting with a scalpel, thermo- and electrocautery, and laser branding. 103  

Scarification does not produce consistent results and does not always produce the outcomes desired. Infection is a possible complication of any of these methods. Scarification artists may not be as experienced with these processes perhaps because of less demand for this method. 3 Additionally, keloids may be a complication (essentially, keloid formation is the complication of any of these body modification methods). There are emerging treatment strategies for keloid scars, but the best strategy is prevention. People who have had keloids or have family members with keloids should be informed that the outcome of scarification is uncertain. 104  

Although not as regulated as tattooing, the amount of state regulation regarding scarification is increasing. As of February 2014, 4 states prohibit scarification, and 16 other states’ legislation could be interpreted as regulating or prohibiting scarification. Eleven other states have some regulation as part of body art practice. Nineteen states do not address scarification. 104  

Pediatricians should recognize the difference between voluntary body modifications and the impulsive NSSI syndrome; and

As with all adolescent decisions that involve significant consequences, it is recommended that adolescents speak with their parents, guardians, or other responsible adults before having tattoos placed.

Adolescents and their families should be informed that tattoos are permanent and that removal is difficult, expensive, and only partially effective;

Pediatricians should advise adolescents with a history of keloid formation to avoid body modifications that puncture the skin. The outcome is uncertain whenever there is trauma to the skin resulting in scar;

Pediatricians should advise their adolescent patients to assess the sanitary and hygienic practices of the tattoo parlors and tattoo artists. This would include observing the use of new, disposable gloves; the removal of the new needle and equipment from a sealed, sterile container; and the use of fresh, unused ink poured into a new, disposable container with each new client;

Pediatricians should advise adolescents to seek medical care if there are signs and symptoms of infection. Normal skin and soft tissue infections should be considered first, but if there are any unusual features, prompt evaluation by a dermatologist is recommended. If there is confirmed mycobacterial infection, consultation with an infectious disease specialist is warranted;

Lesions that appear to grow and/or change within a tattoo are an indication for evaluation for neoplasms;

Pediatricians should inform families of the risk of hemolysis with red henna temporary tattoos for children or others with a positive G6PD deficiency. Black henna temporary tattoos should be avoided because of the significant rate of sensitization;

It may be advisable for pediatricians to familiarize themselves with local laws and regulations related to tattooing to inform families should pediatric patients be interested in having tattoos placed; and

Adolescents should be counseled about the implications on job placement and maintenance and education if the tattoos are at all visible.

Rinsing with nonprescription oral cleansers or the topical application of cleansers is recommended to prevent infection after oral piercing;

Antibiotic agents with good coverage against Pseudomonas and Staphylococcus species (eg, fluoroquinolones) are advised when treating piercing-associated infections of the auricular cartilage;

At clean piercing establishments, the piercer should be observed putting on new, disposable gloves and removing new equipment from a sterile container;

Adolescents contemplating a tongue piercing should be advised of the high incidence of tooth chipping associated with these piercings;

Pediatricians play an important role in promoting injury prevention by recommending that all jewelry be removed during contact sports to avoid endangering the wearer and other players. Jewelry that interferes with mouth guards or protective equipment should be removed before play. Nipple jewelry should be removed before breastfeeding;

It is important for pediatricians to understand local laws and regulations related to piercing to inform families should pediatric patients be interested in having a piercing; and

Adolescents should be counseled about the implications on job placement and maintenance and education if the piercings are at all visible.

Teenagers with a personal or family history of keloids should be cautioned about the risk associated with scarification and other body modification processes; and

Infections resulting from scarification may be treated similar to other skin and soft tissue infections, with standard topical or systemic antibiotic agents.

Alliance of Professional Tattooists Inc: www.safe-tattoos.com ;

About.com Tattoos: tattoo.about.com;

US Food and Drug Administration. Think Before You Ink: Are Tattoos Safe? http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048919.htm ;

US National Library of Medicine. Piercing and Tattoos: https://medlineplus.gov/piercingandtattoos.html ; and

Healthy Children: https://www.healthychildren.org/English/ages-stages/teen/Pages/Tattoos.aspx .

Nagle J. Why Do People Get Tattoos and Other Body Art? New York, NY: Rosen Publishing; 2011;

Baily D. Tattoo Art Around the World. New York, NY: Rosen Publishing; 2011; and

Spalding F. Erasing the Ink: Getting Rid of Your Tattoo. New York, NY: Rosen Publishing; 2011.

Association of Professional Piercers: www.safepiercing.org ;

Healthy Children: https://www.healthychildren.org/English/ages-stages/teen/Pages/Body-Piercing.aspx .

DeBoer S. Body Piercing Removal: Healthcare Professionals Handbook. Dyer, IN: Peds-R-Us Medical Education; 2013 (includes DVD). Available at: www.peds-r-us.com .

glucose-6-dehydrogenase

nonsuicidal self-injury

nontuberculous mycobacteria

paraphenylenediamine

State laws are subject to change, and other state laws and regulations may impact the interpretation of this listing.

Drs Breuner and Levine shared responsibility for all aspects of writing and editing the document and reviewing and responding to questions and comments from reviewers and the Board of Directors, and approve the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

Cora C. Breuner, MD, MPH, FAAP

David A. Levine, MD, FAAP

Cora C. Breuner, MD, MPH, FAAP, Chairperson

Elizabeth M. Alderman, MD, FSAHM, FAAP

Robert Garofalo, MD, FAAP

Laura K. Grubb, MD, FAAP

Makia E. Powers, MD, MPH, FAAP

Krishna K. Upadhya, MD, FAAP

Stephenie B. Wallace, MD, FAAP

Laurie L. Hornberger, MD, MPH, FAAP – Section on Adolescent Health

Liwei L. Hua, MD, PhD – American Academy of Child and Adolescent Psychiatry

Margo A. Lane, MD, FRCPC, FAAP – Canadian Paediatric Society

Meredith Loveless, MD, FACOG – American College of Obstetricians and Gynecologists

Seema Menon, MD – North American Society of Pediatric and Adolescent Gynecology

CDR Lauren B. Zapata, PhD, MSPH – Centers for Disease Control and Prevention

Karen S. Smith

James D. Baumberger, MPP

Competing Interests

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A Study of Body Modification Artists’ Knowledge, Attitudes, and Practices Toward Infection Control: A Questionnaire-Based Cross-Sectional Study

Aiggan tamene.

1 Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosaena, Southern Nations Nationalities and Peoples’ Region, Ethiopia

Bethlehem Yemane

2 Department of Environmental Health, College of Medicine and Health Sciences, Hawassa University, Hawaasa, Sidama Region, Ethiopia

Tattoos and piercings, which were once considered taboo, are now widespread like an epidemic, among people of all ages and gender. The rising demand for such body alterations has given rise to a large number of infective complications. This study was, therefore, designed to assess the infection control knowledge, attitudes, and practices of body modification artists in Ethiopia, 2021.

An anonymous observational cross-sectional study was conducted in Addis Ababa, Ethiopia, from May 25 to June 22, 2021. The data collection instrument was a structured questionnaire that covered the participants’ socio-demographic characteristics, knowledge, attitudes, and practices related to infection control. On the whole, 172 tattoo and body piercing artists participated in the study. SPSS v.20 software was used for data entry and analysis. Pearson’s correlation test, t -test, Tukey’s test, and multiple linear regression analysis were conducted during the data analysis.

Male participants constituted well over three-fourths (96.5%, n = 166) of the sample considered in the study. According to the result, the participants’ knowledge of infection control received the lowest score (7.1 ± 1.22). Participants’ scores of knowledge of infection control increased with an increase in their experience in the multiple linear regression. Experience and training time were also associated with knowledge. Infection control practice was positively associated with the respondents’ attitudes. After controlling other variables, it was found that a one-unit increase in respondents’ attitude scores increased their practice level by 86%.

This is the first study in Ethiopia to examine tattooists’ and body piercers’ infection control knowledge, attitude, and practice. Minimum standards for infection control in inking and piercing establishments are necessary. It is therefore important that local authorities and public health professionals work towards laying down the minimum code of practice for infection control in inking and piercing establishments.

Introduction

Body alteration, commonly known as tattooing, skin piercing, and jewellery insertion, has been practiced by humans for about 5000 years. 1 Modern tattooing is done using an electric machine that has a cluster of fast rotating needles that deposit liquid colour into the upper layer of the dermis. 2 Body piercing, on the other hand, entails the insertion of a needle into the body to create a fistula and implant decorative ornaments in areas other than the ear lobe. 3

Tattoos and piercings which used to be considered taboo in the past, have now become widely accepted forms of body alterations. 4 The practice appears to be particularly acceptable among adolescents and youths. The percentage of tattooed people in these age categories ranges from 1 to 24%, whereas the prevalence of body piercing ranges from 4.3% to 51%. 5 The rising demand for body alterations worldwide has given rise to many unprofessional body art practitioners. Such practitioners lack the knowledge required to carry out procedures following health and hygiene standards.

Skin that is free of cuts, abrasions, or lesions is called intact skin. Intact skin provides a natural barrier to infection. Cuts, sores, and sharp items that penetrate the skin often allow infections to enter the body. 6 Body modification that involves skin penetration, such as tattooing or piercing (T&P), puts people at the risk of contracting blood-borne infections. 7 , 8 It has been proved that blood-borne infections are often etiologically associated with Human Immunodeficiency Viruses (HIV), Hepatitis B, Hepatitis C, Septicaemia, and Tetanus. 9 The prevalence of tattoo complications is estimated to be around 2–3%. The majority of these complications are caused by an infection, which can be traced back to a tattooist who uses a non-sterile technique. A tattoo artist has even been known to transmit syphilis by licking the tattoo needle. 10 , 11 Piercing complications are more prevalent, with rates as high as 9%. 12 , 13

Strict adherence to infection control standards throughout the tattooing and/or the body piercing procedure is recommended to limit the risk of infection. The recommended measures need to be observed until the healing of the wound inflicted by tattooing/piercing of the body. 14 This implies that the services be provided only by a skilled, competent person with sufficient knowledge of infection control. All blood and bodily fluids should be treated as potentially infectious. Taking extra precautions has the potential to minimize risks in this regard. 15 Equally important measures needed to avoid the spread of infection are hand washing, using clean and/or sterile instruments, proper waste disposal, safe procedures, and clean facilities. 16

Adherence to such control measures can primarily be influenced by body modification artists’ knowledge of, attitude to, and practices of infection control. 17 The “KAP theory” is a health behavior change theory that divides human behavior change into three stages: knowledge acquisition, attitude formulation, and behavior adoption (or practice). A person’s KAP level has been connected to optimal illness prevention and management, as well as personal health promotion in past studies. KAP deficiencies, on the other hand, have been linked to poor health and poor disease prevention behavior. 18 This is particularly important for public health because of the immense potential risk of blood-borne infections in nonmedical services. Nonmedical service procedures are conducted with less epidemiological supervision than is required in the healthcare service sector. 19

Over the last couple of decades, Ethiopia has grown more and more urbanized. Following this, body modification has dramatically become popular among teenagers and young adults. In more recent years, tattooing and body piercing have increasingly grown among teenagers as a fashion statement or to improve body image. Despite the rapid growth of the tattoo and piercing industry, however, no systematic regulation is in place in the industry. The sparse literature on Ethiopian T&P regulation reveals that we still lack viable models for standards and techniques that can work at scale to maintain safety in contexts where risks are prevalent, compliance costs are high, and enforcement capability is inadequate.

Several European states have conducted studies on the conditions in which tattoo and piercing parlours operate. 20 However, due to the immense differences in regulatory regimes, solutions that have succeeded in developed countries cannot be automatically applied to the conditions in developing countries. The motivation for the present study arose from this recognition. The goal of this study was therefore to investigate body piercing and tattoo artists’ knowledge of infection control, their attitude to and practice of infection control. It is hoped that the findings will help stakeholders improve T&P safety guidelines and their implementation. The study will also give policymakers relevant insight that will help them make informed decisions about the industry’s future line of development.

Study Area and Setting

A cross-sectional infection control practice survey was conducted in Addis Ababa from May 25 to June 22, 2021. Addis Ababa is Africa’s seventh-largest city. It is a self-administered city that has a population of 5,005,524. The city represents 25% of Ethiopia’s total urban population. 21

Inclusion and Exclusion Criteria

The study included tattooists and body piercers working in Addis Ababa. Individuals not directly involved in the tattooing and body piercing activities were excluded.

Sample Size Calculation and Sampling Procedure

The sample size was determined using a formula for a single population that took into account various assumptions. No prior research on infection control practices among tattooists and body piercers was identified and accessed in Ethiopia. Because of this, the largest sample size assumption was used, with a prevalence among un-exposed at p=50%, a margin of error (d) of 5%, and a 95% level of confidence. The Epi-Info TM7 program generated a total sample size of 384 based on these assumptions.

According to the data acquired from Addis Ababa Commerce and Investment Office, there were 146 body art practitioners in 111 businesses in the city during data collection. Firms that had storefront signage advertising T&P and that offered such services online to the general public were also addressed to compensate for the potential incompleteness of the data received from the bureau. This led to the discovery of 29 more body artists in 16 other establishments. In the end, a total of 175 T&P practitioners working in 117 T&P parlours were discovered.

Next, because the sample was taken from a finite population, a correction formula was applied. The ultimate sample size was 152 after accounting for a 10% non-response rate. However, to enhance the study’s precision or accuracy, all of the 175 study subjects were included in the study. It was also noted that data quality and available resources would not be jeopardized since this sample size of 175 did not differ significantly from the calculated sample size.

The Procedure of Data Collection

The data for the study was gathered using an interviewer-administered questionnaire. The questionnaire comprised socio-demographic questions and KAP-related questions that considered the three elements of KAP. Prior studies were used to identify the content relating to KAP concerns and their correct answers. 22–24 Six questions were asked about the body modification artists’ age, sex, education, participation in infection control, safety training, and experience.

The KAP assessment was divided into three sections. The knowledge evaluation section had ten objective questions related to daily preventative practices. Topics like personal cleanliness and cross-contamination were considered in this section. The three response options used in the questionnaire were “Yes”; “No” and “I don’t know”. Similarly, the attitude evaluation section had ten questions. The focuses of the questions were the relevance of infection control protocols, the responsibility of body modification artists for preventing work-related infections, and the value of continued infection control practices.

In this study, Attitude was defined as a way of thinking that is mirrored in a person’s conduct. On a three-point scale, the tattooists and body modification artists were asked to express their level of agreement with the following response options: I “agree,” “disagree,” and “don’t know”.

The questionnaire’s final section addressed the evaluation of self-reported practices. The section had ten questions about the respondents’ everyday routines. Each practice was assessed using a five-point rating scale (1 = never, 2 = seldom, 3 = sometimes, 4 = frequently, and 5 = always). The scale was scored in reverse order for practices that were deemed inadequate. For knowledge questions, each correct answer received one point, while each incorrect or ‘I don’t know’ response received zero points. The knowledge block had a range of possible scores from 0 to 10. The attitude questions had a possible score range of 0 to 10 points. The available scores for the practice questions ranged from 10 to 50.

Data Quality Control

Distributing the questionnaire to strangers is often a matter of making a delicate balance between etiquette and expediency. Maintaining authenticity and improving the validity of the responses requires that the questionnaire be anonymous. As a result, all the questionnaires were de-identified during the analysis and the reporting of the data used in this study.

The data collecting instrument was translated from English to Amharic (ie, the country’s official language and the major language used in Addis Ababa). The translation was carried out by a health professional that was familiar with both the language and the health issues considered in the study. Cross-cultural translations took precedence over literal equivalencies during the translation. A two-day long training on the data collection procedures was given to the supervisor and the data collectors. The number of data collectors was 4. The data collection was completed in 28 days from May 25 to June 22, 2021.

The internal consistency (reliability) of the data gathering tools was assessed using Cronbach’s alpha test. The Cronbach’s alpha values for the knowledge, attitude, and practice sections were 0.812, 0.782, and 0.751, respectively. Finally, the questionnaire was beta-tested on 21 T&P practitioners at a comparable studio in the neighbouring city of Adama.

Data Management and Analysis

Throughout the data collection procedure, the completeness of the data was regularly checked. Epi-Info 7 software was used to code, label, validate, categorize, and enter data. The demographics of the participants, as well as their KAP of infection control, were described using frequency, percentage, mean, and standard deviation. The Kolmogorov–Smirnov test was used to determine the data’s normality. Under the circumstances in which a non-normal distribution was found, the data were log normalized before the parametric tests were run. The Pearson correlation test (r) was used to assess the correlation between the KAP scores. This was done taking into account the strength of the correlations and the respective likelihood of errors (p≤5%). The correlations were categorized as negligible (0.01 to 0.09), low (0.10 to 0.29), moderate (0.30 to 0.49), considerable (0.5 to 0.69), and high (0.70) based on their strength. 25

To compare the means of the KAP score while considering socio-demographic variables, a t -test and analyses of variance (ANOVA), followed by Tukey’s test, were used. A higher score in the Knowledge, Attitude and Practice domains was indicative of the respondents who had good knowledge, a positive attitude, and safe practice. The variables that influenced the KAP scores were identified using multiple linear regression analysis. The model for multiple linear regression analysis was established to determine the impact of explanatory variables on KAP scores. The variables considered in KAP scores were education, experience, training participation, time since previous training, knowledge, and attitudes. The significance level for all analyses was set at 5%.

Study Demographics

In total, 172 participants took part in the study. A commendable effort of sensitization was made before data collection. This resulted in a 98.2% response rate, with only 1.8% interview refusal. Table 1 shows the socio-demographic characteristics of 172 body modification artists. The majority of the participants (96.5%, n = 166) were male whose ages ranged from 20 to 29 years (44.8%, n = 78). In terms of education, the majority of the participants (57.9%, n = 99) had a high school education while 40.7% (n = 70) attended elementary school. The majority of the participants (39.5%, n = 68) reported having up to 5 years of work experience in body modification. They also reported attending at least two training sessions (74.4%, n = 128). During the data collection, the most recent training the participants claimed to have attended happened within the three months before data collection (52.0%, n = 44) ( Table 1 ).

Socio-Demographic Characteristics of Body Modification Artists in Addis Ababa, Ethiopia

KAP Towards Infection Control

In the current study, the mean score for knowledge of infection control was 7.1, with a standard deviation of 1.22. On the other hand, participants performed well on the questions about attitudes, with a mean score of 9.4 and a standard deviation of 0.98. The mean reported practice score was 47.2, with a standard deviation of 3.80 ( Table 2 ).

Score Obtained for Knowledge, Attitudes, and Practices Regarding Infection Control, Addis Ababa, Ethiopia

Knowledge of Infection Control

The risk of cross-contamination from body artists, the implementation of proper sanitizing measures, and appropriate sharp disposal techniques were among the knowledge-related questions that received a high percentage of correct answers. From the received 91.8% of incorrect answers to Question 1, it was possible to conclude that the respondents found the item to be the most challenging question. The majority of participants (61.6%) incorrectly believed that wearing gloves was a substitute for handwashing. Similarly, three-fourths of the respondents (75%) incorrectly believed dry heating to be one acceptable method of sanitizing needles ( Table 3 ).

Knowledge of Infection Control by Body Modification Artists in Addis Ababa, Ethiopia

Attitude Towards Infection Control

In contrast to the knowledge segment, the participants did well on the questions on Attitudes (See Table 4 ). Item 6 in the section, for example, was correctly answered by all participants. However, it is important to note that 14.5% of the respondents believed that enforcing strict infection control practices increase business expenditures significantly.

Attitude Towards Infection Control by Body Modification Artists in Addis Ababa, Ethiopia

Self-Reported Practice of Infection Control

Hand hygiene was reported to be performed by 72.7% of the respondents before performing a procedure. On the other hand, 84.3% said they wore gloves during procedures. Similarly, 87.8%, of the tattooists and piercing artists reported disposing of contaminated needles, syringes, and gloves. 83.1% reported never using sealed bags when autoclaving equipment ( Table 5 ).

Self-Reported Practice Towards Infection Control by Body Modification Artists in Addis Ababa, Ethiopia

The Pearson correlation test (r) was performed to determine the correlation between the KAP scores, taking into account the strength of the correlations as well as the possibility of errors (p<5%). Knowledge and attitude, as well as attitude and practice, were associated. No association was observed between Self-reported practices and Knowledge scores ( Table 6 ).

Pearson’s Correlation (r) Among the Scores Obtained in the Evaluation of KAP of Body Artists. Addis Ababa, 2021

Table 7 compares the mean scores obtained by body modification artists when socio-demographic characteristics are taken into account. Accordingly, there were significant variances in knowledge scores with regards to the amount of experience in the occupation and the time elapsed since their reported most recent training. Similarly, there was a substantial difference in attitude scores concerning schooling and the time they received the most recent training before data collection. Analysis of the data also revealed no significant differences in the scores obtained for infection control practices.

Relationship Between the Scores Obtained for Knowledge, Attitudes, and Practices of Body Artists

Note : Bold font under p-value indicates statistical significance.

The model for multiple linear regression analysis was generated to determine the impact of explanatory variables (education, experience, training participation, previous training duration, knowledge, and attitudes) on KAP scores. Only variables with statistically significant findings were included in the bivariate analysis. The KAP score considered the assumption of the effect of knowledge on the change in attitudes and practices. The influence of attitudes on practices was also considered in determining the association between the variables. The F-test yielded significant findings, suggesting a good model fit, and the Durbin Watson residual autocorrelation test yielded results ranging from 1.4 to 2.6.

The multiple linear regression analysis revealed that an increase in the respondents’ experience was followed by a similar increase in their knowledge scores. However, this gain was only significant for individuals who had spent 6–10 years in the job (β: 0.56; p=0.01). The length of time that has elapsed since the last training has a substantial impact on the respondents’ knowledge of infection control. When all other variables were adjusted for, those who received training for one year (β: −0.89; p=0.01) and six months before the survey (β: −0.14; p=0.01) had lower levels of knowledge than those who had the training in the last 90 days preceding the data collection time.

Two variables, the respondents’ educational level, and their training status were found to be significantly associated with a good attitude towards infection control. Participants who had a tertiary level of education (β: 0.48; p=0.01) and those with a high school education (β: 0.41; p=0.01), had significantly higher attitude scores. Those who received training six months before the study, on the other hand, had a lower level of attitude towards infection control than those who received the training within the last 90 days (β: −0.56; p<0.001) before data collection.

The respondents’ attitude was positively associated with good infection control practices. After adjusting for other variables, it was found that a one-unit rise in the attitude score of respondents was found to increase the practice level by 86% (β: 0.86; p<0.001) ( Table 8 ).

Multiple Linear Regression Analysis Between Scores Obtained for Knowledge, Attitudes and Practices, and Socio-Demographic Variables

Tattoos and piercings have become more popular than ever before as a result of increased social acceptance. T&P parlours, on the other hand, are directly responsible for a rise in hospital visits due to both immediate and delayed problems. 26 For such issues to be adequately and sustainably handled in the body art community, they must be acknowledged as a major public health concern. 27 From a public health perspective, many European studies have identified critical areas for action within the body modification industry where preventative measures are required to avoid infections. These efforts include education and training, a regulated service infrastructure, client safety insurance, and an ongoing effort to improve personnel knowledge and skill. 9 , 28 Ethiopia, on the other hand, is a country that is undergoing a unique economic transition that includes changes to its social infrastructure still lacks evidence-based infection prevention recommendations.

In any workplace, a high level of knowledge and scientific evidence is required to support safe practices. 29 Many T&P artists are indeed uninformed on subjects that should be part of their professional background, according to past findings. 30 A lack of anatomical knowledge, as well as tattoo and piercing aftercare, are significant challenges to safe practices. 31 In the current study, respondents who received training a year before this study had lower knowledge levels than those who received some training within the last 90 days before collection for the present study.

Given the lack of federal T&P regulations and the scarcity of opportunities for body modification artists to acquire more than a basic understanding of aseptic techniques, the negative impact of inadequate new and refresher training cannot be something unexpected. With a more concerted effort among the concerned parties, seeking strategies of infusing actions into the curriculum of the limited training opportunities may serve as a remedy until further and more lasting solutions can be sought. 32

Similarly, the multiple linear regression analysis revealed that an increase in experience has a positive impact on knowledge scores. Experience is a core element required for success in the workplace. 33 In many occupations, after some time of practicing a discipline, a person begins to take on responsibilities. They begin to collaborate with colleagues, learn from superiors, and work in teams. The need to acquire the necessary qualifications for the job also begins to emerge in their process of practicing the discipline. 34 , 35

Modern occupational health and safety approaches place a greater emphasis on learning and adapting than the emphasis they place on arriving at a job with all of the requisite skills. 34 This makes it necessary for public health experts to commit more effort to foster knowledge-sharing by enlisting the help of veteran body artists.

In this study, attitude was defined as a way of thinking that is reflected in a person’s behavior. Attitude is influenced by situational or extrinsic circumstances. These circumstances are difficult to control. Attitude can also be influenced by dispositional or intrinsic elements such as personal skills. 36 In other professions, the impact of different aspects of education and training on people’s attitudes toward infection prevention and control has been demonstrated. 37–39 Likewise, in the current study, the respondents’ educational level and training status were found to be significantly associated with a positive attitude towards infection control. This can be taken as proof for education and training to help in breaking down attitudinal obstacles to safe care.

Furthermore, the respondents’ attitudes were positively associated with good infection control practices. After adjusting for other variables, a one-unit rise in the attitude score of respondents was found to increase the practice level by 86%. In psychology, the link between people’s attitudes and behaviors is widely recognized, as explained by the Theory of Planned Behaviour. 40 Attitude formation, or a learned tendency to think, feel, and act in a certain way towards a specific set of items, is a crucial motivating factor for behavior adoption. People who are more concerned about T&P infections can engage in more effective protective practices. Such people’s concern about T&P can be revealed in terms of the efforts they make to understand the origin of infection, the occurrence, and frequency of severe episodes, the sterile techniques needed to minimize the extent of infection, and their understanding of the economic and health-related implications of the infection.

While there is evidence for knowledge-practice links among body modification artists, 7 , 12 the hypothesized correlation between the level of awareness (knowledge) and practice was found to be insignificant in this study. A lack of an action learning strategy may have led to a reduced level of transfer of research and medical evidence in the study context. This has a negative impact on the diffusion of ideal infection control practices. The discrepancy might also be a symptom of a broader lack of understanding of the magnitude of public health issues surrounding infections during and after T&P in Ethiopia.

There are some limitations to this study. This is a single-site study. This may make the findings less likely to be representative of all T&P parlours in the country. Other establishments will inevitably have their characteristics that mediate barriers to optimal infection control, though those identified in this study are likely to have a resonance there as well. Furthermore, participant responses may be biased due to their desire to provide socially preferred responses. This means that some participants may be more hesitant than others to share their true experiences. There is also a likelihood of over, under, or misreporting of behavior and practices in self-reported surveys.

Future Direction for Research

A lack of sufficient resources for the research had an impact on the sample size and the areas focused on in this study. For example, it was difficult to collect data from a larger number of body artists and/or their clients who have fallen ill as a result of infectious diseases caused by the practitioners’ unsafe practices. A future study is recommended to consider embracing a larger number of body artists and their clients. Likewise, future research may also be needed to tell us the costs associated with unsafe work practice-related injuries and worker and process downtime due to the injuries caused by unsafe practice in the occupation.

Similarly, there seems to be a need for future research to identify barriers to the implementation of infection control procedures. Other potential research areas include issues related to individuals who perform cosmetic tattoos in beauty parlours and tattooists working outside of legitimate businesses. This may provide a more complete picture of the industry In addition, the current study evidenced training as an important determinant of infection control knowledge acquisition, attitude formation, and behaviour adoption (or practice) in a broader context. Future research may need to further disaggregate and investigate the type and frequency of training, the content delivered, and the effect of body artists’ knowledge on the health of the clients.

This is the first study in Ethiopia to examine tattooists’ and body piercers’ infection control knowledge, attitude, and practice. We hope the study has laid the foundation for a preliminary understanding of the factors related to infection control in the personal appearance service industry. Minimum standards for infection control in inking and piercing establishments are necessary. Local authorities, as well as body artists, should come together and work in unison to put in place such standards. A consistent follow-up of the quality of services offered in this industry is lacking. In addition, there are no systems in place to record complications arising from tattooing and piercing. These lacks deny us the opportunity to assess the scale and type of health-related risks. Public health inspectors, in particular, should not monitor only the facilities but also should consider tattooing and piercing procedures. However, before these steps can be taken, public health officials must become sufficiently aware of the distinct nature of tattooing and piercing. Inspectors can only properly evaluate facilities and procedures if they understand the process. As a result, educational efforts should also be directed at public health officials.

Acknowledgments

The authors wish to thank the respondents and the data collectors for their remarkable contributions to the success of the study. All the firms that took part in the study deserve the authors’ appreciation.

Funding Statement

The authors received no financial support for the research, authorship, and/or publication of this article.

Abbreviations

ANOVA, analysis of variance COVID-19- Covid-19; T&P, tattooing or piercing; HIV, human immunodeficiency viruses; KAP, knowledge, attitude, and practices.

Data Sharing Statement

All the data supporting the findings are included in this paper.

Ethics Approval and Consent to Participate

All methods used in this study were carried out following all relevant guidelines and regulations (Declaration of Helsinki). The Ethical Review Committee at Hawassa University provided ethical clearance. The Addis Ababa City Health Bureau provided the required letter of support. The purpose of the study was fully disclosed to all participants, and all participants provided informed consent. In addition, all data gathered for the study was kept private and secure. All study participants received health education as well as occupational health and safety training on the job site.

The authors declare no competing interests in this work.

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We tend to think of human bodies as simply products of nature. In reality, however, our bodies are also the products of culture. That is, all cultures around the world modify and reshape human bodies. This is accomplished through a vast variety of techniques and for many different reasons, including:

• To make the body conform to ideals of beauty
• To mark membership in a group
• To mark social status
• To convey information about an individual’s personal qualities or accomplishments

Certain body modification practices, such as neck elongation or tooth filing, may strike Americans as strange and exotic, we must realize that we modify our own bodies in countless ways. Dieting, body-building, tanning, ear piercing and cosmetic surgery have long been common in the United States, and practices such as tattooing, body piercing and scarification are becoming increasingly popular.

People may seek to control, “correct” or “perfect” some aspect of their appearance, or to use their bodies as a canvas for creative self-expression. While some seek to improve their body-image, this is not necessarily a motivating factor for everyone who engages in body modification. Additionally, some attempts at body modification can also have unintended negative consequences that might ultimately damage self-esteem.  

Historical and Global Contexts of Body Modification  

Body modification occurs across the globe today in various forms and for many reasons (Barker & Barker, 2002, p. 92). Examples of body modifications from around the world include nose piercing associated with Hinduism, neck elongation in Thailand and Africa, henna tattooing in Southeast Asia and the Middle East, tooth filing in Bali, lip piercing and earlobe stretching in Africa, and female and male circumcision in many areas of the world (Larkin 2004; Barker & Barker 2002; Bendle 2004).

Two prominent historical examples of body modification are foot-binding and corseting. For hundreds of years, foot binding was commonly performed in China on girls, beginning between the ages of 3 and 7 and continuing throughout their lives. All toes but the big one were broken and folded under. The foot was then wrapped very tightly.  The bandages were changed frequently, maintaining constant pressure. By the end of the process, women’s feet were usually only a few inches long (Hong 1997). Men reportedly found the tiny feet, swishy walk, and apparent frailty highly erotic. Although foot binding essentially crippled the women who underwent the process, parents continued the practice to improve their daughter’s chances of attracting a husband. When China was opened to the West, the process began to die out, and by the 1950s it was largely a relic of the past.  

Other cultures have imposed similarly constrictive and debilitating body modifications on women’s bodies. In Western nations during the Victorian era, women were expected to wear stiff corsets in an attempt to obtain the ideal curvaceous feminine figure with broad hips and tiny waists, cinched as small as 12 inches (Riordan, 2007: 263). Such corseting was, in fact, a form of permanent body modification. With severely tight lacing, women’s bodies came to “literally incorporate the corset as the ribs and internal organs gradually adapt[ed] to its shape” (Riordan, 2007:263). This practice both reflected ideas about women’s natural frailty and contributed to such notions, as tight lacing left many short of breath and even unable to stand for long periods of time without support.  

While such restrictive corsetry has gone out of fashion, Western women and girls are now encouraged to discipline and control their bodies with other practices such as extreme dieting and punishing exercise regimes. In addition, both women and men in the US today are increasingly modifying their bodies through practices such as cosmetic surgery, body piercing, tattooing and tanning.

Cosmetic Surgery

According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2008, Americans underwent 10.2 million cosmetic procedures, paying out just under $12 billion (Mann 2009). While the general economic downturn has led to a slight decrease in such procedures, cosmetic surgery has increased dramatically in the last decade. In fact, while the majority of procedures are performed on women, men’s use of cosmetic procedures has increased 20 percent since the year 2000 (Atkinson 2008).  

Opinion is divided on the benefits of cosmetic surgery. Some suggest that cosmetic procedures can improve self-esteem and combat negative body image. Others see surgical interventions as a sad indictment of a culture with rigid and narrow ideas of beauty—a culture that values youth, sexuality and appearance more than experience, character and substance (Jeffreys 2000). Critics also note the potential risks associated with cosmetic surgery. In addition to the risk of post-operative infections and other surgical complications, one recent study revealed a correlation between plastic surgery, substance abuse and suicide (Lipworth, 2007).

Piercing, Tattoos and Scarification

Body piercing has become increasingly popular and socially acceptable in the US in recent years. One recent study of American college students found that 60 percent of women and 42 percent of men were pierced (Kaatz, Elsner & Bauer 2008). Common piercing sites include the ears, nose, tongue, eyebrow, lip, nipple, navel and genitals, with the ear being the most common site for both males and females (Larkin 2004). While some engage in piercing for the sake of fashion, researchers report that for others, it is a way to take control of their bodies, especially after being violated. As one rape victim reported:  

• “I’m getting pierced to reclaim my body. I’ve been used and abused. My body was taken by another without my consent. Now, by the ritual of piercing, I claim my body as my own. I heal my wounds” (Jeffreys 2000: 414). 

Tattooing has likewise grown in popularity over the last decade, with an estimated 10 percent of Americans sporting tattoos (Kaatz, Elsner & Bauser 2008). While once associated largely with criminality and deviance, today Americans are likely to see tattoos as a way of controlling their identities, expressing their creativity, and asserting their identity (Kang & Jones 2007). One recent study suggests that individuals who were moderately to heavily tattooed have “an increased sense of self-confidence after having pierced or tattooed their bodies” (Carroll & Anderson 2002: 628).

Tattoos may also act as a means of commemorating or moving on. It is not uncommon for trauma victims, those with disabilities or serious illnesses, or marginalized groups to tattoo as a way of claiming positive ownership of their own bodies, their own identities (Atkinson 2004). In this way, tattooing can serve to heal, to empowering, and to promote body acceptance and self-esteem. On the flipside, however, researchers have found that for some, tattoos serve as painful reminders of poor choices—rashness, intoxication, failed relationships, and other profound regrets (Houghton 1996). Some also report feeling embarrassment or discomfort about how others might view them because of their tattoos, feelings that can contribute to negative body-image and low self-esteem (Houghton 1996).

While not as common as piercing and tattooing, scarification is also an increasingly visible practice in the US today. Scarification, widely practiced as part of initiation and puberty rites in cultures throughout the world, involves the cutting (or sometimes burning) of the skin in ways designed to leave permanent scars. The scars often form intricate patterns across the skin.

Because scarification is a physically demanding (and painful) process, Jennings (2009) reports that in the US today it is often associated with sadomasochism and other subcultures that stress the experience itself as pleasurable, cleansing or transformative. If practiced as part of a group ritual, many participants report feeling a heightened sense of community, group membership and acceptance (Pitts 2000). Nonetheless, some practitioners also report feeling more vulnerable, even socially ostracized, by such permanent scarring (Pitts 2000).  

Ideas about physical beauty not only vary a great deal from culture to culture, but also change over time. American views of suntanned skin have changed dramatically over the past century. In Victorian America, pale skin was the ideal. Women wore hats and gloves and carried parasols to shield their skin from the sun. At a time when many people still earned a living by laboring out of doors, a pale complexion was an indication of affluence and indoor work and leisure. By the late twentieth century, however, most people were earning a living indoors. So tanned skin became an indication of affluence, a sign that one had the time and money to lounge by the pool, play golf or tennis, or travel to tropical destinations.

As the suntan became associated with both health and wealth, even those without access to swimming pools and tropical vacations increasingly aspired to the new physical ideal. And the indoor tanning industry was born. Tanning is now a $5 billion dollar a year industry with some 40,000 tanning outlets nationwide ( Looking Fit Magazine  2009).  

At least one recent study has suggests that some individuals become addicted to tanning, despite its well documented links to skin damage, severe wrinkling, and skin cancer (Warthan, Uchida & Wagner 2005). Others suggest that tanning addiction, what some have called “tanorexia,” may be linked to Body Dysmorphic Disorder (BDD). Excessive tanning may be stem from an obsession with perceived physical flaws and the compulsion to “correct” them. As health practitioners have observed:  

Only by looking at the psychological factors that go into sun-tanning behavior can we understand the young woman who waits in line at a tanning salon, although she understands that tanning will age her skin and can cause cancer…Low self-esteem, body image distortion and undiagnosed depression and anxiety can drive some to act self-destructively in the pursuit of some idealized image of beauty (Deleo & Silvan, 2006).

Ask Yourself  

How do you and those around you modify your bodies? What motivates you to do so? What are the potential benefits and risks (physical, emotional and social) of such body modification practices?  

To what extent do rigid and unrealistic ideals of beauty encourage us to change our bodies? Should we try to conform to these ideals or try to change these ideals?

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Body Modification: Anatomy, Alteration, and Art in Anthropogeny

Mark Collard , Simon Fraser University Francesco d'Errico , University of Bordeaux

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Summary: Permanent body modification is an intriguing phenomenon. It is regularly practiced by living humans but is not seen in other extant mammals. It is highly variable within and between cultures. It is also often both expensive and risky. All of these characteristics—its uniqueness, its variability, and its actual or potential costliness—make permanent body modification an important behavior for scientists to understand. However, the scientific study of permanent body modification is in its infancy. The goal of this symposium is to provide a snapshot of where we are at with regard to research on permanent body modification and to identify questions that should be prioritized over the next decade. The symposium will bring together academics from a number of disciplines as well as practitioners from the permanent body modification industry. We will cover a wide range of historical and contemporary permanent body modification practices, including but not limited to tattooing, piercing, finger amputation, and cranial modification. In addition to considering the ‘when’ and ‘where’ of permanent body modification, we will delve into the motivations behind this behavior, considering both the personal justifications offered by participants and the scientific hypotheses proposed to explain it.

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Body Modification: Past and Present Research Paper

Introduction, works cited.

The human body modification is represented in its physical transformation. Research has proved that body decoration reflects identity, ideology, and lifestyle of a person. As a result, whichever change is made to one’s physical appearance to reflect spiritual, fashion, social, as well as personal self-expression and identification, it may be classified as body modification.

This comprehensive term includes piercing, tattooing, earlobe stretching, branding, and cutting. Additionally, there are more peculiar ways of body modification, such as dental, facial, or breast implants.

Anthropological study on the history of body modification revealed that many people all over the world have been decorating their body with a selection of artistic designs ever since the ancient times. In spite of the fact that the style in which body modification is done differs, there are common attributes shared by many cultures. Some of which are still practiced in the present day. This research paper will discuss the global history of body modification and its current position in the modern world.

What Is Body Modification?

Body modification can be classified as the art of modifying the body by manipulating color, texture, scent, sounds, and taste or by decorating the body with some painting or jewelry.

Types of Body Modification

The term ‘body modification’ refers to several methods of body transformation which include piercing, tattooing, branding, cutting, binding and inserting implants to alter the appearance and shape the body.

History of Body Modification

Body modification is undoubtedly distinctive feature attributed to the masses. This process has been in the use dated back 30,000 years. Throughout the human history, individuals in many cultures have deliberately altered their physical natural appearance for aesthetic reasons.

There is a general belief which implies that body modification was a mode of one’s expression and identification even in ancient times. However, regardless body decoration which involves painting, tattooing, and other skin modification, people have also ornamented their bodies with piercings, which may be jewelry. In line with this, body piercing has been widely spread during the last ten to seventeen years, but the general society may still view it as dishonor and some inappropriate practice.

Although, what majority of the world populace do not understand is that piercing of the body (excluding ears’ piercing) originated centuries ago, back to the Biblical era, and has cultural and emblematic meaning contrary to the feeling of distress and dishonor.

The creative designing of human body (known as body modification) has been a customary way of human mode of self-expression and identification since the era of the ancient Egypt. This denotes that body modification and ethnicity are linked.

Although ethnicity and ethnic group seem to have clear references in relation to body modification, they are “among the most complicated and charged words and ideas of body modification or supplement in the lexicon of social science” (Nash 1).

According to the history of body modification or supplement, the Egyptians restrain piercing of the navel from the general masses. According to their belief, navel piercing can only be done by the royalties (the pharaohs). However, the Egyptians do not regard the art of body modification as fashion or beauty but as a form of showing their social hierarchical position and status.

On the other hand, the pre-Egyptians developed and improved their skulls and employed an easy method of creating tattoos. Afterward, the ancient Egyptians introduced ear piercing while the prehistoric South Americans, like the Mayans and Aztecs, ritualistically practiced the process of tongue piercing as a ritual of the sacrificial offering of blood to their Gods (Noya, 2005).

Furthermore, Native Australians also performed penile surgical incision and lengthening of the labia as a form of body modification. Native North American and the Inuit (an aboriginal group living on the territory of the modern Canada and presently referred to as Canadians) practiced the piercing of the lip and put on a decorative piece made of bone, which is presently reproduced as the labret stud. Besides, for generations, the aborigines of PacificIsland employed the practice of body modification.

Despite the fact that body modification is not well acknowledged in the Western culture, it has been a custom in many ethnic groups and eastern culture for a long. As an example, the insertion of nose rings in the left nostril originated in India, and symbolizes easier parturition process for Indian women (Noya, 2005).

The Romans had their own body modification traditions. They also believed that all their actions served a purpose, hence, to them, body modifications reflected a practical reason (Roberts, 2004). The ancient Romans believed that their centurions pierced their nipples in order to give them men strength.

Another historical example of body modification popular among the Romans is piercing of the genitals. According to the history of body modification of the archaic culture of the Romans, it was compulsory that the Roman gladiators pierced the head of their penises because they were slaves. The Roman traditional piercing of the gladiators’ penises was made for two reasons.

• This form of body modification was for the purpose of pegging their genitals during a gladiator combat, as well as
• piercing of gladiator’s genital organ was as a means of preventing them from engaging in sexual activities without the consent of their master (Sanders, 2005).

In Sub-Saharan Africa, there are tribal marks that people carry not as a form of body modification but also as a symbol of belonging to a certain community. In Sub-Saharan Africa, body modification dates back to ancestral era when it was made as a cut on the face used to identify one’s tribal affiliation.

Africans viewed their tribal marking as an extension of their native selves, a fleshly embodiment of tribal customs and rich histories. In some cases, the process of scarification marked a coming of age, which is performed as a part of the ceremony in which a young man or a woman ascends to the rank of being adult.

During the period in history between traditional antiquity and the Italian Renaissance, the art of body modification became progressively weaker than it had been in the past, as it was considered by the early church as a sinful act. This is, perhaps, why most of the Western societies have a negative perception of body modification contrary to that of the eastern or African societies (Sanders, 2005).

Body Modification in the Modern age

There are many different methods of decoration that men and women (mostly teens) from all over the world beautify their skin today, they range from tattoos and body piercings to branding and scars. As the world civilizes and encourages the development of the individual, body modification (piercing, tattooing, etc.) is once again revived or brought back to the scene as a way of self-expression.

In the modern era, due to the wide popularity of ear piercing, it became a way for women to proudly display their diamonds and riches, and it has gradually become less exceptionable for men to pierce their ear. Tattooing is also widely spread having successfully entered into the modern culture.

In the modern age, body modification (piercing and tattooing in particular) is of interest to teens who want to explore their identities by experimenting with their body appearances.

It is an accepted belief that physical appearance generally reveals one’s inner self, beliefs, values, and hopes. As a result, body modification can, therefore, be seen as a means for the expression of the inner self, as a communicative medium of telling others what lies within. For some, body modification is considered simply decorative, much like fashion tendency. For the others, it symbolizes momentous transitions in life, indicates group membership, or declares love or some other feelings.

Some people get memorial tattoos to mark the death of friends and family members; for others, body modification offers a means to declare a sense of ownership via their bodies. For girls, body modification often signifies independence and self-asserting action, making an attempt to undermine or challenge more traditional feminine attributes, such as dependence and passivity.

Although many people pierce, decorate their body with tattoos simply to follow certain style and fashion or modify their appearance for a great variety of reasons. Some people are motivated by the desire to show that they are not under somebody’s control. They believe they are able to decorate their bodies as a manifestation that they are free to do what they want and are not obliged to explain or justify their choices.

Some claim that body modification represents who they are and emphasize their individuality and creativity. However, others, sometimes called “modern primitives,” want to establish a link with ancient people or traditional cultures as a way to show that they perceive Western society as a superficial one.

Nash, Manning. The Cauldron of Ethnicity in the Modern World . Chicago: University of Chicago, 1989. Print.

Noya, Charles. History of Body Piercing . 2005. Web.

Roberts, Lucy. P. The History of Body Piercings-Ancient and Fascinating Around the World . Sept. 12. 2004. Web.

Sanders, Diana. A brief history of body piercing in the U.K. 2005. Web.

• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, April 2). Body Modification: Past and Present. https://ivypanda.com/essays/body-modification/

"Body Modification: Past and Present." IvyPanda , 2 Apr. 2024, ivypanda.com/essays/body-modification/.

IvyPanda . (2024) 'Body Modification: Past and Present'. 2 April.

IvyPanda . 2024. "Body Modification: Past and Present." April 2, 2024. https://ivypanda.com/essays/body-modification/.

1. IvyPanda . "Body Modification: Past and Present." April 2, 2024. https://ivypanda.com/essays/body-modification/.

Bibliography

IvyPanda . "Body Modification: Past and Present." April 2, 2024. https://ivypanda.com/essays/body-modification/.

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