Pull and pray – taking withdrawal seriously

A new Guttmacher Institute report, published in Contraception, treats the withdrawal method (aka “pulling out” or coitus interruptus) like a serious method of birth control. This is creating a few ripples in the women’s issues blogosphere.

I was not surprised at all when this article was written, since other sources have long included withdrawal in the discussion. I have always included withdrawal when comparing methods of birth control with poor success rates. The sponge and the cervical cap, especially in parous women (women who have already had a child), spring to mind. Neither offer much STI protection, and the sponge may have side effects such as local irritation. I was surprised, years ago, when I saw a comparison of success rates, and the much derided non pharmaceutical methods such as withdrawal and the fertility awareness (aka symptothermal method, natural family planning, rhythm method) had moderate success rates and fit firmly in the sorta crappy second tier of birth control.

This is the tier my two sons come from. My older, condom son and my younger, vaginal contraceptive film son. I would have never considered withdrawal or fertility awareness. I was in long term monogamous relationships both times and knew that STIs were not a problem. Both would have been good options for me. I cannot use hormonal methods, since I get migraines. Many women don’t want to use hormones or get significant side effects from hormonal methods. I am not saying they don’t work remarkably well for many women, and may even have some therapeutic applications. Different women with different health issues have different needs.

I have known women who have used the withdrawal method intentionally. No, not drunken teenagers, but a woman with a master’s degree in a long term relationship and a midwife(!) who knew the odds and decided it worked for her and her partner. At least one of the sites I linked to above says it shouldn’t be ignored but it shouldn’t be encouraged (and one questioned the ability of teenagers to use the information wisely, which I think is the problem with abstinence only education).

I don’t think any method of birth control should be encouraged. I think every method should be presented without bias, either bias from the sex-is-bad-don’t-encourage-it camp or the must-be-a-pill-or-a-medical-device-or-it-doesn’t-count camp. I thank the medical science gods (ha!) every day for my copper IUD. If it wasn’t refused to me (with bias and non-scientific information from an ob/gyn) I wouldn’t have a contraceptive film child. If I didn’t succumb to “I don’t care what the failure rates say, if it’s a pharmaceutical method, it must be better than our other options” bias in my own head, I wouldn’t have a contraceptive film child. Don’t get me wrong, I love Z and without being refused my IUD the first time and having him, I wouldn’t be the MomTFH I am today, since I ended up training as a midwife at the birth center.

But, I love my IUD now. It is the ideal option for me. It doesn’t protect against STIs. It has a fantastic pregnancy prevention rate. It’s ideal use rate is almost identical to its real use rate, which is what I need. Less room for human error. When I talk about my IUD, I try to present it as honestly as possible. Mutual masturbation is a very viable option that is enjoyed by teenagers extensively. That may not have been ideal for my marriage in my twenties, but at 16 it was a fine option. I know women who are passionately dedicated and successful (to different degrees) with the symptothermal method. I know women who love their pill, hate their pill, and swear they have gotten pregnant on the pill. Hell, IUDs are the top of the top tier of pregnancy prevention, and at the recent ACM some medical students were joking about how their reproductive endocrinologist professor got his wife, their maternal fetal medicine professor, pregnant with twins even while she had an IUD in!

Let’s talk about it all. My ideal teen sex education program would talk about withdrawal and mention how it is dependent on the male being able to control himself, be trustworthy, be sober, and will not prevent STIs. Then I would present the failure rate. I would also talk about sex toys, masturbation, homosexuality, abstinence, anal sex, oral sex, abortion and other topics.

My (almost) ideal sex ed program may be coming to teenagers soon, actually. But it’s not going to be in schools. Rumor has it the Midwest Teen Sex Show is coming to Comedy Central. I hope it does to abstinence only education what the Daily Show has done to cable news.


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27 responses to “Pull and pray – taking withdrawal seriously

  1. I definitely think it’s worth talking about, especially wrt correct use and failure rates. As I mentioned, I’m too much of a control freak for this, though. πŸ™‚ Still need to check out the Midwest Teen Sex Show!

  2. MomTFH

    Oh, check it out!

    Yes, the failure rate is definitely not acceptable to me, either. Nor, the room for error and dependency on the partner. Thus the IUD.

  3. Jess

    Thanks for posting this. It drives me CRAZY when people present, say, the diaphram and the pill together (despite the big difference in their efficacies) without pointing out that the diaphram is not really a super great contraceptive, but then refuse to even present withdrawal as an option. Withdrawal and diaphrams are more similar (in efficacy) than diaphrams and the pill, but that’s almost never recognized. God forbid we have knowledge of contraceptive methods that are free, natural, and don’t have side effects.

  4. I was one of the people who wrote about this skeptically earlier in the week. The Guttmacher stats make it look as though withdrawal is virtually indistinguishable from the condom in its efficacy. Other sources don’t agree.

    By all means let’s talk about everything – including teens learning about non-penetrative ways to play. (Remember how Jocelyn Elders was run out of Washington on a rail for suggesting just that as Surgeon General? I still think she was spot on.)

    But I think the only group for whom it’s a reasonable option is people in committed relationships who are no longer kids and for whom a pregnancy wouldn’t feel catastrophic. I have other reasons for my view besides the failure rates – for instance, the fact that withdrawal demands an awful lot of self-control from the man and puts the woman in an awfully dependent position. But most of all, I’m very wary of revaluing effectiveness on the basis of a single study.

  5. Christopher

    I don’t understand why sympto-thermal FA isn’t more popular. A 2007 study published in Human Reproduction found that FA had a pregnancy rate (for correct use) of 0.6/(100 women * 13 cycles), which is quiet comparable to the hormonal methods. (It was a 22 year, 900 cohort study) In addition to being a contraceptive, users are also immediately aware of a pregnancy and of infections. Why is FA still treated like the “rhythm” method? Women shouldn’t have to rely on the aptly named “pull & pray” method, yet I know many who do.

  6. “Thanks for posting this. It drives me CRAZY when people present, say, the diaphram and the pill together (despite the big difference in their efficacies)”

    Definitely! I feel kinda the same about the common habit of presenting the calendar and sympto-thermal methods together; they may both involve periodic abstinence, but that’s really the only similarity.

    The lactational amenorrhoea method also doesn’t get anywhere near enough love, but I suspect that’s because most of our contraceptive education comes out of places where exclusive/ecologic breastfeeding for six months is rare.

  7. MomTFH

    Thanks for all the comments.

    Sungold, I am not sure where you are getting this “one study” idea. This is a new report, not a new single study, and it has twenty studies referenced in it.

    • If you look at the article’s footnotes, there are indeed twenty notes. Footnote 3 is the only substantiation of the 18% failure rate in “typical” use for withdrawal. It comes from another study published last year in Contraception, where this article also appeared. So that’s why I say it’s a single study. It’s a substantially lower failure rate than Planned Parenthood lists on its website – if the study was really so compelling as to supersede all previous research, PP would presumably revise its figures.

      What I found most interesting in the Rachel Jones et al. article (the one we’re talking about here) is its experiential and phenemonological data on the use of withdrawal. It’s meant to be a commentary, and as such it’s engaging in advocacy. It doesn’t actually contribute statistical data of its own.

      • MomTFH

        No, every article in the review deals with withdrawal. And yes, the article everyone is discussing is a review / commentary / advocacy article. It itself is not a study. I read it before I wrote about it, which I try to do before I write about any article.

        That’s why I was confused why you were writing as if some single new study with new evidence has been printed, but it is an accumulation of current studies being discussed. Not one study, 20. Yes, one statistic was pulled from one study, which is common in a single point in a review articles. But it is hardly the only study in the article on withdrawal. Another study (#2, referred to in the same paragraph) refers to a 4% pregnancy rate with withdrawal.

        And, the article being printed in Contraception while also referring to an article in Contraception also is not surprising to me. Many review articles in peer reviewed journals will refer to other articles, especially clinical studies, in their own journal. Especially if they are writing on a topic that their particular journal specializes in, like, say, contraception.

        • Hey, I don’t want to ruffle feathers – that’s not usually my style, and sure not my intent here. For instance, I mentioned the earlier article being published in contraception not to impute some ZOMG conspiracy, but to give other readers an idea where to look if they cared to hunt down the sources. I’m a nerd, not a tinfoil-hat wearer. πŸ™‚ Also, I have a Ph.D. in the social history of medicine, so I do know from journals and citations, though Contraception isn’t one of my monthly reads.

          I mentioned the “one study” because I’m a realist (so are you, I think) and I’m interested in how techniques work in actual practice rather than in theory. If there’s more research to corroborate the 18% failure rate, I’d be very interested to know about it. I’d still find it an unacceptably high rate, personally, but it would change the parameters of the public-policy discussion for me. It would put withdrawal in a similar category as condoms wrt pregnancy (which Jones et al. are arguing is the case).

          The 4% failure rate is in ideal practice. I tend to think the psychological and somatic barriers to “ideal” withdrawal use are greater than to “ideal” condom use. Achieving a 2% (or better) failure rate with condoms requires mostly that you wear one every single time and apply it correctly (don’t forget the lube). This can be done before passion is totally overwhelming good sense. Whereas withdrawal requires people (mostly the male partner) to make wise decisions at a point when the cerebrum is happily on vacation.

          So, while education might help people approach the 4% rate on withdrawal, I worry that it’s going to be working against even greater embodied resistances than education on condom use.

          Thanks for making me keep thinking about this. I have to say, I find it endlessly fascinating to see how other people handle birth control in such a wide variety of ways. It does go to show that there’s no single method that will fit all lives – and that we need more options for women and men alike.

  8. MomTFH

    Oh, and lauredhel, thanks for mentioning the extended lactation method. I am the failure rate queen. I exclusively breastfed on demand for both of my sons for more than a year each. I got my period six months after my first was born, and 2 months (!!) after my second. I am happy I got an IUD put in at my 6 week post partum visit!

    I have heard exclusive breastfeeding on demand can confer up to 98% effectiveness for 6 months. I think I would have been in the 2% the second time. But, failure rates do happen. I am waiting for an IUD baby.

  9. MomTFH: LAM is more than exclusive BFing-on-cue for six months – you must also be amenorrhoeic. (google the Bellagio Consensus for more detail.) The efficacy lies in the fact that the first cycle, if it occurs before six months, is highly likely to be anovulatory. So your second wouldn’t have made you a “failure” statistic, so long as you realised after the first period that LAM was no longer operative.

    More recent work suggests that while LAM is about as effective as the combined oral contraceptive pill when used up to six months, so long as a breastfeeding mum remains amenorrheic, the effectiveness between six months and a year is around that of condom use.

    • MomTFH

      Thanks for the clarification! I had heard that the first period at menarche was generally anovulatory, but the first period post partum usually followed ovulation. I will look into the Bellagio Consensus.

    • Thanks for pointing to the Bellagio Consensus! It’s just this past year that I’ve really learned about the difference between exclusive breastfeeding and use of LAM as birth control. When they call it a “method”, they mean just that – there’s more to it than just breastfeeding, just as there’s more to the fertility awareness method than a calendar.

      Interestingly, when I asked whether recommending women use LAM leads to a lower contraceptive uptake later (because they have to use LAM first and then find another method of birth control when it’s no longer effective) my professor said there’s actually a higher uptake. I would venture a guess that’s because LAM does require conscious acknowledgment, and practice, of a contraceptive method.

  10. Jess

    “I feel kinda the same about the common habit of presenting the calendar and sympto-thermal methods together”

    Yeah! The calendar method is so so inferior to symptothermal methods…and yet people act as if they are the same (and both horrible.)

    • MomTFH

      I agree, too. This is a method, not just a counting game. I put the many similar levels of it together as if they were synonyms, but it was just a grouping. Obviously there is a difference between the commonly understood rhythm method of just counting to estimate ovulation and the multifactorial symptothermal method.

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  12. Natana

    I had to laugh out loud when reading this. My “fingers crossed” son is sitting behind me and my “fertility awareness” twins are fighting sleep in the other room. The one thing fertility awareness did, was to let me know the exact day I goofed.

  13. PBrim

    A lot of people don’t like to think about it, but any method of BC can fail. A friend of min concieved her first child in her first intercourse (“You can’t get pregnant the first time!”). Her second child was due to failure of a condom, her third was due to failure of a diaphram, her fourth pregnancy (terminated) was due to failure of the pill, her fifth pregnancy (etopic) was due to failure of a tubal ligation. When she had to have emergency surgery for the etopic, she told them to “Take it all out!”

  14. Thank you for taking withdrawal seriously! I get so frustrated with accounts of contraceptives that don’t include or discount it. And while it certainly is challenging to put into practice effectively (example: it’s safest only when the man hasn’t ejaculated in the previous 24 hours), it really does have the potential to be about on par with condom use (my copy of Contraceptive Technologies puts it at 94% perfect use, condoms at 95%).

    Ditto fertility awareness method. Challenging to put into practice, but pretty effective when done well (pet peeve: when people blame FAM with a conception during a known fertile period when another method was used. you knew you were fertile: don’t bad mouth FAM because of a broken condom!)

    Anyway, between my brother being an IUD baby, and over a decade of using combined withdrawal and condoms as a primary birth prevention method effectively myself, and having witness far too many friends struggle with infertility, I have a pretty straightforward opinion on birth control: give real numbers, talk real pros and cons, and accept that nothing is going to be 100% for everyone, save avoidance of PIV sex altogether.

    • MomTFH

      Infertility is a good point. I have not seen this discussed, but some of the success rates of some methods are due to unknown infertility of some subjects, I am sure. There is a wide range of fertility among women. Never been pregnant women (nulliparous) are an untested group, reproductively.

      My friend who practiced withdrawal for years has never had a pregnancy scare that I know of. I know she is planning on having children. She is getting married soon and has the intention of getting pregnant soon after, I think. She is in her late thirties. I am interested in seeing how soon she will get pregnant once she is trying. The other friend of mine who I knew used it has had problems getting pregnant and staying pregnant because of a coagulopathy.

      Failure rates a re a tricky thing. I am sure they may be a lot higher in parous women for many reasons, or lower in nonparous women for many reasons. Confounders galore.

  15. Val

    Great post! I don’t want to clutter up your comments w/my complicated reproductive history, but like you, I developed migraines & had a scary “mini-stroke” (aphasic episode) on the pill…Contraceptive failures w/almost every other method: withdrawal, diaphragm, cervical cap, sponge…
    & I became suicidally depressed w/Norplant. Getting my tubal was such a relief.

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  17. Abby

    I work at a women’s clinic and you my friend, rock. Sex education should include all forms of birth control. I

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