Sex & Travel
The World Health Organization estimates approximately 357 million infections with curable sexually transmitted pathogens (chlamydia, gonorrhea, trichomoniasis, and syphilis) per year, or nearly 1 million new infections per day. More than 30 different sexually transmitted infections (STIs) are caused by a range of pathogens, not all of which are curable or vaccine preventable. Travel health providers have a responsibility to educate their patients about what they can do to reduce the chances of acquiring an STI during travel. Targeted teaching and messaging to travelers at highest risk is a prudent approach.
Global distribution of sexually transmitted pathogens and their sensitivity to available treatment varies. 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 importation of novel or drug-resistant STIs into parts of the world where they are unknown or rare. Gonorrhea, for example, among the more common STIs globally (with an estimated 85 million new cases in 2012), has become extensively drug resistant in some parts of the world. Patients presenting with antimicrobial-resistant gonococcal infections should prompt providers to inquire about their travel history and the travel history of their sex partners.
Casual Sex During Travel
It is important to distinguish between casual sex and sex tourism. Sex tourism (see below) is travel for the specific purpose of having sex, typically with commercial sex workers. Casual sex during travel, by contrast, describes informal sexual encounters with fellow travelers or locals. Although some travelers may expect to have casual sexual encounters, others who have sex do not.
Two meta-analyses (2010 and 2018) provide a range of how many international travelers engage in casual sex, approximately 20%–34%. Although crude—both the 2010 and 2018 pooled prevalence values are based on just a handful of studies, each with considerable variation in their own estimates—these numbers shed some light on how common casual sex during travel may be. These same studies also provide estimates on the number of travelers engaging in unprotected sex (i.e., sex without a condom). The 2010 report indicates that approximately half (49%) of all travelers participating in casual sex abroad have unprotected intercourse, although in the 2018 report, that number was slightly lower (43%).
Populations less well represented in the literature include female travelers and men who have sex with men (MSM). Limited data on the casual sexual activity of female travelers suggest that such activity occurs almost as frequently as it does in male travelers, and that the incidence of unprotected sex is nearly as high. Existing literature concerning MSM is conflicting. Some studies report MSM are more likely to have new sex partners and unprotected intercourse while abroad. A recent study from California, however, demonstrated that MSM who travel internationally are more likely to use condoms and engage in less risky behavior.
As travelers go places where they are not known, they may no longer feel obligated to observe the same moral standards as at home, or they may desire to create connection with others. The act of travel itself may create the potential for casual sex. Disinhibition resulting from drug and alcohol use, a desire for adventure and excitement, peer pressure, and underlying psychological needs and personality traits may contribute, individually or in combination, to travelers having casual sex. Several studies (including the meta-analyses referenced above) have attempted to identify characteristics of travelers who are most likely to have casual sex during travel (Box 9-6). See Chapter 2, The Pretravel Consultation, for additional recommendations and guidance on preventing STIs.
Box 9-6 Factors associated with higher frequency of casual or unprotected sex abroad
- Younger age
- Traveling without a partner (either alone or with friends)
- ≥2 sex partners in the last 2 years
- History of previous sexually transmitted infection
- Illicit drug use, alcohol abuse, tobacco use
- Casual sex at home and during a previous travel experience
- Expectation of casual sex while abroad
- Long-term travel (expatriates, military, Peace Corps volunteers)
“Sex tourism,” as defined above, is travel specifically for the purposes of procuring sex. In one study, typical sex tourists were highly educated men, 30–40 years of age, going to economically disadvantaged countries to pay for sex with commercial sex workers. Fewer than half of these men reported regularly using condoms, even in destinations where the prevalence of STIs (including HIV disease) is high.
In some countries, commercial sex work is legal and culturally acceptable. In many other places, however, sex tourism supports sex trafficking, among the largest and most lucrative criminal industries in the world.
Sexual Abuse, Child Pornography, and the Law
Although commercial sex work may be legal in some parts of the world, sex trafficking, sex with a minor, and child pornography are always criminal activities according to US law; travelers can be prosecuted in the United States even if they participated in such activities overseas. 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.
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. Bear in mind, however, that the legal age of consent varies around the world, from 11–21 years. In some countries, there is no legal age of consent: local law forbids all sexual relations outside of marriage.
Regardless of the local age of consent, participation in child pornography anywhere in the world is illegal in the United States. This includes 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 (sexual, physical, emotional, and psychological), poverty and homelessness, and health problems, including physical injury, STIs, other infections and illnesses, addiction, and malnourishment.
A report published in 2016 by End Child Prostitution, Child Pornography, and Trafficking of Children for Sexual Purposes International (ECPAT) identified that most perpetrators of child pornography are “situational” offenders, people who may have never considered sexually exploiting a child until given the opportunity to do so. Americans and US permanent residents account for an estimated 25% of child sex tourists worldwide and up to 80% in Latin America. They are typically white men aged ≥40 who have been traced visiting Mexico, Central and South America (Brazil, Colombia, Costa Rica, Dominican Republic), Southeast Asia (Cambodia, India, Laos, Philippines, Thailand), Eastern Europe (Estonia, Latvia, Lithuania, Russia), and other regions.
To combat child sexual abuse, some international hotels and other tourism services have voluntarily adopted a code of conduct that includes training and reporting suspicious activities. Tourist establishments supporting this initiative to protect children from sex tourism are listed online (www.thecode.org). Providers and travelers who suspect child sexual exploitation occurring overseas can report tips anonymously by:
- Using the Operation Predator smart-phone app (https://itunes.apple.com/us/app/operation-predator/id695130859).
- Calling the Homeland Security Investigations Tip Line (866-347-2423).
- Submitting information online (www.ice.gov/tips).
In the United States, the National Center for Missing & Exploited Children’s CyberTipline collects reports of child prostitution and other crimes against children (toll-free at 800-843-5678, https://report.cybertip.org).
Since 2003, when Congress passed the federal PROTECT Act, at least 8,000 Americans have been arrested—and 99 convicted—for child sex tourism and exploitation. The PROTECT Act strengthens the US government’s’ ability to prosecute and punish crimes related to sex tourism, including incarceration of up to 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. Some countries are wary of working too closely with the United States. In others, the judicial system may be prone to bribery and corruption, or the government is otherwise willing to expand tourism (and the money it brings in) at the expense of children being trafficked for sex. For more ways you can help, see the Department of State list of 15 ways to fight human trafficking (www.state.gov/j/tip/id/help).
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Jay Keystone, Kimberly A. Workowski, Emily Meites