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Tattooing and Skin Piercing

Volume 477: debated on Wednesday 11 June 2008

The number of people undertaking a tattoo or body piercing is increasing year on year. Ears, tongues, lips, eyebrows, navels and sexual organs are now routinely pierced. More extreme body modifications, such as the creation of patterned scars and the insertion of items such as ball bearings under skin, are also taking place.

High standards of cleanliness and disease control are of the utmost importance in piercing and tattooing. One mistake can have consequences both severe and permanent. Blood-borne infections such as HIV and the more dangerous hepatitis B and C, pain, severe scarring and even death can result. Many working in the industry are increasingly concerned that legislation and regulation have not evolved to cover the ethical and medical problems that need to be addressed.

In preparation for this debate, discussions have taken place with a range of local authorities in England and Wales, with professional tattooists and piercers and with Professor Noah at the department of epidemiology and population health at the London School of Hygiene and Tropical Medicine, all of whom want the industry to be better regulated to protect the public as well as the livelihoods and reputations of professional tattooists and body piercers. I was asked initially to look into the need for improved regulation and standards in the field by the union GMB, whose members include a small group of tattooists and piercers. I was joined in carrying out research among local authorities by my hon. Friend the Member for Northampton, North (Ms Keeble), whose support and interest in the issue I wish to put on record.

Local authorities outside London have powers to regulate acupuncturists and businesses providing tattooing, semi-permanent skin colouring, cosmetic piercing and electrolysis under the Local Government (Miscellaneous Provisions) Act 1982 as amended by the Local Government Act 2003. The legislation provides for the registration of practitioners and premises and the observance of byelaws relating to the hygiene and cleanliness of the practitioner, premises and equipment used.

In September 2007, the Department of Health issued a combined set of model byelaws for local authorities covering cosmetic piercing and semi-permanent skin colouring businesses. However, the speed at which changes take place in the industry means that as soon as I began my research, the vast majority of local authorities to which I spoke called for greater strength and scope in the model byelaws. Although local authorities acknowledge that they can develop individual interpretations of the model byelaws and their own unique way of doing things, and although I found some truly excellent practice with very high standards, in other areas such standards were not in place. The result is a postcode lottery of public protection. Similar comments were made about byelaws issued by the devolved Administrations.

Most local authorities have some system of registering tattooing and piercing businesses. The exact nature of that system varies from area to area. There is no nationally agreed standard for inspection. Consequently, some authorities carry out tougher inspection and licensing regimes than others. For example, Cardiff city council’s licensing system involves prior operating approval before a licence is granted. Then, depending on their assessed risk rating, premises receive a proactive inspection under the provisions of the Health and Safety at Work, etc. Act 1974. Premises receive an annual re-licensing and health and safety visit, but other authorities have much simpler registration systems with no conditions attached other than compliance with byelaws.

Common consensus agrees that the guidance in the model byelaws is not detailed enough. More precise guidance was called for to cover types and storage of equipment, the use of disinfectants and anaesthetics, age limits, consent forms and aftercare advice. Those involved in piercing sexual organs are unable to provide anaesthetics. I am advised by Professor Noah that surface applied anaesthetics that freeze the area are more likely to cause pain than to prevent it. The risk of infection after piercing increases with moisture, friction or lower levels of cleanliness, all of which apply to intimate body parts.

There are calls for clarity about sterilisation equipment and which chemicals should be used to clean premises. Many call for needles to be single use only and for autoclaves to be made compulsory. I was advised by Professor Noah that, despite the wide range of chemicals available, using bleach to clean studios and 70 per cent. alcohol to clean piercings or tattoos, as well as basic hand washing by practitioners, should be standard requirements.

Given the popularity of tattooing and piercing, there is a worrying lack of public awareness of the potential risks involved in those procedures. Practitioners have no legal obligation to advise people of possible risks or side effects, check medical histories or give appropriate advice on aftercare. Scarring after infection of a pierced area can be dramatic.

The hon. Member for Sheffield, Heeley (Meg Munn) has worked with Dan Aid on the issue of checking medical histories. Christina Anderson, an inspiring woman, set up Dan Aid after her son Daniel died of septicaemia after having a lip piercing at age 17. Daniel had a severe heart condition that put him at increased risk of developing complications. He was not told of the risks and therefore denied the opportunity for informed consent.

To protect both practitioners and clients, before every tattoo or piercing, the piercer or tattoo artist should take the time to sit down with the client and run through a detailed checklist covering medical history and potential infection risks. The client should be required to sign confirmation that they have been given advice and a leaflet with advice about aftercare. The process would help to protect clients and practitioners because, when a piercing becomes infected, people often complain but do not remember being given aftercare advice. Records should be kept of the procedures carried out and the advice provided. Aftercare advice is important to avoid bacterial infection, especially in the cartilage in the ear, which is difficult to treat with antibiotics. Simple advice about not removing scabs or using 5 per cent. alcohol solutions as disinfectant is needed, as wetting wounds with 5 per cent. alcohol increases the chances of infection.

We do not ask our doctors and nurses for their qualifications when they treat us; we take it for granted that they cannot practise without the qualifications and skills needed. Yet those who carry out tattooing and body piercing do so without needing a minimum qualification. When a tattooing or piercing business is registered, inspections are made of the equipment and the standard of the premises, but there is no way to assess practitioners’ competence. That is worrying, because the growth in popularity of tattooing and piercing and the more extreme piercings and so-called body modifications means that more untrained and inexperienced people are entering a trade where high profits can be made, especially from more extreme piercing and body modifications.

At the inquest for her son Daniel, Christina Anderson was informed that in having his lip pierced, he had had a minor operation. People are unknowingly submitting themselves to minor operations, sometimes in back rooms, and local authorities have no idea whether a practitioner is competent to carry out such procedures. All piercings are regulated in the same way; at the moment, there is no gradation of piercing. Anyone who pierces ears can pierce anywhere else on the body.

Opinions vary as to the best method of ensuring that people are adequately qualified. Consultation is needed, but options include a recognised college course of one or two years or apprenticeship for a similar period. Both those methods of training would need to include aspects of anatomy, hygiene, disease control, the operation of equipment, health care and significant practical components.

There is no statutory age limit for piercing, and intimate piercings can be carried out at any age. Under sexual offences legislation, genital, navel or nipple piercings on someone under 16 might be regarded as indecent assault, but I found no evidence of prosecutions. We know that such piercings have taken place without parental consent or involvement, some of which have become infected and needed serious medical intervention to protect the life of the young person. I fear, therefore, that there is a lack of protection for minors. Local authorities have complained that, in reality, the most that they can do is revoke the licence of a person who has carried out such a piercing. Tattooing a butterfly on to the arm of a 13-year-old is illegal, but piercing the same person in a genital area is not. That cannot be right. It is time for us to set legally enforceable age limits on any piercing other than of the earlobe.

So far, I have talked about tattooing and piercing parlours, but home-based piercing and tattooing is an emerging problem. The sale of equipment over the internet to unregistered persons and premises is fuelling this problem, as increasing profits are to be made. I am advised that social networking sites carry contacts for unregistered tattooists and piercers selling their services, and legislation is needed to bring such home-based practitioners into the registration system. It is incredible to think so, but home-based piercing parties take place in some communities involving people with no training, qualifications or skills.

Both practitioners and regulators have called for stronger, clearer, more detailed and more precise guidance and byelaws, and many experts and professionals would be more than happy to engage with the process. I understand that Graham Martin and the Tattooing and Piercing Industry Union’s working group have already done much of the necessary work and produced their own model byelaws based on modifications of the Scottish Parliament’s model. That would enable best practice to be rolled out across the UK and provide valuable support to environmental health departments that already do so much good work ensuring public safety.

A national system of licensing is required. Byelaws should specify which type of equipment is acceptable for use and give advice on chemicals and local anaesthetics. They should also include an obligation to ascertain the age and medical history, a consent form and information and obtain on the potential risks associated with any procedures and give accurate aftercare advice. As already stated, such changes could be potentially life saving.

I have commented already on the need for qualifications for those carrying out such interventions. An age limit must be introduced for body piercing with the more intimate and extreme piercings reserved for over-18s, which would give local authorities greater power to protect minors. Everyone would benefit from tightening regulation in this area. The public would be protected as would the excellent and reputable tattoo artists and body piercers who want to see their industry and their livelihoods protected.

I am aware that Professor Noah, and some of his colleagues from the Health Protection Agency, have produced a paper on the hazards of body piercing, based on a survey, which will be published in the British Medical Journal very soon. I urge my hon. Friend the Minister to ensure that that is read and considered by the Department of Health so that we can begin to move forward and provide the level of protection so urgently required for those individuals. Many of us in this House might not understand the motivation for wanting some of the more extreme body piercings and tattoos, but in undertaking such practices, people should be protected by the law as are those going into hospital for minor surgery.

I congratulate my hon. Friend the Member for Bridgend (Mrs. Moon) on her success in securing this debate and apologise for the fact that I am substituting for the Minister with responsibility for public health, my right hon. Friend the Member for Bristol, South (Dawn Primarolo), who is detained by her responsibilities during the Committee stage of the Human Fertilisation and Embryology Bill. I am also grateful to my hon. Friend for setting out her views on the dangers of tattooing and other types of skin piercing, and on the regulatory framework. As she indicated, tattooing or skin piercing carried out incorrectly and in an unhygienic manner can result in a variety of problems, such as local wound infections or serious blood-borne viral infections such as hepatitis B, hepatitis C or even HIV. However, most complications are minor and self-limiting, such as local, minor wound infections that might not be caused by the piercing procedure itself.

As far as we know, serious complications are uncommon according to peer-reviewed literature, but none the less it is important that we have measures in place to ensure public protection, as my hon. Friend said. We have a legislative framework in place and, under the Local Government (Miscellaneous Provisions) Act 1982, local authorities have powers to regulate the practice not only of piercing, but acupuncture, tattooing and other cosmetic activities. In 2003, we strengthened the Act by giving local authorities powers to regulate body piercing and semi-permanent skin-colouring businesses. That legislation provides for local authorities to require the registration of practitioners and premises offering such services, and to introduce local byelaws relating to hygiene and cleanliness.

Local authorities inspect businesses under that legislation, usually based on a local risk assessment, and it is an offence to provide these services without being registered with the local authority or to breach local byelaws. As my hon. Friend will know, in London, the legislative framework is different in that local authorities have chosen to use private legislation to regulate businesses by licensing and inspection. Under licensing provisions in London, local authorities may set conditions under which a licence is granted to cosmetic body-piercing businesses. Again, offences are connected with non-compliance.

In addition, local authorities can use general enforcement powers under health and safety at work legislation, which provides useful flexibility and added protection for the public. That legislation enables local authorities to use improvement and prohibition notices, and ultimately to prosecute cosmetic body piercing businesses, if they judge that there is a risk to customers’ health and safety. Health and safety at work legislation will also apply to other procedures such as scarification and beading.

All that legislation of course applies to people offering tattooing and skin piercing for gain from their homes, not just in commercial premises. In 2007, the Department published an updated model byelaw, which has been well received by local authorities according to the feedback received. For example, Mid Sussex district council recently introduced updated model byelaws provided by the Department to assist local authorities, and stated:

“The new byelaws are good news for the people of Mid Sussex because they give environmental health officers the powers they need to protect public health.”

We have not received representations from local authorities or practitioners about the effectiveness of the current legislative framework.

My hon. Friend suggested that the byelaws should be more detailed, but they do provide a framework for hygienic practice, and we believe that details of hygienic practice and other matters are better covered in guidance by the Health and Safety Executive on enforcement in respect of skin-piercing activities. The guidance covers the issues that she raised, such as pre-consultation with the client, infection control, cleaning, disinfection and sterilisation, aftercare advice, anaesthetics and enforcement.

As my hon. Friend mentioned, the Department has funded new research by the HPA, which has investigated the prevalence and types of body piercing in those aged 16 and over in England and has estimated the proportion of piercings that result in health complications and the proportion of piercings that result in professional help and advice being sought. As she rightly said, that report is due to be published this Friday. However, after she secured this debate, I asked to see some of its draft findings, and without pre-empting too many of its conclusions, I thought that I would give her a foretaste, given her interest in the matter.

Some of the findings are interesting. The prevalence of cosmetic body piercing, excluding earlobes, but including the upper ear cartilage, in adults aged 16 and over is 10 per cent. Body piercing was more common among women than men and among younger age groups. Nearly half the women aged between 16 and 24 who were surveyed reported having had piercings. Some 33 per cent. of piercings were at the navel, followed by 19 per cent. at the nose, 13 per cent. at the ear, 9 per cent. at the tongue, 9 per cent. at the nipple, 8 per cent. at the eyebrow, 4 per cent. at the lip, 2 per cent. at the genitals and 3 per cent. at some other part of the body.

My hon. Friend may also be interested to know that the anatomical sites used for piercings varied by gender. Among women, the most common piercings were, in order, of the navel, the nose, the ear, the tongue, the eyebrow, the nipple and the lip. Among men, they were the nipple, the eyebrow, the ear, the tongue, the nose, the lip and the genitals. Thus, nipple piercing was the most popular among men but one of the least popular among women, and navel piercing was by far the most popular among women, accounting for more than a third of piercings, and much rarer among men. Some of the findings surprised me, and I am sure that they will surprise a lot of hon. Members and members of the public who, like me, are not au fait with the world of body piercing. “Ouch”, I said to myself as I read through a lot of that list.

My hon. Friend will also be interested to know that, overall, about 25 per cent. of those pierced reported complications. Among those aged 16 to 24, about 30 per cent. reported complications with piercings and 15 per cent. sought professional help, for example from pharmacists, piercers themselves or GPs. Piercing was much more common in that age group and more likely to have been done in recent years. The most common complications were local infections and bleeding, but serious complications requiring a hospital admission, for example, were extremely rare, at less than 1 per cent. We believe that the research will show that we probably need to do more work to determine the risk of complications and how best they may be avoided.

My hon. Friend expressed her concern about the fact that children can have body piercing done without parental consent, both from the point of view of whether it is appropriate and because of the possible health risks. I emphasise to her that Government policy on the age of consent is the responsibility of the Ministry of Justice, but she will know that the tattooing of minors is controlled by specific legislation. We think that that is appropriate, because of the permanent skin alteration that it involves. However, the piercing of ears and other parts of the body for decorative or cosmetic purposes is lawful. We have taken that judgment because we believe that cosmetic piercing is usually naturally reversible if jewellery is permanently removed from the piercing. There is no statutory minimum age of consent for body piercing or ear piercing. Minors can give valid consent if they are capable of understanding the nature of the act to be carried out. The degree of competence that can be exercised by children depends on the relative maturity of the child concerned as well as upon his or her age.

I understand that some parents feel concerned when their children have body piercing done without their consent. As with many such matters, a lot of the issues involved should be resolved within the family. However, I am advised that it is generally considered good practice by local authorities and by the industry for cosmetic piercing not to be carried out on minors without parental consent. If local authorities receive complaints from parents that that has been done by a particular practitioner, it is open to them to take action using their existing powers. The Health and Safety Executive guidance includes advice on encouraging businesses to adopt a reasonable approach to age of consent issues. Taking a reasonable stance on the age of consent avoids conflict with parents and enhances the reputation of the business. I would helpfully suggest that it also ensures that a business does not run into difficulties with the local authority, which has the responsibilities that I have described.

I am aware that this is a sensitive matter that concerns parents. However, we are concerned that if we introduced a statutory minimum age of consent, we could end up increasing the health risks of cosmetic piercing. Children might be tempted to try to pierce themselves or each other in an unsafe or unhygienic way, or to go to disreputable practitioners. We receive occasional representations on the subject and, as on all matters, keep our policy position under review.

I reassure my hon. Friend that we have a robust legislative framework that provides for local regulation of tattooing and skin piercing businesses. Centrally, the Department assists by providing model byelaws that local authorities can use.

My hon. Friend the Minister has not addressed the issue of qualifications and competency to practice. Will he comment on that in the remaining few minutes and suggest whether the Department has any concerns about it?

We are aware of the concerns, and although there are currently no formally recognised qualifications or training courses for body piercing, that is partly because the Government-funded project to develop such standards, of which my hon. Friend may be aware, ended prematurely because of opposition from the industry. We believe that it could have led to the development of formal qualifications.

We believe that progress can most quickly and effectively be made by practitioners, their organisations, industry bodies, training bodies and enforcement authorities working together to agree on suitable standards of good practice and competency. That is the best way forward, rather than our imposing statutory training requirements on the industry.

As I have explained, we recognise that there is concern about the lack of a statutory age of consent for cosmetic piercing, about some of the training standards and about how some local authorities are using our new model byelaws. We keep those matters under careful review and consideration, but we are not persuaded that a statutory age of consent would help. Our concern is that it might have the opposite effect.