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60 Criminal Behaviour and Mental Health, 10, 60–66 2000 © Whurr Publishers Ltd

Is prison tattooing a risk behaviour

for HIV and other viruses? Results
from a national survey of prisoners
in England and Wales
JOHN STRANG 1, JOAN HEUSTON 2, CHRISTOPHER WHITELEY 2,
LORAINE BACCHUS2, TONY MADEN3, MICHAEL GOSSOP1 AND
JOHN GREEN 4 1National Addiction Centre, Institute of Psychiatry,
London; 2formerly National Addiction Centre; 3Department of Forensic
Psychiatry, Institute of Psychiatry; 4St Mary’s Hospital, London

ABSTRACT
Background Tattooing has, for more than a century, been recognized as a potential
source of transmission of pathogens such as syphilis and hepatitis B. With the advent
of HIV and other viruses such as hepatitis C, the extent and nature of tattooing war-
rants specific study. Tattoos are commonly found on prison inmates, including crude
tattoos self-applied or inflicted by others. The extent to which such prison tattoos
might constitute a route of HIV transmission is not known and requires exploration.
Method Confidential interviews with 1009 adult male prisoners in 13 prison estab-
lishments across England and Wales were conducted in 1994 by independent inter-
viewers. Subjects were randomly selected through the LIDS (Local Inmate Data
System), with stratification by prison wing, with a sampling fraction varying
between one in four and one in six. An overall consent rate of 72% was achieved.
Results A total of 53% (536) of the 1009 interviewees had been tattooed at least
once in their lifetime, of whom 21% (111) had been tattooed whilst in prison. Of
these, a third had never previously been tattooed. Half of these prison tattoos had
been self-administered, using a wide variety of instruments. However only 20 of the
prison tattoos had been applied within the last year. For a quarter (26) of the 111
prison-tattooed men, the tattoo had been applied at the same time as that of another
prisoner. Crude attempts to sterilize the improvized tattooing equipment were com-
monly applied.
Conclusions Despite a high lifetime prevalence of tattooing amongst this group,
with a substantial proportion bearing prison-applied tattoos, the more recent period-
prevalence of tattooing was low. The widely employed diverse cleaning methods sug-
gest potential value in dissemination of advice about more effective hygiene and
cleaning methods.
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Is prison tattooing a risk behaviour for HIV and other viruses? 61

Introduction

Tattooing has been recognized as a potential behavioural conduit for transmis-

sion of pathogens for more than a century, since Maury and Dulles (1878)
reported in 1878 on the transmission of syphilis through unsterile tattooing.
More recent concern has centred on the transmission of hepatitis B (Scutt,
1972), HIV and hepatitis C (MacDonald et al., 1996).
Prison inmates have already been identified as populations amongst whom
tattoos are particularly common (Haines and Huffman, 1958; Post, 1968;
Lepine, 1969; Curran, 1982), with a large proportion of these tattoos having
been self-applied or inflicted by others with improvized equipment in the
prison setting. However, the extent to which this remains a widespread cur-
rent practice and the associated risk of transmission of pathogens have been
unclear, so that tattooing in prison has continued to be considered as a possi-
ble HIV risk behaviour (Strang, 1993).
There is extensive overlap between the prison sample and the general
community sample, thus making concern about the viral infectivity of pris-
oners an essential component of wider public health planning (Advisory
Council on the Misuse of Drugs, 1988; Farrell and Strang, 1991; McBride et
al., 1994). On any one day, there are now more than 50 000 men held in
prisons in England and Wales, with a total annual population of more than
200 000.

Subjects and methods

The investigation of tattooing was undertaken in the context of a substantial

study of HIV-risk behaviour of prisoners, which mainly concentrated on
examination of their previous and current injecting and sexual risk behav-
iours. These data will be reported separately. The data on the third area of
potential HIV risk – tattooing – are reported in this paper.

Subjects
All 1009 prisoners interviewed were adult males detained in prisons in
England and Wales during 1994. Mean age of the total sample was 32 years
(median 29), with 77% white, 13% black, 3% Asian (7% other or unrecord-
ed). Of these subjects, 71% had had a previous period of custody, and subjects
had already spent a lifetime average of 4.5 years in custody.
At the time of interview, the average length of time already spent in prison
during this period of custody was 1.9 years, although a large proportion of the
subjects had spent much shorter periods of time in custody, so that the modal
value was four weeks and the median 6.5 months.
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62 Strang et al.

Study design
Subjects were chosen randomly from a selected range of prison establishments
by reference by the LIDS (Local Inmate Data System, an alphabetical list of
all prisoners in an individual institution), with the selection of every nth per-
son on the list, so as to obtain the appropriate sample size, and with stratifica-
tion by the prison wing. Establishments were chosen in collaboration with the
Home Office Prison Service Directorate of Health Care and Research
Planning Units, so as to ensure a wide range of establishments whilst simulta-
neously remaining sensitive to the constraints due to rebuilding, overcrowding
and rioting. Between the different target establishments, the sampling fraction
varied between one to four and one to six, across a total of 13 establishments.

Ethical approval and right to refuse

Ethical approval for the study was obtained from the host academic institution
(Institute of Psychiatry, University of London). This was considered more
realistic and preferable to attempting to secure separate ethical approval from
each of the host prison establishments, especially as these establishments did
not have existing standing ethical committees. Prisoners were aware, and were
reminded in the interview, of the voluntary nature of participation in the
interviews. Consent rates are reported later in ‘Method’.

Data collection
Data were collected by independent interviewers in face-to-face interviews
with consenting prisoners from the random sample. The structured interview
was constructed with a stem-and-branch design in order to allow fuller explo-
ration of areas for which a positive initial response had been elicited, without
making the interview unnecessarily lengthy. Pilot interviews were conducted
with 120 prisoners in order to familiarize the interviewers with the schedule as
well as to identify any confusing or unproductive items, following which
minor revisions to the interview schedule were made. The areas of question-
ing mostly concentrated on those aspects of past and current behaviour which
could have a relationship with HIV risk, and hence included two substantial
sections on drug use (especially use of injectable drugs) and sexual behaviour,
and a third briefer section on within-prison and outside-prison tattooing.

Consent rate
Prisoners had been given information about the scope of the enquiries in
advance, and were aware that questions would be asked concerning their per-
sonal HIV risk behaviours and attitudes. An overall consent rate of 72% was
achieved, with the refusal rate being particularly high in two prisons (outside
which the overall consent rate was 83%).
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Is prison tattooing a risk behaviour for HIV and other viruses? 63

Results

Lifetime tattoo history

A total of 536 men (53%) had been tattooed on at least one occasion in their
lives, on an average of 6.7 occasions (mode 1; median 4), with an average age
at first tattoo of 16 years. Of these, 273 men (51% of the tattooed prisoners)
had had a non-professional tattoo applied outside the prison setting.

Prison tattooing history

Some 111 men (11% of prisoners, 21% of tattooed prisoners) had been tat-
tooed whilst in a prison, with a mean 4.5 prison tattoos (mode 1; median 2),
of whom a third (38 men, 35% prison-tattooed prisoners) had received their
first ever tattoo inside a prison. Of the 111 prison-tattooed prisoners, 60
reported having applied a tattoo to themselves, 40 had received a tattoo from
a cellmate, and 35 had been tattooed by another prisoner (not a cellmate).
None had only a self-applied prison tattoo. Instruments used for administering
the tattoo were usually a sewing needle (94 men) although other instruments
occasionally used included a sterile hypodermic needle, safety pin, bedspring,
guitar string, as well as an improvized tattooing machine.

Recency of tattooing behaviour

Despite the extensive lifetime prevalence of prison tattooing amongst the pris-
oners, only 18 men (16% of those with a prison tattoo) had been tattooed dur-
ing their current prison episode (this prison, this time), of whom only four
reported being tattooed with a previously used needle, although seven reported
that their needle had subsequently been used for tattooing by another prisoner.
Only 20 had received their prison tattoo in the year prior to interview,
and only three men in the last month. Indeed, the last prison tattoo
amongst the prison-tattooed sample had occurred a mean of 10 years ago
(median 8). The distribution of intervals since the last prison tattoo is dis-
played in Table 1.

Table 1: Interval since last prison tattoo

Intervals (yrs) n Sample (%)

<1 19 17.4
1–2 6 5.5
2–5 13 12.0
5–10 30 27.5
> 10 41 37.6
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64 Strang et al.

Sharing of tattooing equipment in prison

Twenty-six of the 111 prison-tattooed men (24%) had been tattooed at the
same time as another prisoner. For 12 of these men, a previously used needle
was used to apply the tattoo, with seven of them reporting that the needle was
usually cleaned before applying the tattoo (including five who reported that it
was always cleaned). For 14 of these 26 tattooing-sharers, the tattooing needle
was then used by another prisoner after them, with eight of these men report-
ing that the needle was cleaned (seven of them ‘always’).
A variety of methods had been used for cleaning tattooing needles, but the
most commonly reported method was heating the needle in a flame above a
match, followed by immersion in hot or boiling water.

Perception of risk
Prisoners were also asked to assign a perceived risk status (‘high risk’, ‘low risk’
and ‘no risk’) for a list of behaviours. In the present study, 95% of prisoners
considered ‘sharing a needle for a tattoo’ to be an HIV ‘high risk’ behaviour –
an even higher proportion of prisoners than those rating as ‘high risk’ ‘anal sex
without a condom’ (92%), ‘oral sex without a condom’ (70%), and ‘contact
with blood on open cuts’ (82%).

Discussion

More than half (53%) of the 1009 prisoners had been tattooed, with two-
thirds of these having received a non-professional tattoo. Furthermore, more
than a fifth (111; 21%) of these tattooed prisoners had received at least one
such non-professional tattoo whilst in prison, for one-third of whom it was
their first ever tattoo. These 111 prison-tattooed prisoners bore 240 prison tat-
toos between them.
However, despite the high lifetime prevalence of prison-tattooing amongst
this sample, the more recent period-prevalence is low, with only 20 prisoners
having received a prison tattoo in the year prior to interview, and only three
having received the tattoo in the previous month. Whilst directly comparable
data from earlier national samples are not available, it seems likely that prison
tattooing is no longer the widespread phenomenon in prisoners in England
and Wales that it may have been in earlier times.
Improvized cleaning methods are widely employed (usually through direct
heat from a match or boiling water). This may be a sufficient precaution to
protect against possible HIV transmission in most instances, although it is
doubtful that it would be sufficient to protect against transmission of hepatitis
B or hepatitis C viruses. However, the widespread use of sewing needles as the
instrument for applying prison tattoos is presumably safer than hypodermic
needles, since there is no lumen in which blood or body tissue can lodge.
Finally, the surprisingly high proportion (95%) of prisoners who rated the
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Is prison tattooing a risk behaviour for HIV and other viruses? 65

sharing of tattooing needles as a ‘high risk’ HIV behaviour raises serious ques-
tions. Prisoners’ perceptions of the risk appear exaggerated in comparison with
more clearly established risk behaviours such as anal intercourse without a
condom. Consequently, further specific educational intervention to increase
awareness of risks would be unlikely to confer any substantial benefits. In view
of the risk of hepatitis B and C transmission, prisoners need education about
different methods of cleaning, e.g. bleach tablets, for example. The optimal
approach may be one which seeks to dissuade prisoners from the practice of
prison tattooing, whilst ensuring that, for those who nevertheless apply tat-
toos, the means are available for them to reduce the harm that may result.

Acknowledgement

The authors would like to acknowledge the sensitive persistence of their team
of interviewers, including Rowena Macauley, Kathy Powell, Dawn Gordon,
Hilary Nettleton, Richard Sparks and Brian Whitehead. Funding was received
from the Home Office Research and Statistics Directorate on behalf of the
Prison Service Directorate of Health Care. There was no conflict of interests.

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Address correspondence to: Professor John Strang, National Addiction Centre (Institute of
Psychiatry/The Maudsley), Addiction Sciences Building, 4 Windsor Walk, London, SE5 8AF,
UK. Fax: 0171 701 8454; email: j.strang@iop.kcl.ac.uk