LGB+ Travelers

Introduction

Lesbian, gay, bisexual, and other sexual minority (LGB+) travelers face risks similar to those of other travelers, influenced by age, sex, socioeconomic status, mental health considerations, and substance use, rather than sexual attraction or identity. LGB+ travelers face some unique risks, however, and healthcare professionals counseling them should tailor their advice accordingly.

Overview

LGB+ travelers contribute greatly to economic enrichment and can convey powerful positive messages related to human rights worldwide. The United Nations World Tourism Organization reported in 2017 that LGB+ persons travel more frequently, demonstrate higher than average spending patterns, and demonstrate brand awareness and loyalty. The travel industry has long recognized that marketing to the LGB+ community makes economic sense. The International Gay and Lesbian Travel Association provides free travel resources and information while working to promote quality and safety for LGB+ travelers worldwide. Open for Business is a coalition of leading global companies that recognizes the powerful advantages of societies that include LGB+ communities in improving economic, business, and individual performance. Human rights for LGB+ persons have improved in some countries, and the international tourism industry has become more responsive to LGB+ travelers; many international travel destinations are now recognized as gay-friendly.

LGB+ travelers vary in terms of how, where, and with whom they prefer to travel; sexual behavior; skin color; citizenship; and income. In a 2015 study conducted by Global Marketing, behavior of gay men travelers differed from lesbian travelers in several ways: gay men were more likely to travel with other adults, visit gay bars, and have more disposable time and income; lesbian travelers were more likely to travel with family, be more interested in child-friendly rather than LGB+ friendly environments, and have travel preferences and budget constraints more closely aligned to people who are not LGB+ than to gay men.

Technology also has changed how LGB+ travelers interact with others while traveling. In 1 study, 31% of gay men used dating apps while traveling, compared with 4% of lesbian travelers and 15% of all Americans. Men who used the internet to set up dates prior to travel reported far more sexual partners and were much more likely to report having sex with a new partner (see Sex and Travel chapter).

A paucity of research data on LGB+ travelers has been published. The few that exist reported on men who have sex with men (MSM) from Australia, Belgium, Canada, China, Denmark, India, Sweden, Vietnam, and those going to Mardi Gras in New Orleans or Key West, Florida. No studies specific to lesbian travelers have been published.

There is no single standard message for counseling LGB+ travelers (see Box 1.12.1). During the pre-travel consultation with LGB+ travelers, include routine travel advice and specific counseling tailored to the itinerary and planned activities (see The Pre-Travel Consultation chapter). Focused counseling for LGB+ travelers should include, at a minimum, a discussion of infectious disease risks, legal considerations, safety and security issues (see Safety and Security Overseas chapter), and screening and counseling for potential mental health problems (see Mental Health in Travelers chapter) and substance use disorders (see Substance Use and Substance Use Disorders in Travelers chapter).

Box 1.12.1

Infectious disease counseling

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

In a meta-analysis of foreign travel and sexual behavior (which did not identify patients by sexual preference), the pooled rate of casual sex was 19.5% for all women and 24.8% for all men. In the same analysis, the rate of unprotected intercourse among women who had casual travel sex was 62.1% and 62.3% among men.

The U.S. Preventive Services Taskforce recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. Healthcare professionals should provide nonjudgmental counseling to LGB+ travelers. The Gay and Lesbian Medical Association has resources to assist healthcare professionals in counseling LGB+ patients. Counsel travelers that safer sex is proven to reduce the risk of receiving or transmitting chlamydia, gonorrhea, hepatitis A, hepatitis B, HIV, human papillomavirus (HPV), pubic lice, and syphilis. Depending on a patient's sexual behavior, counsel them on the use of condoms, dental dams, and gloves to reduce risk for STIs (see Sex and Travel chapter, for general counseling recommendations on sex and travel).

Enteric infections

Patients who engage in oral-anal sex might be unaware of their risk for acquiring enteric infections, both bacterial (e.g., Salmonella, Shigella) and parasitic (e.g., Blastocystis, Dientamoeba, Giardia). Counsel patients on the use of dental dams and careful washing of hands and genitalia, before and after sex. Offer typhoid vaccination (see Typhoid and Paratyphoid Fever chapter).

Hepatitis A

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

Hepatitis B

Hepatitis B virus (HBV) is transmitted via percutaneous or mucous membrane exposure to body fluids infected with HBV. MSM have a higher seroprevalence of HBV; offer vaccination irrespective of travel plans. Screen all patients who do not know their status and test those at increased risk for HBV infection, including previously unvaccinated travelers and MSM.

Hepatitis C

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

HIV

Assess sexual behavior and counsel travelers on use of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Remind patients that long-term travel to a country, particularly for work, might require HIV testing prior to entry. Countries might deny entry to people with evidence of HIV infection, and carrying PrEP might be mistaken as evidence of such (see Travelers with HIV chapter, for additional information).

Mpox

Mpox virus spreads person-to-person primarily through close skin-to-skin (including sexual) contact. Most early cases of the 2022 global mpox outbreak occurred among gay, bisexual, and other MSM; international travel played a role in introducing the virus to new countries. Remind all travelers that sex with new partners can increase their risk of contracting infections, including mpox.

CDC recommends mpox vaccination for those who are gay, bisexual, or other MSM who have had in the last 6 months: a new diagnosis of an STI; more than 1 sexual partner; sex at a commercial venue; or sex in association with a large public event in a geographic area where mpox virus transmission is occurring. The vaccine is also recommended for sexual partners of persons with any of the aforementioned risks or persons anticipating experiencing any of the aforementioned risks. People at risk of mpox virus exposure and infection during travel should complete an mpox vaccination series at least 2 weeks prior to departure. Refer susceptible travelers who have been exposed to mpox virus for vaccination as soon as possible (ideally within 4 days of exposure but within 14 days) to help prevent the disease or minimize severity.

Human papillomavirus

HPV is highly prevalent among MSM. HPV infection is associated with penile, anal, and oropharyngeal cancers and precancers. For those at risk and eligible for HPV vaccination, offer vaccine or refer to their primary healthcare professional.

Invasive meningococcal disease

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

Legal considerations

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

The United Nations has been addressing human rights abuses of the LGB+ community since the 1990s. In a 2015 speech, United Nations Deputy Commissioner for Human Rights Flavia Pansieri summarized the abuses of the LGB+ community, including murder, rape, mob attacks, abuse by police and prison officials, criminal sanctions, arrest and imprisonment, blackmail and harassment, forced medications and surgeries in medical settings to try to change sexual orientation, forced sterilization, humiliation, discrimination, job loss, evictions, and refusal of medical treatment. Such issues are a reality in many countries, and healthcare professionals should offer resources to LGB+ travelers on differing international laws, attitudes, and customs, and the realities of behavior constraints that can make a trip safer (Table 1.12.1).

A unique group of travelers includes LGB+ refugees and asylum seekers, who are particularly vulnerable to physical and emotional abuse, assault, and even death. Numerous countries ban sexual conduct between consenting adults of the same sex, and individuals who are traveling to escape persecution. Components of the evaluation of LGB+ refugees and asylum seekers have been recently published. Healthcare professionals may access resources at the Society for Refugee Health Care Providers and can refer LGB+ refugees and asylum seekers to the resource Rainbow Railroad (Table 1.12.1).

Travel medicine specialists also should remind LGB+ travelers that they are subject to the laws of any country to which they are traveling and encourage travelers to read about their destinations before departure. The U.S. Department of State annually publishes Country Reports on Human Rights Practices, which includes a detailed, country-by-country report of issues pertinent to the LGB+ community (Table 1.12.1).

Table 1.12.1: Online resources for LGB+ travelers

Safety and security

A general approach to travel safety and security is outlined in the Safety and Security Overseas chapter. As with many travelers, the joy of feeling more freedom to express oneself while traveling, coupled with substance use, could result in behaviors that put travelers at risk. Travelers' perception of and willingness to accept risk also vary (see Perspectives: Travelers' Perception of Risk chapter).

LGB+ travelers should be aware that gay-friendly neighborhoods might not reflect societal acceptance and safety in a country overall. LGB+ persons have a lifetime of experience assessing situations to determine whether they can safely be themselves. When traveling, LGB+ persons should be aware of sociocultural differences that can affect their true situational safety. The U.S. Department of State notes that authorities in some countries could be involved in entrapment campaigns, with law enforcement monitoring websites, mobile phone apps, or meeting places. Counsel patients to be cautious connecting with the local community. The U.S. Department of State offers tips for the LGB+ community for staying safe while abroad, including researching destinations, updating passports, packing important documents, living abroad with a foreign national spouse or partner, and visa issues (Table 1.12.1).

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

Mental health and substance use

LGB+ identity can be a source of strength and courage for many, but the lack of acceptance, overt discrimination, rejection, and denial of rights can lead to or exacerbate mental health issues among this population. Lesbian, gay, and bisexual adults are more than 2 to 4 times as likely as other adults to experience a mental health condition. Adolescents and young adults are at particularly high risk for suicide, and LGB+ youth are more than twice as likely to experience persistent feelings of sadness and hopelessness than their peers who are not LGB+. Some sexual minorities may face further disparities and may be more likely to experience depressive symptoms, seriously consider suicide, and attempt suicide.

LGB+ adults are 2 to 4 times as likely to experience a substance use disorder (see Substance Use and Substance Use Disorders in Travelers chapter). Heavy drinking, binge drinking, tobacco use, and use of illicit drugs, including amyl nitrate (known as poppers), cannabis, MDMA (known as ecstasy or Molly), and amphetamines, are more common in segments of the LGB+ community. Several studies outline the association of recreational drug use with sexual behavior that places individuals at increased STI risk during travel, including unprotected anal intercourse in MSM.

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