Author(s): Melanie Taylor, Ina Park

A natural human desire for novel experiences, coupled with the often-experienced loss of inhibition associated with being away from home, can lead some travelers to take greater than usual sexual behavioral risks (e.g., engaging in sex with new, unknown partners; having sex with multiple partners; connecting with sex networks) while abroad. Any of these behaviors can increase the traveler’s risk for exposure to sexually transmitted infections (STIs), including HIV. Use of alcohol or drugs (which further decrease inhibition), or geosocial networking applications (“apps” which increase the efficiency of meeting sexual partners while abroad) can amplify a traveler’s chances of having an at-risk exposure, in some cases substantially.

Clinicians have an opportunity to help patients reduce their risk of exposure to STIs through pretravel behavioral-prevention and risk-reduction counseling and medical care. Elements of the pretravel preparation include STI prevention guidance (e.g., advocating for the use of condoms or other barrier methods); STI screening, treatment, and vaccines; and a discussion about HIV pre- and postexposure prophylaxis. Consider providing preexposure prophylaxis (PrEP) to prevent HIV infection in travelers planning to have condomless sex. The pretravel consultation also gives clinicians a chance to review safety recommendations to prevent sexual assault during travel.

Sex While Traveling

Sex while traveling encompasses the categories of casual consensual sex, sex tourism, sexual violence or assault, connection to sex trafficking, and sexual exploitation of children.

Casual Consensual Sex

Casual consensual sex during travel describes informal, non-transactional sexual encounters with other travelers or locals. Longer duration of travel, traveling alone or with friends, alcohol or drug use, younger age, and being single are factors associated with engaging in casual sex while traveling internationally. Other associations with casual sex are listed in Box 9-14. Two meta-analyses estimated that 20%–34% of male international travelers engage in casual sex abroad, and that 43%–49% of all travelers participating in casual sex abroad have condomless sex.

Men Who Have Sex With Men

For men who have sex with men (MSM), conclusions from the literature regarding their sexual behavior when traveling are conflicting. Some studies examining MSM sexual behavior when traveling have concluded that this population is more likely to engage in condomless anal intercourse with partners of unknown HIV status; to have concurrent or multiple sex partners; or to have sex in conjunction with substance use while traveling. These can be particularly true if the reason for travel is to attend group sex events or gatherings (e.g., cruises, circuit parties). Other reports, however, indicate that MSM might adapt their behaviors when traveling to destinations perceived to have a higher risk for HIV. One study found that MSM who travel internationally were less likely to have condomless anal intercourse with partners abroad compared to partners encountered at home or during domestic travel.

Sex Tourism

Travel for the specific purpose of procuring sex is considered “sex tourism,” and sex tourism destinations frequently are countries where commercial sex is legal. In some countries, sex tourism supports sex trafficking, among the largest and most lucrative criminal industries in the world. Sex tourists have traditionally been men from high-income countries who travel to low- and middle-income countries to pay for sex with local women, including commercial sex workers. Sex tourism among American and European women also has been described, particularly to the Caribbean.

Having condomless sex with commercial sex workers is associated with an increased risk for STIs. Multidrug-resistant gonorrhea infections have been linked to encounters with sex workers. High rates of HIV are also frequently found among sex workers, with a systematic review describing a global prevalence of 11.8%. Among sex workers in Thailand, however, HIV rates of up to 44% have been described; in Kenya, the rate among sex workers has been reported to be even higher (up to 88%).

Sexual Violence & Assault

People of any age, gender, or sexual orientation can be victims of sexual violence during travel and should be aware of this risk. The risk for sexual assault is greater among young women traveling alone and in regions of high sexual violence prevalence (e.g., central and southern sub-Saharan Africa, Andean Latin America, Australasia). In addition, some studies have identified that young gay and bisexual males (MSM) traveling internationally might be victims of sexual violence more frequently than females or heterosexual males. Sexual violence can occur more often in association with international recreational travel, but it is also reported in travelers participating in humanitarian aid work. Alcohol and drug use have been shown to increase vulnerability for sexual assault. Unfamiliar cultural norms, environments, language barriers, and safety concerns might also increase the risk.

Post–Sexual Assault Medical Care

Victims of sexual violence (particularly rape) should seek immediate medical attention. Health care sought after 72 hours could negate the benefits of postexposure prophylaxis for HIV and STIs, lower the effectiveness of emergency contraception, and reduce the value of any collected forensic evidence. Seeking medical care following a sexual assault can, however, be difficult in places where safety is a concern, where health care is not easily accessed, and where language and other barriers might not facilitate appropriate evaluation.

In addition to HIV and other STI postexposure prophylaxis, emergency contraception, and the forensic examination, medical attention after sexual assault should include treatment of injuries and provision of mental health and other supportive care. Adolescent-adapted services should be available and sought to address the related but different needs of youth who have been victims of sexual violence.

Sex Trafficking & Sexual Exploitation of Children

Although commercial sex work is legal in some parts of the world, sex trafficking, sex with a minor, and child pornography are always criminal activities according to US law, and travelers can be prosecuted in the United States even if they participated in such activities abroad. The Trafficking Victims Protection Act makes it illegal to recruit, entice, or obtain a person of any age to engage in commercial sex acts or to benefit from such activities.

Sex With Minors

Federal law bars US residents traveling abroad from having sex with minors; this applies to all travelers, both adult and youth. Travel health providers should inform student travelers and other young people going abroad that according to US law, it is illegal for a US resident to have sex with a minor in another country. The legal age of consent varies around the world, from 11–21 years old. Some countries have no legal age of consent, with local laws forbidding all sexual relations outside of marriage.

Child Pornography

Regardless of the local age of consent, participation in child pornography anywhere in the world is illegal in the United States. US Code Title 18, Chapter 110, prohibits sex with minors, as well as the purchase, procurement, holding, or storage of material depicting such acts. These crimes are subject to prosecution with penalties of up to 30 years in prison. Victims of child pornography suffer multiple forms of abuse (emotional, physical, psychological, as well as sexual), poverty and homelessness, and health problems, including physical injury, STIs, other infections and illnesses, drug and alcohol addiction, and malnourishment.

Sexual Exploitation of Children

Sexual exploitation of children in travel and tourism affects all countries of the world regardless of income level. Offenders can include expatriates, humanitarian aid workers, international business travelers, military personnel, people attending large-scale sporting and cultural events, teachers, travelers and tourists, and volunteers. Financial vulnerabilities of families and communities resulting from the millions of travel and tourism jobs lost due to the coronavirus disease 2019 pandemic, the availability of cheap and accessible travel, and expanding access to information and communication technologies are expected to increase opportunities for child sexual exploitation.

Combatting Sexual Exploitation of Children

To combat sexual exploitation of children, some international hotels and other tourism services have voluntarily adopted a code of conduct that includes training their employees to recognize and report suspicious activities. Tourist establishments supporting this initiative to protect children from sex tourism are listed online. Providers and travelers who suspect child sexual exploitation occurring abroad can report tips anonymously by calling the Homeland Security Investigations Tip Line (toll-free at 866-347-2423), or by submitting information online to US Immigration and Customs Enforcement or the International Centre for Missing & Exploited Children.

In the United States, the National Center for Missing & Exploited Children’s Cyber Tipline collects reports of child prostitution and other crimes against children (toll-free at 800-843-5678).

Protect Act

Since 2003, when Congress passed the federal PROTECT Act, US Immigrations and Customs Enforcement has arrested >11,000 offenders for child sex tourism and exploitation, including 1,100 outside of the United States. The PROTECT Act strengthens the US government’s ability to prosecute and punish crimes related to sex tourism, including incarceration of ≤30 years for acts committed at home or abroad.

Cooperation of the host country is required to open an investigation of criminal activity, resulting in a much lower than hoped for conviction rate. In some places, the judicial system might be prone to bribery and corruption, or the government is otherwise willing to expand tourism and the money it brings at the expense of children being trafficked for sex. The US Department of State has published a list of 20 ways to fight human trafficking, including recommendations for youth and their parents, attorneys, health care providers, journalists, and other stakeholders.

Sexually Transmitted Infections

See Sec. 11, Ch. 10, Sexually Transmitted Infections, for details regarding the management of STIs in returned travelers.

Epidemiology

In 2019, the World Health Organization estimated that 376 million new infections with curable sexually transmitted pathogens (chlamydia, gonorrhea, trichomoniasis, and syphilis) occur annually. Globally, >500 million adults are estimated to be infected with a genital herpes virus; ≈40 million people are infected with HIV; and >300 million with human papillomavirus infections, the cause of cervical cancer. Over 30 infections are sexually transmitted, several of which are neither curable nor vaccine preventable.

The distribution of STI prevalence and STI resistance to available treatment varies, and some countries and regions have very high rates of STIs. International travelers having sex with new partners while abroad are exposed to different “sexual networks” than at home and can serve as a conduit for importing novel or antimicrobial-resistant STIs into parts of the world where they are unknown or rare. For example, gonorrhea (among the more common STIs globally with ≈78 million new cases in 2016) has become extensively drug resistant in some parts of the world. Multidrug-resistant gonorrhea infections have been associated with unprotected sex and commercial sex during travel. Patients presenting with antimicrobial-resistant gonococcal infections should prompt providers to inquire about their travel history and the travel history of their sex partners.

Prevention

STI incidence is increased ≤3-fold in people who experience casual sex while traveling internationally, a consequence of new sexual partnerships and unprotected intercourse. Condoms prevent both STIs and unwanted pregnancy. Preventive vaccines (which can be considered as part of pretravel care) are available for some infections transmitted through intercourse (e.g., hepatitis A, hepatitis B, human papillomavirus). HIV PrEP might be appropriate for travelers planning to engage in condomless sex during travel. Travelers should consider packing condoms from their home country to avoid the need to search for them in the countries visited during travel. Women carrying condoms in luggage might need to conceal these to avoid questions related to sexual activity or assumed behaviors.

Mpox

In May 2022, a multinational outbreak of monkeypox (mpox) began; 3 months later (by the end of August) it involved people from >90 countries. During the outbreak, the causative agent, monkeypox virus (see Sec. 5, Part 2, Ch. 22, Smallpox & Other Orthopoxvirus-Associated Infections), spread person-to-person primarily through close skin-to-skin (including sexual) contact. Most cases occurred among gay, bisexual, and other men who have sex with men; international travel played a role in introducing the virus to new countries. Remind all travelers that sex with new partners can increase their risk of contracting infections, including mpox.

People at risk of mpox exposure and infection during travel should complete mpox vaccination series at least two weeks prior to departure.  Refer susceptible travelers who have been exposed to mpox for vaccination, as soon as possible (ideally within 4 days of exposure) to help prevent the disease or make it less severe.