Author(s): Patricia Walker

Lesbian, gay, bisexual, transgender, queer (LGBTQ+) travelers share many of the same hopes and desires as other people when traveling: to have a safe, happy, and memorable trip. LGBTQ+ travelers have similar risk-taking behaviors as other travelers, which are influenced more by age, gender, socioeconomic status, mental health considerations, and substance use, rather than sexual attraction or identity. LGBTQ+ travelers face some unique risks, however, and clinicians counseling them should tailor their advice accordingly.

Overview

LGBTQ+ travelers contribute greatly to economic development and can convey powerful positive messages related to human rights worldwide. The United Nations World Trade Organization Second Global Report on LGBTQ+ Tourism in 2017 acknowledged that LGBTQ+ persons travel more frequently, demonstrate higher than average spending patterns, and demonstrate brand awareness and loyalty. LGBTQ+ travelers have long been aware of gay-friendly destinations in the United States, including Provincetown, Massachusetts, and Fire Island, New York; and in Europe, including Mykonos, Greece, and Sitges, Spain. Human rights have improved in some countries, and the international tourism industry has become more responsive to LGBTQ+ travelers; many international travel destinations are now recognized as gay friendly. Open for Business is a coalition of leading global companies dedicated to LGBTQ+ inclusion, and recognizes the powerful advantages of inclusive, diverse societies that improve economic, business, and individual performance. The travel industry has long recognized that marketing to the LGBTQ+ community makes economic sense; the International Gay and Lesbian Travel Association was founded in 1983, and provides free travel resources and information, while working to promote quality and safety for LGBTQ+ travelers worldwide.

LGBTQ+ travelers are as diverse as other travelers in terms of how, where, and with whom they prefer to travel; risk-taking behavior; gender expression; skin color; citizenship; and income. In a 2015 study conducted by Global Marketing, behavior of gay men travelers differed from lesbian travelers in several ways: gay men were more likely to travel with other adults, visit gay bars, and have more disposable time and income; lesbian travelers were more likely to travel with family, be more interested in child-friendly rather than LGBTQ+ friendly environments, and have travel preferences and budget constraints more closely aligned to people who are not LGTBQ+ than to gay men. People who are transgender might be more likely to travel for medical reasons, seeking high-quality and affirmational medical and surgical care.

Technology also has changed how LGBTQ+ travelers interact with others while traveling. In one study, 31% of gay men use dating apps while traveling, compared with 4% of lesbian travelers and 15% of all Americans. Men who used the internet to set up dates prior to travel reported far more sexual partners and were much more likely to report having sex with a new partner.

There is no single standard message for counseling the LGBTQ+ traveler (see Box 2-14). During the pretravel consultation with LGBTQ+ travelers, include routine travel advice and specific counseling tailored to the itinerary and planned activities (see Sec. 2, Ch. 1, The Pretravel Consultation). Focused counseling for the LGBTQ+ traveler should include, at a minimum, a discussion of infectious disease risks, legal considerations, safety and security issues, and screening and counseling for potential mental health problems and substance use disorders.

Infectious Disease Counseling

A paucity of research data on LGBTQ+ travelers has been published; a 2021 English language, no date filter, PubMed search found only 41 articles, 30 of which focused on men who have sex with men (MSM) and 2 of which were case reports concerning transgender travelers (1 on genital dermatitis, the other on deep venous thrombosis). Studies have been reported on MSM from Australia, Belgium, Canada, China, Denmark, India, Sweden, Vietnam and those going to Mardi Gras in New Orleans or Key West, Florida, but no studies specific to lesbian travelers have been published.

A 2019 review article on MSM who travel provides advice for clinicians counseling this specific patient population. Studies on MSM behavior while traveling show mixed results—some engage in more high-risk sexual behavior during travel, and some less. A greater risk for acquisition of sexually transmitted infections (STIs) has been shown in MSM who travel, use social apps or illicit drugs, engage in unprotected anal intercourse, join mass gatherings (including Gay Pride), and engage in circuit parties.

In a meta-analysis of foreign travel and sexual behavior, the pooled rate of casual sex was 19.5% for all women and 24.8% for all men. In the same analysis, the rate of unprotected intercourse among women who had casual travel sex was 62.1% and 62.3% among men.

The US Preventive Services Taskforce recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. Provide nonjudgmental counseling to LGBTQ+ travelers. The Gay and Lesbian Medical Association has resources to assist clinicians counseling LGTBQ+ patients.

Counsel travelers that safe sex is proven to reduce the risk of receiving or transmitting chlamydia, gonorrhea, hepatitis A and B, HIV, human papillomavirus (HPV), pubic lice, and syphilis. Depending on a patient’s sexual risk behavior, counsel them on the use of condoms, dental dams, and gloves to reduce risk for STIs. See Sec. 9, Ch. 12, Sex & Travel, for general counseling recommendations on sex and travel.

Enteric Infections

Patients who engage in oral–anal sex might be unaware of their risk for acquiring enteric infections, both bacterial (e.g., Salmonella, Shigella) and parasitic (e.g., Blastocystis spp., Dientamoeba fragilis, Giardia). Counsel patients on use of dental dams and careful washing of hands and genitalia, before and after sex. Offer typhoid vaccination per national guidelines (see Sec. 5, Part 1, Ch. 24, Typhoid & Paratyphoid Fever).

Hepatitis A

Hepatitis A virus (HAV) is transmitted via the fecal–oral route during person-to-person sexual contact and from contaminated food and water. Hepatitis A outbreaks have been reported among MSM. Counsel LGBTQ+ travelers on safer sex, including the use of dental dams, and recommend HAV vaccination.

Hepatitis B

Hepatitis B virus (HBV) is transmitted via percutaneous or mucus membrane exposure to body fluids infected with HBV. MSM have a higher seroprevalence of HBV; offer vaccination to this group irrespective of travel plans. Consider screening for HBV infection in high-risk, previously unvaccinated travelers, including MSM.

Hepatitis C

Hepatitis C virus is generally transmitted via parenteral routes but can be transmitted sexually. Hepatitis C outbreaks have been reported among MSM and have been associated with unprotected anal intercourse, genital ulcerative disease, and traumatic sexual practices (e.g., fisting [inserting a hand in the rectum]). Counsel patients on safer sex practices, including the use of condoms and gloves.

HIV

Assess sexual risk behavior and counsel travelers, including people at risk for sexual assault, on use of preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP). Remind patients that long-term travel, particularly for work, might require HIV testing. Countries might deny entry to people with evidence of HIV infection, and carrying PrEP might be mistaken as evidence of such. See Sec. 5, Part 2, Ch. 11, Human Immunodeficiency Virus / HIV, and Sec. 3, Ch. 1, Immunocompromised Travelers, for additional information.

Human Papillomavirus

Human papillomavirus (HPV) is highly prevalent among MSM. HPV infection is associated with penile, anal, and oropharyngeal cancers and precancers. Offer HPV vaccination per national guidelines.

Invasive Meningococcal Disease

Invasive meningococcal disease (IMD) is a risk for travelers going to the African meningitis belt and among Hajj pilgrims (see Sec. 5, Part 1, Ch. 13, Meningococcal Disease). Another, less well-known group at risk for IMD are MSM, who may have higher carriage rates for Neisseria meningitidis. Potential risk behaviors for IMD include regularly visiting crowded venues; traveling to mass gatherings (e.g., Gay Pride festivals); using illegal drugs; and having multiple sexual partners. Recommend vaccination for HIV-positive travelers. Some local public health authorities have also recommended routine vaccination against meningococcal disease for MSM.

Legal Considerations

LGBTQ+ travelers face unique legal issues and risks while traveling abroad. Many countries have made strides toward combating discrimination against LGBTQ+ persons, but many other countries continue to discriminate against and abuse LGBTQ+ persons. Over 70 countries still consider consensual same-sex sexual relations a crime that can carry severe punishment, including the death penalty. Many countries do not legally recognize same-sex marriage or allow or recognize LGBTQ+ adoptions. Attitudes, even within countries with legal protections, will vary among people and communities where LGBTQ+ persons travel.

The United Nations (UN) has been addressing human rights abuses of the LGBTQ+ community since the 1990s. In a 2015 speech, UN Deputy Commissioner for Human Rights Flavia Pansieri summarized the abuses of the LGBTQ+ community, including murder, rape, mob attacks, abuse by police and prison officials, criminal sanctions, arrest and imprisonment, blackmail and harassment, forced medications and surgeries in medical settings to try to change sexual orientation, forced sterilization of people who are transgender, humiliation, discrimination, job loss, evictions, and refusal of medical treatment. Such issues are a reality in many countries, and clinicians should offer LGBTQ+ travelers resources on differing international laws, attitudes, and customs, and emphasize the realities of behavior constraints that can make a trip safer (Table 2-13).

Travel health providers also should remind LGBTQ+ travelers that they are subject to the laws of any country to which they are traveling, and encourage travelers to read about their destinations before departure. The US Department of State annually publishes Country Reports on Human Rights Practices, which includes a detailed, country-by-country report of issues pertinent to the LGBTQ+ community and offers the printable LGBTQ+ Family Travel Tips pocket card at their website (see Table 2-13 for the website address).

Safety & Security

A general approach to travel safety and security is outlined in Sec. 4, Ch. 11, Safety & Security Overseas. As with many travelers, the joy of feeling more freedom to express oneself while traveling, coupled with substance use, could result in behaviors that put travelers at risk. Each traveler’s perception of and willingness to accept risk also varies (see Sec. 2, Ch. 2, . . . perspectives: Travelers’ Perception of Risk).

LGBTQ+ travelers should be aware that gay-friendly neighborhoods might not reflect societal acceptance and safety in a country overall. LGBTQ+ persons have a lifetime of experience assessing situations to determine whether they can safely be themselves. When traveling, LGBTQ+ persons should be aware of sociocultural differences that can affect their true situational safety. The US Department of State notes that authorities in some countries could be involved in entrapment campaigns, with law enforcement monitoring websites, mobile phone apps, or meeting places. Counsel patients to be cautious connecting with the local community. The US Department of State offers tips for the LGBTQ+ community for staying safe while abroad, including researching destinations, updating passports, packing important documents, living abroad with a foreign national spouse or partner, visa issues, and adoption issues.

Advise transgender travelers that the Transportation Security Administration (TSA) offers specific screening considerations for transgender passengers, including information on reporting prostheses or discrimination at screening checkpoints, at the TSA website.

Although published data are lacking, media reports suggest that people who are openly lesbian, whether single or coupled, and people who are transgender might be at greater risk for physical and sexual assault worldwide. LGBTQ+ travelers should contact the nearest US embassy or consulate if they have troubles while abroad; the Department of State website assures travelers that consular officers will protect their privacy and will not generalize, make assumptions, or pass judgment.

Mental Health & Substance Use

LGBTQ+ identity can be a source of strength and courage for many, but the lack of acceptance, overt discrimination, rejection, and denial of rights can lead to or exacerbate mental health issues among this population. Lesbian, gay, and bisexual adults are more than twice as likely as other adults to experience a mental health condition, and people who are transgender are >4 times more likely to experience a mental health condition than people who are cisgender (persons whose gender identity corresponds with their birth sex). Adolescents and young adults are at particularly high risk for suicide, and LGBTQ+ youth are more than twice as likely to experience persistent feelings of sadness and hopelessness than their peers who are not LGTBQ+. Transgender youth face further disparities and are twice as likely to experience depressive symptoms, seriously consider suicide, and attempt suicide compared with cisgender lesbian, gay, bisexual, queer, and questioning youth.

LGBTQ+ adults are twice as likely to experience a substance use disorder, and people who are transgender are 4 times as likely. Heavy drinking, binge drinking, tobacco use, and use of illicit drugs, including amyl nitrate (known as poppers), cannabis, MDMA (known as ecstasy or Molly), and amphetamines are more common in segments of the LGBTQ+ community. Several studies outline the association of recreational drug use with riskier sexual behavior during travel, including unprotected anal intercourse in MSM.

As outlined in Sec. 2, Ch. 12, Mental Health, travel medicine providers should screen for depression and anxiety in people planning extended or frequent travel; participants in humanitarian or disaster relief work; and anyone intending to take up long-term or semipermanent residence in another country. Little research and no published guidelines are available on LGBTQ+ travelers and mental health or substance abuse outcomes during and after travel, but the available data on prevalence of mental health issues and substance use suggest screening is appropriate for all LGBTQ+ travelers, including adolescents, for both mental health and substance use or abuse concerns.

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.