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- Without stigmatizing adolescents with piercing, use the topic of body piercing as a starting point for discussing unhealthy behaviors
Body piercing among young people has been linked with risk behaviors such as the abuse of legal and illegal substances, Perspicacity, profiling, and prejudice
Body art and, more specifically, piercing is becoming normative among adolescents, ("Perspicacity, profiling, and prejudice,”) Body art is more than just an indicator of deviancy.11 In other words, as all adolescents should be screened for risky behaviors, this specific population offers the advantage of piercing as a starting point for a discussion.
We found that body piercing is increasingly popular among adolescents in Switzerland, especially among females. Our prevalence rates are higher than those reported by Roberts,3 but (as they suggest) it may well be due to the societal trend, as their data were collected in 1996.
The pierced and the unpierced
Academic performance was the main sociodemographic difference between pierced and unpierced adolescents. As a marker of risk, piercing was negatively associated with academic performance, as found elsewhere regarding healthy behaviors.12 Like other studies, this sample exhibited increased drug use1,3,5 and risky sexual behavior,10 but no increase in suicide attempt.3
Since the late 1990s, estimates for body modification among US adolescents range from 10% to 25%.8,14 A 2002 study5 assessed tattoos and body piercing as markers of risk-taking in 484 adolescents presenting to an adolescent clinic in California; both were markers of greater instances of, and participation in, such behaviors as eating disorders, illegal drug use, sexual activity, and suicide. Tattooing was reported by 13.2% of respondents, with 5.2% having more than 1 tattoo. Excluding earlobes, 26.9% of adolescents had body piercings at some point during their lifetime, and 11.8% had a history of multiple piercings. Tattooing and body piercing were found to be more common in females than males, 16.6% vs 8.1% for tattoos and 36.7% vs 10.1% for body piercings, respectively. Index scores on 5 of 6 risk-taking indices—including the Disordered Eating Behavior Index, the Gateway Drug Index, the Hard Drug Index, the Sexual behavior Index, and the Suicide Index—were significantly higher in participants with at least 1 tattoo or body piercing compared with those with neither. Illegal drug use also increased with the number of piercings.
Another study15 looked at 14- to 18-year-olds presenting to an urban adolescent clinic in Massachusetts. Of 210 surveyed, 48% reported at least 1 body modification, with girls more likely than boys (59% vs 28%; P≥.0005). Forty-two percent reported piercings, 10% had tattoos, 4% had scarification; 21% had more than 1 type of modification. One third of the sample screened positive for problem substance use. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance abuse with alcohol or drugs than those without (95% CI, 1.7–5.8).
Among females in our sample, more than 1 piercing is associated with having multiple sex partners and marijuana use. Carroll et al5 also found that having multiple piercings was associated with illegal drug use. For males in our study, the only association with multiple piercings was an increase in suicide attempts.
From our results, it could be hypothesized that more than 1 piercing is a cumulative marker for some risk behaviors, mainly among females. Though associations for males were similar to those for females, the differences between pierced and unpierced groups did not reach statistical significance. However, the relatively small sample of pierced males discourages definitive conclusions.
Pierced adolescents were less satisfied with their bodies than their unpierced counterparts, though the difference is significant only for females.
Young people indicate that the main reasons they obtain a piercing are a sense of uniqueness or self-expression, with only one fifth indicating that they obtain it for aesthetics only.2,8 As we did not assess the reasons to obtain a body piercing in this study, it could be that they had it done to increase their body satisfaction, that their body satisfaction was lower after having it done, or simply that they do not get pierced to increase their satisfaction with their body.
Methods
Population. Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health database, a survey of 7548 students ages 16 to 20 years (3658 of whom were female). In Switzerland, school is mandatory up to age 16. Afterwards, about 30% of adolescents follow to further high school, 60% go to vocational school as an apprentice (1 or 2 days of class per week and the rest spent at work), and 10% do not continue their education.
Classroom survey. The survey was an anonymous classroom questionnaire approved by the ethical committee of the Medicine Faculty in Lausanne. The questionnaire and sampling method are described elsewhere.13 Ninety-one subjects (1%) did not answer the question referring to body piercing and were excluded. The final sample had 7457 subjects (3628 females).
(TABLE 1) lists selected characteristics and background variables analyzed. Analyses were performed separately by gender, as the literature indicates that females are more likely to have piercings.2-5 We conducted all analyses with Stata 8 (College Station, TX), which computes coefficient estimates taking into account sampling weights, clustering, and stratification procedure. All significant variables in the bivariate analysis were included in a logistic regression.
In a second step, adolescents having one piercing were compared with those having more than one piercing, using the same method.
TABLE 1
Selected characteristics of pierced and unpierced adolescents—females (N=3628) and males (N=3829)
| FEMALES | MALES | |||||||
|---|---|---|---|---|---|---|---|---|
| PIERCED (N=1225) | UNPIERCED (N=2403) | P VALUE | AOR (95% CI) | PIERCED (N=283) | UNPIERCED (N=3546) | P VALUE | AOR (95% CI) | |
| Age (years±SD) | 17.98±1.17 | 17.77±1.13 | <.001 | 0.94 (0.88–1.01) | 18.21±1.20 | 17.86±1.18 | <.001 | 0.90 (0.80–1.00) |
| Academic track (apprentice) | 73.1% | 53.1% | <.001 | 2.05 (1.75–2.41) | 91.5% | 71.0% | <.001 | 2.97 (1.92–4.62) |
| Body satisfaction (dissatisfied) | 67.4% | 71.2% | .02 | 0.96 (0.82–1.14) | 82.3% | 86.3% | .064 | — |
| Nationality (Swiss) | 10.9% | 13.5% | .027 | 0.72 (0.57–0.92) | 16.6% | 13.3% | .119 | — |
| Perceived puberty (advanced) | 36.6% | 30.2% | <.001 | 1.06 (0.91–1.25) | 39.6% | 23.3% | <.001 | 1.41 (1.07–1.86) |
| Parental status (not together) | 31.3% | 20.8% | <.001 | 1.30 (1.10–1.55) | 32.5% | 21.7% | <.001 | 1.35 (1.02–1.79) |
| Father’s education (low)* | 11.4% | 15.9% | <.001 | 0.67 (0.53–0.84) | 15.5% | 14.0% | .476 | — |
| Mother’s education (low)* | 21.2% | 22.9% | 0.24 | — | 23.0% | 20.8% | .379 | — |
| Sensation seeking (high) | 21.9% | 15.5% | <.001 | 1.14 (0.94–1.39) | 53.0% | 40.0% | <.001 | 1.13 (0.87–1.47) |
| Feeling depressed (yes) | 45.0% | 36.2% | <.001 | 1.16 (0.98–1.36) | 29.0% | 21.7% | .005 | 1.05 (0.78–1.42) |
| Number of sexual partners (≥4) | 20.6% | 8.3% | <.001 | 1.50 (1.20–1.87) | 45.6% | 17.9% | <.001 | 1.71 (1.29–2.28) |
| Condom use at last intercourse (no) | 46.9% | 27.5% | <.001 | 1.63 (1.39–1.92) | 39.6% | 19.5% | <.001 | 1.49 (1.12–1.98) |
| Regular smoker (yes) | 48.9% | 21.9% | <.001 | 2.06 (1.74–2.45) | 66.4% | 30.9% | <.001 | 2.28 (1.72–3.02) |
| Intoxication (last 30 days) | 26.9% | 15.7% | <.001 | 1.19 (0.98–1.44) | 60.8% | 39.0% | <.001 | 1.51 (1.15–1.97) |
| Cannabis use (last 30 days) | 40.9% | 20.6% | <.001 | 1.58 (1.32–1.89) | 67.5% | 39.1% | <.001 | 1.37 (1.05–1.79) |
| Illegal drug use (last 30 days) | 8.7% | 3.4% | <.001 | 1.67 (1.21–2.31) | 26.9% | 8.3% | <.001 | 2.17 (1.59–2.98) |
| Suicide ideation (last 12 months) | 26.8% | 21.2% | <.001 | 1.07 (0.88–1.29) | 22.6% | 15.5% | .002 | 1.22 (0.87–1.72) |
| Suicide attempt (last 12 months) | 5.3% | 2.7% | <.001 | 0.97 (0.65–1.45) | 3.2% | 1.4% | .02 | 1.02 (0.45–2.31) |
| AOR, adjusted odds ratio; CI, confidence interval. | ||||||||
| Statistically significant differences are in bold. | ||||||||
| *Low education=mandatory schooling or less. | ||||||||
Results
Overall, 20.2% (95% confidence interval [CI], 19.3–21.1) of our sample had a piercing, and it was significantly more prevalent among females than males: 33.8% (95% CI, 32.2–35.3) vs 7.4% (95% CI, 6.6–8.2); P<.001.
Single piercing
Bivariate analysis. Having a piercing was significantly associated with all the risk behavior variables both in males and females. In both genders, pierced adolescents were significantly older, more frequently on an apprentice academic track, perceived advanced puberty, not living with both parents, had felt depressed, and were sensation-seeking. Additionally, pierced females were less likely to be satisfied with their body, less likely to be foreign-born, and more likely to have a mother with low education (mandatory school or less).
Multivariate analysis. Controlling for all significant background variables, pierced females were more likely to have had multiple sexual partners, not to have used a condom at last intercourse, to be regular smokers, and to be current users of cannabis or other illegal drugs. Among males, all risk behavior variables remained significant, except suicide ideation and attempt (TABLE 1).
Multiple piercings
One third (34.1% [95% CI, 31.7–36.5]) of pierced subjects had more than 1 piercing, with similar rates for males (35.3% [95% CI, 29.8–40.9] and females (33.8% [95% CI, 31.1–36.4]).
Bivariate analysis. Among females, having more than one piercing was associated with being an apprentice, perceived advanced puberty, parents not living together, sensation seeking, and being depressed. With the exception of condom use at last intercourse, they were significantly more likely to engage in all risky behaviors.
For males, the only difference between single and multiple piercings was that the latter were more likely to have attempted suicide (TABLE 2).
Multivariate analysis. The only variables associated with females having more than one piercing were having multiple sexual partners (adjusted odds ratio [OR]=1.53 [95% CI, 1.13–2.09]) and using cannabis (adjusted OR=1.39 [95% CI, 1.06–1.82]).
TABLE 2
Characteristics of adolescents with more than 1 piercing
| FEMALES | MALES | |||||
|---|---|---|---|---|---|---|
| 1 PIERCING (N=811) | >1 PIERCING (N=414) | P VALUE | 1 PIERCING (N=183) | >1 PIERCING (N=100) | P VALUE | |
| Age (years±SD) | 17.97±1.16 | 18.01±1.18 | .55 | 18.15±1.23 | 18.34±1.15 | .190 |
| Academic track (apprentice) | 67.7% | 83.8% | <.001 | 91.3% | 92.0% | .830 |
| Body satisfaction (dissatisfied) | 67.7% | 66.9% | .781 | 81.4% | 84.0% | .587 |
| Nationality (Swiss) | 11.2 % | 10.4% | .658 | 16.9% | 16.0% | .839 |
| Perceived puberty (advanced) | 33.8% | 42.3% | .004 | 35.5% | 47.0% | .059 |
| Parental status (not together) | 28.1% | 37.4% | .001 | 29.0% | 39.0% | .085 |
| Father’s education (low)* | 11.6% | 11.1% | .803 | 15.3% | 16.0% | .877 |
| Mother’s education (low)* | 20.3% | 22.9% | .292 | 21.9% | 25.0% | .548 |
| Sensation seeking (high) | 81.5% | 72.0% | <.001 | 47.5% | 46.0% | .804 |
| Feeling depressed (yes) | 42.7% | 49.5% | .023 | 29.5% | 28.0% | .789 |
| Number of sexual partners (≥4) | 16.9% | 28.0% | <.001 | 47.0% | 43.0% | .519 |
| Condom use at last intercourse (no) | 45.2% | 50.0% | .115 | 36.6% | 45.0% | .168 |
| Regular smoker (yes) | 44.1% | 58.2% | <.001 | 65.0% | 69.0% | .499 |
| Intoxication (last 30 days) | 23.8% | 33.1% | .001 | 57.4% | 67.0% | .113 |
| Cannabis use (last 30 days) | 36.1% | 50.2% | <.001 | 67.2% | 68.0% | .893 |
| Illegal drug use (last 30 days) | 6.9% | 12.3% | .002 | 24.6% | 31.0% | .245 |
| Suicide ideation (last 12 mo) | 24.4% | 31.4% | .009 | 20.2% | 27.0% | .192 |
| Suicide attempt (last 12 mo) | 3.9% | 8.0% | .003 | 1.6% | 6.0% | .046 |
| Statistically significant differences are in bold. * Low education=mandatory school or less. | ||||||
Limitations of this study
The main strength of our study is that it is based on a nationally representative sample of adolescents. However, a few limitations need to be stressed.
Body piercing leads to medical complications in a non-negligible percentage of cases7,9,10 particularly if done by nonprofessionals.9 Given the high prevalence of adolescents, particularly females, who do body piercing, and their greater tendency to engage in risk-taking behaviors (and thus may be less careful about potential medical consequences), it seems important to make sure that they can do it under the safest conditions. Indeed, in Switzerland, new legislation regulating body piercing went into effect in 2006.
The cross-sectional nature of our survey does not allow us to assess causality. The questionnaire was filled in the classroom, which excludes absentees and dropouts, both known to be at higher risk.12 Additionally, we do not know the location or the size of the piercings; some locations (eg, nipples or genitalia) are more likely associated with risk behaviors.3,4
Can these results be generalized?
But to what extent can our results be generalized to other, non-European adolescent populations? The prevalence rate is similar to those found among North American adolescents4,5 and college students.2 All published studies seem to indicate that pierced adolescents are more likely to be risk-taking.
That would indicate that our results are on the right track. However, more population-based studies need to be done to fully confirm this.
Acknowledgments
The 2002 Swiss Multicenter adolescent Survey on Health survey was carried out with the financial support of the Swiss federal office of Public Health (contract 00.001721/2.24.02.-81) and the participating cantons.
CORRESPONDENCE
Joan-Carles Suris, MD, PhD, MPH Groupe de recherche sur la santé les adolescents, Institut universitaire de médecine sociale et préventive, Bugnon 17, 1005 Lausanne, Switzerland joan-carles.suris@chuv.ch
1. Braithwaite R, Robillard A, Woodring T, Stephens T, Arriola KJ. Tattooing and body piercing among adolescent detainees: relationship to alcohol and other drug use. J Substance Abuse 2001;13:5-16.
2. Armstrong ML, Roberts AE, Owen DC, Koch JR. Contemporary college students and body piercing. J Adol Health 2004;34:224-229.
3. Roberts TA, Auinger P, Ryan SA. Body piercing and high-risk behavior in adolescents. J Adol Health 2004;34:224-229.
4. Deschesnes M, Finès P, Demers S. Are tattooing and body piercing iindicators of risk-taking behaviours among high school students? J Adol 2006;29:379-379.
5. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 2002;109:1021-1027.
6. Muldoon KA. Body piercing in adolescents. J Ped Health Care 1997;11:298-301.
7. Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 2003;361:1205-1215.
8. Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing. Clin Nursing Res 1999;8:368-385.
9. Gold MA, Scorzman CM, Murray PJ, Downs J, Tolentino G. Body piercing practices and attitudes among urban adolescents. J Adol Health 2005;36:352 e15-e21.
10. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77:29-34.
11. Armstrong ML, Roberts AE, Owen DC, Koch JR. Toward building a composite of college student influences with body art. Issues Comprehensive Ped Nursing 2004;27:277-295.
12. Mischaud PA, Delbos-Piot I, Narring F. Silent dropout in health surveys: are nonrespondent absent teenagers different from those who participate in school-based health surveys? J Adol Health 1998;22:326-333.
13. Jeannin A, Narring F, Tschumper A, et al. Self-reported health needs and use of primary health care services by adolescents enrolled in post-mandatory schools or vocational training programmes in Switzerland. Swiss Medical Weekly 2005;135(1-2):11-18.
14. Armstrong ML, Pace Murphy K. Tattooing: another adolescent risk behavior warranting health education. Applied Nurs Res 1997;10:181-189.
15. Brooks TL, Woods ER, Knight JR, Shrier LA. Body modification and substance use in adolescents: is there a link? J Adolesc Health 2003;32:44-49.
- Without stigmatizing adolescents with piercing, use the topic of body piercing as a starting point for discussing unhealthy behaviors
Body piercing among young people has been linked with risk behaviors such as the abuse of legal and illegal substances, Perspicacity, profiling, and prejudice
Body art and, more specifically, piercing is becoming normative among adolescents, ("Perspicacity, profiling, and prejudice,”) Body art is more than just an indicator of deviancy.11 In other words, as all adolescents should be screened for risky behaviors, this specific population offers the advantage of piercing as a starting point for a discussion.
We found that body piercing is increasingly popular among adolescents in Switzerland, especially among females. Our prevalence rates are higher than those reported by Roberts,3 but (as they suggest) it may well be due to the societal trend, as their data were collected in 1996.
The pierced and the unpierced
Academic performance was the main sociodemographic difference between pierced and unpierced adolescents. As a marker of risk, piercing was negatively associated with academic performance, as found elsewhere regarding healthy behaviors.12 Like other studies, this sample exhibited increased drug use1,3,5 and risky sexual behavior,10 but no increase in suicide attempt.3
Since the late 1990s, estimates for body modification among US adolescents range from 10% to 25%.8,14 A 2002 study5 assessed tattoos and body piercing as markers of risk-taking in 484 adolescents presenting to an adolescent clinic in California; both were markers of greater instances of, and participation in, such behaviors as eating disorders, illegal drug use, sexual activity, and suicide. Tattooing was reported by 13.2% of respondents, with 5.2% having more than 1 tattoo. Excluding earlobes, 26.9% of adolescents had body piercings at some point during their lifetime, and 11.8% had a history of multiple piercings. Tattooing and body piercing were found to be more common in females than males, 16.6% vs 8.1% for tattoos and 36.7% vs 10.1% for body piercings, respectively. Index scores on 5 of 6 risk-taking indices—including the Disordered Eating Behavior Index, the Gateway Drug Index, the Hard Drug Index, the Sexual behavior Index, and the Suicide Index—were significantly higher in participants with at least 1 tattoo or body piercing compared with those with neither. Illegal drug use also increased with the number of piercings.
Another study15 looked at 14- to 18-year-olds presenting to an urban adolescent clinic in Massachusetts. Of 210 surveyed, 48% reported at least 1 body modification, with girls more likely than boys (59% vs 28%; P≥.0005). Forty-two percent reported piercings, 10% had tattoos, 4% had scarification; 21% had more than 1 type of modification. One third of the sample screened positive for problem substance use. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance abuse with alcohol or drugs than those without (95% CI, 1.7–5.8).
Among females in our sample, more than 1 piercing is associated with having multiple sex partners and marijuana use. Carroll et al5 also found that having multiple piercings was associated with illegal drug use. For males in our study, the only association with multiple piercings was an increase in suicide attempts.
From our results, it could be hypothesized that more than 1 piercing is a cumulative marker for some risk behaviors, mainly among females. Though associations for males were similar to those for females, the differences between pierced and unpierced groups did not reach statistical significance. However, the relatively small sample of pierced males discourages definitive conclusions.
Pierced adolescents were less satisfied with their bodies than their unpierced counterparts, though the difference is significant only for females.
Young people indicate that the main reasons they obtain a piercing are a sense of uniqueness or self-expression, with only one fifth indicating that they obtain it for aesthetics only.2,8 As we did not assess the reasons to obtain a body piercing in this study, it could be that they had it done to increase their body satisfaction, that their body satisfaction was lower after having it done, or simply that they do not get pierced to increase their satisfaction with their body.
Methods
Population. Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health database, a survey of 7548 students ages 16 to 20 years (3658 of whom were female). In Switzerland, school is mandatory up to age 16. Afterwards, about 30% of adolescents follow to further high school, 60% go to vocational school as an apprentice (1 or 2 days of class per week and the rest spent at work), and 10% do not continue their education.
Classroom survey. The survey was an anonymous classroom questionnaire approved by the ethical committee of the Medicine Faculty in Lausanne. The questionnaire and sampling method are described elsewhere.13 Ninety-one subjects (1%) did not answer the question referring to body piercing and were excluded. The final sample had 7457 subjects (3628 females).
(TABLE 1) lists selected characteristics and background variables analyzed. Analyses were performed separately by gender, as the literature indicates that females are more likely to have piercings.2-5 We conducted all analyses with Stata 8 (College Station, TX), which computes coefficient estimates taking into account sampling weights, clustering, and stratification procedure. All significant variables in the bivariate analysis were included in a logistic regression.
In a second step, adolescents having one piercing were compared with those having more than one piercing, using the same method.
TABLE 1
Selected characteristics of pierced and unpierced adolescents—females (N=3628) and males (N=3829)
| FEMALES | MALES | |||||||
|---|---|---|---|---|---|---|---|---|
| PIERCED (N=1225) | UNPIERCED (N=2403) | P VALUE | AOR (95% CI) | PIERCED (N=283) | UNPIERCED (N=3546) | P VALUE | AOR (95% CI) | |
| Age (years±SD) | 17.98±1.17 | 17.77±1.13 | <.001 | 0.94 (0.88–1.01) | 18.21±1.20 | 17.86±1.18 | <.001 | 0.90 (0.80–1.00) |
| Academic track (apprentice) | 73.1% | 53.1% | <.001 | 2.05 (1.75–2.41) | 91.5% | 71.0% | <.001 | 2.97 (1.92–4.62) |
| Body satisfaction (dissatisfied) | 67.4% | 71.2% | .02 | 0.96 (0.82–1.14) | 82.3% | 86.3% | .064 | — |
| Nationality (Swiss) | 10.9% | 13.5% | .027 | 0.72 (0.57–0.92) | 16.6% | 13.3% | .119 | — |
| Perceived puberty (advanced) | 36.6% | 30.2% | <.001 | 1.06 (0.91–1.25) | 39.6% | 23.3% | <.001 | 1.41 (1.07–1.86) |
| Parental status (not together) | 31.3% | 20.8% | <.001 | 1.30 (1.10–1.55) | 32.5% | 21.7% | <.001 | 1.35 (1.02–1.79) |
| Father’s education (low)* | 11.4% | 15.9% | <.001 | 0.67 (0.53–0.84) | 15.5% | 14.0% | .476 | — |
| Mother’s education (low)* | 21.2% | 22.9% | 0.24 | — | 23.0% | 20.8% | .379 | — |
| Sensation seeking (high) | 21.9% | 15.5% | <.001 | 1.14 (0.94–1.39) | 53.0% | 40.0% | <.001 | 1.13 (0.87–1.47) |
| Feeling depressed (yes) | 45.0% | 36.2% | <.001 | 1.16 (0.98–1.36) | 29.0% | 21.7% | .005 | 1.05 (0.78–1.42) |
| Number of sexual partners (≥4) | 20.6% | 8.3% | <.001 | 1.50 (1.20–1.87) | 45.6% | 17.9% | <.001 | 1.71 (1.29–2.28) |
| Condom use at last intercourse (no) | 46.9% | 27.5% | <.001 | 1.63 (1.39–1.92) | 39.6% | 19.5% | <.001 | 1.49 (1.12–1.98) |
| Regular smoker (yes) | 48.9% | 21.9% | <.001 | 2.06 (1.74–2.45) | 66.4% | 30.9% | <.001 | 2.28 (1.72–3.02) |
| Intoxication (last 30 days) | 26.9% | 15.7% | <.001 | 1.19 (0.98–1.44) | 60.8% | 39.0% | <.001 | 1.51 (1.15–1.97) |
| Cannabis use (last 30 days) | 40.9% | 20.6% | <.001 | 1.58 (1.32–1.89) | 67.5% | 39.1% | <.001 | 1.37 (1.05–1.79) |
| Illegal drug use (last 30 days) | 8.7% | 3.4% | <.001 | 1.67 (1.21–2.31) | 26.9% | 8.3% | <.001 | 2.17 (1.59–2.98) |
| Suicide ideation (last 12 months) | 26.8% | 21.2% | <.001 | 1.07 (0.88–1.29) | 22.6% | 15.5% | .002 | 1.22 (0.87–1.72) |
| Suicide attempt (last 12 months) | 5.3% | 2.7% | <.001 | 0.97 (0.65–1.45) | 3.2% | 1.4% | .02 | 1.02 (0.45–2.31) |
| AOR, adjusted odds ratio; CI, confidence interval. | ||||||||
| Statistically significant differences are in bold. | ||||||||
| *Low education=mandatory schooling or less. | ||||||||
Results
Overall, 20.2% (95% confidence interval [CI], 19.3–21.1) of our sample had a piercing, and it was significantly more prevalent among females than males: 33.8% (95% CI, 32.2–35.3) vs 7.4% (95% CI, 6.6–8.2); P<.001.
Single piercing
Bivariate analysis. Having a piercing was significantly associated with all the risk behavior variables both in males and females. In both genders, pierced adolescents were significantly older, more frequently on an apprentice academic track, perceived advanced puberty, not living with both parents, had felt depressed, and were sensation-seeking. Additionally, pierced females were less likely to be satisfied with their body, less likely to be foreign-born, and more likely to have a mother with low education (mandatory school or less).
Multivariate analysis. Controlling for all significant background variables, pierced females were more likely to have had multiple sexual partners, not to have used a condom at last intercourse, to be regular smokers, and to be current users of cannabis or other illegal drugs. Among males, all risk behavior variables remained significant, except suicide ideation and attempt (TABLE 1).
Multiple piercings
One third (34.1% [95% CI, 31.7–36.5]) of pierced subjects had more than 1 piercing, with similar rates for males (35.3% [95% CI, 29.8–40.9] and females (33.8% [95% CI, 31.1–36.4]).
Bivariate analysis. Among females, having more than one piercing was associated with being an apprentice, perceived advanced puberty, parents not living together, sensation seeking, and being depressed. With the exception of condom use at last intercourse, they were significantly more likely to engage in all risky behaviors.
For males, the only difference between single and multiple piercings was that the latter were more likely to have attempted suicide (TABLE 2).
Multivariate analysis. The only variables associated with females having more than one piercing were having multiple sexual partners (adjusted odds ratio [OR]=1.53 [95% CI, 1.13–2.09]) and using cannabis (adjusted OR=1.39 [95% CI, 1.06–1.82]).
TABLE 2
Characteristics of adolescents with more than 1 piercing
| FEMALES | MALES | |||||
|---|---|---|---|---|---|---|
| 1 PIERCING (N=811) | >1 PIERCING (N=414) | P VALUE | 1 PIERCING (N=183) | >1 PIERCING (N=100) | P VALUE | |
| Age (years±SD) | 17.97±1.16 | 18.01±1.18 | .55 | 18.15±1.23 | 18.34±1.15 | .190 |
| Academic track (apprentice) | 67.7% | 83.8% | <.001 | 91.3% | 92.0% | .830 |
| Body satisfaction (dissatisfied) | 67.7% | 66.9% | .781 | 81.4% | 84.0% | .587 |
| Nationality (Swiss) | 11.2 % | 10.4% | .658 | 16.9% | 16.0% | .839 |
| Perceived puberty (advanced) | 33.8% | 42.3% | .004 | 35.5% | 47.0% | .059 |
| Parental status (not together) | 28.1% | 37.4% | .001 | 29.0% | 39.0% | .085 |
| Father’s education (low)* | 11.6% | 11.1% | .803 | 15.3% | 16.0% | .877 |
| Mother’s education (low)* | 20.3% | 22.9% | .292 | 21.9% | 25.0% | .548 |
| Sensation seeking (high) | 81.5% | 72.0% | <.001 | 47.5% | 46.0% | .804 |
| Feeling depressed (yes) | 42.7% | 49.5% | .023 | 29.5% | 28.0% | .789 |
| Number of sexual partners (≥4) | 16.9% | 28.0% | <.001 | 47.0% | 43.0% | .519 |
| Condom use at last intercourse (no) | 45.2% | 50.0% | .115 | 36.6% | 45.0% | .168 |
| Regular smoker (yes) | 44.1% | 58.2% | <.001 | 65.0% | 69.0% | .499 |
| Intoxication (last 30 days) | 23.8% | 33.1% | .001 | 57.4% | 67.0% | .113 |
| Cannabis use (last 30 days) | 36.1% | 50.2% | <.001 | 67.2% | 68.0% | .893 |
| Illegal drug use (last 30 days) | 6.9% | 12.3% | .002 | 24.6% | 31.0% | .245 |
| Suicide ideation (last 12 mo) | 24.4% | 31.4% | .009 | 20.2% | 27.0% | .192 |
| Suicide attempt (last 12 mo) | 3.9% | 8.0% | .003 | 1.6% | 6.0% | .046 |
| Statistically significant differences are in bold. * Low education=mandatory school or less. | ||||||
Limitations of this study
The main strength of our study is that it is based on a nationally representative sample of adolescents. However, a few limitations need to be stressed.
Body piercing leads to medical complications in a non-negligible percentage of cases7,9,10 particularly if done by nonprofessionals.9 Given the high prevalence of adolescents, particularly females, who do body piercing, and their greater tendency to engage in risk-taking behaviors (and thus may be less careful about potential medical consequences), it seems important to make sure that they can do it under the safest conditions. Indeed, in Switzerland, new legislation regulating body piercing went into effect in 2006.
The cross-sectional nature of our survey does not allow us to assess causality. The questionnaire was filled in the classroom, which excludes absentees and dropouts, both known to be at higher risk.12 Additionally, we do not know the location or the size of the piercings; some locations (eg, nipples or genitalia) are more likely associated with risk behaviors.3,4
Can these results be generalized?
But to what extent can our results be generalized to other, non-European adolescent populations? The prevalence rate is similar to those found among North American adolescents4,5 and college students.2 All published studies seem to indicate that pierced adolescents are more likely to be risk-taking.
That would indicate that our results are on the right track. However, more population-based studies need to be done to fully confirm this.
Acknowledgments
The 2002 Swiss Multicenter adolescent Survey on Health survey was carried out with the financial support of the Swiss federal office of Public Health (contract 00.001721/2.24.02.-81) and the participating cantons.
CORRESPONDENCE
Joan-Carles Suris, MD, PhD, MPH Groupe de recherche sur la santé les adolescents, Institut universitaire de médecine sociale et préventive, Bugnon 17, 1005 Lausanne, Switzerland joan-carles.suris@chuv.ch
- Without stigmatizing adolescents with piercing, use the topic of body piercing as a starting point for discussing unhealthy behaviors
Body piercing among young people has been linked with risk behaviors such as the abuse of legal and illegal substances, Perspicacity, profiling, and prejudice
Body art and, more specifically, piercing is becoming normative among adolescents, ("Perspicacity, profiling, and prejudice,”) Body art is more than just an indicator of deviancy.11 In other words, as all adolescents should be screened for risky behaviors, this specific population offers the advantage of piercing as a starting point for a discussion.
We found that body piercing is increasingly popular among adolescents in Switzerland, especially among females. Our prevalence rates are higher than those reported by Roberts,3 but (as they suggest) it may well be due to the societal trend, as their data were collected in 1996.
The pierced and the unpierced
Academic performance was the main sociodemographic difference between pierced and unpierced adolescents. As a marker of risk, piercing was negatively associated with academic performance, as found elsewhere regarding healthy behaviors.12 Like other studies, this sample exhibited increased drug use1,3,5 and risky sexual behavior,10 but no increase in suicide attempt.3
Since the late 1990s, estimates for body modification among US adolescents range from 10% to 25%.8,14 A 2002 study5 assessed tattoos and body piercing as markers of risk-taking in 484 adolescents presenting to an adolescent clinic in California; both were markers of greater instances of, and participation in, such behaviors as eating disorders, illegal drug use, sexual activity, and suicide. Tattooing was reported by 13.2% of respondents, with 5.2% having more than 1 tattoo. Excluding earlobes, 26.9% of adolescents had body piercings at some point during their lifetime, and 11.8% had a history of multiple piercings. Tattooing and body piercing were found to be more common in females than males, 16.6% vs 8.1% for tattoos and 36.7% vs 10.1% for body piercings, respectively. Index scores on 5 of 6 risk-taking indices—including the Disordered Eating Behavior Index, the Gateway Drug Index, the Hard Drug Index, the Sexual behavior Index, and the Suicide Index—were significantly higher in participants with at least 1 tattoo or body piercing compared with those with neither. Illegal drug use also increased with the number of piercings.
Another study15 looked at 14- to 18-year-olds presenting to an urban adolescent clinic in Massachusetts. Of 210 surveyed, 48% reported at least 1 body modification, with girls more likely than boys (59% vs 28%; P≥.0005). Forty-two percent reported piercings, 10% had tattoos, 4% had scarification; 21% had more than 1 type of modification. One third of the sample screened positive for problem substance use. Controlling for age, adolescents with body modification had 3.1 times greater odds of problem substance abuse with alcohol or drugs than those without (95% CI, 1.7–5.8).
Among females in our sample, more than 1 piercing is associated with having multiple sex partners and marijuana use. Carroll et al5 also found that having multiple piercings was associated with illegal drug use. For males in our study, the only association with multiple piercings was an increase in suicide attempts.
From our results, it could be hypothesized that more than 1 piercing is a cumulative marker for some risk behaviors, mainly among females. Though associations for males were similar to those for females, the differences between pierced and unpierced groups did not reach statistical significance. However, the relatively small sample of pierced males discourages definitive conclusions.
Pierced adolescents were less satisfied with their bodies than their unpierced counterparts, though the difference is significant only for females.
Young people indicate that the main reasons they obtain a piercing are a sense of uniqueness or self-expression, with only one fifth indicating that they obtain it for aesthetics only.2,8 As we did not assess the reasons to obtain a body piercing in this study, it could be that they had it done to increase their body satisfaction, that their body satisfaction was lower after having it done, or simply that they do not get pierced to increase their satisfaction with their body.
Methods
Population. Data were drawn from the 2002 Swiss Multicenter Adolescent Survey on Health database, a survey of 7548 students ages 16 to 20 years (3658 of whom were female). In Switzerland, school is mandatory up to age 16. Afterwards, about 30% of adolescents follow to further high school, 60% go to vocational school as an apprentice (1 or 2 days of class per week and the rest spent at work), and 10% do not continue their education.
Classroom survey. The survey was an anonymous classroom questionnaire approved by the ethical committee of the Medicine Faculty in Lausanne. The questionnaire and sampling method are described elsewhere.13 Ninety-one subjects (1%) did not answer the question referring to body piercing and were excluded. The final sample had 7457 subjects (3628 females).
(TABLE 1) lists selected characteristics and background variables analyzed. Analyses were performed separately by gender, as the literature indicates that females are more likely to have piercings.2-5 We conducted all analyses with Stata 8 (College Station, TX), which computes coefficient estimates taking into account sampling weights, clustering, and stratification procedure. All significant variables in the bivariate analysis were included in a logistic regression.
In a second step, adolescents having one piercing were compared with those having more than one piercing, using the same method.
TABLE 1
Selected characteristics of pierced and unpierced adolescents—females (N=3628) and males (N=3829)
| FEMALES | MALES | |||||||
|---|---|---|---|---|---|---|---|---|
| PIERCED (N=1225) | UNPIERCED (N=2403) | P VALUE | AOR (95% CI) | PIERCED (N=283) | UNPIERCED (N=3546) | P VALUE | AOR (95% CI) | |
| Age (years±SD) | 17.98±1.17 | 17.77±1.13 | <.001 | 0.94 (0.88–1.01) | 18.21±1.20 | 17.86±1.18 | <.001 | 0.90 (0.80–1.00) |
| Academic track (apprentice) | 73.1% | 53.1% | <.001 | 2.05 (1.75–2.41) | 91.5% | 71.0% | <.001 | 2.97 (1.92–4.62) |
| Body satisfaction (dissatisfied) | 67.4% | 71.2% | .02 | 0.96 (0.82–1.14) | 82.3% | 86.3% | .064 | — |
| Nationality (Swiss) | 10.9% | 13.5% | .027 | 0.72 (0.57–0.92) | 16.6% | 13.3% | .119 | — |
| Perceived puberty (advanced) | 36.6% | 30.2% | <.001 | 1.06 (0.91–1.25) | 39.6% | 23.3% | <.001 | 1.41 (1.07–1.86) |
| Parental status (not together) | 31.3% | 20.8% | <.001 | 1.30 (1.10–1.55) | 32.5% | 21.7% | <.001 | 1.35 (1.02–1.79) |
| Father’s education (low)* | 11.4% | 15.9% | <.001 | 0.67 (0.53–0.84) | 15.5% | 14.0% | .476 | — |
| Mother’s education (low)* | 21.2% | 22.9% | 0.24 | — | 23.0% | 20.8% | .379 | — |
| Sensation seeking (high) | 21.9% | 15.5% | <.001 | 1.14 (0.94–1.39) | 53.0% | 40.0% | <.001 | 1.13 (0.87–1.47) |
| Feeling depressed (yes) | 45.0% | 36.2% | <.001 | 1.16 (0.98–1.36) | 29.0% | 21.7% | .005 | 1.05 (0.78–1.42) |
| Number of sexual partners (≥4) | 20.6% | 8.3% | <.001 | 1.50 (1.20–1.87) | 45.6% | 17.9% | <.001 | 1.71 (1.29–2.28) |
| Condom use at last intercourse (no) | 46.9% | 27.5% | <.001 | 1.63 (1.39–1.92) | 39.6% | 19.5% | <.001 | 1.49 (1.12–1.98) |
| Regular smoker (yes) | 48.9% | 21.9% | <.001 | 2.06 (1.74–2.45) | 66.4% | 30.9% | <.001 | 2.28 (1.72–3.02) |
| Intoxication (last 30 days) | 26.9% | 15.7% | <.001 | 1.19 (0.98–1.44) | 60.8% | 39.0% | <.001 | 1.51 (1.15–1.97) |
| Cannabis use (last 30 days) | 40.9% | 20.6% | <.001 | 1.58 (1.32–1.89) | 67.5% | 39.1% | <.001 | 1.37 (1.05–1.79) |
| Illegal drug use (last 30 days) | 8.7% | 3.4% | <.001 | 1.67 (1.21–2.31) | 26.9% | 8.3% | <.001 | 2.17 (1.59–2.98) |
| Suicide ideation (last 12 months) | 26.8% | 21.2% | <.001 | 1.07 (0.88–1.29) | 22.6% | 15.5% | .002 | 1.22 (0.87–1.72) |
| Suicide attempt (last 12 months) | 5.3% | 2.7% | <.001 | 0.97 (0.65–1.45) | 3.2% | 1.4% | .02 | 1.02 (0.45–2.31) |
| AOR, adjusted odds ratio; CI, confidence interval. | ||||||||
| Statistically significant differences are in bold. | ||||||||
| *Low education=mandatory schooling or less. | ||||||||
Results
Overall, 20.2% (95% confidence interval [CI], 19.3–21.1) of our sample had a piercing, and it was significantly more prevalent among females than males: 33.8% (95% CI, 32.2–35.3) vs 7.4% (95% CI, 6.6–8.2); P<.001.
Single piercing
Bivariate analysis. Having a piercing was significantly associated with all the risk behavior variables both in males and females. In both genders, pierced adolescents were significantly older, more frequently on an apprentice academic track, perceived advanced puberty, not living with both parents, had felt depressed, and were sensation-seeking. Additionally, pierced females were less likely to be satisfied with their body, less likely to be foreign-born, and more likely to have a mother with low education (mandatory school or less).
Multivariate analysis. Controlling for all significant background variables, pierced females were more likely to have had multiple sexual partners, not to have used a condom at last intercourse, to be regular smokers, and to be current users of cannabis or other illegal drugs. Among males, all risk behavior variables remained significant, except suicide ideation and attempt (TABLE 1).
Multiple piercings
One third (34.1% [95% CI, 31.7–36.5]) of pierced subjects had more than 1 piercing, with similar rates for males (35.3% [95% CI, 29.8–40.9] and females (33.8% [95% CI, 31.1–36.4]).
Bivariate analysis. Among females, having more than one piercing was associated with being an apprentice, perceived advanced puberty, parents not living together, sensation seeking, and being depressed. With the exception of condom use at last intercourse, they were significantly more likely to engage in all risky behaviors.
For males, the only difference between single and multiple piercings was that the latter were more likely to have attempted suicide (TABLE 2).
Multivariate analysis. The only variables associated with females having more than one piercing were having multiple sexual partners (adjusted odds ratio [OR]=1.53 [95% CI, 1.13–2.09]) and using cannabis (adjusted OR=1.39 [95% CI, 1.06–1.82]).
TABLE 2
Characteristics of adolescents with more than 1 piercing
| FEMALES | MALES | |||||
|---|---|---|---|---|---|---|
| 1 PIERCING (N=811) | >1 PIERCING (N=414) | P VALUE | 1 PIERCING (N=183) | >1 PIERCING (N=100) | P VALUE | |
| Age (years±SD) | 17.97±1.16 | 18.01±1.18 | .55 | 18.15±1.23 | 18.34±1.15 | .190 |
| Academic track (apprentice) | 67.7% | 83.8% | <.001 | 91.3% | 92.0% | .830 |
| Body satisfaction (dissatisfied) | 67.7% | 66.9% | .781 | 81.4% | 84.0% | .587 |
| Nationality (Swiss) | 11.2 % | 10.4% | .658 | 16.9% | 16.0% | .839 |
| Perceived puberty (advanced) | 33.8% | 42.3% | .004 | 35.5% | 47.0% | .059 |
| Parental status (not together) | 28.1% | 37.4% | .001 | 29.0% | 39.0% | .085 |
| Father’s education (low)* | 11.6% | 11.1% | .803 | 15.3% | 16.0% | .877 |
| Mother’s education (low)* | 20.3% | 22.9% | .292 | 21.9% | 25.0% | .548 |
| Sensation seeking (high) | 81.5% | 72.0% | <.001 | 47.5% | 46.0% | .804 |
| Feeling depressed (yes) | 42.7% | 49.5% | .023 | 29.5% | 28.0% | .789 |
| Number of sexual partners (≥4) | 16.9% | 28.0% | <.001 | 47.0% | 43.0% | .519 |
| Condom use at last intercourse (no) | 45.2% | 50.0% | .115 | 36.6% | 45.0% | .168 |
| Regular smoker (yes) | 44.1% | 58.2% | <.001 | 65.0% | 69.0% | .499 |
| Intoxication (last 30 days) | 23.8% | 33.1% | .001 | 57.4% | 67.0% | .113 |
| Cannabis use (last 30 days) | 36.1% | 50.2% | <.001 | 67.2% | 68.0% | .893 |
| Illegal drug use (last 30 days) | 6.9% | 12.3% | .002 | 24.6% | 31.0% | .245 |
| Suicide ideation (last 12 mo) | 24.4% | 31.4% | .009 | 20.2% | 27.0% | .192 |
| Suicide attempt (last 12 mo) | 3.9% | 8.0% | .003 | 1.6% | 6.0% | .046 |
| Statistically significant differences are in bold. * Low education=mandatory school or less. | ||||||
Limitations of this study
The main strength of our study is that it is based on a nationally representative sample of adolescents. However, a few limitations need to be stressed.
Body piercing leads to medical complications in a non-negligible percentage of cases7,9,10 particularly if done by nonprofessionals.9 Given the high prevalence of adolescents, particularly females, who do body piercing, and their greater tendency to engage in risk-taking behaviors (and thus may be less careful about potential medical consequences), it seems important to make sure that they can do it under the safest conditions. Indeed, in Switzerland, new legislation regulating body piercing went into effect in 2006.
The cross-sectional nature of our survey does not allow us to assess causality. The questionnaire was filled in the classroom, which excludes absentees and dropouts, both known to be at higher risk.12 Additionally, we do not know the location or the size of the piercings; some locations (eg, nipples or genitalia) are more likely associated with risk behaviors.3,4
Can these results be generalized?
But to what extent can our results be generalized to other, non-European adolescent populations? The prevalence rate is similar to those found among North American adolescents4,5 and college students.2 All published studies seem to indicate that pierced adolescents are more likely to be risk-taking.
That would indicate that our results are on the right track. However, more population-based studies need to be done to fully confirm this.
Acknowledgments
The 2002 Swiss Multicenter adolescent Survey on Health survey was carried out with the financial support of the Swiss federal office of Public Health (contract 00.001721/2.24.02.-81) and the participating cantons.
CORRESPONDENCE
Joan-Carles Suris, MD, PhD, MPH Groupe de recherche sur la santé les adolescents, Institut universitaire de médecine sociale et préventive, Bugnon 17, 1005 Lausanne, Switzerland joan-carles.suris@chuv.ch
1. Braithwaite R, Robillard A, Woodring T, Stephens T, Arriola KJ. Tattooing and body piercing among adolescent detainees: relationship to alcohol and other drug use. J Substance Abuse 2001;13:5-16.
2. Armstrong ML, Roberts AE, Owen DC, Koch JR. Contemporary college students and body piercing. J Adol Health 2004;34:224-229.
3. Roberts TA, Auinger P, Ryan SA. Body piercing and high-risk behavior in adolescents. J Adol Health 2004;34:224-229.
4. Deschesnes M, Finès P, Demers S. Are tattooing and body piercing iindicators of risk-taking behaviours among high school students? J Adol 2006;29:379-379.
5. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 2002;109:1021-1027.
6. Muldoon KA. Body piercing in adolescents. J Ped Health Care 1997;11:298-301.
7. Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 2003;361:1205-1215.
8. Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing. Clin Nursing Res 1999;8:368-385.
9. Gold MA, Scorzman CM, Murray PJ, Downs J, Tolentino G. Body piercing practices and attitudes among urban adolescents. J Adol Health 2005;36:352 e15-e21.
10. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77:29-34.
11. Armstrong ML, Roberts AE, Owen DC, Koch JR. Toward building a composite of college student influences with body art. Issues Comprehensive Ped Nursing 2004;27:277-295.
12. Mischaud PA, Delbos-Piot I, Narring F. Silent dropout in health surveys: are nonrespondent absent teenagers different from those who participate in school-based health surveys? J Adol Health 1998;22:326-333.
13. Jeannin A, Narring F, Tschumper A, et al. Self-reported health needs and use of primary health care services by adolescents enrolled in post-mandatory schools or vocational training programmes in Switzerland. Swiss Medical Weekly 2005;135(1-2):11-18.
14. Armstrong ML, Pace Murphy K. Tattooing: another adolescent risk behavior warranting health education. Applied Nurs Res 1997;10:181-189.
15. Brooks TL, Woods ER, Knight JR, Shrier LA. Body modification and substance use in adolescents: is there a link? J Adolesc Health 2003;32:44-49.
1. Braithwaite R, Robillard A, Woodring T, Stephens T, Arriola KJ. Tattooing and body piercing among adolescent detainees: relationship to alcohol and other drug use. J Substance Abuse 2001;13:5-16.
2. Armstrong ML, Roberts AE, Owen DC, Koch JR. Contemporary college students and body piercing. J Adol Health 2004;34:224-229.
3. Roberts TA, Auinger P, Ryan SA. Body piercing and high-risk behavior in adolescents. J Adol Health 2004;34:224-229.
4. Deschesnes M, Finès P, Demers S. Are tattooing and body piercing iindicators of risk-taking behaviours among high school students? J Adol 2006;29:379-379.
5. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 2002;109:1021-1027.
6. Muldoon KA. Body piercing in adolescents. J Ped Health Care 1997;11:298-301.
7. Stirn A. Body piercing: medical consequences and psychological motivations. Lancet 2003;361:1205-1215.
8. Greif J, Hewitt W, Armstrong ML. Tattooing and body piercing. Clin Nursing Res 1999;8:368-385.
9. Gold MA, Scorzman CM, Murray PJ, Downs J, Tolentino G. Body piercing practices and attitudes among urban adolescents. J Adol Health 2005;36:352 e15-e21.
10. Mayers LB, Judelson DA, Moriarty BW, Rundell KW. Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications. Mayo Clin Proc 2002;77:29-34.
11. Armstrong ML, Roberts AE, Owen DC, Koch JR. Toward building a composite of college student influences with body art. Issues Comprehensive Ped Nursing 2004;27:277-295.
12. Mischaud PA, Delbos-Piot I, Narring F. Silent dropout in health surveys: are nonrespondent absent teenagers different from those who participate in school-based health surveys? J Adol Health 1998;22:326-333.
13. Jeannin A, Narring F, Tschumper A, et al. Self-reported health needs and use of primary health care services by adolescents enrolled in post-mandatory schools or vocational training programmes in Switzerland. Swiss Medical Weekly 2005;135(1-2):11-18.
14. Armstrong ML, Pace Murphy K. Tattooing: another adolescent risk behavior warranting health education. Applied Nurs Res 1997;10:181-189.
15. Brooks TL, Woods ER, Knight JR, Shrier LA. Body modification and substance use in adolescents: is there a link? J Adolesc Health 2003;32:44-49.