We explore whether the stigma surrounding ‘pulling out’ is entirely fair.
What do you do if you’re in a sexually active straight relationship and don’t want to get pregnant, but also don’t want to use any of the contraceptive methods on offer? For a surprising number of couples, the answer is the withdrawal method (aka coitus interruptus), in which the man pulls out prior to ejaculation.
“My boyfriend and I hate the feeling of condoms, and I’ve had bad experiences with the pill in the past,” says Lotte, 31, from London (name changed). “It seems unfair to me that I should be required to tamper with my hormones, with all the potential side effects that entails, or that I should have to get an IUD fitted. The pullout method makes sense for our stage of life.”
She is not alone – it is thought that around 4-6% of UK women rely on withdrawal as their primary form of contraception, with many others using it on top of other approaches. Nearly 6 in 10 women who have ever used contraception report using withdrawal at some point in their lives.
These figures, to some, might suggest a serious lack of responsibility. Long derided as old-fashioned, reckless, or plain ignorant, the withdrawal method is rarely discussed as a legitimate means of pregnancy prevention.
According to Natika H Halil, chief executive of the sexual health charity FPA, withdrawal isn’t generally advised on its own. “Because it can be so hard to use withdrawal correctly and consistently, we don’t consider it reliable enough to count as a method of contraception, and recommend instead choosing one of the 15 contraceptive methods available. FPA’s My Contraception Tool can help you find a method that suits you and your lifestyle.”
It does reduce the risk of pregnancy
However, not everybody who uses withdrawal is being willfully naïve. Far from being merely ‘better than nothing’, the method is actually somewhat successful at preventing pregnancy. If it is used perfectly, with the man pulling out every time, only 4% of couples will conceive in the course of a year. If used more typically, with some occasional lapses, the figure climbs to 22%.
This failure rate is far higher than, say, the implant or the IUD, which are 99% effective under typical circumstances and don’t require the couple to exert any restraint. However, it is low enough to suggest that the stigma is misplaced.
“When I started out, I didn’t consider withdrawal to be a method of contraception,” says Rachel K Jones, a research scientist at Guttmacher Institute. “But over the course of doing my own research, I was exposed to information that demonstrated it does substantially reduce the risk of pregnancy.”
In 2009, Rachel published an article in the journal Contraception, which argued that withdrawal was only slightly less effective than condoms. (The failure rates were then 18% and 17% respectively, although the discrepancy between the two has since grown.)
Her data sparked lively discussion on women’s websites, with commenters veering between scepticism and outright disbelief. Since then, however, a number of positive articles have cropped up, reframing withdrawal as an educated choice.
Writer Ann Friedman has memorably referred to millennial women as ‘the pullout generation’, arguing that vetoing hormonal birth control could be a feminist decision. “They’re sick of supposedly egalitarian relationships in which they bear the sole responsibility for staying baby-free,” she wrote.
It’s a simple, natural option
So why else might a couple rely on withdrawal when there are so many more reliable options available? According to Dr Anand Patel, a GP specialising in sexual problems, there can be a litany of factors involved.
“The reasons can be cultural, religious, or to do with the potential side effects of hormonal contraception (weight gain, mood changes, loss of libido etc). Certain medical conditions also restrict the use of hormones,” he says.
Rachel K Jones adds that its appeal might be its simplicity: “Qualitative research suggests maybe people are using it because it’s natural, it’s free, it’s available and you don’t have to plan. Some guys also like having that control – if he pulls out, it reassurance for him that he’s done something to prevent pregnancy.”
Natika H Halil adds that the method may often be used in relationships where couples are more relaxed about pregnancy. It goes without saying that this approach is more suited to established relationships (after both partners have been tested for STIs), than more casual contexts (where condoms are advised).
It can be used with period trackers
So for couples who have weighed up the implications, is there anything they can do to make the withdrawal method more effective?
Clearly, the most important factor is whether or not the man pulls out in time – this is what spells the difference between the 4% and 22% failure rates – but even if he is always successful, there are still some risks involved.
“A small study showed that 11 out of 27 men had motile sperm in their pre-cum, which suggests that even reliable withdrawers can still potentially release sperm before ejaculation,” points out Dr Patel.
Some women may therefore opt to monitor their fertility too, for instance via a period tracker app. If they use condoms – or avoid sex altogether – during the days they’re most fertile, their risk is substantially reduced.
“There’s evidence to say so if you avoid sex in the middle part of your cycle (typically around day 12-16 in a 28 day cycle) for up to seven days before and five days after then you may be less likely to conceive. Sperm hang around for up to seven days and eggs last about five, hence the need to avoid sex before and after ovulation,” says Dr Patel.
Information is key
Rachel K Jones advocates strongly for removing the stigma associated with the withdrawal method. She argues that while it does have a relatively high failure rate, information is key, and couples choosing a contraception method deserve to have all the facts at hand.
“People use withdrawal, for better or for worse, so you need to discuss it with them if you’re going to be talking about pregnancy prevention,” she says. “Healthcare providers should acknowledge it is a legitimate method, and talk about the pros and cons.”
Dr Patel adds that, whatever contraceptive method you opt for, it’s important to weigh up what would happen if it failed.
“Have an idea of what you’d want to do in the event of getting pregnant,” he says. “No form of contraception is 100% guaranteed to work.”
This article appears on Netdoctor