Withdrawal Research: Giving Sexual Partners “Permission” to Use Less Reliable Birth Control Methods?


Reading the
new report published by the Guttmacher Institute (PDF) on the withdrawal method
of contraception
— better known by laymen as "pull and pray" — you get the
strong impression that the authors are simply contributing new data to the
discussion about this method in public health circles.  Researchers cobbled together the shockingly
small amount of research on withdrawal as
a method of contraception to suggest that the preliminary findings – 4 percent failure rate for perfect use/18
percent for typical use – could possibly indicate that it’s not as bad a pregnancy
prevention method as usually assumed, but, of course, more research is
needed.  But in the meantime, the authors
suggest there’s nothing wrong with teaching it to couples with low STI risk as
a way to mitigate risk of unintended pregnancy if you’re using no method of
contraception, or as a back-up to pills or condoms, particularly if you have a
history of using those methods improperly.

What they intended was a sober-minded discussion of risk
mitigation, with a particular focus on withdrawal as a back-up method.  What they got was an extremely emotional and
divisive reaction.  The mainstream
media’s take was to have a sexist chuckle over
how women weren’t going to like this, ha ha ha.
  Jezebel defensively argued that
this should mean women who use it as their primary method of birth control
should get a pass
on being judged by others, even falsely claiming that
it’s not the "worst" method, even though with an 18% typical use failure rate,
it might actually be, if you’re using it as a primary method. Feminist blogger
Lindsay Beyerstein pushed back, pointing
out that the paper is not an actual extensive study, and shouldn’t be treated
with the same weight as thorough research.
 
In an article by Dana Goldstein, Heather Corinna got to the heart of why
this subject raises so many hackles, when
she pointed out that withdrawal is associated with pushy young men who exhibit
disregard for women’s health or wishes.

The problem with much of the reaction is that it’s based on
the assumption that the papers’ authors were advocating withdrawal as a method
on par with hormonal or barrier methods. 
When asked about it in email, study author Rachel Jones responded: 

I can’t say I’m surprised, but I’m
still disappointed, that folks are interpreting the commentary and the
subsequent coverage it has generated to mean that we are advocating that they
use withdrawal. The point of the article was to inform, or remind, folks that
withdrawal substantially reduces the risk of pregnancy; those of us who work in
the field of sexual health do everyone a disservice by unilaterally dismissing
it as ineffective….. Alternately, talking about it as a secondary or back up
method-for example, when the condom breaks, when the woman forgets to take her
pill, or "doubling up" so as to be extra sure that the woman doesn’t get
pregnant-might result in fewer unintended pregnancies.

 

Indeed, the paper itself mostly focuses on the use of
withdrawal as a back-up method employed along other methods, or as something to
fall back on for couples that don’t have anything else on hand, but aren’t
letting that deter them from having sex. 
Which happens, even if it makes many of us uncomfortable discussing it.

What Guttmacher researchers tripped over in this discussion
about risk mitigation was the almost-startling revelation that the public at
large has strong stereotypes and opinions about withdrawal, and the people who
use it.  As the defensive post at Jezebel
demonstrated, it’s widely believed that women who use withdrawal are rolling
over for some man who has openly demonstrated his contempt for her well-being
by refusing to wear a condom.  Candidly,
that’s what first comes to mind for me, as well–and let’s face it, I thought,
if a guy cares for you so little he uses the "we don’t need a condom, I’ll pull
out" line, then odds ratchet up dramatically that he won’t keep that
promise.  Because he’s already shown that
he doesn’t care. 

Using the utterly unscientific method of asking people on
Twitter and Facebook what they thought of when they thought about withdrawal, I
found that many others didn’t immediately think of sexist men pushing doormat
women around, as I did.  Instead, they
thought of people who are so prudish and afraid of dealing honestly with
sexuality that they find themselves having sex without even trying to obtain
contraception ahead of time.  People
associated it with drunken sex, with abstinence-only education, being
under-educated, and having a fear of sexuality drilled into your head by religion.  A few people agreed with these stereotypes,
but actually said it worked for them when they were in the position of being
too uneducated or scared to use more effective methods.  More often, people made cracks about how
people who use it call themselves parents, and disdained the idea that perfect
use could even work, because it’s much easier to slip up than it is with
condoms. Some people suggested that it was okay if you were okay with having a
baby, or keeping emergency contraception on hand.  Interestingly, no one suggested that abortion
was an appropriate backup.

With an emotionally laden topic like this, therefore, it
really isn’t surprising that the Guttmacher paper got the reaction that it
did.  For people who feel ashamed of
relying on withdrawal, either as a primary or more commonly as a back-up
method, there was an over-eagerness to embrace the paper as vindication, much
like when people mistakenly believe that "no saturated fat" means the same
things as "no calories,", or that chocolate or wine is actually good for you,
because they think they read in the paper that both had health benefits.  For people who associate withdrawal with
everything from lack of education to the abuse of women, reading the paper from
Guttmacher was frustrating, and even alarming, as it was seen as potentially
giving people "permission" to avoid more reliable methods.

In reality, it’s neither. 
The wishful thinkers would do well to reread the paper and realize that
the sample sizes are small, the questionnaires are inexact, the method mostly
crops up as a back-up (making it hard to measure), and mostly the topic is
ignored on surveys.  In fact, one of the
aims of the paper is to call for more rigorous study of the topic.  Those of us with negative gut reactions would
do well to remember that the authors weren’t saying that withdrawal should be
promoted as an acceptable primary method, especially for teenagers or
non-monogamous people, but more as a back-up, with the knowledge that people
are often not so great at using their primary methods and could benefit from
using two methods at once. But above all, we need more research, both in the
method’s effectiveness and on social attitudes about withdrawal that might make
it harder to incorporate in a risk reduction strategy than it might seem on its
surface.

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  • invalid-0

    Thanks for this post Amanda. I remember asking a question about withdrawal at a peer sex education presentation. I asked if withdrawal increases the efficacy of condoms. The presenter told me she didn’t know, but that spermicides like VCF did. A few other people at the discussion said things like “Huh? Your partner suffered enough wearing a condom. Why would you ask him to pull out too?” Some people think of withdrawal as some big chore that a man does for a woman.

  • invalid-0

    As one of the co-authors of the article you describe, I wanted to applaud your summary of what has been a very contentious debate, one whose fervor and scope are above and beyond anything we could have expected. // Perhaps this kind of debate is the best outcome we could have asked for — that is, a lively conversation that has brought more attention to the issue of withdrawal use, including its widespread prevalence and better-than-most-people-think efficacy. However, as you argue in the last paragraph, with any debate, it’s best if everyone involved holds a good working knowledge of the data, or lack thereof. We have been disheartened to see how some readers (and writers) have misinterpreted out main arguments. // Most centrally, we wanted to call for more research on the method. We also wanted to encourage reproductive health practitioners to take a more pragmatic, less judgmental approach to withdrawal. We believe that many people are already using withdrawal, and they should be encouraged to use this method as effectively as possible, and/or use it in conjunction with other risk reduction strategies such as condom use. // Finally, I wish to note that researchers at the Guttmacher Institute are not the only ones interested in better understandings of withdrawal. The authors of the paper represent four different institutions (The Guttmacher Institute, Central Connecticut State University, Princeton University, and Ibis Reproductive Health), and undoubtedly many similar sounds exist in the field of sexual and reproductive health. // Thank you again for your comments.

  • invalid-0

    Early on in our relationship we practised withdrawal on the basis that this form of contraception was more acceptable to the Church. Each month we went through hell wondering whether my partner was pregnant. As well as a lack of satisfaction for both, use of the pill and/or condoms takes away the uncertain aspect and leads to a much better sex life. I hear about condoms breaking but we have never had such an experience. I was always proud to see the amount of ejaculate one could produce.

  • invalid-0

    I encouraged my college roommate to be ready to get an abortion when she returned from her Wednesday night church service sharing a tale of unplanned sex and withdrawal. She was fortunate that she did not get pregnant and did not need the abortion but she said she was happy to have a roommate who had a handy copy of Cosmopolitan’s issue on abortion providers (mid 1970s) available with the phone numbers. (This was a private religious college and my roommate wasn’t pro-choice but due to having the information she would have made a good choice for herself FOR ABORTION if she had needed to do so.) I do try to speak up and mention that abortion is a choice when anyone shares anything with me about potential need for one.

  • invalid-0

    as a backup method, so i’m not really sure why the push for more research/promotion of withdrawal. i’ve known a number of girls who have gotten pregnant while on the pill, so ever since i’ve been sexually active i’ve used either condoms or withdrawal on top of the pill. it might not make any difference at all, but it sure makes me (not to mention my partner) feel more relaxed. it’s not like anyone ever told me about withdrawal, we just figured it out, unlike some of the more complex and scientific methods that work in unseen ways. EVERYBODY who understands the mechanics of sex understands the mechanics of withdrawal; all people really need to be informed of is that it’s less effective on its own than other methods. what’s the big controversy in that?

    • http://marika-barbie.blogspot.com/ invalid-0

      What man does not wish to have sex without a condom? And at the same time, what man does not want, that to steam of hours of passion have not turned back a birth of the undesirable child? A dilemma, which can be solved or timely interruption of sexual intercourse (that rather risky), or application of methods of contraception by the woman.
      But how to be, if also she does not wish to be protected? Even if both of you do not have venereal illnesses, the consent of the woman to sex without contraception can mean its desire to become pregnant, that to the man is not always comprehensible. In an opposite situation the woman can think, that the man absolutely about it does not worry, and if suddenly that, will throw with the child on hands.
      So, having woken up in the morning after night of love “without protection”, one of partners can become thoughtful seriously, whether it is necessary to it to change the habitual way of life and the relation to sex for the sake of another.

  • invalid-0

    Are there any recent studies on either withdrawal or Circumcision or Withdrawal + Circumcision as effective methods of preventing HIV/AIDS. What were the findings?