A new study assessing the withdrawal method finds it is nearly as effective as condoms. Should we teach it to teenagers?

About a quarter of American high school students receive

abstinence-only sex-education, meaning they learn nothing at school

about contraception methods. But even among American teens who are

offered comprehensive sex-education, there is one birth-control method

routinely derided: the withdrawal method — known colloquially, of

course, as "pulling out" before ejaculation.

Students are told that in addition to providing no protection

against sexually transmitted infections, withdrawal does next to

nothing to prevent pregnancy. Pre-ejaculatory fluid contains sperm that

can lead to pregnancy, teens are taught — despite the fact that

clinical studies show this is highly unlikely.

Now a new paper (PDF), published by the journal Contraception,

culls evidence from several studies to argue that withdrawal is

actually nearly as effective as condoms in preventing pregnancy. The

paper reports that couples who practice withdrawal perfectly over the

course of a year — meaning the male partner always pulls out before

ejaculation — have only a 4 percent pregnancy rate. More "typical"

couples using withdrawal (those who sometimes mess up) have a pregnancy

rate of 18 percent.

Those numbers are very similar to the perfect and typical-use

rates for the male condom, which are 2 percent and 17 percent,

respectively. The typical-use numbers are based on the 2002 National

Survey of Family Growth, which sampled 848 women using withdrawal and

3,800 using condoms.

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Against the back-drop of a rising teen pregnancy rate

and ongoing political fights over the Obama administration’s decision

to cut some abstinence-only funding, public health experts are sharply

divided on the implications of the new paper, especially with regard to

sex-education. Some believe teenagers should be encouraged to practice

withdrawal in some contexts — if they don’t have a condom, but also if

they come from religious backgrounds that eschew hormonal birth

control.

But others caution that emphasizing withdrawal’s success rate

ignores teen boys’ relative lack of self-control compared to adult men,

and downplays teen girls’ need to share control over contraception.

Indeed, there is no reliable research on the method’s success rate

among adolescents in particular. And talking positively about

withdrawal takes the focus off condoms, which are the only way to

protect against most STIs. "A common situation is one in which the

boyfriend doesn’t want to use the condom, period," says Heather

Corinna, a Seattle-based sex-educator who runs the popular sexuality

advice Web site Scarleteen.

"This is a pretty easy slippery slope." Corinna says she was conceived

by parents using the withdrawal method "perfectly." She laughs, "That’s

one of the three things my parents agree on!"

Yet the Contraception paper’s lead author, Guttmacher

Institute researcher Rachel Jones, cautions against relying on

anecdotal evidence when assessing withdrawal. "We’re constantly told by

people in positions of authority that it’s not effective. ‘Don’t use

it, it’s like playing roulette,’" she says. "But it does substantially

reduce the risk of pregnancy. And that’s why it should be part of

sex-education classes."

Former public school sex-ed teacher Debra Hauser, now executive

vice president of Washington-based Advocates for Youth, couldn’t agree

more. She calls the traditional public health line on withdrawal "a

huge pet peeve. I’m thrilled somebody finally did an article like

this."

During a recession, it’s no small thing that withdrawal is

free. What’s more, Hauser points out, many teenagers don’t know how to

access contraception, or are anxious about parents finding out they

have bought condoms or obtained a prescription for hormonal birth

control. And those who hear abstinence-only messaging in church or at

school may have done little or nothing to plan for sex, believing that

to do so would be to give in to temptation.

Despite the prevalence of abstinence-only, 60 percent of all

American high school students have sex before graduation day, and about

95 percent of Americans have pre-marital sex. Research shows teens who

take abstinence pledges delay sex, but do eventually engage in

pre-marital intercourse at the same rate as their peers. When they do

have sex, however, they are less likely than other teens to use

protection.

"When sex is held out as forbidden fruit, young people are

not prepared for planning it. It just sort of happens," Hauser says.

"If at that point, all you have is withdrawal, then my goodness,

withdraw! Unfortunately, if withdrawal is belittled in school, you

think, ‘Why should I?’"

A Kinsey Institute survey of 18 to 30 year old women found

that about 21 percent regularly use withdrawal, most commonly combining

it with another method, such as using condoms during the more fertile

days around ovulation. High school sex-ed curricula rarely delve deeply

into that type of fertility awareness; in comprehensive sex-ed, girls

are usually told to be wary of pregnancy on every day of their cycle.

But considering that more people may be relying on withdrawal than

previously assumed, some sex-educators believe teenagers ought to be

introduced to fertility awareness methods as well, which are most

commonly associated with married couples who oppose other forms of

birth control for religious reasons.

"Religious kids believe contraception is abortion," Hauser says. "Rhythm and withdrawal — at that point, it’s all you have."

TeenStar is a popular international sex-ed curriculum that

emphasizes fertility awareness alongside a pro-abstinence, pro-marriage

message. According to Hanna Klaus, an ob-gyn and the program’s

director, TeenStar students are taught to monitor vaginal mucus in

order to avoid days of peak fertility. The program is active in 30

countries. Under the Bush administration, TeenStar received funding

from both USAID and PEPFAR, the President’s Emergency Plan for Aids

Relief. Yet because it is considered neither abstinence-only nor

comprehensive sex-ed, only a few Catholic schools are using the

curriculum within the United States.

Though TeenStar does less to promote condoms and hormonal

birth control than many comprehensive sex-ed advocates would like, some

see possibilities for cooperation with abstinence proponents like

Klaus, who will at least discuss contraception with teens. In reality

though, the American sex-ed wars have left little space for such common

ground. Influential groups such as the National Abstinence

Clearinghouse and National Abstinence Education Association oppose

giving teens "mixed messages" by discussing any contraceptive methods.

Both organizations ignored several interview requests for this article.

As the political consensus shifts away from abstinence-only,

debates like this one will likely become more common. Even those

skeptical of the reported withdrawal success rates say disagreement

over the method provides a perfect opportunity to teach teenagers the

kind of critical thinking and evidence-assessment necessary in making

health decisions.

"I think everything should be talked about with teens," says

Martha Kempner, vice president of SIECUS, the Sexuality Information and

Education Council of America. "The thing we often forget about

school-based information is that we’re not just giving them the

information they need right now. We’re giving them the information they

need for the rest of their lives."