CABADA, MIGUEL M. MD*; ECHEVARRÍA, JUAN I. MD*†; SEAS, CARLOS R. MD*†; NARVARTE, GUILLERMO MD*; SAMALVIDES, FRINE MD*†; FREEDMAN, DAVID O. MD‡; GOTUZZO, EDUARDO MD*†
EACH YEAR, approximately 50 million travelers visit the developing world. 1 Freed from the normal social constraints of everyday life at home and often with ample time and opportunity, up to 25% of travelers engage in casual travel sex. A number of studies have implicated these risk factors for casual travel sex: male sex, younger age, traveling alone or with friends, homosexual orientation, long duration of stay, and traveling on business. 2–11 The literature focuses almost exclusively on sexual behavior of travelers to Asia, Africa, or Eastern Europe or of clinic cohorts in home countries, without separate analysis by destination. There are few data on rates of casual travel sex among travelers to Peru or, in fact, to any other Latin American destination.
Latin American and Caribbean countries are increasingly frequent destinations for travelers. Rates of sexually transmitted diseases (STDs) and HIV infection there do not yet equal those in Asia and Africa, but an estimated 36 million new cases of STDs occurred in 1995. 12,13 Thus, the risk of STD acquisition by travelers to these regions is substantial and may be even higher than recognized. Conversely, transmission of STD and HIV may occur in the other direction—from traveler to host-country resident. The antibiotic susceptibility and strains of STD pathogens in the traveler's country (or in countries previously visited by the traveler) may differ from those in the host country. 12,13 Thus, in addition to the risk to the individual, there is potential risk of the introduction of new sexually transmitted pathogens in both the country of origin and the host country, and the risk increases as rates of casual travel sex increase.
In order to define the sexual behavior of travelers to Peru, we conducted a written survey in the departures area of Peru's main international airport, in Lima.
The study was conducted in the international departures lounge at the Jorge Chavez International Airport, in Lima, Peru, during August 2000. All flights from Peru to North America or Europe depart from this airport. Both male and female travelers between 15 and 51 years of age departing on flights to the United States or Europe were enrolled. Oral informed consent was obtained. An anonymous written questionnaire requesting demographic information and data on sexual behavior was administered to those who volunteered, and the completed questionnaires were collected on the spot. Variables included in the questionnaire were: sexual orientation, reason for traveling to Peru, presence of travel companions (partner, family members, friends, business colleagues), marital status, expectation to have sex while visiting the country, intention to use condoms, use of illicit drugs, alcohol consumption, history of STD, and nature of sex partners while visiting Peru. Two investigators (C. M. and B. G.) were always available to aid in completing the questionnaire, but not all questions were answered by all participants. Data were stored and analyzed with Epi Info software version 6.04b for Windows (Centers for Disease Control and Prevention, Atlanta, GA). Statistics for categorical data were used in the study; chi-square or Fisher exact tests were used when indicated. Relative risks and 95% confidence intervals were calculated with use of the same software.
Five-hundred seven individuals were approached and 442 (87%) agreed to participate and completed questionnaires. The mean age of participants was 27.6 years (SD, 7.1), 243 (55%) were male, and the majority (87%) were between the ages of 15 and 35 years. The three most common countries of residence were the United States (35%), the United Kingdom (15%), and France (9%). The cities most commonly visited were Lima (79%), the capital of Peru, Cuzco (77%), and Arequipa (36%). The mean number of cities visited was 2.61 (SD, 0.88). Mean duration of stay in Peru was 25.0 days (SD, 86.41), and 92% of participants stayed <30 days. Unmarried travelers predominated (69%); 25.1% of participants (111/441) were traveling with a spouse or regular partner. Tourism (83%) was the most common reason for visiting Peru.
Ninety-five percent of respondents were heterosexual; 54/442 respondents (12.2%) had a new sex partner during their visit, but only 23/51 (45%) had expected to have it. Sex with a local partner (35/52; 67.3%) was more frequent than sex with other travelers (18/52; 34.6%) or with sex workers (4/52; 7.7%). Six travelers had sex with members of 2 of the above-mentioned groups and 1 had sex with all 3 groups; information on category of partner was not available in 2 cases. One-hundred eleven (25.2%) of the 441 respondents were traveling with a spouse or partner, and of these, 3 individuals reported having a new sex partner during their stay. Most sexually active travelers (39/52; 75%) had only one partner during their stay.
Condoms were consistently used by 12/50 (24%), used sometimes by 10/50 (20%), and never used by 28/50 (56%). Condoms were used by 10/27 (37.0%) who had sex with a local partner, 9/15 (60%) who had sex with other travelers, and 0/1 who had sex with a sex worker. Three (6%) of 52 reported a history of STD. Alcohol consumption before the sexual activity was reported by 21/52 travelers (40%) who had sex, but only 4/52 (8%) used illicit drugs during their trip.
Characteristics more commonly identified in travelers who had sexual activity than in those who did not (Table 1) were male sex (relative risk, 1.94; 95% CI, 1.11–3.36); single marital status (relative risk, 2.59; 95% CI, 1.26–5.34); duration of stay longer than 30 days (relative risk, 5.05; 95% CI, 3.16–8.07); traveling alone or with friends (relative risk, 2.88; 95% CI, 1.44–5.73); and bisexual orientation (relative risk, 4.94; 95% CI, 2.47–9.87). There was a trend toward association of three characteristics—being young (aged 15–35 years), being a US resident (see below), and being a business traveler—but no statistical significance was noted.
A subset analysis compared US travelers (USTs) with non-US travelers (NUSTs). The USTs were younger (mean age, 26.7 [SD, 7.8] versus 27.9 [7.9] years), were more likely to be traveling alone (relative risk, 2.11; 95% CI, 1.28–3.49), were more likely to be traveling on business (relative risk, 1.79; 95% CI, 1.25–2.26), and visited fewer cities than NUSTs (mean number of cities visited, 2.33 [SD, 0.80] versus 2.76 [0.88]). The frequency of sexual activity among USTs (15.2% [22/145]) was greater than that among NUSTs (10.6% [30/282]), but the difference was not statistically significant. Sexually active USTs had significantly more sex partners than NUSTs (mean number of sex partners, 2.19 [SD, 1.63] versus 1.20 [0.92];P = 0.002); 8/20 USTs (40%) versus 13/29 NUSTs (44.8%) used condoms all or some of the time. USTs had expected to have sex in Peru more frequently than NUSTs (relative risk, 2.07; 95% CI, 1.05–4.09). Condom, alcohol, or illicit drug use did not differ between USTs and NUSTs.
Pretravel counseling about the risks of casual travel sex was received by 175/441 travelers (40%), and Canadian travelers had the highest frequency of pretravel education (23/33; 70%). NUSTs were more likely to have received pretravel counseling than USTs (relative risk, 1.14; 95% CI, 1.00–1.31). No association between pretravel sexual counseling and risk of having casual travel sex was found. Twenty three (13.1%) of the 175 individuals with a self-reported history of pretravel counseling, compared with 11.7% (31/266) with no such self-reported history, reported sexual activity.
Macchu Picchu, Cuzco, and related Incan ruins in Peru are among the most visited destinations in South America. We present here some of the first data on the sexual behavior and sexual risk factors of travelers to Latin America and to Peru specifically. Sexual behavior among travelers to Africa, Asia, and Eastern Europe has been relatively well studied in comparison, likely because of the perception of higher risk of HIV infection and STD in those regions than in Latin America. 2–11 Although the prevalence of STD is clearly less in Latin America, it is nevertheless substantial. 12,13 In addition, there is a lack of data on whether this lesser prevalence in Latin America has led to the perception by travelers that travel-related sexual activity in Latin America is of low risk. This might engender a false sense of security, which could, in turn, lead to increased sexual activity.
Travelers may not only acquire STDs but also carry and transmit them within their home countries, with potential for international dissemination of agents with genetic diversity and different antibiotic-sensitivity patterns. For example, in a multicenter study carried out to determine the prevalence of genotypes of HIV virus in Latin America, genotype B was the most common. However, people carrying the genotype F were reported to have had more sexual encounters with foreigners than those carrying the genotype B. 14,15 Perhaps less often considered by investigators in industrialized countries is the effect of the introduction of new pathogens into highly visited host countries such as Peru by travelers. Travelers not only may introduce pathogens from their own country of residence but also, because of the propensity of a high proportion of travelers to travel to multiple countries over time, may serve as conduits for multinational dissemination of pathogens.
Our data and findings on sexual behavior of travelers to Peru are largely similar to those collected for travelers to other parts of the world. 2–11 This indicates a similar level of risk for STDs and a similar need for preventive strategies. Overall, 12.2% of travelers (54/442) engaged in casual travel sex during their stay in Peru. Sexual activity was predominantly with local partners (67.3%). Although all study subjects were foreign residents, anecdotally we observed that a small number (certainly fewer than 5%) may have been linked to Peru by family relations. We recognize that our sample was not random, but it was cross-sectional. Young, unattached travelers are likely more amenable to volunteering for a survey on sexual habits in the airport than are those traveling with spouses or partners.
The travel sex literature to date has examined almost exclusively the behaviors of European and Australian travelers. We were unable to find a report of any previous systematic study of sexual behavior among USTs. When a subset analysis comparing USTs to NUSTs was performed on our dataset, the frequency of sexual activity among USTs (15.2%) was greater than but not statistically different from that among NUSTs (10.6%). The finding that USTs are at least as likely (and perhaps more likely) to engage in casual travel sex is significant documentation of a not wholly unexpected finding reflecting human nature. Nevertheless, perceived cultural differences between USTs and NUSTs make this important to document in practice, as we have done.
Overall, 55% of travelers who had sex had not expected to have it during their travel, and only 40% of all travelers had received pretravel sexual counseling. At least some use of condoms was reported by approximately half (44%) of those who had sex. Our findings emphasize that, as in Africa and Asia, there is substantial high-risk sexual activity between host-country populations and travelers. Contacts with sex workers were surprisingly few (7.7%) in comparison with findings in other studies. Peru is not a known destination for dedicated sex tourists, so this finding may not be reflective of other Latin American countries. However, our data have the advantage of reflecting the sexual habits of typical travelers, without significant bias presented by dedicated sex tourists.
Effective pretravel counseling on sexual behavior should be an essential part of advice to travelers, 7,10,15,16 but few travelers received such advice. Existing strategies for such counseling are clearly ineffective; we found no association between a self-reported history of pretravel sexual counseling and risk of having casual travel sex. We did not collect specific data on the type and setting in which any sexual counseling was received. Most travel clinics use unstructured, intuitive approaches with basic advice on safe sex and condom use, which may or may not include specific data on the risk of getting a sexually transmitted infection, according to the destination. As more data on the prevalence of sexually transmitted infection become available from individual developing countries, 12,13 more specific strategies may eventually be possible. Studies indicate that individuals who are promiscuous during travel are also promiscuous at home. Thus, effective campaigns about sexual health targeted at international travelers will also reach an important population with multiple sex partners at home. 8,17 Research on innovative and more effective counseling techniques is needed. 16,18
Counseling and educational campaigns also need to focus on host-country nationals at high risk of having sex with foreign travelers. The tourism industry has been shown to attract workers with a high propensity for sexual interaction with travelers. In a study at a well-known resort in the United Kingdom, only 7% of tourism workers had not engaged in sexual intercourse in the previous year, and 25% had had more than four partners in the previous year. 19 The majority of contacts were with travelers. Our experience suggests that such high-risk groups of individuals who prefer having sex with tourists and business travelers rather than with their comrades are present in the three major Peruvian cities visited by travelers. Identifying these groups is crucial to defining risk factors and to implementing preventive measures. A specific group of young citizens of Cuzco (called “bricheros” in Spanish) who frequently seek tourists for sexual encounters has already been identified for further research. Sexually transmitted infection rates in this group will indicate whether they constitute a specific subpopulation of “core transmitters”20 presenting an especially high risk to travelers. A semantic argument may be made that impoverished local partners are being paid for sex with meals, alcohol, and a warm place to sleep. Because in a broad sense this is the nature of relationships in many settings, we do not consider such local partners to be engaged in sex work.
In summary, this study delineates a profile of travelers who have sex while traveling in Peru and shows that condom use is not common, that pretravel counseling is infrequently provided, and that current pretravel counseling techniques are ineffective. We have also demonstrated that the sexual risk-taking profiles of USTs are similar to those of travelers of other nationalities and that travelers to Latin America deserve the same level of pretravel sexual counseling and STD-preventive interventions as travelers to other destinations.
1. World Health Organization. The state of the world health. In: The World Health Report 1996: Fighting Disease, Fostering Development. Geneva: World Health Organization, 1997: 1–62.
2. Mulhall BP. Sex and travel: studies of sexual behavior, disease and health promotion in international travelers: a global review. Int J STD AIDS 1996; 7: 455–465.
3. Hawkes S, Hart GJ, Bletsoe E, Shergold C, Johnson AM. Risk behavior and STD acquisition in genitourinary clinic attendees who have traveled. Genitourin Med 1995; 71: 351–354.
4. Carter S, Horn K, Hart G, Dunbar M, Scoular A, MacIntyre S. The sexual behavior of international travelers at two Glasgow GUM clinics. Int J STD AIDS 1997; 8: 336–338.
5. Tveit KS, Nielsen A, 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.
6. Bloor M, Thomas M, Hood K, et al. Differences in sexual risk behaviour between young men and women travelling abroad from the UK. Lancet 1998; 352: 1664–1668.
7. Matteelli A, Carosi G. Sexually transmitted diseases in travelers. Clin Infect Dis 2001; 32: 1063–1067.
8. Hawkes S, Hart GJ, Johnson AM, et al. Risk behavior and HIV prevalence in international travellers. AIDS 1994; 8: 247–252.
9. Mulhall BP, Hu M, Thompson M, et al. Planned sexual behavior of young Australian visitors to Thailand. Med J Aust 1993; 158: 530–583.
10. Hawkes S, Hart G. Travel medicine: the sexual health of travelers. Infect Dis Clin North Am 1998; 12: 413–430.
11. Mardh PA, Arvidson M, Hellberg D. Sexually transmitted diseases and reproductive history in women with experience of casual travel sex abroad. J Travel Med 1996; 3: 138–142.
12. World Health Organization/Global Program on AIDS. Global Prevalence and Incidence Estimates of Selected Curable Sexually Transmitted Diseases: Overview and Estimates. Geneva: WHO/GPA/STD, 1995:1–26.
13. Gerbase AC, Rowley JT, Mertens TE. Global epidemiology of sexually transmitted diseases. Lancet 1998; 351 (suppl 3): 2–4.
14. Russell KL, Carcamo C, Watts DM, et al. Emerging genetic diversity of HIV in South America. AIDS 2000; 14: 1785–1791.
15. Thomson MM, Najera R. Travel and the introduction of human immunodeficiency virus type 1 non-B subtype genetic forms into western countries. Clin Infect Dis 2001; 32: 1732–1737.
16. Gagneux OP, Blochliger CU, Tanner M, Hatz CF. Malaria and casual sex: what travelers know and how they behave. J Travel Med 1996; 3: 14–21.
17. Gehring TM. Are preventive HIV intervention at airports effective? J Travel Med 1998; 5: 205–209.
18. Aral SO, Peterman TA. Do we know the effectiveness of behavioural interventions? Lancet 1998; 351 (suppl): 33–36.
19. Ford N, Inman M. Safer sex in tourist resorts. World Health Forum 1992; 13: 77–80.
20. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis 1996; 174 (suppl 2): S201–S213.