An article published last week on New York Magazine‘s The Cut is making waves among feminists and sex educators alike, as it describes a new generation of women unapologetically using withdrawal as their primary method of contraception. Though the headline dubs these women the “pullout generation,” writer Ann Friedman talks mostly about a specific subset of women: 30-somethings in long-term relationships who have been having sex with the same man for years, trust him, and are less than terrified of getting pregnant. These women are tired of the pill and other hormonal methods, skeptical of intrauterine devices (IUDs), and dislike condoms. So they arm themselves with period tracker apps that let them know what days not to have pullout sex, condoms so they can have sex on those days, and packets of emergency contraception in case something goes wrong.
These women seem to have done exactly what I hope every student of sexuality education would be able to do: apply what they have learned about efficacy rates and side effects to their own relationships and lifestyles and come away with the birth control method they think is best for them. So why does their decision make the sex educator in me so uncomfortable? Does withdrawal really work well enough to be someone’s primary method of contraception? And even if it works well, shouldn’t we be steering women toward methods that work even better?
Does It Really Work?
Withdrawal has been around for as long as people have been inserting Tab A into Slot B, but since the advent of more modern methods, from condoms to pills to IUDs, it’s been widely thought of as a non-method—what people do when they don’t have any real birth control around. Recent research, however, suggests that it might be somewhat more effective than that.
Contraceptive efficacy can be confusing because of the way researchers calculate and explain it. Though it is often expressed as a percentage of failures, it doesn’t mean how often a method will fail during sex. Instead it comes down to the math problem, “If 100 couples use method X as their primary method of birth control, how many of them will get pregnant within the first year?” With every method, there are two answers to this question: the one for couples who use the method consistently (every time) and correctly (the right way), and the one for couples who get a little sloppy. The pill, for example, has a 0.3 percent failure rate, which means that fewer than one couple out of 100 who use the pill perfectly would get pregnant in the first year. Of course, people may forget to fill their prescription on time or miss a few nights one month. Under these typical conditions, nine out of 100 couples using the pill would get pregnant in the first year. For comparison’s sake, it’s good to remember that 85 couples out of 100 who use no method of contraception will get pregnant in the first year.
The take-away message from recent research on withdrawal is that it is almost as effective as condoms in preventing pregnancy. If used perfectly, two out of 100 couples who use condoms will get pregnant in the first year, compared to four who use withdrawal. For couples using these methods sporadically or incorrectly, the numbers are, unsurprisingly, worse—about 17 couples who use condoms will get pregnant in a given year, as will 18 couples using withdrawal. Moreover, in a 2009 article, Rachel K. Jones and colleagues at the Guttmacher Institute argued that because of the way usage questions are asked and the perception of withdrawal as a “non-method,” its use is likely underestimated, which may interfere with researchers’ ability to accurately calculate efficacy. As Jones told RH Reality Check in an email, “There’s no denying that it substantially reduces the risk of pregnancy.”
Still, while the typical use rates for withdrawal and condoms may be similar, it’s easy to improve your odds when using condoms—just use one every time, and use it right. Most condom errors are simple user errors, like not putting it on until after intercourse has started, taking it off before ejaculation, or not using it at all. We can’t blame a condom for a pregnancy that happened while it was still in the night table drawer, but the typical failure rates nonetheless include couples who say condoms were their primary method of contraception but weren’t using a condom the night they got pregnant. Fix these things, and condoms can be as much as 98 percent effective in preventing pregnancy.
It’s unclear, however, what can be done to get closer to the perfect use rate for withdrawal. Part of the issue may be physiological and depend on a man knowing his body, sensations, and what it feels like when he’s about to ejaculate so that he can learn when he needs to pull out. Jenny Higgins, a researcher at University of Wisconsin, Madison who worked with Jones on the 2009 article, said some men might have better efficacy rates when they use withdrawal because they have the timing down pat. She suspects that if researchers looked at the rates more closely, they might find that efficacy is related to age, with younger, less experienced men having more failure than older men with more practice.
Which brings us to the issue of control and trust, which goes hand-in-hand with choosing withdrawal. Most birth control methods are within a woman’s control; she knows if she has an IUD or has taken her pill. In consensual relationships, women even have some control over condoms, even though they don’t wear them. Women can buy them, carry them, and put them on men. More importantly, they can see that they are in place before they put themselves at risk of pregnancy. This is not the case with withdrawal. Women must trust that their partners are not just honest (meaning that if he says he is going to pull out he really intends to do so) but also capable (meaning that he knows how to retreat before the moment of no return).
But Jones said she’s always surprised by this “male distrust” argument: “Men can’t win for losing when it comes to pregnancy prevention. We don’t think it’s fair for women to have sole responsibility for preventing pregnancy, but then it seems like we don’t trust men to do it. A lot of safe sex messages promote condom use, and that depends on male cooperation, so withdrawal falls in the same category. If the male partner has a hard time pulling out before he ejaculates, this obviously isn’t an appropriate method. But a lot of men are able to control this and are motivated to do so.”
Jones also pointed out that men have been trusting women who say they are on the pill for years, without ever seeing them pop one. And she’s right. The same two scenarios I describe above could happen in reverse: A woman could say she was on the pill to appease her partner but have no intention of actually taking it, or she could be committed to the pill but just miss a few pivotal days. Still, something about spending a sex act not quite knowing whether he’s going to pull out in time may make some women anxious.
It turns out, however, that part of what makes some men better at withdrawal than others may be purely biological and not within either partner’s control. Most men leak a little fluid before they ejaculate called pre-ejaculate, or pre-cum to the more blunt. In college, I learned that pre-cum absolutely contained sperm and that this was one of the reasons that withdrawal was a bad idea. It appears that this assertion was a bit of an educators’ myth—information that is repeated even though it was never substantiated. The notion may have originated with William Masters and Virginia Johnson, who wrote about it in their famous 1966 book Human Sexual Response but could never produce the scientific basis for it. Nonetheless, it was passed on for decades, until the 1990s and early 2000s, when some researchers took on the subject with mixed results. For a while, the best information said there was no sperm in pre-cum, then new information said there might be. This went back and forth for some time.
The best evidence currently available is from a 2010 study published in the journal Human Fertility. This research analyzed samples of pre-cum and found that in 41 percent of men it contained sperm. Though some experts had theorized that sperm would only be in pre-cum if the man had ejaculated recently and there were some leftover “swimmers” in his urethra, this study refutes that theory as well. The men in this study had urinated numerous times (cleaning the urethra) before the pre-cum was collected, and sperm was still found in their samples. The researchers concluded that some men simply leak sperm as part of pre-ejaculate, and some men don’t. Higgins says this may be why some have better efficacy with withdrawal—they don’t have sperm in pre-cum, which limits their partners’ risk of pregnancy. Unfortunately, there is no way to know which group you or your partner fall into. In terms of withdrawal, the authors of the 2010 study concluded, “We are unable to say how this finding might translate into the chances of pregnancy if these samples of pre-ejaculate were deposited in the vagina except that the chances would not be zero.”
James Trussell, a Princeton-based researcher and one of the study’s authors, pointed out in an email that this negates the idea that withdrawal can be easily supplemented with emergency contraception for those times when it didn’t go so well: “[T]here’s sperm in pre-ejaculate so one would not know that something has gone wrong.” Trussell also writes the chapter on efficacy in Contraceptive Technology, one the bibles of contraception for practitioners. His main point when I asked him about his opinion on withdrawal as a method was pretty simple: “Failure rates during typical use of withdrawal and condoms are similar but are astronomically higher than those for IUDs and implants.”
This may be the bottom line. Withdrawal works, but there are many things that work better. IUDs are now recommended as a first-line birth control method for young women (even teenagers) and those who have never had children. A woman with an IUD has a 0.2 to 0.6 percent chance of getting pregnant no matter what she does, doesn’t do, or forgets about. A women with a contraceptive implant has an even lower risk (0.05 percent). True, each of these methods has some aspect or side effect that some women won’t like, but there are a slew of options that are more effective than withdrawal.
So What’s a Good Sex Educator to Do?
The sources in Friedman’s article are older, educated women who most likely have access to whatever method of contraception they choose, and they choose withdrawal. They are not alone. Friedman also interviewed a number of women in their 20s who have used withdrawal, though their decisions seemed to be more spur-of-the-moment and less well reasoned. Teens use it too. In fact, the most recent National Survey of Family Growth found that about 60 percent of sexually active women have used withdrawal at some point in their lives. Higgins explained that overall the research seems to show that couples use withdrawal in different ways—some couples use it because they have nothing else, and others use it in conjunction with another method, like a condom or the pill, to make extra sure they don’t get pregnant. She suggested, “We at least need to acknowledge that people are using it and that it has averted many [pregnancies]. Instead of pretending it doesn’t exist, let’s talk about it.”
And when we talk about it, we have to be honest, even if our gut instinct would be to discourage it or at least continue to relegate withdrawal to the “better than nothing but please use something else” category. As Deb Hauser, president of Advocates for Youth, said, “I believe that young people should be given honest, accurate information. They have the right to all of the information and when empowered with that information are more able to take agency over their sexual health. That means we should teach youth about withdrawal as an option when they don’t have anything else with them. Withdrawal is much more effective at preventing pregnancy than using nothing. To withhold that information is misguided.”
Elizabeth Schroeder, the executive director of ANSWER, a national organization that provides sexuality information to youth and trains teachers, said much the same thing about giving honest information. She also stressed the importance of including sexually transmitted diseases (STDs) in the discussion, which Friedman’s article largely glossed over. “I find it striking,” she said, “that the article only talks about pregnancy prevention—nothing about STDs. While the risk is lower in a long-term committed relationship, if the couple truly is monogamous and committed, when we talk about teens and folks in their early 20s, they may be in shorter-term relationships or have one-night stands. To only talk about birth control ignores a huge part of this sexual health issue.”
It is true that withdrawal provides no real protection against STDs, as bacteria and viruses can be present in pre-cum, and some STDs, like HPV, are transmitted through skin-to-skin contact. Condoms remain the only birth control method, other than abstinence, that can prevent STDs.
Rachel Jones summed it up this way: “Withdrawal isn’t an appropriate method for every couple. But it can be a good backup option when used in conjunction with condoms, and it can provide ‘extra insurance’ against pregnancy for all couples, even those using hormonal methods. And for couples that don’t want to be pregnant, it’s certainly a better than using nothing.” She added that she would not discourage its use even as a primary method of contraception because it really does reduce the risk of pregnancy.
Essentially there was unanimous agreement among the researchers and sexuality educators I spoke with that we need to acknowledge and further examine the role that withdrawal plays in preventing pregnancy, give people honest information, and let them make their own decisions. And while I agree wholeheartedly, I can’t help but wonder if the women in the article didn’t make the right one.