When four teenage girls in Anne Arundel County, Md., contracted a tough-to-treat bacterial skin infection last fall that landed two of them in the hospital, the county health department quickly zeroed in on the cause: their new body art.
"The common factor was ... these tattoos," says Elin Jones, a spokeswoman for the Anne Arundel County Department of Health.
The girls had picked up methicillin-resistant Staphylococcus aureus -- or MRSA -- from a local tattoo artist working out of his basement. MRSA, which can appear as pimples or boils, grows rapidly, resists common antibiotics, and can infect the blood and bones if left untreated -- not exactly a desired after-effect of having your body inked.
Yet, according to a county police spokesman, the tattoo artist had "violated no criminal laws."
That's probably because there were few laws to break.
Maryland, like many other states, doesn't license its body artists. The state has passed some laws pertaining to sterilization but doesn't require its body artists to undergo any formal training or prove actual knowledge of sterile practices or blood-borne diseases -- nor does it mandate inspections.
"You could do it from home," says Brenda Roup, a nurse consultant in infection control for the Maryland Department of Health and Mental Hygiene. "No one is looking over your shoulder."
The craze for tattoos, nose and tongue studs, and lip, tongue and belly-button rings has spawned a burgeoning body art industry that lawmakers can't quite keep up with. A Journal of the American Academy of Dermatology study released this week suggests that nearly half of 18- to 29-year olds have either a tattoo or piercing.
One reason so many young people are painting or piercing their bodies ... their idols do it. Stars such as Angelina Jolie, Pamela Anderson, Britney Spears, Johnny Depp, the Rock, and rappers 50 Cent and Eminem all have body art in common, as do sports superstars Shaquille O'Neal, Jason Giambi and English soccer star David Beckham.
"People are looking at sports and celebrities and want to affiliate themselves with that," says Terisa Green, author of "The Tattoo Encyclopedia" and "Ink." "All the top models have a little something on their ankle, so there's also a little bit of a fashion thing."
Despite the growing legions undergoing the repetitious prickings of the tattoo needle or the one-two punch of the pierce, many are surprised to learn just how scantily the body decorating industry is regulated.
"They think it's been taken care of," says Myrna Armstrong, a professor of nursing at Texas Tech Health Services Center, who has studied body art for 15 years.
Yet no federal laws govern any aspect of the business, and state efforts to codify health, safety and training standards have been limited and scattershot. The strength of the regulations varies widely across the country, and even within states, according to Armstrong.
Fewer than 10 states specify any requirements for training, apprenticeships or continuing education, according to Armstrong, who reviewed body art regulations for an article in the Journal of Environmental Health last year.
Some states require only that anyone under the age of 18 obtain parental consent before getting pierced or tattooed. "That's often the only part of the regulations that gets implemented," says Jim Weber, who works on legislative issues for the Association of Professional Piercers and co-owns Infintite Body Piercing in Philadelphia.
Only about 19 states require a course in universal precautions -- a set of steps prescribed by the Centers for Disease Control and Prevention -- to prevent cross-contamination and transmission of blood-borne bacteria and viruses, such as hepatitis, tetanus and HIV. A handful require a course in sterile technique; and two call for courses in anatomy and physiology.
"There aren't enough regulations around body art," says Dr. Jeff Morehouse, chairman of cosmetic and reconstructive surgery at Lovelace Health Systems in Albuquerque, N.M., who lectures frequently on anatomy at body-piercing conventions. "There's no sort of certification you need to go through to become a body piercer."
Medical professionals generally agree that life-and-death complications arising from body art -- such as septicemia, endocarditis, toxic shock -- are rare, especially considering the large numbers of people getting pierced or tattooed every day.
"The complications I've seen are less related to the piercings themselves than to poor healing or how people take care of them," says Morehouse.
Still, experts warn, any breaking of the skin brings risk, especially in the absence of mandated safety and hygiene protocols. "Body art is an invasive procedure. You have a hole. You have a portal for infection," says Armstrong.
According to the recently released Journal of American Dermatology study, nearly one in four people surveyed reported medical complications -- including skin infections -- from piercings, and 13 percent reported problems with tattoos.
"Different sorts of piercings, when they're put in by people who don't understand or do a lot of piercings, can become a problem," Morehouse says, "particularly some of the genital piercings, where you can end up with nerve injuries."
Tongue piercings can also give trouble. The jewelry can crack, chip or knock out teeth, and cause gums to recede. The tongue can swell to the extent that it interferes with breathing.
State legislators haven't necessarily sat out the body art revolution, oblivious to its potential dangers.
"A lot of states have been looking at regulations for the last two or three years," says Weber, with attention sometimes piqued by the resurrection of such ancient practices as scarification and branding, tongue-splitting and skin suspension.
Pennsylvania, for example, introduces legislation almost every year. "It's just never voted on," says Richard McGarvey, a spokesman for the Pennsylvania Department of Health.
Body art bills also died this year in Minnesota and Washington state.
"Many states have tabled legislation," says Weber. "They simply don't have the funding to look at it right now." New York passed laws in 2004 but didn't allocate the dollars to give them regulatory teeth.
As it turns out, some of the biggest advocates for tighter regulations are the body artists themselves, eager to come out of the shadows and gain respectability.
"It's important for us to come forward and present our industry with the degree of professionalism a lot of people might not normally associate with us," says Troy Amundson, a body piercer at Apocalypse Tattoo in Seattle.
For the past two years, Amundson has trekked to Olympia, the state capital -- his piercings and tattoos sticking out of his suit -- lobbying for legislation to establish sterilization requirements for body piercing and scarification that would at least match what the state passed for tattooing in 2001.
"Body piercing has been totally unregulated in the state of Washington," he says.
Amundson's bill was one of three shot down this year. Undaunted, he says, "I'll return in 2007."
Where states have dragged, some counties and cities have stepped in with their own codes to pick up the regulatory slack.
Philadelphia, for example, requires training certificates and apprenticeships for body artists, along with regular inspections. Albuquerque, N.M., has also put in place its own regulations, requiring permits, training in blood-borne pathogens, continuing education and inspections -- again, with help from the local body art industry.
But such a piecemeal approach still leaves large swaths of states unregulated.
"It's nice when you have universal standards at the state level, so there's a level playing field," says Dean Peterson, director of environmental health for San Mateo County, Calif. After waiting eight years for the California Department of Health Services to write the rules for a body art law the state passed in 1998, San Mateio County, along with five other counties in the state, put its own monitoring and enforcement system in place last November.
"We could not wait," says Peterson. "We're concerned about the potential for disease that body art can pass on if not done correctly. These are vulnerable procedures."