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
control.

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
this."

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
protection.

"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.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary Sexual Health

Fewer Teens Are Having Sex, But Don’t Pop the Champagne Yet

Martha Kempner

The number of teens having sex may be less important than the number having protected sex. And according to recent data from the Centers for Disease Control and Prevention, condom use is dropping among young people.

Every two years, the Centers for Disease Control and Prevention’s Division of Adolescent and School Health (CDC-DASH) surveys high school students to gauge how often they engage in perceived risky behaviors. The national Youth Risk Behavior Surveillance (YRBS) is wide ranging: It asks about violence, guns, alcohol, drugs, seat belts, bicycle safety, and nutrition. It also asks questions about “sexual intercourse” (which it doesn’t define as a specific act) and sexual behaviors.

Started in 1991, this long-running study can provide both a picture of what high school students are doing right now and a historical perspective of how things have changed. But for more than a decade, the story it has told about sexual risk has been the virtually the same. Risk behaviors continually declined between 1991 and 2001, with fewer high school students having sex and more of them using condoms and contraception. But after the first 10 years, there has been little change in youth sexual risk behaviors. And, with each new release of almost unchanging data, I’ve reminded us that no news isn’t necessarily good news.

This year, there is news and it looks good—at least on the surface. The survey showed some significant changes between 2013 and 2015; fewer kids have ever had sex, are currently sexually active, or became sexually active at a young age. More teens are relying on IUDs and implants, which are virtually error-proof in preventing pregnancy.

In 2015, 41 percent of high school students reported ever having had sexual intercourse compared to 47 percent in 2013. The researchers say this is a statistically significant decrease, which adds to the decreases seen since 1991, when 54 percent of teens reported ever having had sexual intercourse.

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Another change is in the percentage of students who had sex for the first time before age 13. In 2015, 4 percent of high school students reported this compared to almost 6 percent in 2013. This is down from a full 10 percent in 1991. As for number of overall partners, that is down as well, with only 12 percent of students reporting four or more partners during their lifetime compared to 15 percent in 2013 and 19 percent in 1991. Finally, the percentage of students who are currently sexually active also decreased significantly between 2013 (34 percent) and 2015 (30 percent).

These are all positive developments. Delaying sex can often help prevent (at least temporarily) the risk of pregnancy or STIs. Having fewer partners, especially fewer concurrent partners, is frequently important for reducing STI risk. And those teens who are not currently having sex are not currently at risk for those things.

While I want to congratulate all teens who took fewer risks this year, I’m not ready to celebrate those statistics alone—because the number of teens having sex is less important to me than the percentage of teens having sex that is protected from both pregnancy and sexually transmitted infections. And that number is lower than it once was.

Among sexually active teens, there were no significant positive changes in measures of safer sex other than an increase in the number of sexually active high school students using the IUD or implant (up to 4 percent from 2 percent in 2013).

Moreover, some results indicate that today’s teens are using less protection than those who were teens a decade ago. The most telling finding might be the percentage of teens who used no method of contraception the last time they had sex. This decreased between 1991 and 2007 (from 17 percent to 12 percent), inched up to 14 percent in 2013, and stayed the same in 2015 (14 percent). There was also little to no change in the percentage of high school students who say that either they or their partner used birth control pills between 2013 (19 percent) and 2015 (18 percent) or those who say they used the contraceptive shot, patch, or ring (5 percent in 2013 and 2015).

For me, however, the most distressing finding is the backward progress we continue to see in condom use. The prevalence of high school students who used a condom at last sex went up from 45 percent in 1991 to 63 percent in 2003. But then it started to drop. In 2015, only 57 percent of sexually active high school students used condoms the last time they had sex, less than in 2013, when 59 percent said they used condoms.

It’s not surprising that teens use condoms less frequently than they did a decade ago. In the 1990s, the HIV epidemic was still front and center, and condoms were heavily promoted as a way to avoid infection. As this threat waned—thanks to treatment advances that now also serve as prevention—discussions of the importance of condoms diminished as well. The rise of abstinence-only-until-marriage programs may have also affected condom use, because these programs often include misinformation suggesting condoms are unreliable at best.

Unfortunately, some of the negative messages about condoms inadvertently came from public health experts themselves, whether they were promoting emergency contraception with ads that said “oops, the condom broke”; encouraging the development of new condoms with articles suggesting that current condoms are no fun; or focusing on teen pregnancy and the use of highly effective contraceptive methods such as long-acting reversible contraceptives (LARC). The end result is that condoms have been undersold to today’s teenagers.

We have to turn these condom trends around, because despite the decreases in sexual activity, young people continue to contract STIs at an alarming rate. In 2014, for example, there were nearly 950,000 reported cases of chlamydia among young people ages 15 to 24. In fact, young people in this age group represented 66 percent of all reported chlamydia cases. Similarly, in 2014, young women ages 15 to 19 had the second-highest rate of gonorrhea infection of any age group (400 cases per 100,000 women in the age group), exceeded only by those 20 to 24 (489 cases per 100,000 women).

While we can be pleased that fewer young people are having sex right now, we can’t fool ourselves into believing that this is enough or that our prevention messages are truly working. We should certainly praise teens for taking fewer risks and use this survey as a reminder that teens can and do make good decisions. But while we’re shaking a young person’s hand, we should be slipping a condom into it. Because someday soon (before high school ends, for more than half of them), that teenager will have sex—and when they do, they need to protect themselves from both pregnancy and STIs.