Original Pace Report is indented and in BOLD formatting.

760-Pace Report Updated 10-08-06 10-19-06 10-30-06

We are always glad to see academics and professionals outside the body art field take an interest in body arts.  We appreciate knowing more about our own profession.

However, we find it distressing when a study under the banner of the Mayo Institute makes its way into print that even on a quick read reveals discrediting flaws.

That the Pace study is the reference of choice to justify the Department's action is unfortunate.

Prevalence of Body Art (Body Piercing and Tattooing) in University Undergraduates and Incidence of medical Complications
by  Mayers, Judelson, Moriarty and Rundell

Objectives: To survey the prevalence of body art (body piercing and tattooing) in university undergraduate students and to determine the incidence of medical complications from these procedures.

This Pace critique to be concise will focus specifically on the two areas used by the Department to support Article 14.

The first, most quoted use of the report is a stated conclusion of the study

 "...these morbid events (overall medical complications reported by the students)
comprise a considerable demand on and cost to the health care system."

This conclusion is false, does not follow from the evidence.

The questionnaire does not include any reference to any cost, any method of care, any resolution of cases, whether they required medical attention, were self-resolving or otherwise. There is not one piece of evidence to support this statement. It is completely an invention of the authors and the circumstantial evidence that is available supports the opposite.

The evidence to the contrary is right in front of them: 82% of the students still had their piercings. There were no questions asking what prompted the removal. This implies the opposite, that complications if they were severe, such as a hospital stay, would have necessitated removal or abandonment of the piercing. But this was not the case. The reasonable implication is these were self-resolving with little or no medical cost to the health care system. There is no evidence that any student used any part of the health care system to intervene in their medical complications.

The further illustrate the distortion of the evidence: there were no medical complications associated with tattoo. (It is doubtful when The Pace questionnaire includes scarring as a medical complication.)

Life experience with piercing shows the opposite. There is often swelling, redness and pain following the procedure. Throughout the duration of the piercing-life minor injuries occur from pulling, yanking, catching the piercing and these accidents result in varying levels of pain, discomfort and if severe, bleeding, even ripping of skin such as an earlobe might be subject to.

Most of us have never seen anyone who had to be rushed to the emergency room or be hospitalized. Where in teh report does the question ask anything about the "considerable" demand on the health care system? Nowhere. There is no excuse for this kind of "doctoring" of a report.

The second disturbing use of the report: the report is used to support the Department's contention that piercing and tattooing mucosal tissue should be prohibited.

First of all, there were no medical complications reported with any tattooing so including tattooing in that prohibition was not even supported.

Second, the statistics support the opposite of the Board's prohibitions.

"Pierced navels were particularly prone to infection." the report says, showing a 24% rate from all causes. Mucosal piercings show the least, a 6% incidence and genitals only 14%. The Department should be asking for a different list: prohibition of Navel (24%), Nose (20%), Genital (14%) and Ear (13%) and only allow mucosal piercings. Now that would make sense if they were using the report as an assessment tool.

There are many things wrong with the Pace report.

Not to dwell on them here, but a good example is the attempt of the Pace Report to offset its inability to produce evidence to support its conclusions.

It is common in a new study to establish that their findings are in line with what other researchers have found. This adds credibility to a new study.

The Pace study does this by listing 5 studies in support of their contention that hepatitis/HIV are risk factors for tattoo/piercing.  

The studies they reference do not support their conclusion.

The 5 references they used have been checked and are found mis-used because
a) none show causal relationship and
b) none mention HIV at all and 2 do not even mention tattooing.

The report is an intellectual disgrace.

"Several authors have reported tattooing in a variety of settings as a risk factor for hepatitis and HIV infections."

This is their conclusion and it is false.

(# 1. Reference) The first reference is about a "fulminant hepatic failure (FHF)" in France, admitted by the reference as cause unknown, tangentially mentioning that the patient did have a piercing before the hepatic failure. This reference does not mention tattooing and states that it offers no explanation for the FHF.

(# 2. Reference) A study from Italy from the 1980s "The role of ear-piercing, tattooing, attendance at chiropodist or manicurist and barber shop shaving in transmitting hepatitis B and hepatitis non-A, non-B was evaluated." Non-A and non-B are giveaways of how dated this report is. Their conclusion was modest: "The role of beauty treatments in transmitting hepatitis should not be underestimated."  The Pace report claimed the opposite for this report.

(#3. Reference) "To understand the intra-familial transmission and the existing risk factors related to HCV infection in subjects confirmed anti-HCV positive, their sexual partners and household contacts in Friuli, North-East Italy." The conclusion stresses the importance of abortion and/or uterine curettage, the important role of blood transfusions in the past, a higher prevalence of HCV infection within a household of a HCV positive member compared to all other existing data in the area. Because tattooing is specifically stated as excluded as a risk factor this reference was included, knowing that it was false.

(#4. Reference) This 1989 Taiwan University study compares Taiwan tattooed men (criminals) to university students in Taiwan. There are many reasons to discredit these findings: political climate repressing the reporting of unfavorable studies, lack of western disinfection and sterilization, community healers spreading disease and tattooing practices. In an area of the world with undocumentable health status this reference is not deserving of citation.

(#5. Reference) This study concludes "if causal, Heavy Beer Drinking accounts for 23% of HCV cases - in other countries." "If causal, these 4 risk factors account for 91% of HCV infections, with tattooing explaining 41%, heavy beer drinking 23%, injection-drug use 17%, and ancillary health care jobs for men 8%. Transfusions, promiscuous sexual activity, bone grafts, acupuncture, perinatal or intimate transmission in families, and other modes were not independently associated with serologic evidence of HCV infection. A bizarre report.

None of the 5 cited support documents even mention HIV

In short, it is my opinion that the misuse of documentation and improper inference is too widespread to not be intentional.  Conclusions: the report does not get our respect.

Prevalence is simply defined as the proportion of the total population that is diseased either at one point in time or a specified duration of time. Essentials of Epid. In Public Health, Aschengrau, Seage

The objective "to determine medical complications from these procedures" has a medical meaning not normally understood without formal medical training.  A medical complication is a disease or injury to a previously existing medical disease or injury.  Medical complications do not include, for example bleeding that occurs during or as a direct result of the procedure; it hurt; pain, redness, swelling.  It is something that happens to it later from a different cause. The injury or disease cannot be the cause of itself.

Conclusion: It is likely students confused medical complications with the results of the procedure itself because there are no questions or instructions to avoid this confusion.

It is admitted that "our students cannot be presumed to have a high degree of medical sophistication."

Conclusion: it is likely students were not aware of the meaning of the terms.

Conclusion: The students cannot accurately assess medical complications.

Also consider the goal: "to determine medical complications from these procedures".

There is no recognition that a complication resulting from the procedure is different than something occurring afterwards not "from" the procedure. 

One final footnote: The Pace report is a classic that is destined to be used in textbooks to illustrate the Bayesian observation that. "The independence of evidence is immediately seen to be untrue...assumptions and expectations are incorporated about outcomes before the data is examined..." and applied when the outcome is not supported, (Risk Communication and Public Health by Bennett, Calman) The Pace report says.

The absence of reported medical complications from tattooing among our subjects is noteworthy...none of our respondents reported viral infection as a medical complication either from piercing or tattooing.

Keep in mind:
(a) there were no reports of viral infections, hepatitis/HIV, only bacterial infections in piercing and no infections in tattoo at all and
(b) zero mysteriously increases in size from zero to quite low. 

And so, in spite of the evidence, in a clear Bayesian illustration of how posterior expectations influence the evidence:

Even if the risk of hepatitis/HIV transmission as a consequence of piercing/tattooing is quite low, the high prevalence of these practices may imply a potentially important long-term public health problem.

These are personal views and opinions of Wes Wood and do not necessarily represent the views and opinions of Unimax Supply Co Inc.
Copyright 2006