by JUDITH GREIF WALTER HEWITT Rutgers University Health Service
MYRNA L. ARMSTRONG Texas Tech University Health Sciences Center

Tattooing and body piercing are increasing, especially among college students. A study of 766 tattooed and/or body-pierced college students In 18 universities across the Untied States and one in Australia was conducted to discover the demographic characteristics, motivational factors and health concerns. The traditional college time of 18 to 22 years of age (69%) was when they obtained their tattoo (73%) and/or body piercing (63%). More frequent health problems and impulsive decision-making were noted for those with body piercing when compared to those tattooed. Three cases of hepatitis were reported. Health professionals should openly discuss body art with students, convey a nonjudgmental attitude, and assist with informed decision-making information to either reduce risks or dissuade. Open communication and applicable health education will be very important.

Body art, specifically tattooing and body piercing, has been practiced in almost every culture around the world, and for thousands of years. Tattoos are now being reported on archaeological findings including a 2,400-year-old Russian mummy with a tattoo still clearly visible on her biceps (Polosmak, 1994). Royalty, especially the name of Queen Victoria, is frequently mentioned as having had a tattoo, and her consort, Prince Albert, is said to have had a penile piercing through his urethra (Greif &Hewitt, 1996). Anthropologists describe body art or modification as a way of identifying oneself as being a part of a specific group, whether a religious group, a tribe, or gang: of denoting one's financial or marital status; or even as a way of beautifying the body [Myers, 1992; Saunders, 1989). Many, from pirates to Roman Centurions, have had body piercings - sometimes symbolizing royalty, bravery, virility, or as a rite of passage. Yet in Western culture, tattooing and piercing often have been considered taboo, perhaps stemming from the Bible's Old Testament citing in Leviticus 19:28 and Deuteronomy 14:1 that prohibits the marking of one's flesh in celebration of other gods.

Today, both genders are almost equally represented in obtaining tattoos and body piercing. This description includes both adults and adolescents from a wide range of occupations and socioeconomic groups {Anderson, 1992; Armstrong, 1991; Armstrong, Ekmark, & Brooks, 1995). Between 7 million and 20 million adults are reported to be tattooed. Armstrong and Pace Murphy (1997) reported 1in every 10 adolescents are tattooed, and Sperry provided an even higher estimate of 25% of all 15-to 25-year-olds being tattooed (quoted in O'Hara, 1995), Webster's Dictionary (1993) defines the word tattoo, from the Tahitian term, "tatu, as an indelible mark or figure fixed upon the body by the insertion of pigment under die skin or by the production of scars" (p. 1207). Today, that is often accomplished in a studio by artists using a rapid-injecting electrical device that delivers a uniform series of punctures into the dermal layer of the skin (Greif& Hewitt, 1998). The pigment for the tattoo is injected into the skin "50 to 3,000 times per minute up to, or into the dermis at a depth of 1/64 to 1/16 of an inch" (Armstrong. 1991, p. 216). Although many of the ingredients in tattoo pigments were approved as cosmetics for topical use by the FDA in 1938. They have not been approved for invasive procedures, with some pigments containing lead, mercury, and trace amounts of arsenic (Tope, 1995). In addition, many of these tattoo pigments do not contain standardized Ingredients. This "lack of purity and Identity" can prevent effective results if the tattoo recipients change their mind about the tattoo and want it removed (Anderson, 1992). Although "almost all tattoos can be lightened, Q-switched laser treatment truly clears only about 70% and some inks have proven to be resistant to laser treatment, particularly dark green and yellow varieties" (Armstrong, Stuppy, Gabriel, & Anderson, 1996, p. 415).

"Piercing involves the insertion of a needle into various areas of the body to create an opening through which decorative ornaments such as jewelry may be worn" (Greif & Hewitt, 1998, p. 26). The procedure only takes a few minutes to perform and is frequently done on body areas such as the ears, nose, eyebrows, lips, tongue, nipples, naval, and genitals. Specific jewelry (surgical-grade stainless steel or solid 14-karat yellow gold, niobium, or titanium) is strongly recommended for insertion into the opening to avoid allergic and infectious responses.

Most body piercing is performed in tattoo studios; unfortunately it is also self-inflicted and done in temporary establishments such as flea markets, rock concerts, and college parties as part of the entertainment. Gauntlet, an International chain of body piercing shops in California, New York, and Paris, reports at least 30,000 piercings each year (Michaela Grey, personal communication, June 17, 1997). Statistics on the amount of body piercing done is difficult to determine as the procedure lacks the permanency of tattooing; if the person doesn't like the piercing, they can remove the jewelry and the hole will close. Then, other than the frequent formation of scar tissue at the site, no one knows of their previous piercing actions.

Tattooing and body piercing are still primarily an artist-consumer regulated business {Armstrong, 1991). Many states (N = 27) do not have any regulations for tattooing (Tope, 1995) and few states N = 5) have statutes for body piercing (Armstrong & Fell, in press). If there are regulations, enforcement is of concern as most local and state health departments prioritize Inspections: those with complaints are reviewed and those with no complaints are often left alone (Armstrong & Pace Murphy, 1997). Thus, the customer must have knowledge of the health concerns and risks for safe practice of body art.

In general, for the amount of body art that is done, there seem to be relatively few health problems although the potential of blood-borne disease risk still exists and the medical literature describing the complications seems to be evolving. The major risk is due to the small amount of bleeding present with both procedures. Hepatitis B remains the significant concern and recently both the American and Canadian medical literature have documented transmission of Hepatitis C (Long & Rickman, 1994, Shimokura & Gully, 1995; Sperry, 1992; Tweeten & Rickman, 1998). Two brief reports have raised the question of human immunodeficiency virus (HIV) transmission in both types of body art (Doll, 1988; Pugatch, Mileno, & Rich, 1998). Following body piercing, local site infections remain common. Some life-threatening outcomes with body piercings have been reported including septic arthritis, acute glomerulonephritis, and endocarditis (Armstrong, Ekmark, & Brooks, 1995; Tweeten & Rickman, 1998). Psychosocial risks with body art are also documented and include "embarrassment, low self esteem, and disappointment" (Armstrong, 1991; Armstrong & McConnell, 1994; Armstrong & Pace Murphy, 1997; Armstrong, Ekmark, & Brooks, 1995).

Although the phenomenon of obtaining body art is gaining in popularity, little is known about the tattooed and pierced college-age student. The purposes of this exploratory study were to identify the characteristics of students enrolled in college that have a tattoo(s) and/or body piercing, the frequency of occurrence, their decision making and experiences, and health issues of those with body art. Information about the college student's decision making when obtaining a tattoo or body piercing could alert the health care professional to risk-taking behavior and help in effective planning for health promotion strategies. Information from this type of study can build a larger knowledge base for further work on the risk-taking behavior of college students.

METHODOLOGY

A descriptive and primarily quantitative design, similar to the Armstrong and McConnell (1994) and the Armstrong and Pace Murphy studies (1997), was used to describe the present situation and generate knowledge.

INSTRUMENT

An 86-ltem self-reporting, anonymous survey was used that focused on questions about the participant's experiences of tattooing and body piercing. The survey Instrument was based on a review of literature, personal interviews with college students with body art, data from a pilot study, and four published studies on body art (Armstrong, 1991: Armstrong, Ekmark, & Brooks. 1995; Armstrong & McConnell, 1994; Armstrong & Pace Murphy. 1997). An expert panel of college health physicians, nurses, and counselors reviewed the questionnaire for this study. Thirty questions of the survey were from the Armstrong Tattoo Survey (ATS). Face and content validity were established for these questions and reestablished by expert panels before the initiation of the studies. Similar questions about body piercing were incorporated, based on author experiences. A pilot study (N=12) was conducted to test and refine the survey tool used in this research. The pilot study helped clarify the direction of questioning for the college student respondents.

An introduction to the survey provided the study's purpose, benefits, and statements regarding the respondent's voluntary participation; completion of the survey implied consent to participate in the study. The survey was divided into four sections with 31 questions about tattooing, 31 questions about body piercing, 4 general questions related to body art, and 20 demographic questions. Demographic questions included age, race, gender, sexual orientation, academic major, academic performance, family history and income, and attendance at religious services. The reading level of the survey was at the 10th grade. A variety' of query formats were used such as multiple choice and Likert scale questions. Questions inquired about motivating factors, costs, number of body art procedures, health issues, risk behaviors, as well as parental Involvement In decision-making. Open-ended questions were provided so respondents could comment more extensively on their participation with body art.

PROCEDURE

Following approval by the Institutional review board as an exempt study, personnel from college health services were sought from a wide geographic region by word of mouth and messages on the college health bulletin board of the Internet. College health personnel from 18 American universities, as well as one Australian university, responded and volunteered to assist in the distribution of the survey. School size of these 19 universities varied from one student body of 479, to the largest campus of 46,000 (Figure 1). The number of surveys sent to each university depended on specific requests of the college health personnel; a total of 1,700 surveys were sent out.

DISTRIBUTION

When college students with body art presented at the participating universities for any health services, they were asked by the health care providers If they would like to volunteer to complete a questionnaire about their body art experiences. Students with only traditional earlobe piercings were excluded for this study because reasons for this type of piercing tend to be different than body piercing. All respondents were asked to complete the general body art and demographic questions. In the directions of the survey, tattooed and/or body-pierced respondents were asked to complete the specific section(s) of the survey applicable to them; that Is, if they were tattooed they were to complete those questions. If they had a body piercing, they were asked to complete those questions. If they were both tattooed and pierced, they were asked to complete two sections. For the purpose and eligibility of this study, tattoos were defined as permanent marks or designs applied to the skin, not temporary decals (Armstrong & McConnell, 1894). Body piercing was referred to as the penetration of the skin with a sharp implement to create openings through which jewelry may be worn (Greif& Hewitt, 1998). On completion of the survey, respondents placed their answers in a large envelope and this envelope was placed in a sealed drawer for confidentiality. To achieve an adequate sample size, data collection extended over two full semesters. At the end of the second semester, the surveys were sent to the authors for analysis.

RESULTS

A total of 828 surveys were returned to the investigators for a 49% response rate. Reasons for not returning the other surveys included lack of time to distribute the surveys and the lack of tattooed and/or pierced students that presented for health services during the time of data collection. On review, several surveys (N=52) were disqualified due to large blocks of incomplete data. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) computer software. For those schools with 40 or more completed surveys, specific data for their university were later provided following data analysis. The following is a discussion of 766 completed surveys. Qualitative comments were reviewed and recorded separately; many of these comments are not addressed in this analysis.

SAMPLE

Respondents in this cross-sectional, convenient sample (N=766) were from 18 universities in the United States and one university in Australia. No unique responses were noted from the international school so all students were grouped together and Included 630 full-time undergraduate students, 86 full-time graduate and doctoral students, and 45 part-time or non-matriculating students. Five subjects did not answer this question. More women (70%) participated in this study than men (29%); 1% of the respondents did not identify their gender. The age range of the respondents was from 17 to 54 years of age, with 69% of the respondents between the ages of 18 to 22. That specific 4-year age span, the traditional college age years, is also when 74% of the tattooed respondents and 63% of those with body piercings had obtained their first body art procedure.

Ethnic representation included White (71%), Black (7%), Asian (5%), Hispanic (4%), and "others" (13%). Class distribution included freshmen (17%), sophomores (16%), juniors (23%), seniors (26%), graduate students (11%), and others (6%). Many of the respondents were first or only born (46%), had grown up with both natural parents (66%), and were raised in households with an income of $35,000 or more (73%). The respondents attended religious services between one to five times per year (33%) and another 33% never attended church. Almost one third (30%) declared their academic majors as liberal arts, social science studies (27%), and basic sciences (22%). Nearly 60% self-reported grade point averages of 3.0 or better.

The average cost of a respondent's tattoo was $67 and of a piercing, $50, with the total cost for the entire 766 respondents' body art as $148.000. The highest amount reportedly paid for a tattoo was $750 and another respondent paid $215 for a single piercing, including the jewelry. Most students (76%) did not notify their parents of the intent to obtain a tattoo or body piercing, even when some were minors, but eventually the parents were Informed (75%). Both those with tattoos and piercings cited the same major reasons for their body art as self-expression (50%) and "just wanted one" (48%), (Table 1).

When asked about the purpose of their body art, 61% of the respondents strongly agreed/agreed with the statement "to be myself, I don't need to please or impress anyone." Other statements that inquired about the purpose of the body art and the relationship of their friends' acceptance and expectations were strongly excluded. Those with multiple body piercings, as well as tattoos, often commented that they found them to be "addicting" and "I like the way they feel."

TABLE 1 REASONS WHY STUDENTS OBTAIN BODY ART

TATTOO (N=561)	N	%
Self Expression	296	53
Just Wanted One	200	35
To Remember an Event	121	21
Feel Unique	100	17
Independence	62	11
BODY PIERCING (N=391)	N	%
Self Expression	189	48
Just Wanted One	149	38
To Be Different	81	21
Beauty Mark	80	21

Note: Total Percentage is higher than 100 because multiple reasons could be selected by respondents.

RISK-TAKING BEHAVIORS Questions were asked about the respondents' risk-taking behaviors such as the use of drugs, cigarettes, and alcohol. More than half of the respondents (53%) reported having more than five drinks of alcohol weekly or monthly. Thirty-nine percent of these college students had used recreational drugs and 24% reported daily cigarette use. Only 13% cited the use of drugs and/or alcohol before their body art procedure.

Three demographic questions asked about sexual intercourse, the number of sexual partners, and sexual preference. Only 5% of the participants in this study reported never having sexual intercourse. Forty percent of the respondents reported between 1 and 5 partners, 6 to 10 partners (24%), and 11 or more partners (26%). The majority of students (87%) reported heterosexual orientation, 12% reported bisexual activity, and less than 1% reported homosexual preference.

Most students (88%) reported their first body art was done by professional artists in a studio using sterile, disposable needles, skin disinfection, proper hand washing, and clean latex gloves. Following the procedure, 66% of the respondents reported receiving both written and verbal Instructions regarding potential risks and aftercare.

TATTOOED COLLEGE STUDENTS

In this study, 561 college students or 73% of the respondents were tattooed; 84% of them had one or two tattoos. One respondent was tattooed at the age of 13 and another respondent obtained his first tattoo at 40 years of age. The most tattoos one respondent reported was 20 tattoos. Decision-making concerning having tattoos seemed to range from a group of respondents (20%) that took a few minutes to make their decision to another group that took years to decide (23%). Most of the respondents (90%) reported continual satisfaction with their tattoos and 82% would do it again.

Although many students (71%) reported no health problems secondary to their tattooing, 14% had skin irritations (short-term redness, dry skin, or tenderness) and 1% cited site infections (blister, pus, swelling, pain, or redness). Only 4% of those with skin problems sought assistance from a health professional. One student reported contracting hepatitis after her tattooing procedure. This respondent had obtained her first tattoo at 16 in a professional studio with an autoclave on the premises, an artist using a new pair of disposable latex gloves for the tattoo, and skin disinfection done before and after the procedure. She denies use of alcohol or drugs before her tattoo, has never smoked cigarettes or used recreational drugs, and limits alcohol use. She commented, "I tested positive for antibodies twice after the tattoo and then 2 years later tested negative-I never displayed symptoms of the disease." Currently, she ranked herself as a junior in college, would have the tattooing done again, and would not have the tattoo removed as it "makes me feel unique and individual." In her comments to the question of "What would you like to tell someone else considering body art?", she wrote "check health (and) NEW NEEDLES."

COLLEGE STUDENTS WITH BODY PIERCINGS

Fifty-one percent (n = 391) of the respondents in this study report body piercings. Most had one or two piercings (76%). The earliest age reported for an initial piercing was 11 and the oldest at the time of their first piercing was 42. One respondent reported 12 piercings. More of the respondents took a "few minutes" for their decision (29%) with body piercing as compared to thinking about it for a year (5%).

Health problems with body piercing were frequent and sometimes produced multiple problems. Although 30% reported "no problems," 45% reported infections at the site (blister, pus, drainage, pain, and redness). Skin irritation (short-term redness, dry skin, or tenderness] was the second most prevalent problem (39%), yet overall, only 13% presented themselves to health professionals for assistance in managing their body-piercing problems. Despite these health problems, 91% reported continued satisfaction with their body piercing and 78% would do it again.

Two students from different universities reported hepatitis after their piercings. Both respondents described the use of sterile, disposable needles to puncture the skin for their piercing, but aftercare instructions were not provided. Both still like their piercings, would have it done again, and would recommend the procedure to others, although one mentioned that it "limits job possibilities." The respondents have never used alcohol or smoked cigarettes but use recreational drugs monthly. One recommended to others that they "take care of it during the healing process and go to [a] well-established studio."

Almost one quarter of the pierced respondents (24%) reported nipple and genital piercings. Their major reason for getting this particular body art was "enhanced sexual experiences." Although many respondents in the study (69%) reported "no change" regarding their sexual experiences and less than 1% stated their sexual experiences were worse after their body art, 70% of those respondents with nipple and genital piercings reported significant improvement.

DISCUSSION AND APPLICATION OF RESEARCH TO CLINICAL NURSING

This research expands on earlier work by Armstrong and McConnell (1994) and Armstrong and Pace Murphy (1997) and is the first published research investigating body art practices of college students (N = 766) enrolled in universities. In this study, the respondents reported most of their body art was done after they were enrolled in college (tattooing, 74%, and body piercing, 63%) and obtained during the traditional college age years of 18 to 22. Three areas of interest will be discussed, namely the decision making for the body art, characteristics of the sample and the reported risk-taking of those who were pierced and/or tattooed, and the cited health problems. The authors are aware that these findings have limited general application as a small sample was used and any college students who volunteered may be a unique sample wanting to discuss their experiences with body art. In addition, self-reporting can be subject to bias due to inaccurate recall or a desire to relate things as they should be; yet, this was thought to be the best method to obtain Initial data from such a diverse, widely scattered group of subjects.

DECISION MAKING FOR THE BODY ART

Decision making for the body art seemed to vary. In this study, about one quarter of the respondents reported their class ranking as freshmen and sophomores. Almost one third of those with body piercing reported only taking a few minutes deciding on their body art, illustrating impulsive decision-making. As the media portrays body art as carefree and risqué behavior, many could perceive body piercing as a temporary procedure or at least one that can be "undone, with little, or no residual," giving them freedom to feel they can proceed with the piercing without many perceived risks (Armstrong, Ekmark, & Brooks, 1995, p. 25). Thus, could the nature of body piercing procedure produce more casual decision-making?

A small group of impulsive decision makers with tattooing was also reported. This finding seems to correspond with Armstrong and McConnell (1994) and Armstrong and Pace Murphy's studies (1997) with tattooed adolescents where the short decision-making was frequently present. Could these responses still correspond to the late adolescent developmental activities of impulsiveness and the lack of effective decision-making when away from home?

In this study, there also was a sizable group of respondents who took more time for deliberate decision making, especially with tattooing; some describe making their decisions over months and even years. The price of the body art also related to their deliberate decision-making; reported costs were not inexpensive. This subgroup of respondents seemed to align more with the Armstrong study (1991) examining tattooed career-oriented women where more deliberate decision-making was observed for the body site, the artist, the studio, and the design. This delayed decision-making could correspond to the group of the respondents (more than half) who were enrolled in upper division undergraduate and graduate education. The longer amount of time taken for the tattoo decision could relate to the permanency of the tattoo procedure as well as the increased education level. This better decision-making also seemed to lead to the high rate of satisfaction with their body art and the large amount of respondents that would do the procedure again.

The college students made the decision to obtain body art. Often, the parents were not consulted on decisions for tattooing and body piercing. If they were minors, parental permission was not sought. College health personnel were not part of their decision making also. If there were complications from the body art, many times the participants tried to take care of it themselves rather than consult with health professionals.

The participants' major reasons for the body art were the same, self-expression and "just wanted one." The body art procedures seemed to be deliberate, done specifically for themselves as illustrated by their strong agreement about the purpose of their body art to "be myself, I don't need to please or impress anyone." This agreement of strong self-identity for the body art is similar to findings in Armstrong and McConnell (1994) and Armstrong and Pace Murphy (1997) studies.

Overall, these participants were intent to obtain some form of body art regardless of money, regulations, or risks, focusing more on the identity rather than the assessment of risks. These findings are similar to other studies examining body art participants (Armstrong, Ekmark, & Brooks, 1995; Armstrong & McConnell, 1994; Armstrong & Pace Murphy, 1997). The respondents did not report any feelings of deviancy when they obtained their body art; in fact, many provided comments hoping society could accept their tattoo and/or piercing as a work of art that made them feel "good, unique, and special." These feelings correspond with Delene and Brogowicz's (1990) top findings of health care concerns of college students as body image and personal appearance.

As with all art forms, tattooing and body piercing seem to be means of communicating thoughts, ideas, and feelings. Thus, the development of proactive, applicable communication about this topic is important. Avoid using instructional scare tactics. Purposeful dissemination of information, whether with brochures, videos, and/or even college health fairs, is helpful. Health professionals should share information about body art in general, including the inherent risks, maintaining a non-judgmental perspective and continuing an open channel of communication. As part of that message, students must be encouraged to contemplate their decisions carefully. Encourage them to take time In their decision making to talk with others about body art, ask specific questions of the artists, and know enough about the procedure to judge the quality and hygiene of the activity. The authors have found that open communication about body art is often a bridge for further expression about other issues that may be concerning their physical and emotional well-being while within the college milieu.

CHARACTERISTICS AND RISK TAKING

Many of the respondents in this study were White women in undergraduate programs from a variety of class rankings, academically successful, and majoring in either liberal arts or social sciences. Could women be more interested in body art? Although there are no previous studies investigating college age students with body art, Armstrong and Pace Murphy's (1997) study examining adolescents (N=2101) had more tattooed girls [55%, n=117) as compared with boys (45%, n=96). Those authors commented on the gender distribution as supporting Keyes and Block's (1984) belief that greater risk-taking behaviors are present in adolescent girls because of their earlier maturation. Further investigation regarding this observation is suggested.

Specific risk-taking behaviors of drugs, cigarettes, and alcohol use were reported with the participants of body art. These risk-taking behaviors also could reflect the developmental phase of late adolescence in the college student who Is away from the family for the first time and lacks experience with health-influencing activities and mature decision making. Further study should examine the association of body art as a risk-taking behavior with other risk-taking behaviors commonly cited for this population.

HEALTH CONCERNS WITH TATTOOING AND BODY PIERCING

Health problems can arise either during the body art procedure or from lack of proper aftercare. Repeated needle injections of a foreign substance for tattooing and bleeding can predispose subjects to blood borne diseases as well as the penetration of a needle or piercing gun for body piercing. Overall, for the amount of body art that Is done, most of the respondents in this study reported effective, safe hygiene practices of their tattooist and piercer with the use of sterile, disposable needles, skin disinfection, proper hand washing, and latex gloving for the procedure. Many seemed to observe the procedure and artist's techniques before the procedure, yet some respondents received no aftercare Instructions for proper skin treatment. This could be one reason for almost half of the respondents with body piercing, and others with tattoos, to have skin irritations and Infections. Informed customers should know that skin care is essential following procurement of the body art. Specific written and verbal instructions from the artist should be followed, especially with body piercing that inherently has higher rates of infections. Consumers should know that a consistent amount of cleansing of the piercing site is necessary to assure proper healing. More research is also recommended to obtain larger proportions of student populations on campuses and expand beyond those coming for health services to further explore the amount, decision making, and health concerns associated with body art.

In this college population, 3 respondents reported contracting hepatitis, a major risk factor of body art procedures. Although the methodology of this study did not include serum antibody screenings for verification of the participant's report of infectious hepatitis, the documentation of this health risk remains troublesome when students In higher education encounter serious health threats that can influence their health status over a long-term basis. Further research is recommended that includes a pre-body art blood sample and subsequent testing at 3 and 6 months post-body art to determine any changes.

Health care professionals should be advocates for college students as well as the community. Thus, it would be good to investigate current body art legislation locally and statewide as well as visit the local studios to observe techniques and procedure. Ask specific questions because often It Is assumed that body art establishments are routinely inspected and monitored by health officials. If your jurisdiction does not have any regulations or they are limited, contact the National Environmental Health Association (303-756-9090, staff@neha.org, or http//www.neha.org). Obtain the Model Body Art Code, a document produced by a 21-member committee of body artists, sanitation specialists, and health professionals to proactively promote the standardization of body art regulations and acknowledge the universal public health mission for the protection of disease. All or parts of this code can be used in health jurisdictions. These actions, as well as effective health education, can assist college students In enhanced decision making on a variety of body art issues such as health risks, anticipatory generation biases, and permanence factors to reduce risks or even produce dissuasion from body art.

REFERENCES

Anderson. R. R. (1992). Tattooing should be regulated. New England Journal of Medicine. 326.207.

Armstrong, M.L. (1991). Career-oriented women with tattoos. IMAGE: journal Of Nursing Scholarship. 23(4), 215-219.

Armstrong, M. L. (1998). A clinical look at body piercing. RN. 61 (9), 26-30.

Armstrong, M.L, Ekmark, E., & Brooks, B. (1995). Body piercing: Promoting Informed decision-making. Journal of School Nursing, 11(2). 20-25.

Armstrong, M. L., & Fell, P. H- (In press). Popular or not, a model body art code is needed for tattooing and body piercing. Journal of Environmental Health.

Armstrong, M.L., & McConnell, C. (1994). Tattooing in adolescents: more common than you think; The phenomenon and the risks. Journal of School Nursing, 10(1). 22-29.

Armstrong, M. L., & Pace Murphy, K. (1997). Tattooing: Another adolescent risk behavior warranting health education. Applied Nursing Research, 10(4), 181-189.

Armstrong, M. L., Stuppy, D. J" Gabriel, D.C., & Anderson. R. R. (1996). Motivation for tattoo removal. Archives of Dermatology. 132(4), 412-416,

Delene, L. M., & Brogowicz, A. A., (1990). Student health care needs, attitudes, and behavior: Marketing implications for college health centers. Journal of the American College Health, 38(1), 157-164.

Doll, B, C. (1988). Tattooing In prison and HIV [Letter]. Lancet, 8575. 66-67.

Greif, J., & Hewitt, W. (1998). The living canvas: Health Issues In tattooing, body piercing and branding. Advances far Nurse Practitioners, 12(3), 26-31, 82.

Keyes, S., & Block, J. (1984). Prevalence and patterns of substance use among early adolescents. Journal of Youth & Adolescents, 13, 1-13.

Long, G. E., & Rickman, L.S., (1994), Infections and complications of tattoos. Clinical Infectious Disease, 18(4), 610-619.

Myers, J. (1992). Nonmainstream Body Modification. Journal of Contemporary Ethnography, 21(3), 267-306.

O'Hara, D. (1995, December 18). Risky Fashions. AM News. pp. 11-12, 21-22.

Polosmak, N, (1994). Mummy unearthed from the pastures of heaven. National Geographic. 186(4), 80-103.

Pugatch.D., Mileno, M..& Rich. J.D. (1998). Possible transmission of human immunodeficiency virus type 1 from body piercing. Clinical Infectious Diseases, 6(3), 767-768.

Saunders, C. (1989). Customizing the body: The art and culture of tattooing, Philadelphia: Temple University Press.

Shimokura, G.H., & Gully. P. R. (1995). Risk of hepatitis C virus infection from tattooing and other skin piercing services. Canadian Journal of Infectious Diseases. 6(5). 235-238.

Sperry, K. (1992). Tattoos and tattooing: Part II, Gross pathology, histopathology, medical complications, and applications. American Journal Of Forensic Medical Pathology, 13(1), 7-17.

Tope. W. D. (l995). State and territorial regulation of tattooing in the United Slates. Journal of the American Academy of Dermatology, 32(5). 791-799.

Tweeten. S. S., & Pickman, L. S. (1998). Infectious complications of body piercing. Clinical Infectious Diseases, 26(3), 735-740.

Merriam-Webster's collegiate dictionary (10th ed.), (1993), Springfield, MA: Merriam-Webster.

Judith Greif. R.N., N.P., C., M.S., Is a family nurse practitioner at the Hurtado Health Center, Rutgers University Health Service, New Brunswick, NJ.

Walter Hewitt, R.N., C., B.S.N., Is the assistant clinical coordinator, Hurtado Health Center, Rutgers University Health Service, New Brunswick, NJ.

Myrna L. Armstrong, Ed.D., R.N., F.A.A.N., is a professor in the School of Nursing, Texas Tech University Health Services Center, Lubbock, TX.

Authors' Note: We gratefully acknowledge the though.tJiil re\'le\v oF Janet K Bundy. M.S.. R.N. C.I.C., Dr.PH(c): alao. aervicea of Judy Soncrant, proJec nianager, and Dawil Walct. supervisor, computer services, and the late Rita Pu iltz, Administrative assistant. Rutgers University.

CLINICAL NURSING RESEARCH, Vol. 8 Mo. 4, November 1999 368-385