Exit Strategy: Does Withdrawal Deserve Another Look?

Dana Goldstein

A new study assessing the withdrawal method finds it is nearly as effective as condoms. Should we teach it to teenagers?

About a quarter of American high school students receive
abstinence-only sex-education, meaning they learn nothing at school
about contraception methods. But even among American teens who are
offered comprehensive sex-education, there is one birth-control method
routinely derided: the withdrawal method — known colloquially, of
course, as "pulling out" before ejaculation.

Students are told that in addition to providing no protection
against sexually transmitted infections, withdrawal does next to
nothing to prevent pregnancy. Pre-ejaculatory fluid contains sperm that
can lead to pregnancy, teens are taught — despite the fact that
clinical studies show this is highly unlikely.

Now a new paper (PDF), published by the journal Contraception,
culls evidence from several studies to argue that withdrawal is
actually nearly as effective as condoms in preventing pregnancy. The
paper reports that couples who practice withdrawal perfectly over the
course of a year — meaning the male partner always pulls out before
ejaculation — have only a 4 percent pregnancy rate. More "typical"
couples using withdrawal (those who sometimes mess up) have a pregnancy
rate of 18 percent.

Those numbers are very similar to the perfect and typical-use
rates for the male condom, which are 2 percent and 17 percent,
respectively. The typical-use numbers are based on the 2002 National
Survey of Family Growth, which sampled 848 women using withdrawal and
3,800 using condoms.

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Against the back-drop of a rising teen pregnancy rate
and ongoing political fights over the Obama administration’s decision
to cut some abstinence-only funding, public health experts are sharply
divided on the implications of the new paper, especially with regard to
sex-education. Some believe teenagers should be encouraged to practice
withdrawal in some contexts — if they don’t have a condom, but also if
they come from religious backgrounds that eschew hormonal birth

But others caution that emphasizing withdrawal’s success rate
ignores teen boys’ relative lack of self-control compared to adult men,
and downplays teen girls’ need to share control over contraception.
Indeed, there is no reliable research on the method’s success rate
among adolescents in particular. And talking positively about
withdrawal takes the focus off condoms, which are the only way to
protect against most STIs. "A common situation is one in which the
boyfriend doesn’t want to use the condom, period," says Heather
Corinna, a Seattle-based sex-educator who runs the popular sexuality
advice Web site Scarleteen.
"This is a pretty easy slippery slope." Corinna says she was conceived
by parents using the withdrawal method "perfectly." She laughs, "That’s
one of the three things my parents agree on!"

Yet the Contraception paper’s lead author, Guttmacher
Institute researcher Rachel Jones, cautions against relying on
anecdotal evidence when assessing withdrawal. "We’re constantly told by
people in positions of authority that it’s not effective. ‘Don’t use
it, it’s like playing roulette,’" she says. "But it does substantially
reduce the risk of pregnancy. And that’s why it should be part of
sex-education classes."

Former public school sex-ed teacher Debra Hauser, now executive
vice president of Washington-based Advocates for Youth, couldn’t agree
more. She calls the traditional public health line on withdrawal "a
huge pet peeve. I’m thrilled somebody finally did an article like

During a recession, it’s no small thing that withdrawal is
free. What’s more, Hauser points out, many teenagers don’t know how to
access contraception, or are anxious about parents finding out they
have bought condoms or obtained a prescription for hormonal birth
control. And those who hear abstinence-only messaging in church or at
school may have done little or nothing to plan for sex, believing that
to do so would be to give in to temptation.

Despite the prevalence of abstinence-only, 60 percent of all
American high school students have sex before graduation day, and about
95 percent of Americans have pre-marital sex. Research shows teens who
take abstinence pledges delay sex, but do eventually engage in
pre-marital intercourse at the same rate as their peers. When they do
have sex, however, they are less likely than other teens to use

"When sex is held out as forbidden fruit, young people are
not prepared for planning it. It just sort of happens," Hauser says.
"If at that point, all you have is withdrawal, then my goodness,
withdraw! Unfortunately, if withdrawal is belittled in school, you
think, ‘Why should I?’"

A Kinsey Institute survey of 18 to 30 year old women found
that about 21 percent regularly use withdrawal, most commonly combining
it with another method, such as using condoms during the more fertile
days around ovulation. High school sex-ed curricula rarely delve deeply
into that type of fertility awareness; in comprehensive sex-ed, girls
are usually told to be wary of pregnancy on every day of their cycle.
But considering that more people may be relying on withdrawal than
previously assumed, some sex-educators believe teenagers ought to be
introduced to fertility awareness methods as well, which are most
commonly associated with married couples who oppose other forms of
birth control for religious reasons.

"Religious kids believe contraception is abortion," Hauser says. "Rhythm and withdrawal — at that point, it’s all you have."

TeenStar is a popular international sex-ed curriculum that
emphasizes fertility awareness alongside a pro-abstinence, pro-marriage
message. According to Hanna Klaus, an ob-gyn and the program’s
director, TeenStar students are taught to monitor vaginal mucus in
order to avoid days of peak fertility. The program is active in 30
countries. Under the Bush administration, TeenStar received funding
from both USAID and PEPFAR, the President’s Emergency Plan for Aids
Relief. Yet because it is considered neither abstinence-only nor
comprehensive sex-ed, only a few Catholic schools are using the
curriculum within the United States.

Though TeenStar does less to promote condoms and hormonal
birth control than many comprehensive sex-ed advocates would like, some
see possibilities for cooperation with abstinence proponents like
Klaus, who will at least discuss contraception with teens. In reality
though, the American sex-ed wars have left little space for such common
ground. Influential groups such as the National Abstinence
Clearinghouse and National Abstinence Education Association oppose
giving teens "mixed messages" by discussing any contraceptive methods.
Both organizations ignored several interview requests for this article.

As the political consensus shifts away from abstinence-only,
debates like this one will likely become more common. Even those
skeptical of the reported withdrawal success rates say disagreement
over the method provides a perfect opportunity to teach teenagers the
kind of critical thinking and evidence-assessment necessary in making
health decisions.

"I think everything should be talked about with teens," says
Martha Kempner, vice president of SIECUS, the Sexuality Information and
Education Council of America. "The thing we often forget about
school-based information is that we’re not just giving them the
information they need right now. We’re giving them the information they
need for the rest of their lives."

This article was published by The American Prospect.

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