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It’s Okay to Say “I Don’t Like Them:” On Body Modifications

[Content Notice: pictures of scars]

When I first discovered that there are people who think nothing of circumcising their infant sons for social reasons (i.e. “so that he looks like everyone else”) but who clutch their pearls with clammy fingers if they spot a baby with pierced ears, I had no idea what to think. I’ve come to understand that there are cultural reasons behind what’s considered acceptable to do to a baby’s body.

a drawing of a hand with the pointer finger raised

Most white Americans consider piercings to be edgy in a way that people of other backgrounds may not. For example, many people who are assigned female at birth and hail from Desi backgrounds like mine had their ears pierced as infants. I am no exception. Since I’ve been rocking lobe jewelry since I was three months old, for me to consider ear piercings to be “daring” in any way seemed utterly ludicrous.

My conception of bodily autonomy affirms that people should have a say in any modifications made to body parts as significant as their genitalia to as seemingly-insignificant as their earlobes. At the same time, though, I cannot help but notice that those from a more mainstream cultural American background tend to become quite upset over piercings in a way I can’t understand.

Setting aside the obviously judgmental, subjective statements that dub piercings and/or pierced people as “not classy,” “gross,” “unprofessional,” and so on, there are some notions regarding piercings that masquerade as objective in some way that simply are not. The same goes for tattoos. Finger-waggers will often make claims akin to the three below.

Piercing [insert body part here] in [insert place on said part here] can cause paralysis.

I’ve heard this notion used to dissuade people from piercings in as mundane of a place as ear cartilage. There is no evidence that piercing some part of your body is a surefire way to induce paralysis of any kind. There is a rare paralysis-causing condition that was known to be have been triggered via an ear piercing in one case, but anything from a vaccine to the flu can trigger it, too.

a brain with three of its parts labelled

Not pictured: A direct line from piercing to brain

If you pierce your nose or tongue and it gets infected, the infection could spread to your brain.

Tongue piercings have been named as the culprit in a few severe cases of infection that led to harm and death, but in both cases, there was an infection involved. Merely getting the piercing doesn’t cause the brain to become infected; furthermore, other causes can lead to the same sort of infection. There doesn’t seem to be any recorded case where a nose piercing caused a brain infection. I’d imagine that an infected nose or tongue piercing could cause sepsis if left untreated for too long, just like any other infection.

Piercings and tattoos cause unsightly scarring.

It is true that for people with certain skin types and scarring predispositions, both piercings and tattoos can develop into a highly-visible and sometimes disfiguring scar. So can any other injury to the skin, however, especially if you are predisposed to such marking.

What the naysaying really boils down to is this: any kind of injury to the body can develop into further problems like infections and scarring that are potentially harmful. Piercings are no different, but aren’t as dangerous or as risky as many hand-wringers would have you believe. Practicing care, sense, and caution, as well as accepting the level of risk inherently involved in body modifications, is key.

a grid depicting scars of varying size and pigmentation

top to bottom, L to R: right knee after three surgeries; left leg with shaving scars from over 10 years ago; left arm, left forearm, and right wrist with scars from random scrapes

Personally (and yes, anecdotally, in 25 years of life, I’ve gotten 14 different piercings as well as one tattoo. Not one of my body modifications, not even the one ear piercing that I allowed to heal or the tattoo that took over 5 hours to complete, left me scarred. The tissue around my nose stud did become darkened post-piercing, but that’s because it was made by a gun wielded by some beautician rather than by a sterile needle in the hands of a professional piercer (I didn’t know any better at 17).

It’s not that I’m resistant to scarring, either. I have many, many hypertrophic and keloid scars from surgeries as well as from the various little scrapes and injuries I’ve acquired over the course of my life (not to mention the stretch marks courtesy of puberty and weight fluctuations). I am happy to take the risk every time I get a mod because my body is already riddled with unwanted marks; the ones I’ve placed there of my own volition please me aesthetically and psychologically.

If you are not aesthetically pleased by body modifications, by all means refrain from getting any. I don’t believe that anyone should have any piercings or tattoos that they didn’t consent to getting. Playing up the risks of tattoos and piercings as way to disguise the fact that you don’t approve of them for subjective reasons, however, strikes me as rather petty.

Heina Dadabhoy

Heina Dadabhoy

Heina Dadabhoy [hee-na dad-uh-boy] spent her childhood as a practicing Muslim who never in her right mind would have believed that she would grow up to be an atheist feminist secular humanist, or, in other words, a Skepchick. She has been an active participant in atheist organizations and events in and around Orange County, CA since 2007. She is currently writing A Skeptic's Guide to Islam. You can follow her on Facebook, Twitter, or Google+.

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47 Comments

  1. October 8, 2013 at 2:40 pm —

    Holla from a pink-haired, nose-studded, no-bra-wearing lady working a corporate job! People–yeesh.

  2. October 8, 2013 at 2:48 pm —

    Considering how many people I’ve known with multiple piercings and tattoos, these post hoc health rationalizations against it always rang hollow. Playing American football has a far greater likelihood of causing paralysis, brain injury and unsightly scarring (from surgeries if nothing else) … but that’s totes cool, of course!

  3. October 8, 2013 at 6:16 pm —

    These “arguments” always seemed to me to just be people who don’t like body mod coming up with a thin excuse not to like them. Then again, people usually aren’t too shy about saying how ugly they think [insert decorative body thing here] is.

    My response to anything about how I’ll regret doing it is…well, so what? It’s not going to kill me to end up with an ugly tattoo or a scar. I already have scars and stretch marks and cellulite and whatever else, and I’m somehow carrying on.

    Getting through life without ever doing anything dumb (assuming it doesn’t have serious consequences) seems a little boring anyway.

  4. October 8, 2013 at 9:34 pm —

    Fair enough. So where do you stand on acupuncture? The risks you’re arguing against are largely the same as those decried by the skeptical community on sites like “What’s the Harm?” and “Science Based Medicine” for acupuncture. Actually, I’d imagine they’d be slightly higher for body modification. Are we being hysterical about the risks of acupuncture?

    • October 8, 2013 at 9:49 pm —

      Obviously I can’t speak for the author, but I think you’re making an unequal comparison here. Somebody who sets out to get a piercing gets exactly what they pay for, same as somebody getting a tattoo. Somebody getting acupuncture doesn’t get what they seek (healing).

    • October 9, 2013 at 1:17 am —

      From what I’ve seen in the skeptical community, we criticize acupuncture because it’s based on bad science, so when they get acupuncture, people are taking risks for no demonstrable benefits.

      On the other hand, I got my ink and my metal in me because I like the way they look, and I like the way they look, so I got what I paid for. No one lied to me and no false science was involved, and I’m happy with how it all turned out.

      • October 9, 2013 at 5:08 am —

        Your ink and metal don’t strengthen your immune system, promote healing and positive energy balance, and repel mountain lions? Demand your money back!

      • October 9, 2013 at 8:19 am —

        The RISKS we argue about for acupuncture are the same. Steve Novella is always talking about with acupuncture are the very same risks everyone here is waving off as overblown and not a big deal. “What’s the Harm?” is filled with anecdotes of the same kinds of rare horror stories. It’s inconsistent to call those risks a great danger and these risks overblown.

        So how about all three of the people who just made lazy, snide responses to my question try to have some intellectually honesty and really think about this? Is Steve hysterical? Is “What’s the Harm” a collection of overblown horror stories? Responding with “Acupuncture is more woo woo than a choo choo!” is just ignoring my question. We can’t have our cake and eat it, too. We can’t scream about acupuncture killing patients with one breath and then debunk the exact same risks

        • October 9, 2013 at 11:43 am —

          I can’t speak for Steve Novella or anyone else nor did I intend to be snide.

          I think the point of What’s the Harm is to debunk the notion that practices like acupuncture cannot harm you. Obviously they can. Piercings and tattoos can harm you, too. However, there is a large backlash and awareness of the harms of piercings and tattoos than there is of the potential harms of alt-med practices.

          I didn’t ignore your question, I think your question is based on bad premises. Level of risk is not the sole factor taken into consideration when we’re talking about acceptable level of risk — there’s also benefit/pay-off. We do risky things all the time based on the pay-off but don’t do other things that are equally risky or even less risky than the things we do because there’s no benefit to them. For example, most Americans drive all the time, one of the riskiest activities available, without a second thought because the benefits outweigh even that high level of risk for injury and death, but there are far less risky activities that people who happily drive will not participate in because the benefit isn’t worth it.

          That the risks of acupuncture may or may not be the same as or fewer than those of body mods is irrelevant. The problem is that even the slightest amount of risk you’d take in getting acupuncture isn’t worth it because the purported perceived benefit simply isn’t there. I know people who get acupuncture despite knowing that it doesn’t do what it claims to do because they think it feels good and/or they like pain. I think that’s fine. What’s not okay is people being promised all kinds of healing through acupuncture and taking on its risks for bogus, pseudo-scientific reasons. A lot of those people wouldn’t take those risks if they knew that acupuncture doesn’t actually do what it claims to do.

          • October 9, 2013 at 4:21 pm

            Thank you thank you thank you! This is a good argument, and you’ve written it very clearly. Then again, maybe I’m a bit biased, because I think you basically articulated my position better than I could. I really appreciate that you thought about this and wrote down a nuanced response. All too often, I see hand waving crap from skeptics. We can’t do that if we want to help people.

            Here’s my take: Fundamentally, when someone is undergoing any kind of procedure (elective or not, invasive or not) they have a right to know the true risks and the true benefits. They deserve to know the risks unclouded by hysteria and the benefits without hype before making a decision. We can’t JUST say “acupuncture is dangerous!” We also can’t JUST say “body mods are safe!” There’s some (minimal) risk involved with either procedure. How that risk compares to the benefits is what really matters. Skeptics have to live with that nuance. And, for what it’s worth, I think you articulated that nuance quite well in your blog post.

            “A lot of those people wouldn’t take those risks if they knew that acupuncture doesn’t actually do what it claims to do.” Precisely. They’re misinformed about the benefits AND the risks of acupuncture.

          • October 9, 2013 at 7:27 pm

            I have never heard anyone argue against acupuncture by saying JUST “acupuncture is dangerous.” Acupuncture is not especially dangerous. It’s certainly way less dangerous than, say, chemotherapy. The argument against acupuncture is not, and never has been, its safety/dangerousness, but the unfavorable risk profile. Chemotherapy is, unequivocally, less safe than acupuncture, but the expected cost of NOT getting chemo is, typically, dying of cancer, whereas the expected cost of NOT getting acupuncture is … well, there isn’t any because acupuncture isn’t doing anything positive for you above placebo. In that light, any risk whatsoever from acupuncture is too much, and that is the point of What’s The Harm. =Any= case of an adverse outcome from a “therapy” that has no foreseeable benefit is one too many.

            On the other side, I =have= heard arguments against (just to carry the example) chemotherapy, by saying JUST “chemotherapy is dangerous.” Arguing against a therapy by looking =only= at the risks presented by the therapy itself (rather than by comparing those risks against the expected cost of NOT using the therapy) is something that people with an anti-science position do =all the time.= You =always= have to look at the expected cost of NOT doing the thing you are considering.

            This can be applied to cosmetic procedures as well (piercing and tattooing can be thought of as cosmetic medical procedures). What is the cost of NOT getting a tattoo? Well, I have to live without a tattoo, and having the tattoo will make me really happy, so there is a happiness cost in not doing it that must be weighed against the risks associated with obtaining one. No different than getting a nose job.

          • October 10, 2013 at 1:22 pm

            “I have never heard anyone argue against acupuncture by saying JUST “acupuncture is dangerous.”” I have, but I admit it’s not very often.

            “Acupuncture is not especially dangerous.”

            This is more the fact I think skeptics aren’t always entirely honest about. We can be a bit hyperbolic about the risks of acupuncture. From a medical perspective, ANY risk is silly for a procedure that doesn’t work. But from a practical perspective, that risk is very, very small.

      • October 9, 2013 at 8:59 am —

        There is actually a scientific explanation for an acupuncture effect but that does not make it ‘scientific’.

        If it does work at all it is probably the result of crosstalk across the nerve bundles or in the brain similar to the effect that causes synesthesia. There is a multiplexing scheme going on with the main nerve trunks, it is not one nerve fiber per sensor.

        Lots of traditional Chinese medicines have measurable effects too, which is hardly surprising when analysis shows that they are filled with steroids.

        That does not make the approach scientific. For that there has to be a model of the effect of the treatment that is scientifically testable which there isn’t. Not being as bad as homeopathy does not make an approach good.

        • October 9, 2013 at 11:54 am —

          Are you proud that you’ve thrown out your very own pseudoscientific conjecture about the mechanism of acupuncture in a blog comment? Are you proud that this conjecture you’ve pulled out of your ass hasn’t been studied? I know I wouldn’t be. In fact, I’d be doing some self reflection about whether I was really more interested in critical thinking or sounding smart.

          • October 9, 2013 at 2:39 pm

            What in the world are you talking about? No one is pretending that piercings or tats are medicinal.

          • October 9, 2013 at 3:47 pm

            I wrote the comment you responded to in response to this paragraph, “If it does work at all it is probably the result of crosstalk across the nerve bundles or in the brain similar to the effect that causes synesthesia. There is a multiplexing scheme going on with the main nerve trunks, it is not one nerve fiber per sensor.”

          • October 9, 2013 at 4:19 pm

            Oh, okay. Sorry, I was very confused. =}

          • October 9, 2013 at 4:23 pm

            My fault. I should’ve quoted the relevant paragraph.

  5. October 8, 2013 at 11:31 pm —

    I have no problem with body mods but I do have a problem with mods that are poorly done. Its like getting cheap plastic surgery that looks bad. Some tats look good but a lot of people just have poorly drawn scribbles. Anyone deciding to get one done should only do it if they can afford it to be done well.

    As for circumcision, I find the justification utterly preposterous. Yes, I know that there are folk who push it as a medical necessity but it really is nothing of the sort, the advantages are dubious at best and there are real risks. I am aware of the purported studies showing it helps avoids AIDS infection but there are many issues that could complicate those results and I am always skeptical of single scientific studies in areas that are very difficult to investigate that come up with surprising results on a loaded political issue.

    • October 9, 2013 at 1:14 am —

      Personally, I don’t think it’s my place to tell people what to choose, even if their choice is to have even “poorly drawn scribbles” on their bodies. That’s their body, not mine.

    • October 9, 2013 at 9:43 am —

      What’s it to you if someone gets an ugly or bad tattoo? So big deal if someone got a weird-looking dolphin while drunk in Cancun. This to me is like complaining about what other people choose to wear.

      “I have no problem with fat people but I do have a problem with fat people wearing bad clothes…Some fat people look good but a lot of people just have poorly chosen Walmart stretch pants. Anyone fat should only do it well.”

      Personally, I see some value in letting oneself be “ugly”. It’s so ingrained to avoid it, the subversion is interesting. Plus muumuus are just freaking great.

      • October 9, 2013 at 12:05 pm —

        Phil never mentioned anything fat shaming or body shaming in his entire post. You literally could’ve made your exact point by substituting “bad clothes” for “body mods,” but you had to add “fat people” to his comment as well to make him look bad? He made what might be the dumbest argument I’ve ever read on the internet, and you had to resort to a cheap tactic like this? Come on!

        • October 9, 2013 at 1:26 pm —

          Oh my glob, seriously? I have no words.

          Okay, I’ll scrounge up a couple: fat people and body mods both have a high likelihood of being “trashy” if they are not expensive or deemed acceptable enough. I see a lot of parallels in the way they are judged that just “bad clothes” are not.

          But I’ll apologize for being a meanie who made him look all bad if you think I should, Sir Arbiter of Similes. I trust your excellent values deeply.

          • October 9, 2013 at 3:54 pm

            “fat people and body mods both have a high likelihood of being “trashy””

            YOU made this connection, not him. This is a classic strawman argument. You made his position easier to attack by inferring a position he didn’t take. If he did, I’d expect everyone to flay him for it. But he didn’t.

            If you don’t care about making a good argument, or you’re not willing to take criticism when you make a bad argument, please don’t call yourself a skeptic. If you’re above criticism, you’re not a critical thinker.

          • October 9, 2013 at 4:08 pm

            mac was making an analogy, not a “connection”. It wasn’t stated well, but it was still just an analogy, and U understand completely what mac was trying to say. mac was trying to make an analogy regarding judgements from people who view people who have piercings, and/or who are overweight, as “unacceptable”. this is pretty much true.

          • October 9, 2013 at 4:42 pm

            No. This wasn’t just some abstract analogy. Mac literally quoted Phil and then edited what he said to include the fat shaming bit. He never said that fat people are trashy. He never even said tattoos are trashy. We don’t get to just assume he holds those opinions.

            There’s plenty to disagree with in what he actually said, and we’ve got enough brain power around here to take down his actual argument without cheating. You and mrmisconception already did exactly that below.

          • October 9, 2013 at 5:06 pm

            Perhaps I am reading mac’s comments wrong, but from what I can gather, mac is saying that OTHER PEOPLE often consider fat people and piercings and whatnot “trashy” or unattractive or whathaveyou. Not that Phil was making that argument. Just that other people often feel that way. Which isn’t untrue. But perhaps I am reading mac’s comments wrong.

          • October 9, 2013 at 5:17 pm

            Welp, this is why I pretty well just lurk for years on end. It’s like being right back at About Agnosticism/Atheism! All this thanks to someone’s dumb comment about bad tattoos. I’d forgotten what it was like, thank you.

          • October 9, 2013 at 5:22 pm

            You do realize I was trying to defend your comments, right? Because I think delphi_ote is just not understanding you, which can happen if you’re not clear enough (and I don’t think you’re being clear enough, either).

            Delphi_ote has been quite patient and far from rude, and yet you’re getting all defensive and starting to flounce.

            Perhaps instead of flouncing, you should CLARIFY YOUR ARGUMENTS.

            And perhaps give ME points for trying to help clarify FOR YOU, rather than getting butt-hurt and flouncing.

        • October 9, 2013 at 8:00 pm —

          Wow, I should have read the whole comment thread before putting the effort into constructing a reasonable reply for you upthread. Because your pearl-clutching here is unbelievable.

          Nobody “added” fat people to Phillip’s argument. What mac did is no different from taking an argument against gender equality (for instance, “women are under-represented in STEM fields because their brains are not constructed for logical thinking”) and subbing in a racial group (“black people are under-represented in STEM fields because their brains are not constructed for logical thinking”) in order to show that the structure of the argument is discrimination and not science. It’s no different from taking a politician’s syllogism and substituting terms in order to show clearly why the =structure= of the argument is fallacious.

          Phillip’s argument is based on discrimination (against “bad tattoos” and by extension against people who get bad tattoos) and mac changed the words in order to demonstrate the discriminatory structure.

          And that’s honestly more effort than your fainting spell deserves.

          • October 10, 2013 at 12:39 pm

            that’s what i’m sayin’. i just wish mac had been mature enough to clarify their points.

          • October 10, 2013 at 1:16 pm

            “It’s no different from taking a politician’s syllogism and substituting terms in order to show clearly why the =structure= of the argument is fallacious.”

            You’re not free to substitute ANY of the words you like. You’re not demonstrating that the argument is fallacious if you create a strawman, which is exactly what mac did. mac could’ve just substituted “bad clothes” or “cheap clothes” and demonstrated that it’s elitist and discriminatory to judge other people by your own aesthetic taste. mrmisconception did this quite well below by substituting “bad tattoos” for “cheap cars”.

            Instead, mac added demeaning and judgmental words that were never a part of Phil’s argument. He said, “Some tats look good but a lot of people just have poorly drawn scribbles,” not, “Some tats look good but a lot of cheap people just have poorly drawn scribbles.” If you’re adding words instead of substituting words, you’re changing their argument. If you’re changing their argument, you’re creating a strawman. If you’re creating a strawman, you’re not being intellectually honest.

            “And that’s honestly more effort than your fainting spell deserves.” I’m not worked up about this. Are you? Ostensibly, this is a site about critical thinking. If we agree that’s important, than we shouldn’t be above listening to criticism. The community that comments here is important enough to me that I’m willing to spend a few minutes making sure we make good arguments.

          • October 10, 2013 at 3:58 pm

            It was a poorly written and executed analogy, but that’s still all it was….

          • October 10, 2013 at 5:45 pm

            Delphi, you’re a ditz and you obviously don’t understand logic. Swapping terms in an invalid logical construction in order to show its fallacious STRUCTURE is very common and done =all the time= especially to make fallacious reasoning clear to people like you who don’t understand logic.

            Here is the politician’s fallacy (and I’m pulling the example off Wikipedia because I frankly cannot be bothered to come up with something original for you):

            1. We must do something.
            2. This is something.
            Therefore: we must do this.

            This is a fallacious argument and we could talk about the undistributed middle term and explain why an undistributed middle term is faulty reasoning, but it’s way easier to just swap out the TERMS in order to show you, in an easy-to-recognize way, how two true premises can lead to a false conclusion:

            1. All cats have four legs.
            2. My dog has four legs.
            Therefore: my dog is a cat.

            This is the =same= argument as the first one above, with only THE TERMS SWAPPED OUT. So that you can =see very clearly= that it is faulty reasoning without having to know anything about logical structures or syllogisms.

            That’s not a strawman argument and it’s not “adding” dogs and cats to the original argument. The original argument is completely unchanged, and we are only showing that the STRUCTURE of it is bad reasoning.

            I mean, for fuck’s sake, what the hell is wrong with you that you can’t comprehend this? How do you get through life not understanding this concept?

          • October 10, 2013 at 6:16 pm

            Serioulsy, skeith? A “ditz”?

            Just stop.

            Stop right there with that nonesense.

            Won’t even bother to read the rest of your comment.

            Do you have any idea the sexist connotations such an insult holds? Can’t you just argue your points instead of calling people names? JFC.

            Stop.

          • October 11, 2013 at 5:24 pm

            You know what, marilove? You are absolutely correct. It actually hadn’t even crossed my mind, because “ditz” is an equal-opportunity label in my circle. It’s not like a Y-chromosome immunizes men from ditziness and we call men ditzy all the time.

            But you’re right, and I shouldn’t have used the word outside that context.

          • October 11, 2013 at 6:24 pm

            Or you could just refrain from calling people such childish names to begin with, all because you dislike their arguments.

  6. October 9, 2013 at 1:50 pm —

    I have no problem with people driving cars but I do have a problem with cars that are cheap. Its like having an old phone that looks bad. Some cars look good but a lot of people just have basic transportation. Anyone deciding to drive should only do it if they can afford an expensive car.

    That might help you see how your comment could come across as elitist.

  7. October 9, 2013 at 2:07 pm —

    Not to mention what one might consider a “good” tattoo, another may consider a “bad” tattoo. It’s not as objective as some of you are trying to make it.

    Placement, style, subject matter … it can all change how someone views a tattoo.

    One of my friends is a piercer. A damn good one. He has piercing and tattoos EVERYWHERE — including his face! Including “bad” tattoos which he consideres awesome, because, as he says, they ALL have a story. They are part of who he is. He loves his tattoos, bad ones and all. He has some really good ones, too, but some are pretty funky and done by total newbs to the business. He loves them.

    Craig Ferguson made a comment once about tattoos, good and bad: They are all part of who he is. They are his story. He is proud of his story, even if his story isn’t always perfect.

  8. October 9, 2013 at 9:59 pm —

    So the lesson from this thread is that “fat” is the equivalent of “Hitler.” Just drop it into any discussion and any point will immediately get squashed.

    • October 10, 2013 at 12:38 pm —

      Hey, I tried, I really did, but mac decided to flounce. mac wasn’t innocent. mac was also really not clear enough, imo.

  9. October 10, 2013 at 9:09 am —

    Do body mod practitioners explain all the potential risks to their customers? Should they achieve some sort of peer review followed by certification and licensure? If a physician is obligated to warn a patient of the rare risk of cavernous sinus thrombosis by picking your nose zit in the facial danger triangle, should a nasal piercing practioner do the same? Indeed, these sorts of risks are far less likely than getting into a car wreck while driving but physicians and surgeons are mandated to review common and rare adverse events with their patients. Therefore should nose piercing practitioners do the same? Should they take courses in head and neck anatomy like medical and dental students? Should they learn all about head and neck pathology, pathophysiology, microbiology, etc..?

    I’m not being facetious here. Given that this site is dedicated to scientific literacy in matters of health for the masses, what are your thoughts on this? And yes, I would even include ear piercing as part of this discourse.

  10. October 10, 2013 at 9:22 am —

    Just googled tatoo artist licensure in Florida which mandates completion of courses on blood bourne pathogens. I think my preceding post written in haste was bourne out of ignorance. Indeed, body mod practioners do need certification to protect us from the quacks.

    • October 10, 2013 at 12:35 pm —

      Good ones, should. Do they all? No. And regulations depend on the state.

      But then again, plenty of asshole doctors exist.

    • October 10, 2013 at 12:51 pm —

      My piercers and tattoo artists are certified, but as marilove pointed out, it depends on the area.

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