Body Modification and Substance Use in Adolescents: Is There a Link?

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1 JOURNAL OF ADOLESCENT HEALTH 2003;32:44 49 FELLOWSHIP FORUM Body Modification and Substance Use in Adolescents: Is There a Link? TRACI L. BROOKS, M.D., ELIZABETH R. WOODS, M.D., M.P.H., JOHN R. KNIGHT, M.D., AND LYDIA A. SHRIER, M.D., M.P.H. Purpose: To describe the characteristics of body modification among adolescents and to determine whether adolescents who engage in body modification are more likely to screen positive for alcohol and other drug problems than those who do not. Methods: Adolescents aged 14 to 18 years presenting to an urban adolescent clinic for routine health care completed a questionnaire about body modification and a substance use assessment battery that included the 17- item Problem Oriented Screening Instrument for Teenagers Alcohol/Drug Use and Abuse Scale (POSIT-ADS). Body modification was defined as piercings (other than one pair of bilateral earlobe piercings in females), tattoos, scarification, and branding. Problem substance use was defined as a POSIT-ADS score >1. Data were analyzed using logistic regression to determine whether the presence of body modification was an independent predictor of problem substance use. Results: The 210 participants had a mean ( SD) age of 16.0 ( 1.4) years and 63% were female. One hundred adolescents (48%) reported at least one body modification; girls were more likely than boys to have body modification (59% vs. 28%, p <.0005). Ninety (42%) reported piercings, 22 (10%) tattoos, 9 (4%) scarification, and1(< 1%) branding; 21 (10%) had more than one type of body modification. These were in a variety of locations, most commonly the ear and the nose (piercings) or From the Division of Adolescent/Young Adult Medicine (T.L.B., E.R.W., J.R.K., L.A.S.); Division of General Pediatrics (J.R.K), and Center for Adolescent Substance Abuse Research, Children s Hospital Boston, Harvard Medical School, Boston, Massachusetts (J.R.K., L.A.S.). Presented in part at the annual meeting of the Ambulatory Pediatrics Association, May 16, 2000, Boston, Massachusetts. Address correspondence to: Lydia A. Shrier, M.D., M.P.H., Division of Adolescent/Young Adult Medicine, Children s Hospital Boston, 300 Longwood Avenue, Boston MA lydia.shrier@ tch.harvard.edu. Manuscript accepted July 15, the extremities (tattoos). One-third of the sample (33%) screened positive for problem substance use on the POSIT-ADS questionnaire. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance use than those without body modification (95% CI 1.7, 5.8). Conclusions: Body modification was associated with self-reported problem alcohol and other drug use among middle adolescents presenting for primary care. More research is needed to determine the clinical and sociocultural significance of body modification and its relationship to substance use in this population. Society for Adolescent Medicine, 2003 KEY WORDS: Adolescents Body modification Gender differences Piercing Risk behaviors Substance use Tattooing Body modification, an ancient art, is the practice of permanently altering one s appearance [1]. Body modification, including piercing, tattooing, scarification, and branding, may be used by individuals as a means of self-expression and a vehicle for selfawareness [1,2]. The practice is becoming increasingly common, especially among teenagers [1 4]. Most of the information currently available is about piercing [1,5 16], which may be heavily influenced by peer pressure. Piercing might be obtained because it is viewed as carefree, risqué behavior that makes a fashion statement, but is not as permanent as other forms of body modification [1]. Compared with X/03/$ see front matter PII S X(02) Society for Adolescent Medicine, 2003 Published by Elsevier Science Inc., 360 Park Avenue South, New York, NY 10010

2 January 2003 BODY MODIFICATION AND SUBSTANCE USE 45 those without tattoos, young people with tattoos rate themselves as more adventurous, creative, artistic, individualistic, and risky, and report more behavioral risks, including drug use [17]. After piercing or other body modification, medical complications specific to the anatomic location may occur, including foreign body reaction, oral and tooth complications, aspiration and hypoxia, edema and swelling, streptococcal infections, and viral transmission, including hepatitis and HIV [3,5 7,9,11 16,18,19]. One study of university undergraduates reported that the incidence of medical complications from piercings and tattooing was 17% and 0%, respectively [20]. The practice of body modification is not always well-regulated, although certain professional groups are trying to change that pattern to prevent the spread of infection [21]. In 1998, the American Dental Association issued a statement opposing the practice of oral piercing, citing it as a public health hazard because of its potential for negative sequelae [7]. Body modification may be associated with behavioral risks as well [22 24]. In one study among patients committed to a psychiatric institution [23], increasing sites and numbers of body modification were associated with more severe violent behavior. Among adolescent detainees, tattooing has been correlated with alcohol and drug use [25]. An Australian study of amateur tattooing practices among high school students showed that students with tattoos had higher scores on school-related problem scales than those without tattoos [24]. Recent data from the National Longitudinal Study of Adolescent Health demonstrated that tattooing was associated with sexual intercourse, substance use, violence, and truancy among teens [22]. Additionally, body piercing was correlated with truancy among both male and female adolescents, and with sexual intercourse and smoking among female adolescents [26]. Finally, a study of Australians aged 14 years found that approximately 8% of those who had obtained body modification reported that they were under the influence of alcohol or other drugs while undergoing the procedure [27]. Because little is known about the range of body modification practices among adolescents, we sought to describe the prevalence and patterns of body modification in our adolescent clinic patient population. Substance use is a prevalent risk behavior in adolescents that may be associated with body modification because of clustering of risk behaviors, as suggested by Problem Behavior Theory [22,28,29]. In addition, alcohol and drugs may impair judgment, resulting in a decision to obtain body modification, or they may be used for pain control during or after body modification procedures. We therefore hypothesized that adolescents who engage in body modification are more likely to report problem substance use than those who do not. Methods Participants The sample was composed of 210 patients aged 14 to 18 years receiving routine health care at an adolescent clinic of an urban children s hospital and participating in a larger ongoing study of substance use among adolescents [30]. After providing informed assent (age 18 years) or consent (age 18 years), participants completed a structured interview about substance use and self-administered the Problem Oriented Screening Instrument for Teenagers/Alcohol and Drug Abuse Scale (POSIT-ADS) [31 33] and a questionnaire on body modification. Administration time of the entire assessment battery was approximately 30 to 60 minutes. The hospital s Institutional Review Board approved the protocol and authorized a waiver of parental consent. Questionnaire Demographic variables included age, gender, and race/ethnicity. For the purposes of this study, a 12-item questionnaire was developed to assess the type, extent, and anatomic site of body modification, which participants indicated on a schematic drawing. In addition, participants were asked where and how the body modification was obtained, attitudes toward their body modification, and whether and why substances had been used immediately before obtaining the body modification. Body modification was defined as tattoos, piercing (beyond one pair of bilateral earlobe piercings in females), branding, or scarification. The POSIT-ADS questionnaire is designed to detect substance-associated problems and risks. The reliability and validity of the POSIT have been established in adolescents, including high school students [31] and youth attending a general adolescent clinic [33]. The 17 yes / no POSIT-ADS questions include During the past month have you driven a car while you were drunk or high? and Do you miss out on activities because you spend too much money on drugs or alcohol? Each positive response is

3 46 BROOKS ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 32, No. 1 Table 1. Demographic Characteristics and Frequency of Body Modification for Youth Aged 14 to 18 Years Attending an Adolescent Clinic, by Problem Substance Use a Problem Substance Use Characteristic Total (n 210) Yes (n 70) No (n 140) p value Age in years (mean SD) Gender.289 Male 78 (37) 22 (28) 56 (72) Female 132 (63) 48 (36) 84 (64) Race/ethnicity.365 Black, non-hispanic 101 (48) 34 (34) 67 (66) White, non-hispanic 45 (21) 18 (40) 27 (60) Hispanic 42 (20) 14 (33) 28 (67) Other 22 (11) 4 (18) 18 (81) Body modification b.0005 None 110 (52) 23 (21) 87 (79) Any 100 (48) 47 (47) 53 (53) a Results are presented as n (%) unless otherwise noted. b Beyond one pair of bilateral earlobe piercings in females. scored as one point; a score of one or higher indicates that a problem with substance use may exist [34]. Data Management and Statistical Analysis Data entry was performed by the first author (T.L.B.) and verified by a research assistant checking all of the entries. Discrepancies were resolved by consensus of the co-authors. Analyses were performed using SPSS 10.0 for Windows (SPSS, Inc., Chicago, IL, 1999). Descriptive data are presented as means ( standard deviation) for continuous variables and as frequencies for categorical variables. Associations of the demographic variables and the presence of body modification with problem substance use were analyzed using the Chi-square test, Fisher s Exact test, or Student s t-test, as appropriate. Logistic regression analysis was performed to determine whether the presence of body modification was an independent predictor of problem substance use. Effect modification by demographic variables was evaluated by testing the significance of interaction terms with the body modification variable [35]. The presence of confounding by demographic variables was determined using the change in estimate method (i.e., whether the estimate of the beta for the body modification variable and its standard error changed by at least 10% with inclusion of the demographic variable in question in the model) [36]. Results Descriptive data are shown in Table 1. The mean age of the sample was 16.0 ( 1.4) years; 63% were female and 48% were black. One hundred adolescents (47%) reported some type of body modification. More than twice as many teens with any body modification reported problem substance use, compared with those without body modification (47% vs. 21%, p.0005). Older adolescents were more likely than younger adolescents to have obtained any body modification (p.004) and were somewhat more likely to report problem substance use (p.05). Girls were more likely to report body modification than boys (55% vs. 28%, p.0005); gender was not associated with problem substance use. Race/ethnicity were not associated with either problem substance use or body modification. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance use compared with those without body modification (95% CI 1.7, 5.8). There was no evidence of effect modification or confounding by either gender or race/ethnicity, so these variables were excluded from the model. Table 2 displays the types of the body modifications and their anatomic locations. The majority of teens with body modifications reported piercings (beyond one pair of bilateral earlobe piercings in girls), followed by tattoos. Few adolescents had scarring or branding. The 90 adolescents with piercings reported 227 separate piercings (range, 1 to 7 per adolescent); most had piercings in the ear lobe (94%), upper ear or tragus (34%), or nose (26%). Most adolescents with piercings (89%) had obtained them from a professional in a jewelry store or salon, with fewer having the piercings done by a relative (10%), self (7%), friend (4%), or other nonprofessional (6%). The 22 adolescents with tattoos had 36 distinct

4 January 2003 BODY MODIFICATION AND SUBSTANCE USE 47 Table 2. Types and Locations of Body Modifications for Youth Age 14 to 18 Years Attending an Adolescent Clinic n (%) Type of body modification (N 210 respondents) Piercing a 90 (42) Tattoo 22 (10) Scarring 9 (4) Branding 1 ( 1) More than one type 21 (10) Anatomic locations of piercings (n 90 respondents) a Ear lobe 85 (94) Upper ear or tragus 31 (34) Nose 23 (26) Eyebrow 3 (3) Tongue 4 (4) Navel 7 (8) Nipple 1 (1) Anatomic locations of tattoos (n 22 respondents) Leg or ankle 13 (59) Arm or shoulder 9 (41) Torso 4 (18) Groin or buttocks 2 (9) Head 1 (5) a Beyond one pair of bilateral earlobe piercings in females. tattoos, (range, 1 to 4 per adolescent); most reported at least one tattoo on a lower or upper extremity (77%). The majority of adolescents with tattoos reported obtaining them from a professional, either in a tattoo parlor (46%) or at a tattoo party (36%). Although most adolescents with piercings or tattoos reported using a new or sterilized needle to obtain the body modification, 10% of those with piercings and 10% of those with tattoos reported using an unsterile needle. Two percent of adolescents with piercings reported sharing a needle when obtaining a piercing. Sixty-seven percent of adolescents with body modification reported positive feelings about their body modification; 45% were pleased, 33% were proud, and 15% felt attractive. Fifty-five percent felt neutral about their body modification. Only 9% reported any negative feelings about their modifications (7% regretful, 3% angry, and 1% guilty ). All of these adolescents had piercings. Five had just piercings, two also had tattooing, one also had scarring, and one also had scarring and branding. Four adolescents reported using substances at the time body modification was obtained and all cited the reason was to control pain. Only one participant reported becoming intoxicated before making the decision to obtain body modification. Discussion In this adolescent clinic sample, body modification and self-reported problem substance use were common, associated risk behaviors. Not surprisingly, older age was associated with the presence of both body modification and problem substance use. The relationship between age and other risk behaviors has been previously reported [28], and is likely owing to longer time for exposure to risk behaviors and opportunity to engage in risk. In addition, both liquor stores and venues offering body modification, such as tattoo parlors, may have required proof of age, presenting a barrier to younger adolescents engaging in the risk behaviors. Also, because tattoo parlors were illegal in Massachusetts at the time of this study, those who wished to obtain them legally were required to travel to another state, which was more likely to be accomplished by older adolescents who could drive. Almost one-half of adolescents participating in this study reported some form of body modification beyond a pair of bilateral earlobe piercings in girls, suggesting that body modification may be a relatively normative risk behavior. Most modifications were on visible sites of the body, such as the face and head for piercings, and on the extremities for tattoos. Unfortunately, a few adolescents had negative feelings about their body modifications. Health care providers should discuss permanence while a patient is making a decision about obtaining body modification. Most adolescents obtained their modifications using professional assistance and sterile materials. However, 22% of teens with piercings and 18% of those with tattoos opted to perform the modifications themselves or by a friend, relative, or other nonprofessional, putting them at increased risk for medical complications. Furthermore, 1 in 10 adolescents with piercings and 1 in 10 with tattoos did not use a sterile needle, increasing their risk of infection. Although infrequently reported in this study, sharing needles risks transmission of blood-borne pathogens, including human immunodeficiency virus, hepatitis B, and hepatitis C [16,37]. The conditions under which the adolescents in this study reported obtaining body modification points to the continued need for providers to educate patients about the hazards of unsafe body modification. Adolescents who choose to obtain body modification often repeat the behavior; nearly three out of four adolescents with body modification had more than one. If health care providers observe body modification, they

5 48 BROOKS ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 32, No. 1 should take the opportunity to discuss and promote safe body modification practices for the future. By obtaining body modification, adolescents may be seeking individuation, incorporating closely held persons or concepts (e.g., on a tattoo), declaring their allegiance to a group, or fulfilling a quest for permanence and stability [2]. In assessing an adolescent with body modification, it is important to explore the motivations, significance, and feelings behind the modification to distinguish positive self-expression from destructive self-mutilation. There are several strengths to this study. First, few studies have described body modification in general adolescent populations [10,22,24] or examined the association between body modification and other risk behaviors [22]. Second, this study sampled a general adolescent clinic population, rather than psychiatric inpatients [23] or incarcerated youth [25]. Third, we developed a comprehensive instrument to assess body modification in adolescents. Fourth, we had a substantial representation of youth of color. Our findings must be interpreted in light of some limitations to this study. Because this sample was drawn from patients in an adolescent clinic, street or other disenfranchised youth were likely not wellrepresented. Although diverse, the demographic characteristics of adolescents attending our clinic may be unique and thus limit the generalizability of the results to other adolescent populations. Furthermore, the sample was not selected randomly, which may have resulted in selection bias. Because healthy, low-risk adolescents are more likely to participate in clinical research, we suspect that any selection bias would have most likely produced an underestimation of body modification and problem substance use in our sample. However, it is possible that health care providers chose to refer higher risk adolescents to this study. Because the POSIT-ADS score was dichotomized, no measure of severity of problem substance use was made. Additionally, in exploring the association between body modification and problem substance use, we did not seek to differentiate among the types of body modification or the types, forms, or quantities of substances used because of small cell sizes. Finally, we were not able to determine directionality or causality in this cross-sectional study. Although unlikely, it is possible that body modification may lead to substance use, perhaps mediated by entrance into a peer group engaging in drug use. The reverse may also be true, that substance use may lead to body modification by way of a peer group. Substance use may impair judgment, resulting in a decision to obtain body modification. However, we found that very few adolescents reported substance use before obtaining their body modification. It is most likely that body modification and substance use are co-occurring risk behaviors, as suggested by Problem Behavior Theory [29]. Although we found evidence of an association between body modification and self-reported problem substance use, adolescents with body modification should not be automatically labeled as substance abusers. More than one-half of adolescents with body modification were at low risk for problem substance use (had a score of zero on the POSIT- ADS) and more than one in five respondents without body modification scored positively on the POSIT- ADS screen. Body modification, like substance use/ abuse, is a risk behavior. The finding of body modification in an adolescent may indicate other risk behaviors, including substance use, and he/she should be screened appropriately. Body modification must be seen within a cultural context. In some cultures, body modification practices are normative. For example, many African and Pacific nations use scarification and tattooing as symbols of coming of age [3,9,38]. Risk associated with body modification may also vary within a geographic region. At the time this study was conducted, adolescents desiring tattoos had to drive out of state to obtain them lawfully. Tattoo parlors have since been legalized in Massachusetts and many have opened; as a result, tattooing may now be more common. The findings from this study suggest the need for in-office screening questionnaires encompassing substance use and body modification. Health care providers, as well as patients, need to be educated about the different health risks associated with each type of body modification. Future research should explore the utility of body modification as a marker for risk behaviors other than substance use. Because body modification may also be associated with factors that protect against risk, such as higher selfesteem or membership in a cultural group [39], studies of health behaviors should incorporate assessment of body modification practices to determine which adolescents who engage in body modification are at risk for substance use and other problem behaviors. We thank Erin Gates for collection of the data, Stacy Taylor for verification of data entry, and S. Jean Emans, M.D. for her helpful comments and reading of the manuscript. This work was supported by #R01 AA A1 from the National Institute on Alcohol Abuse and Alcoholism, # from the Robert Wood Johnson Foundation, and LEAH 5 T71 MC from the

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