Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis
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Figure 1
Literature search and selection flowchart.
Figure 2
Proportion meta-analysis of new sexual partnerships acquired abroad, overall and by sex.
Figure 3
Proportion meta-analysis of unprotected intercourse, overall and by sex.
Figure 4
Risk of sexually transmitted infection associated with casual travel sex, by sex.
Article Outline
- 1. Introduction
- 2. Methods
- 3. Results
- 3.1. Study characteristics
- 3.2. Type and quality of studies
- 3.3. New sexual partnerships abroad
- 3.4. Unprotected intercourse
- 3.5. Risk factors
- 3.6. Cultural differences
- 3.7. Women travelers
- 3.8. Long-stay travelers
- 3.9. Male travelers who have sex with men
- 3.10. HIV-positive travelers
- 3.11. Commercial sex work and tourists
- 3.12. Incidence of travel-related STIs
- 3.13. Prevention
- 4. Discussion
- References
Summary
Objectives
With increasing international travel it is important to understand how frequent casual travel sex and unprotected intercourse are, and what impact this may have on the risk of acquiring sexually transmitted infections (STIs).
Methods
We conducted a systematic review, and where appropriate meta-analyses, to ascertain the influence of foreign travel on behavior, including new partnerships, unprotected intercourse, and STI acquisition.
Results
The pooled prevalence of travel-associated casual sex was 20.4% (95% confidence interval (CI) 14.8–26.7%), with 49.4% (95% CI 38.4–60.5%) of these having unprotected intercourse. The predominant characteristics of people who had new sexual partners abroad were: young age, male gender, single status, and traveling alone or with friends, with a previous history of multiple sexual partners or an STI. People who travel or stay abroad for longer periods and men who have sex with men are at higher risk of developing new sexual partnerships and having unprotected intercourse. The risk of developing an STI is increased up to 3-fold in people who experience casual travel sex.
Conclusions
New sexual partnerships and unprotected intercourse abroad are relatively common. People who develop new sexual partnerships and have unprotected intercourse abroad have an increase risk of STIs. There is, however, a paucity of information related to strategies to prevent the risk of STI acquisition during foreign travel.
Keywords:
Sexual behavior, International travel, Sexual partnerships, Systematic review, Meta-analysis1. Introduction
The number of individuals traveling abroad has increased consistently over the last three decades.1x1Office for National Statistics, UK Government. Travel and tourism. UK residents visits abroad up by 2 per cent. London: ONS; 2007. Available at: http://www.statistics.gov.uk/pdfdir/ottnr0807.pdf (accessed).
Google ScholarSee all References Foreign travel is in many ways related to the spread of diseases and, with the increasing affordability of air travel, there is a risk of the rapid globalization of emerging infections. These trends are also likely to affect the incidence, distribution, and types of sexually transmitted infections (STIs).
Historic trends suggest that this phenomenon is not new and has had devastating consequences in certain populations. Syphilis is said to have been taken into America by explorers, the globalization of HIV has also been helped by travel and migration,2x2Hawkes, S.J. and Hart, G.J. Travel, migration and HIV. AIDS Care. 1993;
5: 207–214
Crossref | PubMed | Scopus (41) | Google ScholarSee all References and cases of resistant strains of Neisseria gonorrhoeae in the UK and other developed countries have also been identified as imported.3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 4x4Patrick, D., Shaw, C., and Rekart, M.L. Neisseria gonorrhoeae with decreased susceptibility to ciprofloxacin in British Columbia: an imported phenomenon. Can Commun Dis Rep. 1995;
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PubMed | Google ScholarSee all References, 5x5Turner, A., Gough, K.R., Jephcott, A.E., and McClean, A.N. Importation into the UK of a strain of Neisseria gonorrhoeae resistant to penicillin, ciprofloxacin and tetracycline. Genitourin Med. 1995;
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Crossref | PubMed | Scopus (14) | Google ScholarSee all References There are many reasons that make foreign travel a risk factor for the acquisition of STIs. When abroad, whether on business or on holiday, people may feel less inhibited due to a perceived relaxation of social and moral constraints, leading to changing sexual behavior and exposure to STIs.
We conducted a systematic literature review to identify the prevalence of new sexual partnerships acquired abroad and the rate of unprotected intercourse, factors associated with increased sexual risk behavior, in order to assess the implications that these may have on prevention.
2. Methods
2.1. Search strategy and selection criteria
We searched Medline (from 1950), CINAHL (from 1980) and EMBASE (from 1974) up until the end of January 2008 with the terms ‘sexually transmitted diseases’, ‘sexually transmitted infections’, or ‘sexual behavior’, and ‘travel’ or ‘holiday’, and ‘international’, ‘foreign’ or ‘abroad’. Truncations were used for terms that could have more than one spelling and to include the plural and singular of the same word. Specific infections were also searched using MeSH terms. Titles and abstracts identified were screened. We retrieved any original research article. We also screened the references of identified review articles.
Studies were included in the review if they related to sexual behavior in the context of foreign travel and reported figures on casual sex, unprotected intercourse with a new partner, or incidence of STIs; they were excluded if they related to migration and travel in-country or if travel was between two developing countries only. Any study designs (i.e., cohort, case–control, and cross-sectional) and studies in any language were included.
Studies were read by two reviewers, who extracted the data. Discrepancies were discussed to reach agreement. The following information was extracted where available: prevalence of new sexual partnerships, unprotected intercourse, the risk factors associated with these, and the incidence of STIs. The same researchers independently reviewed all studies included in the review, paying attention to the following criteria: whether the research question was clearly stated; the study design and methods appropriately addressed the research question; the recruitment framework used minimized bias and the sample was representative of the population being studied; the criteria for inclusion/exclusion were explicit; the outcome measures were adequate for inclusion in a meta-analysis (i.e., they reported either new sexual partnerships, unprotected intercourse, or a new diagnosis of STIs) or if other outcomes were included, these were relevant; the analysis used any form of adjustment or correction for possible or known confounders; and claims in the discussion were supported by the data presented.
The questions relating to recruitment framework and explicitness of inclusion and exclusion criteria were used to assess the possibility of bias, whereas the assessment of the type and rigor of analysis were used to assess the possible effect of confounders. For each of these topics, reviewers were asked to state whether the study addressed the issue adequately, not adequately, or whether the information provided was not reported or unclear. Overall, studies were rated depending on the reviewers’ impression of how well the study was conducted as ++ (>75% criteria well covered), + (50–75% criteria well covered), or − (<50% criteria well covered).
Studies were not excluded on the basis of quality criteria if they met the inclusion criteria. Instead, a descriptive summary of the quality of studies is provided in the Results section and this was used as the basis to stratify the analysis. In broad terms a quality gradient exists from larger population-based studies (highest quality or ++), through clinic-based studies (mostly +), to studies sampling populations of travelers (generally lowest, + or −). This classification is also convenient, as the background risk is also likely to be highest among clinic users and lowest in the general population samples. Meta-analysis was done with all the studies together, but also stratified by gender and by type of population sampled to assess whether differences exist in the prevalence of casual travel sex and unprotected intercourse.
To explore cultural differences associated with casual travel sex and unprotected intercourse we compared the pooled rates between studies that sampled UK residents only with those that drew samples from other countries or international students.
2.2. Quantitative analysis
Studies reporting either occurrence of new sexual partnerships, unprotected intercourse, or STIs in groups of men and women traveling were included in a meta-analysis. A random effects model was used to estimate pooled rates of casual travel sex and unprotected intercourse through meta-analysis if the I2 statistic was high; otherwise a fixed effect model was used. To ascertain the rate of casual sex and unprotected intercourse with a new partner associated with foreign travel we calculated pooled proportions, while to estimate the risk of acquiring an STI through casual travel sex we calculated pooled odds ratios (OR). A 95% confidence interval (CI) was estimated for all the results. All the analyses were conducted using StatsDirect version 2.6.3 (StatsDirect, 2007).
We used Forest plots for graphical representation of the various meta-analyses. This type of representation shows the estimate from each individual study with 95% CI, together with the pooled estimate; it can also show the amount of variation between the studies and the overall result at a glance.
A narrative synthesis of studies reporting characteristics associated with sexual partnership acquisition abroad or unsafe sex was used, as meta-analysis was not appropriate due to heterogeneity of study design and differences in the populations being studied.
3. Results
3.1. Study characteristics
A total of 246 articles were identified with the initial search (115 in MEDLINE, 21 in CINAHL, and 110 in EMBASE). After removing duplicated articles 75 and 59 reviews, and adding 3 articles identified cited elsewhere, we reviewed the title, keywords and abstract of the remaining 115 articles. A further 71 articles were excluded because they were letters, editorials, or guidelines and did not report primary research. Fourty-four articles were selected for further assessment (Figure 1).
Figure 1
Literature search and selection flowchart.
Of the 44 articles reviewed, only 37 fulfilled the inclusion criteria. Twenty-eight studies included groups of men and women of mixed sexual preferences. Of these, two studies were later excluded because they studied samples of people who had traveled, but not necessarily abroad.7x7Apostolopoulos, Y., Sonmez, S., and Yu, C.H. HIV-risk behaviours of American spring break vacationers: a case of situational disinhibition?. Int J STD AIDS. 2002;
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Crossref | PubMed | Scopus (13) | Google ScholarSee all References Three articles reported different aspects of the same study.9x9Arvidson, M., Kallings, I., Nilsson, S., Hellberg, D., and Mårdh, P.A. Risky behavior in women with history of casual travel sex. Sex Transm Dis. 1997;
24: 418–421
Crossref | PubMed | Scopus (11) | Google ScholarSee all References, 10x10Arvidson, M., Hellberg, D., and Mårdh, P.A. Sexual risk behavior and history of sexually transmitted diseases in relation to casual travel sex during different types of journeys. Acta Obstet Gynecol Scand. 1996;
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Crossref | PubMed | Scopus (20) | Google ScholarSee all References, 11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References This was a study of foreign travel-associated casual sex in women only. Additionally, seven studies referred to people who had stayed in foreign countries for a prolonged period of time (e.g., volunteers, casual workers, and military personnel),12x12Hopperus Buma, A.P., Veltink, R.L., van Ameijden, E.J., Tendeloo, C.H., and Coutinho, R.A. Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia. Genitourin Med. 1995;
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Crossref | PubMed | Scopus (46) | Google ScholarSee all References two to male travelers who have sex with men,19x19Clift, S.M. and Forrest, S.P. Factors associated with gay men's sexual behaviours and risk on holiday. AIDS Care. 1999;
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3.2. Type and quality of studies
Of 25 remaining studies included in the qualitative analysis, nine were conducted in clinical settings,10x10Arvidson, M., Hellberg, D., and Mårdh, P.A. Sexual risk behavior and history of sexually transmitted diseases in relation to casual travel sex during different types of journeys. Acta Obstet Gynecol Scand. 1996;
75: 490–494
Crossref | PubMed | Scopus (20) | Google ScholarSee all References, 22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60
Crossref | PubMed | Scopus (19) | Google ScholarSee all References, 23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References, 24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
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PubMed | Google ScholarSee all References, 25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
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Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 27x27Mendelsohn, R., Astle, L., Mann, M., Shahmanesh, M., Mendelsohn, R., Astle, L. et al. Sexual behaviour in travellers abroad attending an inner-city genitourinary medicine clinic. Genitourin Med. 1996;
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PubMed | Google ScholarSee all References, 28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
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Crossref | PubMed | Google ScholarSee all References mainly genitourinary medicine (GUM) clinics, 11 were surveys of travelers, generally returning from a journey overseas or in the departure lounge of the airport,3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
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Table 1 summarizes the characteristics of the studies included in the review. One study referred only to women.10x10Arvidson, M., Hellberg, D., and Mårdh, P.A. Sexual risk behavior and history of sexually transmitted diseases in relation to casual travel sex during different types of journeys. Acta Obstet Gynecol Scand. 1996;
75: 490–494
Crossref | PubMed | Scopus (20) | Google ScholarSee all References Two studies focused mainly on men who had sex with commercial sex workers (CSWs) among frequent travelers to mainland China from Hong Kong, although information was also available on casual travel sex with non-CSW partners.39x39Lau, J.T. and Wong, W.S. Behavioural surveillance of sexually-related risk behaviours for the cross-border traveller population in Hong Kong: the evaluation of the overall effectiveness of relevant prevention programmes by comparing the results of two surveillance surveys. Int J STD AIDS. 2000;
11: 719–727
Crossref | PubMed | Scopus (24) | Google ScholarSee all References, 40x40Lau, J.T. and Thomas, J. Risk behaviours of Hong Kong male residents travelling to mainland China: a potential bridge population for HIV infection. AIDS Care. 2001;
13: 71–81
Crossref | PubMed | Scopus (64) | Google ScholarSee all References Most of the studies were conducted in the UK or sampled UK travelers (Table 1).
| Author (year) [Ref.] | Study type | Analysis | Setting | Participants | Population studied | Sample size | Period |
|---|---|---|---|---|---|---|---|
| Abdullah (1998) [3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144 PubMed | Google ScholarSee all References] | Cross-sectional | Adjusted | Departing international travelers | Men and women aged 18–65 years not accompanied by their family | International | 383 | CTS within last 12 months |
| Arvidson (1996) [10x10Arvidson, M., Hellberg, D., and Mårdh, P.A. Sexual risk behavior and history of sexually transmitted diseases in relation to casual travel sex during different types of journeys. Acta Obstet Gynecol Scand. 1996;
75: 490–494 Crossref | PubMed | Scopus (20) | Google ScholarSee all References] | Cross-sectional | Family planning clinic | Women only | Sweden | 996 | CTS ever | |
| Batalla-Duran (2003) [30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494 Crossref | PubMed | Scopus (2) | Google ScholarSee all References] | Cross-sectional | Unadjusted | Returning UK travelers from Tenerife (Spain) | Men and women aged 15–62 years | UK | 136 | CTS in recent visit abroad |
| Bavastrelli (1998) [22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60 Crossref | PubMed | Scopus (19) | Google ScholarSee all References] | Case series | Unadjusted | O&G/ID or tropical medicine clinic | Men and women aged 14–25 years | Italy | 130 | |
| Bellis (2000) [34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244 Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References] | Cross-sectional | Adjusted | Returning travelers from Ibiza (Spain) | Men and women aged 15–35 years | UK | 846 | CTS in recent visit abroad |
| Bellis (2004) [31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47 Crossref | PubMed | Scopus (97) | Google ScholarSee all References] | Cross-sectional | Adjusted | Returning travelers from Ibiza (Spain) | Men and women aged 15–35 years | UK | 1559 | CTS in recent visit abroad |
| Bloor (1998) [43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668 Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References] | Case–control | Adjusted | General population | Men and women aged 18–34 years who had traveled without a partner; cases had a new sexual relationship during their trip | UK | 5276 | CTS in previous 2 years |
| Cabada (2002) [32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513 Crossref | PubMed | Scopus (40) | Google ScholarSee all References] | Cross-sectional | Unadjusted | Returning travelers from Peru | Men and women aged 15–49 years | International | 442 | CTS in recent visit abroad |
| Cabada (2003) [33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218 Crossref | PubMed | Google ScholarSee all References] | Cross-sectional | Adjusted | Returning travelers from Cuzco (Peru) | Men and women aged 15–51 years | International | 2540 | CTS in recent visit abroad |
| Carter (1997) [23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338 Crossref | PubMed | Scopus (46) | Google ScholarSee all References] | Cross-sectional | Unadjusted | GUM clinic | Men and women aged 15–57 years who had traveled | UK | 325 | CTS in last 3 months |
| Croughs (2008) [41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12 Crossref | PubMed | Scopus (38) | Google ScholarSee all References] | Cross-sectional survey | Adjusted | Patients recruited prospectively from a travel clinic and surveyed 6 weeks later, after travel. | Men and women aged 18–50 years, who traveled for less than 4 weeks and spoke Dutch | The Netherlands | 1907 | CTS in recent visit abroad |
| Daniels (1992) [24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
3: 437–438 PubMed | Google ScholarSee all References] | Cross-sectional | Unadjusted | GUM clinic | Men and women aged 18–64 years | UK | 243 | |
| Egan (2001) [35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58 Google ScholarSee all References] | Cross-sectional | Unadjusted | Traveling backpackers | Men and women aged <35 years staying at youth hostels and self-defined as backpackers | International | 504 | CTS while traveling in Canada |
| Gagneux (1996) [42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21 Crossref | PubMed | Scopus (37) | Google ScholarSee all References] | Cross-sectional/intervention study | Unadjusted | People seeking pre-travel advice | Men and women | Switzerland | 1839 | CTS during recent visit abroad |
| Gehring (1998) [36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209 Crossref | PubMed | Scopus (17) | Google ScholarSee all References] | Cross-sectional/intervention study | Unadjusted | Arriving and returning travelers | Men and women aged 16 years or older | German-speaking | 1381 | CTS in recent visit abroad |
| Hawkes (1994) [26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252 Crossref | PubMed | Scopus (77) | Google ScholarSee all References] | Cross-sectional | Adjusted | Tropical medicine clinic | Men and women attending clinic | UK | 757 | CTS in recent visit abroad |
| Hawkes (1995) [25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354 PubMed | Google ScholarSee all References] | Cross-sectional | Unadjusted | GUM clinic | Men and women attending clinic | UK | 386 | CTS in last 3 months |
| Lau (2000) [39x39Lau, J.T. and Wong, W.S. Behavioural surveillance of sexually-related risk behaviours for the cross-border traveller population in Hong Kong: the evaluation of the overall effectiveness of relevant prevention programmes by comparing the results of two surveillance surveys. Int J STD AIDS. 2000;
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| Lau (2001) [40x40Lau, J.T. and Thomas, J. Risk behaviours of Hong Kong male residents travelling to mainland China: a potential bridge population for HIV infection. AIDS Care. 2001;
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| Mendelsohn (1996) [27x27Mendelsohn, R., Astle, L., Mann, M., Shahmanesh, M., Mendelsohn, R., Astle, L. et al. Sexual behaviour in travellers abroad attending an inner-city genitourinary medicine clinic. Genitourin Med. 1996;
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| Mercer (2007) [44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
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| Nemoto (2002) [38x38Nemoto, T., Yokota, F., Hanafusa, K., and Wada, K. HIV-related risk behaviors among Japanese tourists in the Khaosan Road area, Bangkok, Thailand. AIDS Behav. 2002;
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| Nemoto (2007) [37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
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| Tveit (1994) [28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
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| Velasco (2001) [29x29Velasco, M., Morote, S., Aramburu, C., Quinto, L., Corachan, M., Gascon, J. et al. [Sexual behavior risk in Spanish international travelers] (In Spanish). Med Clin (Barc). 2001;
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CTS, casual travel sex; O&G, obstetrics and gynecology; ID, infectious diseases; GUM, genitourinary medicine.
Of the 25 studies analyzed, two were case series,22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60
Crossref | PubMed | Scopus (19) | Google ScholarSee all References, 27x27Mendelsohn, R., Astle, L., Mann, M., Shahmanesh, M., Mendelsohn, R., Astle, L. et al. Sexual behaviour in travellers abroad attending an inner-city genitourinary medicine clinic. Genitourin Med. 1996;
72: 43–46
PubMed | Google ScholarSee all References another two were intervention studies,36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References, 42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References one was a case–control study,43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References and the rest were cross-sectional surveys. The period of travel studied varied from study to study, from the trip people were returning from or the most recent journey abroad to any travel within the past five years.
All the studies together represent a sample of 33 966 participants who had traveled. However, the two studies that sampled directly from the general population had the largest number of participants,43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References and they also had the most rigorous sampling frameworks to reduce selection bias. Most studies recruited subjects after the period of travel; however, two studies recruited participants prospectively before the planned travel and surveyed them after the period in which travel took place.41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
Crossref | PubMed | Scopus (38) | Google ScholarSee all References, 42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References
From an analytical point of view, only nine studies that assessed the characteristics of risks associated with engaging in casual travel sex adjusted the analysis for known confounders or used multivariable logistic regression in their analyses.3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47
Crossref | PubMed | Scopus (97) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References, 41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
Crossref | PubMed | Scopus (38) | Google ScholarSee all References, 43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References
In general terms, studies that recruited from the general population were of highest quality because they had larger samples, more strict sampling frameworks, and provided adjustment for possible confounding factors in their analyses. Conversely, studies that sampled from returning travelers were more vulnerable to bias because they used convenience samples, with less strict sampling frameworks and were less likely to use adjustment in the analysis. Studies that recruited from a clinical setting lay somewhere in between those using convenience samples and those using populations.
3.3. New sexual partnerships abroad
Twenty-two studies of men and women of mixed or undetermined sexual preference and the study of women only, reported on or had enough information to allow estimation of the proportion of subjects engaged in casual sex abroad. The prevalence of travel-associated casual sex ranged between 5.6% and 62.9%. There was considerable variation across studies (I2 99.5%, 95% CI 99.4–99.5%). The pooled prevalence from all the studies was 20.4% (95% CI 14.8–26.7%) with considerable variation between studies, shown in the Forest plot (Figure 2). The prevalence of new sexual partnerships associated with foreign travel varied depending on the type of population sampled, being highest among samples drawn from clinical settings (31.8%, 95% CI 20.7–43.9%; I2 98.6%) and travelers (19.7%, 95% CI 10.3–31.3%; I2 99.6%) and lowest in samples drawn from people in the general population (9%, 95% CI 6.3–12.13%). It also depended on travel destination and age of the sample. For example, people returning from Peru32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
Crossref | PubMed | Scopus (40) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References had lower rates than people returning from Ibiza30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494
Crossref | PubMed | Scopus (2) | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References or Tenerife.31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47
Crossref | PubMed | Scopus (97) | Google ScholarSee all References
Figure 2
Proportion meta-analysis of new sexual partnerships acquired abroad, overall and by sex.
Carter et al. found an increase in the rate of sexual contact during travel abroad compared with the 3 months before, suggesting that there are changes in sexual behavior with travel.23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References On the other hand, a similar study by Hawkes et al. suggested a greater rate of new sexual contacts in the 3 months before travel.25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References Also, Nemoto et al. asked about people's behavior abroad and back in their home country and found that the rate of casual sex abroad was lower than in the home country.37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References As these studies asked retrospectively about behavior before traveling abroad, they are subject to recall bias; also the periods of observation are different (i.e., recent casual sex abroad compared with casual sex in the home country). None of the studies compared a group that had traveled abroad with one that had not traveled; as a result, it is not possible to ascertain from their results whether the prevalence of casual travel sex is any different to that of casual sex in those who do not travel.
3.4. Unprotected intercourse
Only 14 studies had enough information to estimate the rate of unprotected intercourse among those who have casual travel sex. Again there was a high level of heterogeneity across studies (I2 97.5%, 95% CI 97.1–97.9%), therefore a random effects model was used to calculate the pooled rate; this was 49.4% (95% CI 38.4–60.5%). The Forest plot (Figure 3) shows variations between the studies used in the meta-analysis. There were no differences in the rates according to recruitment setting: returning travelers 43.1% (95% CI 27.9–59%; I2 98.7%) and clinical setting 55.2% (95% CI 47–63.2%; I2 78%).
Figure 3
Proportion meta-analysis of unprotected intercourse, overall and by sex.
Carter et al. suggested that there is no change in the rate of unprotected intercourse associated with foreign travel and that those who inconsistently use condoms before travel also do so when they have new sexual contacts abroad.
3.5. Risk factors
Eighteen studies looked at the characteristics associated with developing new sexual partnerships abroad (Table 2). Most studies agreed that typically those engaging in casual travel sex are men,3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References, 24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
3: 437–438
PubMed | Google ScholarSee all References, 32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
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10: 214–218
Crossref | PubMed | Google ScholarSee all References, 36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References, 41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
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3: 14–21
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352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References single,30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494
Crossref | PubMed | Scopus (2) | Google ScholarSee all References, 32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
Crossref | PubMed | Scopus (40) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
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352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References and of younger age.3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494
Crossref | PubMed | Scopus (2) | Google ScholarSee all References, 31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47
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29: 510–513
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10: 214–218
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352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
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Crossref | PubMed | Scopus (17) | Google ScholarSee all References or without their partner,41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
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3: 14–21
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352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References Six studies identified people who stayed abroad for longer periods of time as being at an increased risk of developing new sexual relations.26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
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29: 510–513
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10: 214–218
Crossref | PubMed | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
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| Author (year) [Ref.] | Male | Single | Homo/bisexual | Young age | Travel alone | Travel with friends | Multiple partners | Previous STI | Business travel | Drugs | Alcohol | Condom or expect to have sex | Longer duration | Other |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Abdullah (1998) [3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144 PubMed | Google ScholarSee all References] | Y | 18–25 | Y | White ethnic background | ||||||||||
| Arvidson (1996) [10x10Arvidson, M., Hellberg, D., and Mårdh, P.A. Sexual risk behavior and history of sexually transmitted diseases in relation to casual travel sex during different types of journeys. Acta Obstet Gynecol Scand. 1996;
75: 490–494 Crossref | PubMed | Scopus (20) | Google ScholarSee all References] | ||||||||||||||
| Batalla-Duran (2003) [30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494 Crossref | PubMed | Scopus (2) | Google ScholarSee all References] | Y | <25 | Y | |||||||||||
| Bellis (2000) [34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244 Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References] | Y | Y | ||||||||||||
| Bellis (2004) [31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47 Crossref | PubMed | Scopus (97) | Google ScholarSee all References] | 16–25 | Y | Y | |||||||||||
| Bloor (1998) [43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668 Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References] | Y | Y | 18–24 | Y | Y | Y | Y | Y | Holidaymakers, long haul destinations and first sexual experience at ≤16 years | |||||
| Cabada (2002) [32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513 Crossref | PubMed | Scopus (40) | Google ScholarSee all References] | Y | Y | Y | 15–35 | Y | Y | Being American | |||||||
| Cabada (2003) [33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218 Crossref | PubMed | Google ScholarSee all References] | Y | Y | Y | 15–35 | Y | Y | Y | Y | Being American | |||||
| Carter (1997) [23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338 Crossref | PubMed | Scopus (46) | Google ScholarSee all References] | Y | Y | Y | Y | ||||||||||
| Croughs (2008) [41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12 Crossref | PubMed | Scopus (38) | Google ScholarSee all References] | Y | h/o casual sex | Y | Y | Travel without steady partner and high-risk destination (Central and South America) | |||||||||
| Daniels (1992) [24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
3: 437–438 PubMed | Google ScholarSee all References] | Y | |||||||||||||
| Egan (2001) [35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58 Google ScholarSee all References] | h/o casual sex | Y | Y | Y | ||||||||||
| Gagneux (1996) [42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21 Crossref | PubMed | Scopus (37) | Google ScholarSee all References] | Y | h/o casual sex | Travel without partner or family, visited the country on two or more occasions; also women over the age of 35 years | |||||||||||
| Gehring (1998) [36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209 Crossref | PubMed | Scopus (17) | Google ScholarSee all References] | Y | Y | Y | Y | Y | Large number of visits to the country and traveling to Thailand | ||||||||
| Hawkes (1994) [26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252 Crossref | PubMed | Scopus (77) | Google ScholarSee all References] | Y | Y | Paid for sex in last 5 years | |||||||||||
| Hawkes (1995) [25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354 PubMed | Google ScholarSee all References] | Y | Y | Previous visit to STI clinic | No regular partner | ||||||||||
| Mendelsohn (1996) [27x27Mendelsohn, R., Astle, L., Mann, M., Shahmanesh, M., Mendelsohn, R., Astle, L. et al. Sexual behaviour in travellers abroad attending an inner-city genitourinary medicine clinic. Genitourin Med. 1996;
72: 43–46 PubMed | Google ScholarSee all References] | MSM are more likely to have multiple sexual partners abroad | |||||||||||||
| Mercer (2007) [44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522 Crossref | PubMed | Scopus (41) | Google ScholarSee all References] | Y | 16–24 | Y | Y | White ethnic background, residence in London and paid for sex in last 5 years (male only) | |||||||||
| Nemoto (2007) [37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81 Crossref | PubMed | Scopus (9) | Google ScholarSee all References] | Y | No differences in casual sex and influence of alcohol/drugs between home and abroad | ||||||||||||
| Tveit (1994) [28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
70: 12–14 PubMed | Google ScholarSee all References] | Y | Y | Paid for sex in last 5 years |
STI, Sexually transmitted infection; h/o, history of; MSM, men who have sex with men.
From their sexual behavior, men who have sex with men (MSM) are more likely to engage in casual travel sex.32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
Crossref | PubMed | Scopus (40) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References Similarly, people who have casual travel sex tend to have a history of multiple partnerships3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47
Crossref | PubMed | Scopus (97) | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58
Google ScholarSee all References, 41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
Crossref | PubMed | Scopus (38) | Google ScholarSee all References, 42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References, 43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References and a history of previous diagnosis with an STI26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References or visit to a sexually transmitted diseases clinic.25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References Three studies linked the development of new sexual partnerships with having paid for sex in the past, although this was only applicable to men.26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
70: 12–14
PubMed | Google ScholarSee all References, 37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References Some studies have described an expectation to have sex or packing condoms.30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494
Crossref | PubMed | Scopus (2) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58
Google ScholarSee all References, 43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References
Other risk-taking behaviors have also been studied. Both drug31x31Bellis, M.A., Hughes, K., Thomson, R., and Bennett, A. Sexual behaviour of young people in international tourist resorts. Sex Transm Infect. 2004;
80: 43–47
Crossref | PubMed | Scopus (97) | Google ScholarSee all References, 35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58
Google ScholarSee all References and alcohol34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 35x35Egan, C.E. Sexual behaviours, condom use and factors influencing casual sex among backpackers and other young international travellers. Can J Hum Sex. 2001;
10: 41–58
Google ScholarSee all References, 37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References use have been associated with casual travel sex. However, Nemoto et al.37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References suggested that there is no difference in drug and alcohol use pre- and during travel in those who develop new sexual partnerships .
3.6. Cultural differences
Sub-analysis by country of residence suggests that a larger proportion of UK residents engage in casual travel sex (27.4%, 95% CI 15.8–40.9%; I2 99.7%) when compared with those of other countries (16.1%, 95% CI 10.7–22.2%; I2 98.9%). However, the 95% CI of the pooled proportions are wide and overlap. On the other hand, there is no difference in the proportion of casual sex that is unprotected in UK residents (48.2%, 95% CI 33.6–62.9%; I2 97.8%) compared to those from other countries (50.6%, 95% CI 34.9–66.4%; I2 96.4%).
3.7. Women travelers
One study was based on a female-only sample,9x9Arvidson, M., Kallings, I., Nilsson, S., Hellberg, D., and Mårdh, P.A. Risky behavior in women with history of casual travel sex. Sex Transm Dis. 1997;
24: 418–421
Crossref | PubMed | Scopus (11) | Google ScholarSee all References while another conducted stratified analyses by gender.44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References Another 12 studies provided enough information to calculate a pooled rate of casual travel sex.3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 8x8Finney, H. Contraceptive use by medical students whilst on holiday. Fam Pract. 2003;
20: 93
Crossref | PubMed | Scopus (13) | Google ScholarSee all References, 23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References, 24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
3: 437–438
PubMed | Google ScholarSee all References, 25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References, 26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
70: 12–14
PubMed | Google ScholarSee all References, 30x30Batalla-Duran, E., Oakeshott, P., and Hay, P. Sun, sea and sex? Sexual behaviour of people on holiday in Tenerife. Fam Pract. 2003;
20: 493–494
Crossref | PubMed | Scopus (2) | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 37x37Nemoto, T., Iwamoto, M., Morris, A., Yokota, F., Wada, K., Nemoto, T. et al. Substance use and sexual behaviors among Japanese tourists, students, and temporary workers in Honolulu, Hawaii. AIDS Educ Prev. 2007;
19: 68–81
Crossref | PubMed | Scopus (9) | Google ScholarSee all References, 41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
Crossref | PubMed | Scopus (38) | Google ScholarSee all References, 43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References Only four of these studies provided sufficient information to allow the calculation of a pooled rate of unprotected intercourse.3x3Abdullah, A.S., Fielding, R., and Hedley, A.J. Travel, sexual behaviour, and the risk of contracting sexually transmitted diseases. Hong Kong Med J. 1998;
4: 137–144
PubMed | Google ScholarSee all References, 8x8Finney, H. Contraceptive use by medical students whilst on holiday. Fam Pract. 2003;
20: 93
Crossref | PubMed | Scopus (13) | Google ScholarSee all References, 23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References, 24x24Daniels, D.G., Kell, P., Nelson, M.R., Barton, S.E., Daniels, D.G., Kell, P. et al. Sexual behaviour amongst travellers: a study of genitourinary medicine clinic attenders. Int J STD AIDS. 1992;
3: 437–438
PubMed | Google ScholarSee all References
The pooled rate of casual travel sex in women from these studies was 19.5% (95% CI 12.4–27.8%; I2 98.9%), while that of men was 24.8% (95% CI 18.3–31.9%; I2 98.6%) (Figure 2). The rate of unprotected intercourse among those women who had casual travel sex was 62.1% (95% CI 52.9–70.9%; I2 35.8%), while that in men was 62.3% (95% CI 40.6–81.7%; I2 95.5%) (Figure 2).
Two studies agree that women who have casual travel sex are more likely to be single and living alone.9x9Arvidson, M., Kallings, I., Nilsson, S., Hellberg, D., and Mårdh, P.A. Risky behavior in women with history of casual travel sex. Sex Transm Dis. 1997;
24: 418–421
Crossref | PubMed | Scopus (11) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References The study by Arvidson et al., conducted in a sample of only Swedish women attending a clinic for contraceptive advice, also suggested that they are usually of higher education and are more likely to use alcohol, smoke, and use cannabis.9x9Arvidson, M., Kallings, I., Nilsson, S., Hellberg, D., and Mårdh, P.A. Risky behavior in women with history of casual travel sex. Sex Transm Dis. 1997;
24: 418–421
Crossref | PubMed | Scopus (11) | Google ScholarSee all References Mercer et al. found a greater risk in residents from Greater London and those who have had same-sex partners.44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References
Women who experience casual travel sex have a higher reported incidence of STIs compared to women who do not report new sexual partnerships abroad.11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References Mårdh et al. also found a higher prevalence of human papilloma virus associated with casual travel sex.11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References At the same time they also experience higher rates of induced abortion, a higher incidence of pelvic inflammatory disease, and lower rates of childbirth.11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References Mercer et al. also found an association with greater perception of HIV risk and higher rates of reported HIV testing.44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References
3.8. Long-stay travelers
A number of studies on people traveling internationally have identified those who stay for longer periods abroad as being at a higher risk of getting involved in new sexual partnerships and casual sex.26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
Crossref | PubMed | Scopus (40) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References, 43x43Bloor, M., Thomas, M., Hood, K., Abeni, D., Goujon, C., Hausser, D. et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet. 1998;
352: 1664–1668
Abstract | Full Text | Full Text PDF | PubMed | Scopus (60) | Google ScholarSee all References In addition one study comparing British visitors to an international holiday destination with British casual workers at the resort suggests that the latter are five times more likely to have casual sex and three times more likely to have unprotected intercourse.16x16Hughes, K., Bellis, M.A., Hughes, K., and Bellis, M.A. Sexual behaviour among casual workers in an international nightlife resort: a case control study. BMC Public Health. 2006;
6: 39
Crossref | PubMed | Scopus (24) | Google ScholarSee all References In this group, drug use is associated with having multiple sexual partners. Another study of US Peace Corps Volunteers also highlights the influence of alcohol use, in this case related to inconsistent use of condoms with new sexual partners acquired abroad.17x17Moore, J., Beeker, C., Harrison, J.S., Eng, T.R., Doll, L.S., Moore, J. et al. HIV risk behavior among Peace Corps Volunteers. AIDS. 1995;
9: 795–799
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Studies conducted in expatriates posted overseas suggest that casual sex and unprotected intercourse are relatively common despite improvements achieved over time.14x14de Graaf, R., van Zessen, G., Houweling, H., Ligthelm, R.J., and van den Akker, R. Sexual risk of HIV infection among expatriates posted in AIDS endemic areas. AIDS. 1997;
11: 1173–1181
Crossref | PubMed | Scopus (27) | Google ScholarSee all References, 15x15Houweling, H. and Coutinho, R.A. Risk of HIV infection among Dutch expatriates in sub-Saharan Africa. Int J STD AIDS. 1991;
2: 252–257
PubMed | Google ScholarSee all References Moreover, in expatriates working abroad the proportion of men with casual sexual partners admitting to having paid for sex at least once was found to be around 59%, and higher than that of men who had casual sexual partners back in the Netherlands.14x14de Graaf, R., van Zessen, G., Houweling, H., Ligthelm, R.J., and van den Akker, R. Sexual risk of HIV infection among expatriates posted in AIDS endemic areas. AIDS. 1997;
11: 1173–1181
Crossref | PubMed | Scopus (27) | Google ScholarSee all References This study also identified younger age, being single, and working for a commercial company as independent characteristics associated with casual sex abroad.
In-depth interviews among a group of expatriates who had casual sex abroad suggest that there may be four different groups in relation to having sex abroad, depending on their pre-travel sexual behavior, this abroad, and their perception of HIV risk and condom use.13x13de Graaf, R., van Zessen, G., and Houweling, H. Underlying reasons for sexual conduct and condom use among expatriates posted in AIDS endemic areas. AIDS Care. 1998;
10: 651–665
Crossref | PubMed | Scopus (14) | Google ScholarSee all References These varied from those who have little or no experience with casual sex and no expectation of having sex abroad, to those who have had multiple partners, who experience both casual sex and paying for sex, and who have multiple casual sexual contacts abroad.
As a subgroup within those who have longer stays abroad we identified two studies relating to military personnel deployed overseas.12x12Hopperus Buma, A.P., Veltink, R.L., van Ameijden, E.J., Tendeloo, C.H., and Coutinho, R.A. Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia. Genitourin Med. 1995;
71: 172–175
PubMed | Google ScholarSee all References, 18x18Malone, J.D., Hyams, K.C., Hawkins, R.E., Sharp, T.W., and Daniell, F.D. Risk factors for sexually-transmitted diseases among deployed U.S. military personnel. Sex Transm Dis. 1993;
20: 294–298
Crossref | PubMed | Scopus (46) | Google ScholarSee all References These studies agree in highlighting the high rates of casual sex with locals and sex with CSWs among the armed forces deployed abroad. These studies also highlight inconsistent condom use in this group. Characteristics identified as independently associated with paying for sex in this group are younger age and being single or divorced; however, those with inconsistent condom use are mainly older12x12Hopperus Buma, A.P., Veltink, R.L., van Ameijden, E.J., Tendeloo, C.H., and Coutinho, R.A. Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia. Genitourin Med. 1995;
71: 172–175
PubMed | Google ScholarSee all References or from a Hispanic ethnic background.18x18Malone, J.D., Hyams, K.C., Hawkins, R.E., Sharp, T.W., and Daniell, F.D. Risk factors for sexually-transmitted diseases among deployed U.S. military personnel. Sex Transm Dis. 1993;
20: 294–298
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3.9. Male travelers who have sex with men
A number of studies from mixed samples of men and women travelers identified MSM as being at increased risk of casual travel sex;32x32Cabada, M.M., Echevarria, J.I., Seas, C.R., Narvarte, G., Samalvides, F., Freedman, D.O. et al. Sexual behavior of international travelers visiting Peru. Sex Transm Dis. 2002;
29: 510–513
Crossref | PubMed | Scopus (40) | Google ScholarSee all References, 33x33Cabada, M.M., Montoya, M., Echevarria, J.I., Verdonck, K., Seas, C., and Gotuzzo, E. Sexual behavior in travelers visiting Cuzco. J Travel Med. 2003;
10: 214–218
Crossref | PubMed | Google ScholarSee all References, 34x34Bellis, M.A. Ibiza uncovered: changes in substance use and sexual behaviour amongst young people visiting an international night-life resort. Int J Drug Policy. 2000;
11: 235–244
Abstract | Full Text | Full Text PDF | PubMed | Scopus (69) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References also two clinic studies found that MSM have a higher rate of casual travel sex than heterosexual men,23x23Carter, S., Horn, K., Hart, G., Dunbar, M., Scoular, A., MacIntyre, S. et al. The sexual behaviour of international travellers at two Glasgow GUM clinics. Glasgow genitourinary medicine. Int J STD AIDS. 1997;
8: 336–338
Crossref | PubMed | Scopus (46) | Google ScholarSee all References, 25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References and another one that they are more likely to have multiple sexual partners abroad.27x27Mendelsohn, R., Astle, L., Mann, M., Shahmanesh, M., Mendelsohn, R., Astle, L. et al. Sexual behaviour in travellers abroad attending an inner-city genitourinary medicine clinic. Genitourin Med. 1996;
72: 43–46
PubMed | Google ScholarSee all References However, one study found that MSM are more likely to use condoms when they engage in casual travel sex.28x28Tveit, K.S., Nilsen, A., and Nyfors, A. Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection. Genitourin Med. 1994;
70: 12–14
PubMed | Google ScholarSee all References
In addition, we identified two studies that focused on sexual behavior of MSM abroad.19x19Clift, S.M. and Forrest, S.P. Factors associated with gay men's sexual behaviours and risk on holiday. AIDS Care. 1999;
11: 281–295
Crossref | PubMed | Scopus (32) | Google ScholarSee all References, 20x20Ford, K., Wirawan, D.N., Fajans, P., and Thorpe, L. AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia. AIDS. 1995;
9: 751–759
Crossref | PubMed | Google ScholarSee all References The main characteristics associated with sexual relations while on holiday among MSM appear similar to those previously described for heterosexuals: traveling with companions, having a history of multiple sexual partners, and taking condoms;19x19Clift, S.M. and Forrest, S.P. Factors associated with gay men's sexual behaviours and risk on holiday. AIDS Care. 1999;
11: 281–295
Crossref | PubMed | Scopus (32) | Google ScholarSee all References while having multiple partners during the holiday, taking condoms, and ‘gay social life and sex’ motivation are independently associated with having penetrative anal sex. Generally, tourists who had sex with CSWs had knowledge of the routes of HIV and STI transmission, although only one third thought they were at risk of contracting HIV. The main reason why people did not see themselves at risk was that they perceived their activities as ‘low risk’. The main services paid for were masturbation and oral sex. Penetrative sex was only practiced with CSWs in a small proportion of cases.20x20Ford, K., Wirawan, D.N., Fajans, P., and Thorpe, L. AIDS knowledge, risk behaviors, and factors related to condom use among male commercial sex workers and male tourist clients in Bali, Indonesia. AIDS. 1995;
9: 751–759
Crossref | PubMed | Google ScholarSee all References
3.10. HIV-positive travelers
One study reported on the sexual behavior of HIV-positive people traveling internationally [21x21Salit, I., Sano, M., Boggild, A., and Kain, K. Travel patterns and risk behaviour of HIV-positive people travelling internationally. CMAJ. 2005;
172: 884–888
Crossref | PubMed | Scopus (49) | Google ScholarSee all References]. Despite their higher knowledge of the health risks associated with travel, a small proportion sought pre-travel advice, and of those on antiretroviral therapy (ART) about 30% discontinued this during their trip abroad. As with other studies of general international travelers, a quarter of HIV-positive travelers engaged in casual sex while abroad, but more worryingly, about 40% inconstantly used condoms with new sexual partners. The poor adherence to ART together with the risky sexual behavior poses a risk for the development of antiviral-resistant strains of HIV and their onward transmission.
3.11. Commercial sex work and tourists
A couple of studies have highlighted that those men who engage in casual travel sex are also more likely to have ever paid for sex.26x26Hawkes, S., Hart, G.J., Johnson, A.M., Shergold, C., Ross, E., Herbert, K.M. et al. Risk behaviour and HIV prevalence in international travellers. AIDS. 1994;
8: 247–252
Crossref | PubMed | Scopus (77) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References While abroad, certain groups are more likely to seek commercial sex, particularly expatriates working overseas for longer periods,14x14de Graaf, R., van Zessen, G., Houweling, H., Ligthelm, R.J., and van den Akker, R. Sexual risk of HIV infection among expatriates posted in AIDS endemic areas. AIDS. 1997;
11: 1173–1181
Crossref | PubMed | Scopus (27) | Google ScholarSee all References, 15x15Houweling, H. and Coutinho, R.A. Risk of HIV infection among Dutch expatriates in sub-Saharan Africa. Int J STD AIDS. 1991;
2: 252–257
PubMed | Google ScholarSee all References military personnel,12x12Hopperus Buma, A.P., Veltink, R.L., van Ameijden, E.J., Tendeloo, C.H., and Coutinho, R.A. Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia. Genitourin Med. 1995;
71: 172–175
PubMed | Google ScholarSee all References and business men.39x39Lau, J.T. and Wong, W.S. Behavioural surveillance of sexually-related risk behaviours for the cross-border traveller population in Hong Kong: the evaluation of the overall effectiveness of relevant prevention programmes by comparing the results of two surveillance surveys. Int J STD AIDS. 2000;
11: 719–727
Crossref | PubMed | Scopus (24) | Google ScholarSee all References, 40x40Lau, J.T. and Thomas, J. Risk behaviours of Hong Kong male residents travelling to mainland China: a potential bridge population for HIV infection. AIDS Care. 2001;
13: 71–81
Crossref | PubMed | Scopus (64) | Google ScholarSee all References One qualitative study of Japanese tourist sexual behaviors associated with paying for sex in Bangkok suggests that the main drivers for this are a sense of freedom and anonymity, a sense of loneliness, and peer influence, coupled with the availability of inexpensive sexual services.45x45Yokota, F. and Yokota, F. Sex behaviour of male Japanese tourists in Bangkok, Thailand. Cult Health Sex. 2006;
8: 115–131
Crossref | PubMed | Scopus (12) | Google ScholarSee all References
3.12. Incidence of travel-related STIs
We identified five studies that estimated the rate of travel-related STIs. Only one assessed this at a population level, relying on self-reported diagnosis of STIs;44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References the others drew samples from clinics where STIs are diagnosed.11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References, 22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60
Crossref | PubMed | Scopus (19) | Google ScholarSee all References, 25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References, 29x29Velasco, M., Morote, S., Aramburu, C., Quinto, L., Corachan, M., Gascon, J. et al. [Sexual behavior risk in Spanish international travelers] (In Spanish). Med Clin (Barc). 2001;
116: 612–613
Crossref | PubMed | Google ScholarSee all References
Mercer et al. estimated the rate of STIs in people who had new sexual partners abroad over a five-year period to be 18.2% for women and 35.2% for men;44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References however, as the follow-up period was long it was not possible to ascertain how much was due to casual travel sex and what relates to high sexual risk in the home country. Also, Mårdh et al. estimated the lifetime prevalence of STIs in women who admitted to having had casual travel sex to be around 38%.11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References They found increased rates of Chlamydia trachomatis, N. gonorrhoeae and genital warts; however, after adjustment for age, number of partners, and age at first intercourse, only genital warts was significantly higher in those women with a history of casual travel sex. Again this figure was based on self-reported STIs over an undetermined period.
On the other hand, two clinic-based studies estimated the rate of travel-related STIs to be between 5% and 12%.25x25Hawkes, S., Hart, G.J., Bletsoe, E., Shergold, C., and Johnson, A.M. Risk behaviour and STD acquisition in genitourinary clinic attenders who have travelled. Genitourin Med. 1995;
71: 351–354
PubMed | Google ScholarSee all References, 29x29Velasco, M., Morote, S., Aramburu, C., Quinto, L., Corachan, M., Gascon, J. et al. [Sexual behavior risk in Spanish international travelers] (In Spanish). Med Clin (Barc). 2001;
116: 612–613
Crossref | PubMed | Google ScholarSee all References Moreover, Velasco et al. found up to 3.4% HIV infection in those who had unprotected casual travel sex among attendees to a tropical medicine clinic.29x29Velasco, M., Morote, S., Aramburu, C., Quinto, L., Corachan, M., Gascon, J. et al. [Sexual behavior risk in Spanish international travelers] (In Spanish). Med Clin (Barc). 2001;
116: 612–613
Crossref | PubMed | Google ScholarSee all References
Three studies provided enough information to estimate pooled unadjusted ORs to assess the risk of acquiring an STI associated with casual travel sex (Figure 4).11x11Mårdh, P.A., Arvidson, M., and Hellberg, D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med. 1996;
3: 138–142
Crossref | PubMed | Scopus (10) | Google ScholarSee all References, 22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60
Crossref | PubMed | Scopus (19) | Google ScholarSee all References, 44x44Mercer, C.H., Fenton, K.A., Wellings, K., Copas, A.J., Erens, B., Johnson, A.M. et al. Sex partner acquisition while overseas: results from a British national probability survey. Sex Transm Infect. 2007;
83: 517–522
Crossref | PubMed | Scopus (41) | Google ScholarSee all References The pooled OR was 3.09 (95% CI 2.44–3.92). The risk was higher in men (OR 3.68, 95% CI 2.64–5.13) than in women (OR 2.45, 95% CI = 1.95–3110; I2 8.6%). Bavastrelli et al.22x22Bavastrelli, M., Midulla, M., Rossi, D., Salzano, M., Calzolari, E., Midulla, C. et al. Sexually active adolescents and young adults: a high-risk group for Chlamydia trachomatis infection. J Travel Med. 1998;
5: 57–60
Crossref | PubMed | Scopus (19) | Google ScholarSee all References also suggest that the risk of C. trachomatis infection associated with travel is higher in people with multiple sexual partners and aged 14–19 years (OR 10; 95% CI 1.86–30).
Figure 4
Risk of sexually transmitted infection associated with casual travel sex, by sex.
However, in most cases adjustment of the risk for pre-existing sexual behavior was not carried out.
3.13. Prevention
We were only able to identify two studies that had looked at health promotion information aimed at international travelers.36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References, 42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References Gehring et al. displayed promotional information in the departure lounge of an international airport and asked returning passengers whether they recalled the material and about their sexual behavior while abroad.36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References This study did not find any differences in the sexual behavior of returning travelers; however, recall bias is likely. In the other study, Gagneux et al. allocated patients seeking pre-travel advice to receive a health leaflet, a leaflet about the risks of ‘sex tourism’, or none.42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References They also found no differences in sexual behavior. However, their sample was recruited from people who seek pre-travel advice and may therefore not be representative of most international travelers, as only those going to places where there are other perceived health risks may seek pre-travel advice. They may be generally more cautious about risks.
Interestingly, in the study by Croughs et al. of a sample recruited among people consulting for pre-travel advice, recall of reading a leaflet on STIs given at the clinic was independently associated with having casual travel sex; however, those who read the leaflet were also more likely to consistently use condoms.41x41Croughs, M., Van Gompel, A., de Boer, E., and Van Den Ende, J. Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008;
15: 6–12
Crossref | PubMed | Scopus (38) | Google ScholarSee all References
4. Discussion
To our knowledge this is the first systematic review of the literature on the sexual behavior associated with foreign travel and the implications for rates of STIs. We have also used meta-analysis to estimate the prevalence of casual travel sex and the rate of unprotected intercourse among those developing new sexual partnerships abroad. The current literature suggests that casual travel sex is relatively common, although variation exists according to country of residence, destination, and nature of travel. More importantly, about 50% of people engaging in new sexual relationships abroad inconsistently use condoms.
Although sexual partnership acquisition associated with foreign travel is relatively common, the studies shed little light on whether people's sexual behavior changes with foreign travel or whether it is predetermined. This is important, as preventive interventions would be different if sexual behavior abroad mirrored people's behavior while in their home countries or if foreign travel enhanced or changed sexual behavior. As most studies on this subject have been cross-sectional surveys, there is an inherent methodological inability to compare pre-existing sexual behavior with changes associated with travel; as a result, a prospective cohort study is needed that can assess changes with travel.
Although there is some evidence of transmission of sexual infections associated with foreign travel, this is in the main from self-reported rates of infection. Also, on most occasions these studies did not compare rates with similar groups who have not traveled abroad. In the few cases where estimates are from the diagnosis of STIs, the lack of adjustment for baseline sexual behavior makes it difficult to estimate the exact risk of infection associated with casual travel sex. Therefore, prospective studies using molecular techniques to ascertain the incidence of STIs and a control group who have not traveled are also needed to determine the true impact of casual travel sex on the incidence of STIs.
We could only identify two studies that assessed health promotion interventions aimed at reducing the risks associated with unprotected casual sex abroad.36x36Gehring, T.M., Widmer, J., Kleiber, D., Steffen, R., Gehring, T.M., Widmer, J. et al. Are preventive HIV interventions at airports effective?. J Travel Med. 1998;
5: 205–209
Crossref | PubMed | Scopus (17) | Google ScholarSee all References, 42x42Gagneux, O.P., Blochliger, C.U., Tanner, M., and Hatz, C.F. Malaria and casual sex: what travelers know and how they behave. J Travel Med. 1996;
3: 14–21
Crossref | PubMed | Scopus (37) | Google ScholarSee all References Generally, although these provided some evidence of the likely effect of certain interventions, they suffered from a number of methodological limitations. They relied on recruiting from convenience samples, like people seeking pre-travel advice, or on recollection of whether they had seen the promotional advice. Both intervention studies lacked clear sampling frameworks and randomization to reduce the effect of bias. Further evaluation of preventive activities targeted at those most at risk is needed.
In particular, preventive information should be aimed at younger groups of people traveling together, such as those on package holidays or stag or hen night parties, and people traveling alone, whether on holiday, a gap year, or on business, who are at increased risk of engaging in casual sex. As most young people traveling alone or with friends may not come into contact with health professionals or book their holidays through the internet, innovative approaches to delivering health promotion messages are needed, perhaps using the internet as well.
Also, particular attention is needed for people working or staying abroad for prolonged periods of time. As most people in this group are generally working for commercial companies or volunteering they are better targeted through an occupational health approach, including a confidential sexual risk assessment and health promotion as part of their pre-employment assessment.
Conflict of interest: No conflict of interest to declare.
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