Withdrawal as Contraception: Why So Skeptical?

To my surprise, my recent article in the journal Contraception
on the effectiveness of withdrawal in preventing pregnancy unleashed
a ministorm of commentary in the blogosphere. On Jezebel alone, an article on the
had (at last
count) 15,000 views and well over 300 comments – more attention than
was garnered by "Slutty Feminists," a popular topic on which Jezebel
also posted around the same time.  

The original article – written
for health care professionals and social scientists who deal with contraception
and family planning – presented data showing that withdrawal, widely
viewed as useless in preventing pregnancy, is only slightly less effective
than condoms.  Used consistently and correctly, condoms and withdrawal
are both very effective; even with typical use rather than perfect use,
both are comparable, at 17% and 18%, respectively. I also noted that
while many women use withdrawal at some point in their lives, often
as a back-up or secondary method (most commonly in alternation or in
conjunction with condoms), there is persistent reluctance among professionals
and individuals alike to consider withdrawal as a viable method of contraception.  

It’s great to see such lively
discussion about withdrawal and intriguing to see the comments, the
most interesting of which fall into three broad categories: personal
accounts of using withdrawal; skepticism, or outright disbelief, that
withdrawal reduces the risk of pregnancy; and claims that withdrawal
places responsibility on the male, who may be less than trustworthy
given the self-control required. 

The many personal accounts
of withdrawal use – in keeping with data showing that 56% of women who
have ever used a contraceptive method report using withdrawal at some
point in their lives – make clear that the method is part of the contraceptive
repertoire for many women, if only occasionally for most. It suggests
that sex education curricula and health care providers should present
withdrawal in its proper context, with both pros and cons, rather than
simply disparaging the method or erroneously presenting it as comparable
to using no method at all.  

This general view of withdrawal
informs another response – sheer disbelief. In my work I’ve grown
used to promoters of abstinence-only-until-marriage programs dismissing
facts about the effectiveness of contraception. However, I’m surprised
to see such disparagement of withdrawal among a crowd that is presumably
younger, more diverse and more open-minded. Perhaps because most of
us have been told for so long that withdrawal doesn’t work, we are
unable or unwilling to embrace scientific evidence that counters what
we "know." 

Most interesting, perhaps,
is the response expressed by many that men can’t be trusted to withdraw
in the heat of the moment. Sometimes it seems men can’t win for losing
when it comes to sexual and reproductive health. We argue that contraception
is a couples’ issue and that women should not be solely responsible,
yet we don’t think men can handle the responsibility. While some women
may not be comfortable depending on their partners to pull out before
ejaculating, and some men may not be able to do it, that does not mean
we should promote a false view of the method’s effectiveness. Withdrawal
may not be appropriate for some couples and individuals, but it is being
used at times by many, so why not ensure they have accurate information
about it?

Withdrawal will not prevent
exposure STIs and is not appropriate for those at high risk of exposure.
But I don’t buy the argument that accurate information about withdrawal
will discourage folks from using condoms and more effective hormonal
methods. The same argument was made about emergency contraception, and
numerous studies have demonstrated that the concern was groundless.
Disparagement of condoms by conservatives has led to more people putting
themselves at risk for STIs, including HIV, because they’ve been told
"condoms don’t work." Although no method can guarantee 100% protection,
condoms are an important option for both STI and pregnancy prevention,
and withdrawal should be considered as an option for preventing pregnancy.

For me, most heartening were
comments like the one offered by Flackette Goes Retro on Jezebel: "I
think the answer here is really just to give people lots and lots of
facts and education on their options. That includes failure rates for
all the various types of BC (pills, IUDs, condoms, withdrawal, NFP,
whatever-all of it, both perfect and "typical" use), information
about the pros and cons, information about protection from STDs (even
if condoms aren’t perfect they are MUCH MUCH better than nothing) and
information about how their bodies work. Then hopefully people will
be able to make informed decisions." Well said.

Than Nothing or Savvy Risk-Reduction Practice? The Importance of Withdrawal,"

by Rachel
K. Jones
of the
Guttmacher Institute, Julie Fennell of Central Connecticut State University,
Jenny A. Higgins of the Office of Population Research at Princeton University,
and Kelly Blanchard of Ibis Reproductive Health, was published in the
June 2009 issue of Contraception.

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  • invalid-0

    You’re basically making the same argument that NFP proponents have been making for years. Sure, the technique can work, if you’re diligent about it. But people aren’t perfect, and if the technique is flubbed, who ends up bearing the burden?

    It’s bad enough that all responsibility for withdrawal falls upon the male, entrenching a power inequality that many males have abused by intentionally not pulling out “fast enough.” But it’s worse in that the technique is so dependent on timing, and on resisting the massively instinctual urge to make that final hard thrust. Compare that, to, say, a male Pill—which the male could lie about having taken, but at least if he is speaking truthfully, you have 99.9% reliability regardless of how nimble and disciplined he is in bed. (I’m aware that no male Pill exists as yet; the point is, if the male is entirely responsible for contraception, the situation is better if it’s a form that does not rely on physical skill.)

    Withdrawal may not be one of those techniques that you discourage due to low reliability, like NFP. But it’s one of those that you discourage because in the real world, it’s asking for trouble. You have multiple things that can go wrong, and the woman really can’t do anything about it. At least with NFP, she knows her schedule, and can always say no. With withdrawal, it’s completely out of her hands.

  • http://globalhealth.change.org invalid-0

    I have been feeling doubtful about promoting withdrawal, for the reasons you addressed. It’s so hard to get right, it doesn’t prevent STIs, and it puts so much power and responsibility into the hands of men alone. Your condom analogy is a good one, though, and has me thinking twice.

  • http://www.randijames.com invalid-0

    If all things are equal (or at least some supposedly want them that way), then there should be no problem with using withdrawal effectively.

    A man must rely on a woman’s word that she has taken the pill CORRECTLY and you know how they bitch and moan about that one.

    Both people can ensure that a condom is placed on correctly, but women still have to assume that the man is skilled to withdraw his penis WITH the condom on–and that he didn’t lose it WITHIN the vagina (especially if he has a small penis, or waits until he is flaccid to withdraw)…else the woman will be aiding him throughout…

    A man must rely on a woman’s word about her ovulation time…

    A woman must rely on the man’s word about having a vasectomy (unless he carries his “papers” around..LOL)…

    Well, upon writing this, I’m not sure what I was getting at, but I guess people shouldn’t be having sex with those that they do not or cannot trust…because when it comes down to it, it is your body, your health. You have to take full responsibility.

    I have used withdrawal successfully as both a teen and an adult. It took skill and determination and only the best can do it. Nothing more, nothing else. There are no excuses when it comes to that method. Nothing is an accident, I would say–it is on purpose [when you use that method].

    Teens can be responsible, although we seem to know them, in general, as NOT. However when it comes down to it, there are many teens, regardless of the access to condoms, that will not utilize them for a myriad of reasons. If you want to talk about about pregnancy, withdrawal must be respected as an option.

    All things considered, we need a social revolution to get men and women to be responsible for themselves, and to stop placing all the blame on women.

  • invalid-0

    Thank you so much for publishing this Ms. Jones (and also Ms. Fennell, Ms. Higgins, and Ms. Blanchard). I was thrilled to see this article published in Contraception, but unfortunately not at all surprised by the backlash. I have been talking about this issue for several years to fellow professionals in the field of reproductive health and this has always been the response from people up and down the spectrum of experience and education. Despite the fact that the research on which your article was based is fairly easy to find and doesn’t require medical degrees to understand, very few (in my experience) health educators, clinic employees or administrators are aware of either the Zuckerman article or the Kost article, which I think easily make your case on their own. Even presented with these data, resistance usually comes down to a paternalistic insistence that if we give people the information that withdrawal is “better than nothing” we risk giving them permission to use something that might be less than perfect effectiveness. The most disturbing aspect of this is the lack of irony with which the same people who denounce abstinence-only will deploy this nonsense.

  • heather-corinna

    My issue was with the data (as well as with the specific population I work with — teens — per withdrawal).  I didn’t actually see your published commentary showing any new isolated *study* on withdrawal, but rather, some data taken from a broad census (which I presumed, as a census, was no less self-reported or anecdotal than anything else: please correct me if that was an incorrect presumption), where the number of people using withdrawal alone seemed so small, esp. compared to the number using condoms, that extrapolating from that data to draw those conclusions didn’t seem sound.


    Actually, let me restate that: drawing those conclusions per an efficacy statistic and stating them as firm, rather than simply calling for further study — which we DO need — seemed hasty to me.  For instance, the figure given for condom effectiveness in typical use was so much lower than all the other data we have on condoms, most of which is consistently different than the 18% figure you’re citing, that it seemed quick to suddenly list the figure from that census as THE figure.


    Mind, I think the point of your piece was mostly to talk about how providers and educators should talk about withdrawal, and be sure to include it like every other method when discussing methods, which I absolutely agree with. I also agree that when we present methods, or clients ask about them, we need to try and treat all of them the same way.


    I’m glad to see you here, and if you’d not mind, I’d personally love to hear more about the data itself, particularly if any of us (myself obviously included) are misunderstanding it or making incorrect presumptions about it.

  • http://figleaf.blogspot.com invalid-0

    Hi Rachel,

    As Rj and Anonymous point out, yes, there are all sorts of stories about conniving wymmen and controlling menz — there are more stories these days about pins and condoms these days than about razorblades in apples at Halloween. That’s not to say they never happen since they surely do. It’s just that as with *everything* about sex you also need to address it where it happens most often: in relationships where both partners have some degree of familiarity and good will towards each other.

    But consider the more reasonable cases. Let’s say you and your partner face the prospect of relying on condoms only (X% failure in “typical” use) or only Today sponges (Y% failure in “typical” cases) and you (very intelligently) feel a 15% or greater annual failure rate isn’t worth the stress. Instead of a) crossing your fingers and using a single method or b) taking a cold shower and not having intercourse at all it might be nice to consider c) combining condom or sponge with a second, comparably reliable method that you *also* might not care to use by itself: withdrawal.

    The only problem? (I mean besides the usual menz/wymminz conspiracy-theories.) As you point out in your paper withdrawal is neither well studied, well understood, or, especially, well explained to potential users but *is* used “informally” by a heck of a lot of people. Which means people either rely on their “approved” but relatively low-reliability single methods, or they abstain, or they “wing it” with withdrawal… without a well-informed understanding of their risks or of the best way to proceed.

    All of which is why I think it’s great that you’ve raised the issue. Not because I think withdrawal is the best thing since condoms (um, I wouldn’t have felt comfortable consistently trusting the annual risk of pregnancy for any single barrier method) but because it considerably reduces the relative unreliability of one’s primary method.

    A couple other points:

    * If withdrawal is often practiced without reporting (because, say, researchers or their subjects “know better” than to believe it’s a method at all) does this affect what we know about other methods of contraception? Especially their less formal “typical use?” Because if we’re looking at, say, 17% annual typical risk for condoms and it turns out that part of that protection comes from users also practicing unreported withdrawal then… eww! I’m not saying this is really true, I’m saying it looks like it doesn’t appear to be well researched.

    * As anonymous, above, hints, one standard definition of “withdrawal” involves the man continuing intercourse to the brink of orgasm (or, worse, beyond) before pulling out in hopes that his ejaculation will happen outside his partner’s body. When I discussed this on my blog, though, one commenter expressed shock and cited what she felt was more conventional wisdom that “you have to beat it for at least 15 seconds.” The former method would seem considerably more perilous than the latter. And *if* that was true then in if 56% of women (and, presumably, men) report using withdrawal at least once then yeah, if there are two ways to do withdrawal and one is much safer than the other then it would make sense to teach that. But, again, do we *know* which people mean when they say they use “withdrawal?” No, as far as I know this too is not well researched.

    All of which means that while I’m not confident (based on current lack of research and maybe after) that I’d ever endorse withdrawal as a primary form of contraception I seriously appreciate you dragging it out of the cellar, or closet, or where ever it’s already being practiced, and shining light on it.

    Oh, and final point? Until I read some of the reactions to your paper I’d never considered that withdrawal might be a third form of contraception available to men, after condoms and vasectomy. My first thought, though, was “well, another non-permanent method for men that’s even less reliable than the other one.” My second thought was “great, another method for men that’s even older than vasectomies — which were first described 179 years ago, in 1830!!!” It’s hard to be enthusiastic about this rate of progress. :-)

    I look forward to follow-up research in this area either from you or from others inspired by your paper.


  • http://figleaf.blogspot.com invalid-0

    Eek! I said “It’s just that as with *everything* about sex you also need to address it where it happens most often…” I really should have said “It’s just that as with everything about contraception you need to address it where it happens most often…”

    Also I want to be clear that I completely agree with Heather’s concerns about use of contraception among teens. On the one hand most teens have all the good will in the world and are often them most conscientious users of contraception. On the other hand errors are most likely at the beginning of the learning curve. And so even if I wasn’t teaching withdrawal as a formal method, based on the fact that withdrawal isn’t 0% percent effective I’d probably add the recommendation that beginning barrier-method users aim for outside ejaculation until they’re comfortable with all the other elements. (I.e. plan on intercourse as “foreplay” to be concluded with manually-, or instrument-, or, say, orally-induced orgasms at first.)


  • http://momstinfoilhat.wordpress.com invalid-0

    Some of us, like the commenter in the original post, fall into category #4.

    We take withdrawal seriously and think information in a woman’s mind is the best form of contraception for a woman.

  • invalid-0

    Withdrawal is a risky practice as part of the pleasure is the final thrust and to miss out on this again and again and not to mention the mess over your partner is hardly ideal.

    I don’t know why there is objection to condom usage overall. In respect to the risk rate we never had a problem. 100% effective. The keys are a strong hard-on and to withdraw soon after cumimg.

    • invalid-0

      If the girl has become pregnant, and you during sex did not use a condom and did not ask, whether she drinks tablets, you have the right to insist on that it has kept pregnancy, but should not insist on its interruption.

      If the man and the woman simply meet, that, having faced with the partner accompanied by someone another, they should pretend, that are unfamiliar not to put each other in awkward position. At desire this meeting can be discussed then in a comic key.

    • http://trendever.blogspot.com/ invalid-0

      At every fifth woman after abortion there comes proof barreness. If to add to these figures number of women, fruitless for other reasons it is possible to assume, that in the near future we will die out… Artificial fertilisation should not replace natural at all.

      Therefore each woman should put a maximum of efforts to keep the ability to conception for human race continuation. Today the medicine has sharply moved ahead in questions of contraception and offers the broadest assortment of contraceptive means