The ins and outs of body piercing – Home Study Program

The ins and outs of body piercing – Home Study Program – Cover Story

Brenda G. Larkin

This program meets criteria for CNOR and CRNFA recertification as well as other continuing educution requirements.

A minimum score of 70% on the multiple-choice examination is necessary to earn 2.4 contact hours for this independent study.

Purpose/Goal: To educate perioperative nurses about ensuring the safety of surgical patients with body piercings while also respecting differing cultural volues.

The article “The ins and outs of body piercing” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.

Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2007.

Complete the examination answer sheet and learner evaluation found on pages 345-346 and mail with appropriate fee to

AORN Customer Service

c/o Home Study Program

2170 S Parker Rd, Suite 300

Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study via AORN OnUne at


After reading and studying the article on the ins and outs of body piercing, the nurse will be able to

1. explain the history of body piercing,

2. define the demographics of people who undergo body modification procedures,

3. identify common types of body piercings, and

4. discuss the implications of caring for patients with body piercings who are undergoing surgery.

Patients with body piercings present a challenge for today’s perioperative nurses in physiological, psychological, and cultural aspects of care. The incidence of body piercing in the Western world has increased significantly in the past decade. The need to prepare patients for surgery while promoting safety, preserving body image, and respecting cultural values has gone beyond the routine practice of jewelry removal. (1) As early as 1997, heath care providers had questions concerning the safety of surgical patients with body piercings. (2)


Body art (ie, tattooing, piercing) has been practiced by men, women, and children in many societies from ancient times to the present. 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; and

* fashion trends.

Body piercing is one of the oldest forms of body art, and modification and examples of piercings exist among museum antiquities. The University of Pennsylvania’s Museum of Archeology and Anthropology, Philadelphia, recently hosted an exhibit about body art. Among the artifacts were the head of a female figurine from Iran with holes for multiple ear piercings that was approximately 4,000 years old, and a photograph of a Tlinglit Alaskan native with a large nose ring from the late 19th century. (3) The Kama Sutra refers to apadravya (ie, genital piercing), and Mayan Indians pierced their tongues as a spiritual ritual. Many Asian cultures practiced ear piercing and stretching of the earlobes. It also is conjectured that the body piercings and stretched earlobes or lips common among some African natives dissuaded slave traders from potentially victimizing them.

Egyptian pharaohs used navel piercing as a rite of passage. Roman soldiers pierced their nipples to show their manhood, but the piercing also functioned as a method for attaching their cloaks. (4) Evidence of body modification also can be found in the Bible. Rebekah was presented with and wore the nose ring and bracelets given her by Abraham’s servant in Genesis 24. (5) Leviticus 19:28 states “Never cut your bodies in mourning for the dead or mark your skin with tattoos, for I am the Lord.” (6) This warning against altering the body was given to the Israelites to keep them separate from the pagan groups surrounding them. New Testament author, Paul, also warns women concerning their appearance. I Timothy 2:9 states,

And I want women to be modest in

their appearance. They should wear

decent and appropriate clothing and

not draw attention to

themselves by the way

they fix their hair or by

wearing gold or pearls or

expensive clothes. (7)

These Judeo-Christian precepts helped to dissuade individuals from the use of both tattooing and body piercing in the Western world.

Attitudes shaped by religious beliefs led to the philosophy that body alterations were associated with criminal behavior. In 1896, a criminal anthropologist proposed the theory that criminal behavior was a defect that prevented a person from developing the necessary skills for a civilized life. (4) He proposed that a person’s love for “gaudy clothing, a passion for obscure demotic jargon, deficient normal sensitivities, and irresistible disposition to become tattooed” were hallmarks of criminality. (4)

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. Ironically, it was during the Victorian era that the practice of body piercing in the Western world reemerged. Many men and women of the Victorian royalty chose to receive nipple and genital piercings.

Although body piercing did not grow in popularity as rapidly as tattooing, the practice was more commonplace by the 1960s during the hippie movement. Later, unusual body piercings (ie, other than a single piercing per earlobe) became associated with fringe cultural groups, such as punk rockers and a new group known as modern primitives.

The modern primitive group comprises a wide array of individuals who may be characterized by their variety of body modifications. (4) They are characterized further by their desire to explore and experience the body as a method to express themselves in ways society finds difficult to tolerate. (4) The purpose for this is to allow them freedom to live “away from the ideals of Western society, to live what they consider a more mentally and spiritually, if not physically and economically, balanced life style.” (4) Members of the movement want to live in balance with their primal urges and the needs of modern society.


The resurgence of body piercing began in the 1960s. As rock stars, popular athletes, and other youth culture icons publicly displayed their body modifications, tattooists and piercers became “artists,” and efforts were made to legitimize their creations as art forms. (8) By the late 1980s, tattooing and piercing had gained popularity beyond fringe groups and bikers. Several medical researchers have conducted studies on the growing phenomenon of body modification to define the character of people involved. One investigator conducted a research project that examined tattooing and body piercing as risk-taking behaviors in adolescents, among whom the practice has gained popularity. The researcher conducted a survey in urban high schools in 1993 and again in 1995. These surveys focused on tattoos only, but they also can provide an indication of the probability that participants would obtain nonconventional body piercings (ie, piercings other than a single piercing per ear in females, which is considered a cultural norm). The researcher found in 1993 that 8.6% of 642 high school students had a tattoo. Very few markings were associated with gang symbols, and 65% of students with tattoos reported academic grades of As and Bs. Gender distribution of the students with tattoos was 65% male and 35% female. The 1995 study demonstrated a slightly increased percentage of students with tattoos (ie, 9%). In addition only 60% of those with tattoos reported academic grades of As and Bs. (9)

Two studies on prevalence of body modification in college-age students have been reported. One group of researchers surveyed college students at a large southwestern university to determine both prevalence and occurrence of medical complications from piercings. Female ear piercing was considered to be a cultural norm and, therefore, was excluded from results. The findings demonstrated that of 454 students who completed the survey, 51% had body piercings and females were more likely to be pierced than males. (10) The most commonly pierced site among both male and female students was the ear. Females reported that the navel was the next most common piercing site. The tongue, nipple, lip, eyebrow, and genitals were reported less often as being pierced by both genders. (10 (p32))

Another researcher surveyed college students to assess attitudes of individuals who had piercings compared to those who did not. He examined demographic and background information, personality traits, and body acceptance. The results corroborate the findings from a study that examined career women with body piercings, in which body modifications were not associated with reported drug use or alcohol toxicity before modification procedures. (8 (p775)) There also was no evidence that tattooing or piercing were impulsive acts.

Results demonstrated, however, that both men and women with body modifications report engaging in more risk-taking behaviors from childhood into adulthood. This finding is consistent with the hypothesis that people with body modifications exhibit more risk-taking behavior and conform less to social expectations. (9 (p785)) Interestingly, the results demonstrate that people without body modifications perceive their peers with body modification as being dramatically different from themselves, although demographic results did not demonstrate the groups to be dramatically different. The results of these studies confirm that many of the negative stereotypes about body piercing are not based on concrete differences between those who have piercings and those who do not.

An owner of a tattoo shop in Wisconsin reports that the average age of people seeking nonexotic piercings (eg, ears, navels, eyebrows, nose) is between 18 and 24. Of those opting for exotic piercings (eg, nipples, tongues, genitals), most individuals are in their late 30s and older. (11)

There are several reasons for the prevalence of modern body piercing. Many young adults see this as another fashion option, and others, such as the modern primitives, view piercing as a rite of passage. Highly visible piercings of the ears, nose, eyebrow, and navel provide a means of creative self-expression. Intimate piercings of the tongue, nipples, and genitals have more sexual connotations or function. When significant numbers of well-educated, middle-class people begin to display tattoos or piercings, it becomes difficult to view these modifications as signs of personal or social pathology. (4)


Body jewelry ranges from fairly inexpensive to more elaborate with semiprecious and precious stones. There are numerous types of body jewelry (ie, barbells, capture bar rings, labrets, tubes, flared eyelet flesh tunnels, safety pins, studs) (Figure 1). One of the most common types of body jewelry is the barbell. The barbell can be either straight or curved, and the ball on the barbell can be internally or externally threaded. Common sites for barbell-style jewelry are the ear, eyebrow, tongue, navel, and genitals. A second type of body jewelry is the capture ball ring. These circular rings contain spheres that are held in place by tension. Labret type jewelry has a flat portion on one side and a threaded ball on opposite side. Tubes and flared eyelet flesh tunnels often are used to enlarge a pierced hole, particularly in the earlobe.



Piercings can be categorized by their body placement as exotic versus nonexotic and as sexual versus nonsexual. Piercings of the face generally

are considered to be exotic and nonsexual. The exception to this is a single piercing of the earlobe, which is not considered exotic.

EYEBROWS AND NOSE. Facial piercings have both descriptive and location names. The eyebrow is the only location around the eye where piercing is possible (Figure 2). An eyebrow piercing usually is placed at the far lateral edge of the eyebrow using a capture ball ring. Figure 3 shows that the nose may be pierced at the bridge using curved barbell jewelry and at the septum and nostril using a nose stud in place of the barbell or capture ball jewelry.


EAR PIERCINGS. Ear piercings usually are named according to their location. Most ear piercings use capture ball jewelry. Figure 4 shows the various types of ear piercings with which patients may present. Helix piercing is placed through the outer cartilage of the ear. This may be the second most commonly seen ear piercing after the lobe. Industrial helix piercing is a variation of the helix piercing in which a long barbell connects two helix piercings across the outer cartilage of the ear. Rook piercing basically is the opposite of helix piercing and is placed through the upper cartilage fold of the ear. Inner conch piercing looks very similar to lobe piercing, but it is placed on the inner conch and surrounds the lower outer helix. Antitragus piercing is performed through the ridge of cartilage immediately above the earlobe. Daith piercing is a piercing through the piece of cartilage that sticks out of the inner cartilage of the ear.


A variation of ear lobe 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 accomplished 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.

LIP AND TONGUE. Other piercings of the face include the medusa, located just above the center of the upper lip; the Madonna, located at the outer corner of the mouth above the lip; and the labret piercing, located centrally below the lower lip. These piercings use labret type jewelry with the flat portion resting inside the lip and the threaded ball on the outside (Figure 5). Figure 6 shows how the tongue may be pierced horizontally or vertically. The tongue first is pierced 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 facial area that is considered to be a sexual piercing. (11)


NAVEL. The most common piercing of the trunk is the navel (Figure 7). Navel piercing frames the rim of the navel, usually above or beneath the navel, and most often is performed vertically. Most common is the piercing above the navel. Another version of navel piercing is the horizontal piercing through the skin surrounding the navel. This is a more complicated and problem-prone piercing.


NIPPLES. The nipples also may be pierced vertically, horizontally, or at any other angle. Some individuals may choose to have jewelry placed both vertically and horizontally through the nipple. (Figure 8)


FEMALE GENITALIA. Finally, the genitals of both sexes can be pierced. The genitals generally are pierced to increase intensity of stimulation. For females, the most common piercings are vertical or horizontal piercings of the clitoral hood, although the outer and inner labia also can be pierced (Figure 9). Small capture ball ring jewelry often is used with the ball resting on the clitoris. The location and size of the jewelry tend to make it difficult for patients to remove without help.


MALE GENITALIA. There are many variations of male genital piercings (Figure 10). From a historical aspect, 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. 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 piercings of the male genitalia include guiche piercing, pubic piercing, and frenum piercing. Uncircumcised men may have their foreskin pierced.



The expanding popularity of body piercing increases the likelihood that patients will arrive for surgery with body jewelry in place. Measures must be taken to remove this jewelry, as with other more traditional jewelry (eg, rings, watches), to prevent alternate site burns when using electrosurgery. Jewelry in and around the mouth must be removed to avoid dislocation and aspiration during intubation. When a procedure is not going to use electrosurgery, caregivers may be inclined to allow patients to keep their jewelry on if it is not in or around the mouth or within the surgical area. This is not a good practice because the jewelry may cause pressure injuries, depending on the patient’s position during the procedure. Finally, piercings of male and female genitalia often interfere with the successful passage of an indwelling urinary catheter and should be removed before surgery.

Some patients may not be able to remove the jewelry themselves. Perioperative nurses should be prepared to help patients remove jewelry in such a way that the jewelry is not damaged and the patient is not physically harmed, while also remaining sensitive to the patient’s cultural preferences. There are specific tools (ie, ring closing pliers, ring opening pliers) available for removing body jewelry (Figure 11). It may be necessary to use two such 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 examination gloves for personal protection when removing body jewelry. Temporary, radiolucent, polypropylethylene (PPE) jewelry also is available to act as place keepers, if needed.


Barbell jewelry has a ball that unscrews. Using pliers, such as ring closing 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 and the straight end of the bar pulled toward the side of the stationary ball and removed.

The easiest way to remove capture ball rings, in which spheres are held in place by tension, 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.

Patients requiring preoperative magnetic resonance imaging (MRI) must remove body jewelry. If the piercing has been well established, the jewelry can be removed without much concern, similar to jewelry in well-established ear piercings. Occasionally, the patient may require a place keeper for the pierced location. For these patients, the facility may choose to provide temporary PPE jewelry that is radiolucent and will not react to the MRI. Both the temporary PPE jewelry and the tools to remove body jewelry are available from commercial suppliers and can be found by typing the term body and piercing jewelry and removal and tools into the search line on any Internet service provider home page. (11)


Perioperative nurses strive to achieve holistic and culturally sensitive care for all patients. Patients with body piercings present a challenge to the perioperative setting requiring that perioperative nurses learn new techniques to deliver safe and culturally competent care. Understanding the cultural and social meanings of some body piercings provides nurses with the educational foundation they need. Ideally, all jewelry should be removed to prevent alternate site burns from electrosurgery and difficulties with intubation, positioning, or urinary catheterization without damaging the jewelry or harming the patient, physically or psychologically. Understanding the proper way to remove jewelry and having the correct tools to do so is essential. With greater understanding of patients who have body piercings, perioperative nurses will be able to expand their ability to care for a more diverse population.


The ins and outs of body piercing

1. Body art has been used in the past, as it is now, for

1. religious ritual.

2. rite of passage.

3. official or royal distinction.

4. fashion trends.

a. 2 and 3

b. 1, 2 and 4

c. 1, 3, and 4

d. 1, 2, 3, and 4

2. Biblical warnings against tattooing and body piercing were given to the Israelites

a. to keep from angering Egyptian leaders.

b. to separate them from the pagan groups surrounding them.

c. because body modifications were reserved only for royalty.

d. to help prevent the spread of infection.

3. In the latter part of the 1800s, tattooing was considered to be a sign of criminality.

a. true

b. false

4. Surveys of college students regarding attitudes about piercing determined that

1. the modifications were not obtained impulsively.

2. those with piercings did not report more risk-taking behaviors.

3. drugs and alcohol were not used before modification procedures.

4. those with body modifications were dramatically different in demographic characteristics from those without body modifications.

a. 1 and 3

b. 2 and 4

c. 1, 3, and 4

d. 1, 2, 3, and 4

5. Piercings of the face generally are considered to be

a. exotic and sexual.

b. nonexotic and sexual.

c. exotic and nonsexual.

d. nonexotic and nonsexual.

6. Piercing through the piece of cartilage that sticks out of the inner cartilage of the ear is called a/an–piercing.

a. antitragus

b. daith

c. helix

d. rook

7. The only piercing on the facial area considered a sexual piercing is the

a. eyebrow.

b. lip.

c. nose.

d. tongue.

8. A piercing that passes horizontally through the glans, either through the urethra or just above it, is called

a. ampallang.

b. apadravya.

c. dydo.

d. hafada.

9. Measures must be taken to remove all jewelry to prevent

1. alternate site burns when using electrosurgery.

2. pressure injuries as a result of patient positioning.

3. interference when placing an indwelling urinary catheter.

4. injury during fluoroscopy.

5. aspiration during intubation.

a. 1 and 3

b. 2, 4, and 5

c. 1, 2, 3, and 5

d. 2, 3, 4, and 5

10. To remove barbell jewelry, insert ring opening pliers into the middle of the ring and pry the ring open.

a. true

b. false

Learner EvaLuation

The ins and outs of body piercing

This evaluation is used to determine the extent to which this game Study Program met your learning needs. Rate these items an a scale of lto5.

Purpose/Goal: To educate perioperative nurses about ensuring the safety of surgical patients with body piercings while also respecting differing cultural values.


To what extent were the following objectives of this Home Study Program achieved?

1. Explain the history of body piercing.

2. Define the demographics of people who undergo body modification procedures.

3. Identify common types of body piercings.

4. Discuss the implications of caring for patients with body piercings who are undergoing surgery.


5. Did this article increase your knowledge of the subject matter?

6. Was the content clear and organized?

7. Did this article facilitate learning?

8. Were your individual objectives met?

9. How well did the objectives relate to the overall purpose/goal?

Test Questions/Answers

10. Were they reflective of the content?

11. Were tbey easy to understand?

12. Did they address important points?

Learner Input

13. Will you be able to use the information from this Home Study in your work setting?

a. yes

b. no

14. I learned of this Home Study via

a. the Journal I receive as an AORN member.

b. a Journal I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

15. What factor most affects whether you take an AORN Journal Home Study?

a. need for contact hours

b. price

c. subject matter relevant to current position

d. number of contact hours offered

What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): —

Author names and addresses: —

Editor’s note: The author acknowledges the contributions made to this article by Jill Jones, patient care manager, perioperative services and Sandra Karnold, librarian, West Allis Memorial Hospital, West Allis, Wis.


(1.) S D Krau, “Working toward cultural competence in the workplace,” SCI Nursing 19 (Winter 2002) 193-194.

(2.) M O’Neale, “Body piercing jewelry,” (Clinical Issues) AORN Journal 65 (February 1997) 422-426.

(3.) “Bodies of culture: A world tour of body modification,” University of Pennsylvania Museum of Archeology and Anthropology, /online_exhibits/body_modification/bodmodintro.shtml (accessed 9 Oct 2003).

(4.) “Piercing and the modern primitive: The history of contemporary body piercing,” Piercing and the Modern Primitive, /history.html (accessed 9 Oct 2003).

(5.) “Genesis 24:29,” The Holy Bible: New Living Translation (Carol Stream, Ill: Tyndale House Publishers, 1996).

(6.) “Leviticus 19:28,” The Holy Bible: New Living Translation (Carol Stream, Ill: Tyndale House Publishers, 1996).

(7.) “I Timothy 2:9,” The Holy Bible: New Living Translation (Carol Stream, Ill: Tyndale House Publishers, 1996).

(8.) G B Forbes, “College students with tattoos and piercings: Motives, family experiences, personality factors, and perception by others,” Psychological Reports 89 (December 2001) 774-786.

(9.) B Freyenberger, “Tattooing and body piercing: Decision making for teens,” Virtual Children’s Hospital, (accessed 9 Oct 2003).

(10.) L B Mayers et al, “Prevalence of body art (body piercing and tattooing) in university undergraduates and incidence of medical complications,” Mayo Clinic Proceedings 77 (January 2002) 29-34.

(11.) G Kremser, personal communication with the author, Lake Geneva, Wis, 10 May 2003.

Brenda G. Larkin, RN, MS, CNOR, is a clinical nurse specialist for perioperative services at West Allis Memorial Hospital, West Allis, Wis.

COPYRIGHT 2004 Association of Operating Room Nurses, Inc.

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