As a sex educator, I have always been skeptical about the idea of using withdrawal as a method of contraception. I worry that a man might promise to pull out but forget in the heat of the moment. I worry about sperm in pre-
ejaculatory fluid, which the latest research suggests some men have and some men don’t. And I worry about sex that is not protected against sexually transmitted infections (STIs) or HIV. Although research has found that withdrawal can be as effective in protecting against unintended pregnancy as condoms, I’m not a risk-taker and I don’t understand why couples would want to rely on “pulling out” when so many other more effective contraceptive methods exist.
As I explained in a piece for RH Reality Check last year, I
have been especially concerned at the idea of the so-called pullout generation —30-something women, in long-term relationships, who could easily access and afford other methods but choose withdrawal instead. New research, however, suggests that this cohort might not represent most withdrawal users.
Researchers collected data from a national sample of 4,634 women between the ages of 18
and 39. They asked a number of questions about contraceptive use—both about hormonal methods (such as the birth control pill or shot) and coital methods (such as withdrawal and condoms). They found that among women at risk of unintended pregnancy, 33 percent had used withdrawal at least once in the last 30 days; 13 percent reported withdrawal was the most effective method of contraception they used in the last 30 days; and 12 percent had only used withdrawal in the last month.
The findings on withdrawal show higher use among women than other surveys, such as the National Survey of Family Growth (NSFG), which
found that 3 percent of women currently use withdrawal. The authors noted several reasons for these discrepancies. First, they explained that a methodological difference in how they asked the question may have increased the likelihood that women noted withdrawal use. While the NSFG put withdrawal at the bottom of its list of birth control methods, this study put it at the top. Rachel Jones, a researcher at the Guttmacher Institute and the lead author of the study, told RH Reality Check that the group put withdrawal at the top of its list to confirm its standing as a legitimate method. “Women don’t even think of it as a method,” said Jones, “so sometimes they don’t even see it when it’s listed under all the other methods.”
The other major difference is more inclusion of dual-method users. The authors explained that in the NSFG, current use figures represent only the most effective method of contraception that a woman had used in the last 30 days. If a woman
said she used both the pill and withdrawal, for example, she was counted as a pill user. The current study included all methods women had used in the last 30 days and found that dual-method use was common. In fact, 28 percent of pill users and 13 percent of users of long-acting reversible contraception methods (LARCs), such as IUDs and implants, reported using withdrawal at least once during the last 30 days. And 33 percent of women who relied on condoms also reported using withdrawal. In response to an additional survey, most dual-method users—77 percent—said they used the two methods at the same time, while 12 percent said they switched between methods.
Jones summarized the findings by saying, “Contraceptive use is messier than we think. Women are using different methods. They are changing their methods over time. Withdrawal is often used as a back-up method or as extra protection.”
Jenny Higgins, a professor at the University of Wisconsin and one of
the co-authors of the study, added that the data highlighted two types of users: those she calls “eroticizers of safety,” who are really motivated to prevent pregnancy and add withdrawal to the other methods they are using, and the group of “switch hitters,” who go back and forth between methods depending on what’s available or where they are in their menstrual cycles.
Both authors said that the most striking finding in this study was how many women were using withdrawal as extra protection. As Higgins explained to RH Reality Check, “There is a reputation of withdrawal users as being lazy or ambivalent or uneducated, but at least in this sample they seem to be extra motivated to prevent pregnancy.” Jones added that their study, which included a large, though not necessarily
representative, sample of women, does not support the anecdotal stories about the “pullout generation” of women in their 30s who may be ambivalent about pregnancy and rely primarily on withdrawal. In their study, withdrawal users were younger, and use of themethod declined with age. Moreover, the study found that women who expressed strong pregnancy avoidance attitudes had a higher level of reliance on withdrawal (35 percent) and about half of these women were using withdrawal in combination with a highly effective contraception method.
While this study paints a more responsible picture of withdrawal users, I still have a hard time with the promotion of withdrawal as anything other than “better than nothing” or “something to use when you have no other options.” Higgins said that this is part of the problem: “Withdrawal has been unfairly maligned. There is no accepted narrative for how even to talk about its use, and that hurts young people.”
Jones said that I’m not alone, but also suggested a change in message: “I know sex educators don’t like to talk about withdrawal, but we have to recognize that people are using it, so we have to talk about it.” At the very least, she suggested, sex educators should be talking about withdrawal as a good backup method and extra protection against pregnancy for those who are using other methods.
I am willing to take the advice of both of these colleagues, and I do believe that it is important to tell the truth about all contraceptive methods. Withdrawal has undoubtedly prevented countless pregnancies over the years, and as such anyone who doesn’t want to get pregnant should know that it can work really well when used with another method or even by itself when other methods aren’t available. Of course, I would still tell anyone who doesn’t want to get pregnant about the other contraception methods that work even better, and about the importance of condoms to prevent STIs.