Analysis Contraception

The ‘Pullout Generation’ Is Here. What Do Sex Educators Think?

Martha Kempner

The Internet has been abuzz this week with talk of the "pullout generation"—women who eschew modern birth control methods in favor of "coitus interruptus." It's a method that has been around since the dawn of time and has likely averted millions of pregnancies, but is it really good enough?

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.

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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 Rewire 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.

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.

News Politics

Former Klan Leader on Senate Run: My Views Are Now the ‘GOP Mainstream’

Teddy Wilson

David Duke has been a fervent support of the Trump campaign, and has posted dozens of messages in support of Trump on Twitter. Duke has often used the hashtag #TrumpWasRight.

David Duke, convicted felon, white supremacist, and former leader of the Ku Klux Klan, announced Friday that he will run for U.S. Senate in Louisiana, Roll Call reported.

Duke said that after a “great outpouring of overwhelming support,” he will campaign for the open Senate seat vacated by former Republican Sen. David Vitter, who lost a bid for Louisiana governor in a runoff election.

Duke’s announcement comes the day after Donald Trump accepted the GOP nomination in the midst of growing tensions over race relations across the country. Trump has been criticized during the campaign for his rhetoric, which, his critics say, mainstreams white nationalism and provokes anxiety and fear among students of color.

His statements about crime and immigration, particularly about immigrants from Mexico and predominantly Muslim countries, have been interpreted by outlets such as the New York Times as speaking to some white supporters’ “deeper and more elaborate bigotry.”

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Duke said in his campaign announcement that he was the first candidate to promote the policy of “America first,” echoing a line from Trump’s nomination acceptance speech on Thursday night.

“The most important difference between our plan and that of our opponents, is that our plan will put America First,” Trump said Thursday night. “As long as we are led by politicians who will not put America First, then we can be assured that other nations will not treat America with respect.”

Duke said his platform has become “the GOP mainstream” and claimed credit for propelling Republicans to control of Congress in 2010. He said he is “overjoyed to see Donald Trump … embrace most of the issues I’ve championed for years.”

Trump in February declined to disavow the support of a white supremacist group and Duke, saying he knew “nothing about David Duke” and knew “nothing about white supremacists.” He later clarified that he rejected their support, and blamed his initial failure to disavow Duke on a “bad earpiece.”

Trump’s candidacy has also brought to light brought many incidents of anti-Semitism, much of which has been directed at journalists and commentators covering the presidential campaign.

Conservative commentator Ben Shapiro wrote in the National Review that Trump’s nomination has “drawn anti-Semites from the woodwork,” and that the Republican nominee has been willing to “channel the support of anti-Semites to his own ends.”

Duke took to Twitter after Trump’s acceptance speech Thursday to express his support for the Republican nominee’s vision for America.

“Great Trump Speech, America First! Stop Wars! Defeat the Corrupt elites! Protect our Borders!, Fair Trade! Couldn’t have said it better!” Duke tweeted.

Duke has been a fervent Trump supporter, and has posted dozens of messages in support of Trump on Twitter. Duke has often used the hashtag #TrumpWasRight.

Duke was elected to the Louisiana house in 1989, serving one term. Duke was the Republican nominee for governor in 1991, and was defeated by Democrat Edwin Edwards.

Duke, who plead guilty in 2002 to mail fraud and tax fraud, has served a year in federal prison.