Withdrawal: What Every Woman Should Know

Withdrawal: Are you sure you are using it correctly? What Every Woman Should Know

“The proportion of all sexually experienced women who have ever used withdrawal increased from 25% in 1982 to 60% in 2006–2010.”- Guttmacher Institute

If you are using withdrawal as birth control, you’re not alone. Over 3 million women are using it in the U.S. and it’s on the rise (1). Withdrawal is getting so popular with millennials that one author has called them the ‘Pull Out Generation,” (2). This doesn’t appear to be due to being naive of the consequences and risks involved. Why women are opting out of more effective methods ranges from experiencing negative side effects from the more 'modern methods,' to a desire to live a more natural lifestyle (3). While the pill is still the most common form of birth control, the CDC reports that 4 out 5 women who have used hormonal birth control at some point in their lives, 63% of pill users, 74% of Depo-Provera users, and 45% of contraceptive patch users, all quit due to unwanted side effects (4).



While women using this method may be educated on the risks involved, it’s not clear on how many women are actually aware of their options when it comes to using natural fertility methods effectively. That is, unless you were born into a Catholic family. In the Catholic religion, artificial contraception is seen as sinful. However, ‘natural’ family planning was sanctioned by Pope Pius XII in 1955 as a natural method for regulating procreation. For Catholic couples, there are resources and fertility educators readily available to provide education on using the most effective natural methods (5). For all other women interested in natural fertility, they are left to learn about it on their own either in books or online. It is highly unlikely they will learn about it from their doctors, which is the primary source of fertility education (6) for women in the U.S. In fact, only 3-6% of OB/GYN and Family Medicine physicians are knowledgeable about modern Fertility Awareness-Based Methods (FABMs) (7).

Is it possible to use a natural fertility method and not end up as one of the 1 in 5 women each year using withdrawal with an unintended pregnancy (9)? Here is what you need to know:

What may surprise withdrawal and rhythm method users: not even the Catholic Church teaches those methods any longer. An article from USCatholic.org explains: “Modern Natural Family Planning (NFP) methods are a significant improvement over the old calendar-rhythm method. Many doctors and health care professionals believe the methods are the same. The calendar-rhythm method is based on research from the 1930s and is no longer taught by any NFP provider.” (8)

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What on earth are NFP and FABMs? Click here to learn more: Natural Fertility Methods for Preventing Pregnancy Blog
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What is the difference between withdrawal and The Rhythm Method (aka Calendar Method)?

Withdrawal: Withdrawal or the pull-out method, also known as coitus interruptus, is withdrawing the penis from the vagina and ejaculating away from the vagina and vulva. Some consider using this method relatively safe while others define it as unprotected sex.

The Rhythm Method (Calendar Method) and Standard Day Method: The Mayo Clinic explains that this method is used by women with regular cycles and uses a calculation based on your longest cycle and shortest cycle to determine the fertile days. During the fertile days, the method instructs to either not have sex or use a barrier method.

The Standard Day Method: CDC explains that this method is a method based on fertility awareness; users must avoid unprotected sexual intercourse on days 8–19 of the menstrual cycle (10).

Who is using withdrawal?

Withdrawal is not as commonly used by women ages 15-24 as much as the 25+ age groups. In fact, women over the age of 35 are 3 times more likely to not use contraception than women aged 20-24  (11) (12). While there is a growing trend for using withdrawal, sterilization remains the most popular choice for those over 35 years of age (12).

If you are 35+, not using contraception, and believe you are less fertile due to your age, that is not a safe bet when it comes to avoiding pregnancy. While it is true that fertility starts to decline significantly for women starting between the ages of 30- 35 years (13), doctors recommend using birth control for a solid year after your last period to avoid pregnancy. This typically happens to women between the ages 40-55 (14).

Another study found that increased use of withdrawal occurred mostly among women who were between the ages 25 and 29, were non-Hispanic white, had high income, were cohabiting, had the highest education, were using private insurance, had had 1–2 births and expected no future births.

Interestingly, the small increase in the overall use of natural family planning in this study was also driven primarily by women ages 25–29, but who had never given birth, and who expected 1 to 2 future births. (15)



How effective is withdrawal?

Photo Credit: guttmacher.org

If you search ‘effectiveness of withdrawal’ online, you may come across the statistic that, with perfect use, it is 96% effective (9). Sounds pretty good right? Not exactly. That number reflects using withdrawal perfectly every time. For typical use, as mentioned above, the number turns out to be 1 in 5 women using withdrawal having a chance getting pregnant in a year (9). If getting pregnant would be the end of the world as you know it, you should be using something closer to 100% effective, such as an IUD or implant. As an OB/GYN told me once: “We aren’t talking about getting a cold here. With pregnancy, anything less than 99% effective shouldn’t be used by a person dead set on not getting pregnant.”  

Research shows that Fertility Awareness Methods effectiveness, in comparison, to be 1-5 women out of 100 become pregnant in the first year with perfect use. In the first year of typical use, 12-24 women out of 100 will become pregnant. Typical use, as explained by ACOG means, “that you use the method the way the average person does, which is sometimes incorrectly or inconsistently” (16). When you look at the stats provided by ACOG and Guttmacher, you will notice that they do include the Standard Days Method, which is a method similar to the Rhythm Method.

Sterilization, implants, and IUDs are the most effective because there is little room for human error (see chart). Other forms of birth control such as the patch, pill, ring, or shot are also effective methods, but only if used perfectly. As you can see in the chart, the ring has a 9% failure rate with typical use.

As a reminder, the only form of contraception that protects against sexually transmitted infections (STIs) is the male and female condom. To protect against sexually transmitted STIs and pregnancy, it is recommended to also use condoms along with other forms of birth control.



Why Withdrawal and/or the Rhythm Method Can Fail:

When using withdrawal, it must be done perfectly to be effective, and while it is simple in theory, it may prove difficult in practice. Withdrawal requires the man to have a lot of self-control, enough familiarity with his body to know before ejaculation is going to happen, and to pull out before that happens. For these reasons, withdrawal might be difficult or inappropriate for those who prematurely ejaculate or don’t have enough experience to recognize that they are about to ejaculate (9).

This method may fail for a few reasons other than the obvious of not pulling out in time. If ejaculation happened recently, it is more likely that live sperm will be in the precum. The Mayo Clinic suggests if you have sex again within a short period of time, for the man to urinate and clean off the tip of his penis first (17).  Even if ejaculation hasn’t happened recently, there is a chance that some sperm can also be present in the pre-ejaculation fluid (pre-cum). A small study about the presence of sperm in pre-ejaculate found that 41% of the subjects had sperm in their pre-ejaculate, and that the sperm was either always present in the pre-ejaculate, every time, or never present. The samples were all given after urination, so the suggestion for the man to pee before sex to wash out any sperm may not be effective. Although the number of viable sperm in pre-cum in these samples was low, the presence of any viable sperm still creates a risk of pregnancy (18). Another contributing factor to failure rates of withdrawal is that sperm on the skin in the vicinity of the woman’s genitals -- on the vulva or even upper thighs -- can make its way into the vagina and result in a pregnancy (19).

Couples that use the Rhythm Method may use withdrawal on what is perceived to be fertile days. One reason this is not reliable is because women with regular cycles can be fertile on each day between days 6 and 21 (20). Additionally, the timing of the fertile window is highly variable each month, even among women who have regular menstrual cycles. It’s even more unpredictable for women with irregular cycles (21).  

Photo Credit: NIH

Partners who abstain from sex or use condoms during their fertile window have lower risk for conception. As one study that looked at the methods usage stated:

It is clear that the users who became pregnant in this study were more likely to expose themselves to risk by not using protection on fertile days. It is thus of highest importance to educate the user on the risks involved in having unprotected intercourse on red days (22).

Summary

As you can see, withdrawal is not an effective method to avoid pregnancy for everyone, whether it’s due to having irregular cycles, sperm in the pre-cum or not willing to use the barrier method during fertile days. While it has been referred to as “better than nothing” (23), there are steps to take to make a natural contraceptive method more effective if you are unable or unwilling to use the other contraceptive methods (Ie: pill, implant, or shots). It takes time and education to use them effectively, but if you are willing and able, the option is out there.

If you are interested in learning more about how to use Fertility Awareness-Based Methods for your fertility goals, sign up below for an upcoming email educational series.

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References:
  1. https://www.guttmacher.org/fact-sheet/contraceptive-use-united-states
  2. https://www.thecut.com/2013/09/pill-no-prob-meet-the-pullout-generation.html
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959010/
  4. https://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf
  5. https://case.edu/affil/skuyhistcontraception/online-2012/Rhythm-method.html
  6. https://www.npr.org/assets/news/2011/11/FertilityWhitePaper_Final.pdf
  7. https://www.factsaboutfertility.org/  
  8. https://www.uscatholic.org/life/2009/04/not-your-mother%E2%80%99s-rhythm-method
  9.  https://www.plannedparenthood.org/learn/birth-control/withdrawal-pull-out-method/how-effective-is-withdrawal-method-pulling-out
  10. https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/days.html.
  11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373981/
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3050835/
  13. https://www.fertstert.org/article/S0015-0282(06)03274-2/fulltext
  14. https://healthcare.utah.edu/the-scope/shows.php?shows=0_04x5n0fe
  15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5959010/
  16. https://www.acog.org/Patients/FAQs/Fertility-Awareness-Based-Methods-of-Family-Planning?IsMobileSet=false#fertility
  17. https://www.mayoclinic.org/tests-procedures/withdrawal-method/about/pac-20395283
  18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3564677/
  19. https://www.webmd.com/sex/birth-control/pull-out-withdrawal
  20. https://www.aafp.org/afp/2001/0501/p1829a.html
  21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27529/
  22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898152/
  23. https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/reprints/Contraception79-407-410.pdf
  24. http://time.com/5365564/fertility-apps-contraception/

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