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Author:    Patricia Hartley (RNC, MSN)

Purpose/Goals

The purpose of this course is to make the healthcare professional aware of the special implications of caring for clients with body piercing, including cultural competence.

Objectives

Upon completion of this self-study module, the participant will be able to:

  1. Discuss the rationale for body piercing
  2. Identify common types of body piercing
  3. Discuss the cultural implications that may impact care of a client with body piercing
  4. Describe the implications of caring for clients with body piercing in various healthcare settings
  5. Identify complications associated with body piercing

Introduction

What was once considered a practice of bikers, sailors and rebellious teenagers has now entered into general society. These invasive procedures have flourished in the United States of America with increasing prevalence and steady persistence for the past two decades. Little is known about those who have intimate piercing. Clients with body piercing present a challenge for healthcare professionals in all areas of patient care and for nurses in physiological, psychological and cultural aspects of care. Pierced ear lobes have been commonplace for many years, but now, devotees are also piercing the nose, eyebrows, tongue, lip, navel, nipple, clitoral hood, inner and/or outer labia, perineum, penis, foreskin and scrotum. The need to prepare clients for procedures while promoting safety, preserving body image and respecting cultural values has gone beyond the routine practice of jewelry removal. Little is known about intimate body piercing or its relevance to human behavior. When clients with nipple and/or genital piercing seek health care, they may receive that care from professional nurses who lack information or understanding about the practice of intimate body piercing. Awareness of purposes and decision making about intimate piercing can help nurses be sensitive to client needs and plan appropriate health education. The information in this module is intended to assist nurses in developing better understanding of body piercing and to enhance the nursing knowledge base about intimately pierced individuals and health issues surrounding body piercing.

History

Body piercing is relatively new to American culture. Body art (i.e. tattooing, piercing) has been practiced by men, women and children in many societies. The practice of inserting needles, rings and other objects into the flesh has been documented in most cultures for thousands of years for various ornamental and religious reasons. It was used then as it is now, for:

  • Personal expression
  • Religious ritual
  • Rite of passage such as reaching sexual maturity
  • Official or royal distinction
  • Fashion trends

Piercing is one of the oldest forms of body art and modification and examples of piercing exist among museum antiquities. Piercing is, in fact, an ancient tradition dating back to the Egyptian pharaohs who pierced their navels as a rite of passage. Roman soldiers spiked/pierced their nipples to show their manhood but the piercings also functioned as a method for attaching their cloaks. Male genital piercing is discussed in the Kama Sutra, an ancient text estimated to have been written around 250 A.D.

Evidence of body modification can be found in the Bible. The Old Testament mentions ear piercing to identify slaves. Rebekah was presented and wore a nose ring and bracelets given to her by Abraham’s servant in Genesis 24. Leviticus 19:28 warns Israelites against altering the body to keep them separate from the pagan groups surrounding them. The Judeo-Christian precepts helped to dissuade individuals from using body piercing in the western world. Attitudes shaped by religious beliefs led to the philosophy that body piercing was associated with criminal behavior. Historically, most piercing was confined to the ears, mouth and nose.

Attitudes that promoted the idea of denying one’s physical nature prevailed in Victorian times. Restraint of passion, especially of a sexual nature, was practiced. It is, however, ironic that Victorian-era journals for society girls discussed using jewelry to enhance the shape and size of the nipples. Body piercing was often identified with royalty and portrayed courage and virility. Both sexes of Victorian royalty chose nipple and genital piercing. According to the November 1997 issue of the Journal of Pediatric Health Care, even in prudish Victorian-era England, Queen Victoria’s husband, Prince Albert, had his penis pierced. In past centuries, cultural groups near the Indian Ocean used bone pieces for genital piercing. The fad had pretty much died out in western civilization by the early 20th century. But in the 1960s, ear piercing among girls and women began to appear again in certain groups and then quickly infiltrated mainstream society. Later, unusual body piercing (other than a single ear piercing per earlobe) became associated with fringe cultural groups like punk rockers and modern primitive groups. The piercing of other body parts besides the ears did not see resurgence in popularity until the 1990s.

Rationale of Piercing

Piercing of the labia originated as a way of ensuring chastity. Mayans pierced their tongues as a spiritual ritual. Samoans believed that tongue piercing ensured “better communication with the creator.” Male genital piercing was a rite of passage in Egypt, Pakistan, Iran and Iraq. Many piercings today have common significance. Nose piercing often marks independence or breathing easily. Some people feel they reclaim their body after a traumatic illness or event. Piercing can be extremely therapeutic. It is sometimes used by individuals seeking to assert their independence or promote their individuality. A recent study found the major reason for college students to seek one or more types of body art is self-identity. The younger college students’ reasoning was more about impulsiveness – something that sounded like a good idea at the time or because they were away from parents for the first time. Older college students’ decisions were based more on emulating older adults and definite decision-making. The older students took more time to research their decision.

Body piercing provides an internal meaning to those who choose to get them. Studies have shown that both men and women with multiple piercings report engaging in more risk-taking behavior and conform less to social expectations. These studies have confirmed the negative stereotypes about body piercing are not based on concrete differences between those who are pierced and those who are not. Young adults see body piercing as another fashion option. Highly visible piercings of the ears, nose, eyebrows and naval provide a means of creative self-expression. Intimate piercing of the tongue, nipples, and genitals has more sexual connotations or function. However, it is difficult to view multiple piercings as signs of personal or social pathology when significant numbers of well-educated, middle-class people begin to display more piercings.

Types of Jewelry/Hardware

Body piercing is a quick procedure without anesthesia. It is created by developing tracts under the skin with large bore needles to insert decorative ornaments such as jewelry. Retract the skin with a hemostat, pierce the skin with a hollow 12 to 16 gauge needle, attach the jewelry to the needle, and thread the jewelry through the hole. This jewelry ranges from fairly inexpensive to more elaborate with semi-precious and precious stones. Recommended jewelry materials are considered hypoallergenic and biocompatible. Most starter jewelry is nickel-free and includes nontoxic metals such as surgical stainless steel, 14-karat gold, niobium, platinum, or titanium. The jewelry typically ranges in thickness from 1Z4” to 13Z”. The thicker/heavier grades are more difficult to remove. Jewelry that is too thin can lead to rejection, migration or tearing (the narrow wire acts like a cheese slicer). Thicker jewelry is typically used for genital piercing. There are numerous styles of jewelry:

  • Barbell is a post with balls on both ends. One or both balls unscrew from the post. It can be straight, curved or fish-tail and the ball on the barbell can be internally or externally threaded.
  • Captive/Capture bead hardware looks like a simple hoop earring with a decorative bead that is held in place by tension.
  • Labret type has a flat portion on one side and a threaded ball on the opposite side.
  • Tubes and flared eyelet flesh tunnels are used to enlarge a pierced hole, particularly in the ear lobe.

Types of Piercing

Piercings are categorized by their location as exotic versus non-exotic and sexual versus nonsexual. Facial piercing is considered exotic and nonsexual except for the single piercing of the earlobe. The lateral edge of the eyebrow is the only location around the eye where piercing is possible using a capture ball ring. The nose may be pierced at the bridge and septum using a barbell or capture ring, whereas the nostril uses a nose stud. Traditional clasp-style jewelry increases the risk of foreign body aspiration. The piercing of the upper lip is called Medusa, the piercing of the outer corner of the mouth above the lip is referred to as Madonna, and the piercing located centrally below the lower lip and above the chin is called the Labret. The tongue may be pierced horizontally or vertically with a long barbell until the swelling subsides. When the tongue returns to its normal size, a smaller barbell is inserted. The tongue is the only piercing of the face that is considered to be a sexual piercing.

Ear piercings usually are named according to their location using the capture ball. A helix piercing is placed through the outer ear cartilage. A variation of this is the industrial helix in which a barbell connects two helix piercings across the outer cartilage of the ear. Rook piercing basically is the opposite of the helix and is placed through the upper cartilage fold of the ear. Inner conch looks similar to lobe piercing except that it is placed on the inner conch and surrounds the lower outer helix. Tragus can be pierced. Antitragus piercing is performed through the piece of cartilage immediately above the earlobe. Daith piercing is placed through the piece of cartilage that sticks out of the inner cartilage of the ear. A variation of earlobe piercing that allows the use of large gauge placeholders, such as flared eyelet flesh tunnels and plugs, is known as stretching or gauging. The initial piercing is done with a punch tool to remove the central tissue. After it is healed, the circumference can be stretched to accommodate larger diameter jewelry. The amount of stretching depends on the length of time the jewelry is left in place and elasticity of the tissue.

Navel piercing is becoming quite popular and is the most common piercing of the trunk. Navel piercing frames the rim of the navel, usually above or beneath the navel and most often is performed vertically but can also be done horizontally, piercing through the skin surrounding the navel. This is a more complicated and problem-prone piercing. Navel piercing can accommodate either a captive bead or curved barbell. Rejection is a common occurrence with poorly placed navel piercings. Rejection is related to a chronic inflammatory process. The offending object is walled off from the body and the hardware is pushed out of the body laterally. New scar tissue is formed as this process progresses.

Nipple piercing is popular with both men and women. The nipple may be pierced vertically, horizontally or at any other angle. The piercing crosses the nipple base but not through the areola. Many find this piercing pleasurable. Newer ornamentation includes a device known a nipple shield. This decorative metal disk is held in place over the areola by use of barbell jewelry through the nipple piercing. Important potential complications include mastitis, spontaneous milk production in females and localized infection.

Men with genital piercings are found in both the heterosexual and homosexual communities. Men find these piercings attractive and find urethral stimulation arousing. Men may choose these piercings for simple ornamentation or for their partner’s pleasure. There are many variations of male genital piercing. The Prince Albert may be the most widely known. This piercing commonly uses a capture ball ring and passes directly through the urethra, exiting on the bottom behind the glans penis. The reverse Prince Albert passes vertically through the top center of the glans. The reverse Prince Albert has increased healing time when compared to the Prince Albert. Two more extreme piercings of the glans include the apadravya and the ampallang. The apadravya passes vertically through the glans and is a combination of the Prince Albert and reverse Prince Albert. The ampallang passes horizontally through the glans, either through the urethra or just above it. Other piercing of the male genitalia includes guiche piercing, pubic piercing and frenum piercing. Uncircumcised men may have their foreskin pierced. Depending on the gender of the receiving partner and sexual position used, this transurethral piercing can stimulate the male partner’s prostate or female partner’s G-spot. Jewelry sizing is an important concern with all piercing that transects the penile glans and is highly individualized. Care must be taken to size jewelry so that there is minimal extension of the hardware while the penis is flaccid and for the jewelry to not impinge on the penis when in the erect state.

The most common female genital piercing is to the clitoral hood. By piercing the tissue that covers the clitoris additional stimulation can be provided to this sensory organ. Not all women find this piercing pleasurable, and response to clitoral hood piercing is highly individualized. The deep clitoral or triangle piercing is placed below the clitoral nerve bundle and initially is one of the more painful female piercings. Capture bead or semi-circular barbell hardware is usually chosen to encircle the clitoris. The Princess Albertina is a female variant of the male Prince Albert. This piercing enters the female urethra. The exit site is anatomically dependent and can occur above or just inside the vaginal orifice. The location and size of the jewelry tend to make it difficult for clients to remove without help.

Cultural Competence

Cultural competence is imperative when providing care to individuals who practice body modification. Since most healthcare providers have significant knowledge deficits regarding body modifications in general, the risk for provider bias is high when working these clients. Health care providers must not only possess the knowledge necessary to care for clients with body piercing, but must also possess the ability to communicate with these clients in a culturally-sensitive manner. Empathy is an important component to therapeutic communication practice and helps open communication channels. Using a judgmental approach when interacting with a client can create a defensive response. An expression of disgust or surprise toward body modifications found during client care is a speedy manner in which to alienate the client and inhibit communication. Although people who practice body modification come from various socio-economic and ethnic groups in every community, the risk for stereotyping does indicate the need to practice cultural competence with individuals who choose this method of self-expression. Most nurses have developed individualized communication techniques that are used to develop a therapeutic relationship with clients when discussing sensitive subjects. It is important to remain open and non-judgmental during client care to encourage further disclosure of pertinent information. Treating body modifications as a normal part of the client's physical assessment is important to maintaining the therapeutic relationship.

When Body Jewelry Should Be Removed

In some medical situations, such as defibrillation or surgery, body jewelry greatly increases the risk of an electrical arc and should be removed. Jewelry needs to be removed for diagnostic, elective, and emergency procedures. Pregnancy related airway engorgement might increase the severity in bleeding and edema caused by tongue jewelry. Even without engorgement there might be an increase in the severity in bleeding and edema caused by tongue jewelry. Even without engorgement, tongue jewelry could interfere with intubation.

Documented rate of complications associated with piercing ranges from 17%-35%. Localized infections that often occur due to inadequate care of the piercing site are the most common problems seen with body piercing. If the client is in the early stages of a localized infection, the piercing site should be treated as a puncture wound. The jewelry should be kept intact so it can serve as a portal for drainage and healing. Removing it could lead to an abscess formation in the deep skin structures. The site should be cleaned two to three times a day and use a small covering of antimicrobial ointment. If the infection does not resolve after five to seven days, the client may require a systemic antibiotic. If the course of antibiotics does not clear up the infection, the jewelry should be removed to facilitate more aggressive treatment. It is important to note that the antiseptic Hibiclens™ for cleaning should not be used on any piercing above the shoulders as it may result in deafness or blindness.

The backing of a nasal stud – another common type of body jewelry – could work loose and be aspirated. A piercing between the eyebrows could make it difficult to get a good seal with the bag valve mask if a client needs resuscitation. This type of piercing should be removed before any invasive procedures.

Breast abscesses, mastitis, and female milk production have been reported with nipple piercings. Breastfeeding with nipple rings remains controversial. An English nurse recommended a small plastic nipple barbell. There is a small chance that nipple piercing might interfere with lactation but in the 18th century nipple piercing was a common treatment for women with inverted nipples who wanted to breastfeed.

Numerous health problems have been attributed to genital piercing including infections, allergic metal reactions and rejection, scarring, bleeding, impotence, sterility, loss of sexual response, tearing and high risks of sexually transmitted disease. The most common of all the various types of genital piercing, the Prince Albert, produces the most problems by affecting urine flow and aim. The Prince Albert perforates the urinary meatus and corona. Some men who have this type of piercing have to sit down to urinate. Since the most common female genital piercing sites are the clitoral hood and labia, there is no urethra involvement.

Other situations where removal is indicated include:

  • Catheterization: Jewelry on the head and body of the penis and in the clitoris could interfere with insertion of a urinary catheter.
  • Cervical spine immobilization and evaluation: Facial piercing could interfere with attempts to stabilize the cervical spine.
  • Child birth: Genital piercing could interfere with delivery.
  • Electrosurgery: Site burns could be caused by the metal conducting electricity.
  • Radiographs, CT Scans and MRIs: The presence of jewelry could interfere with the image and the radiologist interpretation.
  • Surgery: A client’s body jewelry could become trapped in a drape or on the bed, restricting movement or pulling on the client’s skin.
  • Use of antishock trousers for pelvic fracture stabilization: Navel or genital jewelry could pierce the pants and render them ineffective.

Some clients may not be able to remove the jewelry themselves. Health care providers should be prepared to remove jewelry in such a way that the jewelry is not damaged and the client is not physically harmed while remaining sensitive to the client’s cultural preferences. Before attempting jewelry removal for a diagnostic or elective procedure there are a couple of things to keep in mind. The client will most likely resist, often because of fear that the opening will close. For a new piercing this fear is well-founded. Reassure the client that jewelry can be replaced soon after the procedure. In the meantime a temporary radiolucent polypropylethylene post or retainer if available should be inserted to maintain patency. There are specific tools (i.e. ring closing pliers, ring opening pliers) available for removing body jewelry. It may be necessary to use these pliers for jewelry that is difficult to grasp by hand or if the threads of the jewelry have become stripped. It is advisable to wear personal protective equipment when removing body jewelry. Barbell jewelry has a ball that unscrews. If using pliers grasp the removable ball while holding the opposite side still and turn counter-clockwise to loosen. When loosened the ball may be unscrewed by hand then the straight end of the bar pulled toward the side of the stationary ball and removed. The easiest way to remove capture ball rings is by inserting ring opening pliers into the middle of the ring and prying the ring open. The ball will drop out and the ring may be removed from its location. Take care not to lose the ball as it drops away from the ring.

Complications

Complications from body piercing are related to the site pierced. Health care providers should be prepared to address piercing-related problems particularly those that are advanced. People who are pierced or tattooed usually don’t seek medical advice in a timely fashion. By the time they seek medical care they have a fully blossomed medical problem. Body piercings can develop systemic infections requiring hospitalization. It has been reported that a nasal piercing that got infected got into the sinus tracts and then the blood stream and caused infections of the heart. As many as 45% of nasal piercings become infected.

Piercing related infections:

  • Pseudomonas
  • Staphylococci
  • Streptococci
  • Hepatitis B & C

Signs of inflammation at the newly pierced site can mean several things:

  • Reaction to the trauma of the piercing
  • Allergic reaction to antiseptic
  • Allergic reaction to the metal of the jewelry
  • Normal healing

Signs of infection can be difficult to diagnose:

  • Green or gray discharge
  • Progressive swelling beyond normal tissue that occurs in the first 24 hours
  • Increasing warmth to the touch
  • Increasing pain

Ear cartilage piercing does not heal as quickly as lobe piercing because of the different types of tissue and pressure on the piercing area during sleep. A nipple piercing may burrow through some of the lactating ducts. A navel piercing becomes infected easily because tight fitting clothes do not allow adequate air circulation and allow moisture to collect around the piercing site. Some piercing-related complications that have required aggressive treatment include:

  • Pseudomonas aeruginosa in seven confirmed cases and 18 suspected infections in customers of a jewelry kiosk in Oregon who had their ear cartilage pierced with a spring-loaded gun. Some of the clients were hospitalized, some required incision and drainage surgery, and several were left with cosmetic deformities.
  • Infective endocarditis was reported in a 26-year-old male who presented to the emergency department with worsening flu-like symptoms three weeks after having his tongue pierced. Echocardiogram revealed mitral valve endocarditis with mitral regurgitation. The identified bacterium was haemophilus parainfluenzae which is found in the oropharyngeal cavity. The client underwent mitral valve replacement.
  • Cerebellar brain abscess occurred in an otherwise healthy 22-year-old two days after tongue piercing who developed increasing pain and swelling, plus a purulent ill-tasting discharge from the piercing site. The jewelry was removed but four weeks later, she developed acute headaches, nausea, vomiting and vertigo. A CT scan revealed a right cerebellar enhancing lesion with surrounding edema. An MRI confirmed the brain abscess that was traced to the piercing. The client had a craniotomy for drainage of the abscess.

Tongue piercings initially swell greatly but heal quickly because of the vascular nature of the tongue. Problems associated with tongue piercing are chipped or cracked teeth, nerve damage, aspiration and withdrawal of the jewelry by gases or fluids. “Wrecking ball syndrome” may occur which refers to the constant motion of the ball on the tongue hitting against the teeth. The type of jewelry selected must accommodate the swelling that follows the piercing procedure. For example, a short barb in the tongue will lead to complications when the tongue starts to swell.

Healing times for body piercing will vary with the site

Ear lobe

6 to 8 weeks

Ear cartilage

4 months to 1 year

Eyebrow

6 to 8 weeks

Nostril

2 to 4 months

Nasal septum

6 to 8 months

Nasal bridge

8 to 10 weeks

Tongue

4 weeks

Lip

2 to 3 months

Nipple

3 to 6 months

Navel

4 months to 1 year

Female genitalia

4 to 10 weeks

Male genitalia

4 weeks to 6 months

Summary

Body piercing is more common than ever. Health care providers need to include it in client assessment. Not only can these barbells, rings, and studs cause infections but they can complicate medical procedures. It is increasingly likely that you will see a client with body piercing. Many young adults consider body art to be a mainstream activity. To properly care for clients with body piercing, health care providers need to understand the attraction of piercing, know what piercing-related complications to look for, and be prepared to remove body jewelry if necessary.

References

Armstrong, Myra L., (2004) Caring for the Patient with Piercing; RN Magazine: June 1, 2004.

Caliendo, Carol, Armstrong, Myrna L., & Roberts, Alden E., (2005) Self-reported characteristics of women and men with intimate body piercing, Journal of Advanced Nursing 49 (5), 474-483; Blackwell Publishing, Ltd.

Erwin, Jane, (1998) Piercing the Skin, Nurseweek: November 16, 1998.

Halliday, Kym A., (2005) Body Piercing: Issues and Challenges for Nurses; J. Foren. Nurs. 1(2):47-56.

Hudspeth, Mary, (2001) Body Art: Piercing, Tattoos and Health, Texas Tech Education News.

Larkin, Brenda G., (2004) The Ins and Outs of Body Piercing, AORN Journal February 2004, Vol. 79, No. 2.