We characterize associations with and motivations for tattooing in adolescents through data from a controlled, three-group comparison of adolescents from a substance abuse treatment program, detention center, and private pediatric practice. We surveyed 474 adolescents (12 to 18 years old) with tattoos (12%) and without tattoos (88%). The private pediatric practice was the control site. A 34-item questionnaire was used to profile the three groups and their primary associations with tattooing with respect to race, drug use, school attendance, school grades, parental marital status, family income, tattooing by family members, criminal activity, and involvement with satanic rituals. Tattooing was significantly (P less than .005) associated with all of these variables in the ways described, as was knowledge of its association with human immunodeficiency virus infection. No interventions were made. Tattooing is common in adolescents and is associated with low self-esteem, delinquency, drug abuse, family and peer modeling, and participation in satanic rituals. Addressing the behavior as a health problem is discussed.