Studies show that pulling out is as effective as condom use. Why do we still consider it irresponsible and lazy?
Photo by Carolyn Lagattuta via Stocksy
Eliza and her partner used it for a year without incident. Catherine and her partner, for three. Christina estimates she's relied on it for 12 years total, across three long-term, monogamous relationships with men. These women, and myself, are all members of what Ann Friedman famously dubbed "the pullout generation," straight cis women comfortable with making pulling out their primary form of protection against pregnancy.
Read More: Animal Urges: Women and Bestiality
You'd be hard-pressed to find a form of birth control more maligned than withdrawal, otherwise known as "pulling out." It's a tactic usually sneered at as being merely "better than nothing," regarded as irresponsible and ill-conceived. When a recent CDC report estimated pulling out is the second-most commonly tried form of contraception among teenagers, it illustrated the option with an image of a hand with crossed fingers, affirming the idea that it's a practice more fueled by hope and prayer than biological practicality. Teens mirror adults in this, by the way; about 60 percent of adult women in the US reported using the pullout method at least once. Actual numbers are probably higher, since many folks don't regard the practice as "real" birth control.
When practiced perfectly, withdrawal is about as effective as condoms at preventing pregnancy.
Media coverage of the CDC study, which otherwise praised a burgeoning commitment to contraception among young people, gave an obligatory finger wag to withdrawal, "one of the least effective ways to prevent pregnancy." What most media coverage doesn't reveal is that research puts pulling out on par with one of medical professionals' favorite forms of contraception: the condom.
"Withdrawal...is about as effective as condoms at preventing pregnancy" begins a 2014 study published by Contraception, an international journal on reproduction. When practiced perfectly—in other words, when the male partner pulls out before ejaculation during every incidence of vaginal intercourse—only 4 percent of couples who use the pullout method will get pregnant within a year. Imperfect, or typical, use bumps that to 18 percent. (Male condoms failure rates are 2 percent for perfect use and 17 percent for typical.) This is a minor discrepancy, yet pulling out has a reputation for being dangerously cavalier, while condoms are the gold standard of sexual responsibility. Several of the medical professionals I reached out to for this piece were sympathetic to withdrawal use but afraid to say so publicly.
Read More: The Broadly Guide to Pregnancy
"There's definitely a stigma among many educators and medical providers," confirms Aida Manduley, queer sexuality educator and executive committee member at the Women of Color Sexual Health Network. Part of that has to do with the long-standing assumption that the method isn't effective. Folk wisdom is incredibly hard to shake, and no one wants to be responsible (or liable) for an unwanted pregnancy. Even when presented statistics clearly put withdrawal level with other forms of birth control, as in a recent Marie Claire piece, the method is still described as—you guessed it—"super risky" and "not a 'method' as much as 'better than nothing.'"
Several of the medical professionals I reached out to for this piece were sympathetic to withdrawal use but afraid to say so publicly.
Manduley also attributes medical professionals' resistance to withdrawal to anxiety about STIs and notes that HIV "can be much scarier and permanent than a pregnancy." Rachel Jones, principal research scientist at the Guttmacher Institute and contributor to two important studies about withdrawal, confirms there's a perception that "young people especially should be using condoms every time they have sex, and saying anything positive about withdrawal will discourage that."
Nevertheless, withdrawal is derided when pregnancy is the only point of discussion, too. Articles on the topic usually steer readers towards hormonal options and IUDs while brushing off even the possibility of successfully using pulling out—which means there's more going on than just STI concerns and old-fashioned sensibilities.
Corporate interests are another element at work. Manufacturers of condoms, hormonal birth control, and implantation devices are FDA-required and commercially incentivized to perform numerous studies on the efficacy of their products. No one profits from pulling out, so it's harder to find funding to regularly test it. More important, perhaps, is that no one profits from advocating withdrawal or promoting the solid research that already exists on it. Those who do promote it may even risk censure.
Then there's the pervasive mistrust of sperm-producing partners, the direct result of a social environment that insists on treating men as lust-mad maniacs who can't control themselves when they're aroused. Unreliability and untrustworthiness are regularly cited as the biggest problems with pulling out as a method: It gives a man far too much control; he isn't capable of doing it in time or won't be able to sense when it is the right time; he won't even try because it feels better not to.
No one profits from pulling out, so it's harder to find funding to regularly test it.
While this might be a sensible presumption in early-stage dating situations or one-night stands, during which an amount of skepticism is healthy, it's an awfully bleak view of the cooperation possible between two committed partners—the type of couple that seems to most commonly use the withdrawal method for long-term pregnancy prevention. Manduley agrees that pulling out should probably "not be the top recommended method for folks just starting out their sexual journeys," but that doesn't mean it's not viable for others. As Rachel Jones wrote in an incisive article on anti-withdrawal attitudes, "Some women may not be comfortable depending on their partners to pull out before ejaculating, and some men may not be able to do it, [but] that does not mean we should promote a false view of the method's effectiveness."
The women I spoke with had used withdrawal successfully for years but still sometimes felt compelled to disavow it as risky and irresponsible. Those who'd never been pregnant joked they may be infertile, a dramatic illustration of how wildly unreliable pulling out is seen even by those who've had firsthand experience to the contrary. Courtesy of pulling out, Haley enjoyed five-and-a-half years of non-pregnancy—followed by an intentional conception—but she was hesitant to praise or even admit she relied on it. "I was scared to mention to friends for fear I would be shamed and ridiculed," she says. "I still don't know if it was stupid or not."
Some of this stigma is grounded in woman-to-woman sexism, surely a result of internalizing the idea that unintended conception indicates a catastrophic failure of both morals and practical vigilance on the part of the pregnant party. But the idea of the irresponsible urban bimbo too drunk and too flippant to be bothered with a "real" form of birth control isn't just misogynistic, it's dead wrong. A recent study in which Jones participated found that many women use pullout in conjunction with other forms of protection, including birth control and condoms. "There is a reputation of withdrawal users as being lazy," one of the other researchers told RH Reality Check, "but at least in this sample they seem to be extra motivated to prevent pregnancy or uneducated." This was confirmed casually in my conversations. The women I spoke to who relied on pulling out were incredibly thoughtful, capable, and savvy. One kept an emergency abortion fund; another already had a plan to fly out of her southern state to a different region should an abortion be necessary. They'd given much serious thought to why other methods weren't right for them, and planned for what they would do in case of accidental conception.
There is a reputation of withdrawal users as being lazy.
Social mores, as usual, aren't able to fully control the way people have sex, and a majority of cis, heterosexual adults have at least tried withdrawal, even if not regularly relied upon it. It's easy to see why: It's always available, costs nothing, aggravates no allergies, presents little barrier to pleasure, and has no negative side effects. Given how adversely many forms of female-focused birth control affect those using them, this last point is a considerable advantage. Our cultural tendency is to ignore the numerous, well-established, and uncontested negative effects of hormonal birth control, which include severe mood swings, decreased or eliminated sex drive, and tripled or even quadrupled risk of developing blood clots. This complacent attitude persists despite recent media attention paid to lawsuits against the oral contraceptive Yaz and hormonal patch Ortho Evra. Treating these potentially serious consequences as undesirable but unavoidable indicates a belief that women's mental, emotional, and physical health will necessarily be compromised in their pursuit to remain un-impregnated—an ugly notion that is far from fact.
It also fails to take into account that no method of birth control—not even tubal ligation—makes penis-in-vagina sex completely risk free. As Jones put it, medical providers "have no problem advocating the use of condoms even though those are flawed." Stacey, who's never been pregnant in 13 years of using the pullout method with long-term partners, conceived once when a condom broke and once while on the pill. Two other women I spoke with also got pregnant on the pill, which made it a form of birth control they were, understandably, reluctant to return to. Two others mentioned uterine malformations that kept them from being good IUD candidates.
In the words of the seminal 2009 study on withdrawal cited earlier, "if more people realized that correct and consistent use of withdrawal substantially reduced the risk of pregnancy, they might use it more effectively." The knee-jerk dismissal of withdrawal as a useful birth control method is is unhelpful if not outright dangerous; the practice certainly isn't going away, but the current rhetoric around it obscures the idea that it can be effectively executed. "We can't assume people's needs when choosing birth control methods, or try to foist things upon them," Manduley says. Rather than withholding information or denying existing studies, "professionals should be educating folks about what's available and helping them navigate the options."