Your Baby Wants Body Art

Tattoo Who?!

From the WebMD Archives

Aug. 27, 2001 -- Ear piercing was once a rite of passage for girls -- the slumber party, the ice cubes, mom's sewing needle. But it's a new world out there. Hot role models like Britney Spears and the Backstreet Boys are inspiring younger and younger kids to ask their parents for navel rings, tongue studs -- and tattoos.

Some call it self-expression. Some say disfigurement. But the issues are larger than just style or rebellion.

There's a real health danger that parents need to know more about -- especially with tattooing.

People with tattoos are nine times more likely to be infected with hepatitis C, according to a recent study by Robert Haley, MD, chief of epidemiology at the University of Texas Southwestern Medical Center, in Dallas. His report appears in the March issue of the journal Medicine.

Hepatitis C is spread by infected blood and infected needles, which is the virus' connection with tattooing. Tattoos involve lots of needles making lots of sticks in the skin. Each stick carries potential for contamination -- and not just with hepatitis, but also HIV, the virus that causes AIDS -- if the needles and the "tattoo machine" are not sterilized properly.

"The scary thing about hepatitis C is that the virus can live outside the body -- in the environment -- for up to three months," Haley tells WebMD. One drop of blood on a telephone, a counter, a chair, a piece of equipment, can potentially contaminate someone.

Equally frightening: About 75% of people with acute hepatitis C will develop a chronic infection that attacks the liver, leading to cirrhosis, liver failure, and liver cancer at an early age.

Yet there are no symptoms early on. While treatments are available, they are costly and, to be effective, have to begin early in the disease process.

"People can have the virus for 10 years and not know it," says Haley. "In another 10 to 20 years, they likely will be dead."

Hepatitis C Already an Epidemic

Take it seriously, says Haley.

"There's a major epidemic of hepatitis C in this country, which most people do not realize," he says. "Parents need to educate their teenagers that [a tattoo] is more than just a pretty picture on their skin. They're risking a lifelong infection."

At school, kids will likely be hearing more about the tattoo-hepatitis C connection, thanks to a nationwide campaign launched by the Hepatitis Foundation International, says Thelma King Field, chairperson and CEO.

"In most schools, kids are not taught how important the liver is, that they can do serious damage to their health but not realize it," she tells WebMD.

"They see rock stars with tattoos, yet they go into these tattoo shops and they don't see viruses," Field says. "They don't see that they can get sick."

Body piercing is another story, Hayley says.

"It doesn't seem to have the same hepatitis C risk that tattooing does," he says. "Even tongue piercing is pretty safe. Saliva has a lot of anti-infective immune processes, so generally people tend not to get a lot of bacterial infections [or hepatitis C]."

Tattoo Shops Under the Gun

The crux of the problem, says Haley, is sterilization practices in tattoo shops.

By and large, tattoo artists and shops are not required -- by state or local governments -- to follow the same sterile operating practices as other operations that use needles, like hospitals and doctor's offices.

Some states and cities have a few regulations in place, but Texas is the only state to pass a law (in the mid-1990s) that requires all tattoo parlors to be licensed, with regular inspections of equipment and sterilization procedures.

Even then, says Haley, the inspections are not as frequent as they should be.

Also, kids are buying tattoo kits -- advertised in the back pages of popular tattoo magazines -- and trying them out on their friends. Other kids get tattoos at flea markets or fly-by-night shops that want to make easy money. Think any of them are concerned about hepatitis C?

"It's a difficult situation," says Dennis Dwyer, executive director of the Alliance for Professional Tattoo Artists (APT), an organization that educates the public and tattoo practitioners about infection control procedures.

APT is the tattoo industry's attempt at self-monitoring, says Dwyer.

"Many people are trying their best to provide safe tattooing. But this industry has a lot of nonconformists," he says "Even if health departments or cities passed laws, they would not be able to catch up with 'Johnny Tabletop' at the flea markets."

Helping Kids Make Good Decisions

But if kids want tattoos, they likely will get them.

"Regardless of risk, regulation, and cost, they will get them," says Myrna Alexander, EdD, RN, a nurse-turned-tattoo expert. "Tell a kid 'no' and you know what will happen."

Alexander is a nursing professor at Texas Tech University in Lubbock, and has had her eye on the tattoo industry for about 10 years. She has also authored a study looking at the whole adolescent/tattoo scene.

Turning kids into smarter consumers is the answer, says Alexander.

She's seen some clean, top-notch tattoo shops.

"There are some very reputable tattoo artists out there," Alexander tells WebMD. "They work hard, and their studios are as clean as medical clinics. They do a good job because they believe what they are doing is art. The problem is, there are many who don't."

Touring a Tattoo Shop

In Atlanta, Sacred Heart Tattoo shop has been voted as "the best in the city" in a local survey. It might not be what you'd expect. Inside, it looks much like any trendy graphic arts studio -- a top-floor loft with high ceilings, big windows, white-washed walls.

"Ask me anything," says tattoo artist Chris Clark.

To operate in Atlanta, Clark had to obtain city certification, which involves a full physical examination, background check, blood testing. He also answered questions from a board hand-picked by the mayor's office, regarding needle disposal and other biohazard issues.

Georgia law doesn't say much about tattooing, but anyone age 16 and over can get tattooed. Sacred Heart Tattoo takes the law a step further: "We don't feel that's good business ethics," Clark says. "We say 18 and that's it; please don't bring children into the shop."

How can you know if a tattoo shop is safe?

  • Ask questions about sterilization procedures, says Clark. "If people really want to see the autoclave, the sterile room, the biohazard room, we'll show them. We'll explain how the autoclave works."
  • Make sure the shop is APT certified. The APT offers eight-hour courses on blood-borne pathogens, safety, and prevention procedures. Since many cities and states do not require city certification, APT certification is the only way to ensure sterile operating procedures, says Clark.

To combat hepatitis C and other bloodborne pathogens, APT-member tattoo artists are taught to autoclave their equipment, use individual portions of ink and lubricant, and dispose of used needles according to federal guidelines set up by the Occupational Safety and Health Administration, or OSHA. They also use EPA-registered "virucidals" to clean their stations in between clients. For more information about these procedures, check out "Basic Guidelines for Getting a Tattoo" at the APT website,

  • Ask to see the monthly reports of autoclave tests -- called "spore tests" -- an indication the sterilization equipment is working properly.

If tattoo artists won't talk about these things, "get out of there," says Clark.

Time for a Family Conference

But what about underage kids? How can parents discourage them from sneaking off to get tattoos?

Clark's advice to parents: Be proactive. "Talk to kids about it," he says. "Bring it up, right along with the drug talk. Lay it out there. Say, these are the main facts."

Tell them they'll regret it later, says Clark. Seriously.

"Parents should explain to their children that their bodies are still growing, and that decisions made at that age are usually pretty bad decisions," he says.

Case-in-point: the "bad-looking tattoo" that Clark got at age 17, "home-done in a friend's house -- in the bedroom -- with sewing needle dipped in India ink," he says.

"I was into the early punk rock scene, got a skull and crossbones on my arm," Clark says. "It was small, I kept it covered up ... my parents didn't know about it until I was 19. I wish I would have waited to get it done the right way."

Point them toward alternatives. Sheets of rub-on tattoos can be purchased in office-supply stores, Clark says.

Some kids like henna tattoos -- made with Indian henna dye -- which stay on for about six weeks. But watch out for "black henna" which is actually toxic hair dye, and can cause an allergic reaction, says Clark.

While it's a different artistic style than tattooing -- more like body adornment -- it doesn't involve piercing the skin with needles, he tells WebMD.

Turn to a Dermatologist

In New York, "tattooing is a really big issue," says Beth Potashkin, PhD, a Manhattan psychologist and child/adolescent specialist. "It's very stylish, but when there's significant danger of health complication, then I think parents have to take it very seriously."

"Parents should really discuss with kids the medical risks and permanency issue," she tells WebMD.

Tattoos can be removed with laser surgery, "but kids need to know about the scarring that comes with that kind of plastic surgery," Potashkin says. "Most kids are put off by that. When they understand that this is could be a long-term mutilation of a visible part of the body, that often is a very persuasive argument. I've seen the laser removals -- they're horrendous."

She suggests taking the child to the family doctor. Some in New York will perform piercing or tattooing, or will recommend a dermatologist. "Then you know that the instruments used will be sterile and the doctor will be able to tell the adolescent exactly what will happen down the line," she says.

"Dermatologists are doing it by default because there are too many kids getting infected with hepatitis C," says Potashkin. "It's because of the unreliability of tattoo and piercing places in Soho, East Village, even in shopping malls in New Jersey."

Also, a physician can explain the risks to the adolescent, providing an expert second opinion. "Since kids assume the parent has ulterior motives, are just being mean, or don't quite understand 'our style,' this is a good approach," she tells WebMD. "When they can hear it from another person, about the medical risk, about the permanency of what they're doing, it tends to have great impact."

If you're vehemently against tattooing or piercing, "set a strict bottom line," says Richard Sackett, PhD, a psychologist in New York.

"You need to be up front at the very beginning with kids," Sackett tells WebMD. "You have to stand by your authority and right as a parent -- make that decision and back it up. You can then go back and discuss reasons, and learn the kid's perspective. But you must set the framework that your bottom line is not negotiable."