Which birth-control method is more effective: condoms
For sex educators and others, the answer is glaringly obvious. Withdrawal before ejaculation, the so-called pullout method, is a last resort, they say — something to be used only if there are no other options. The effectiveness of condoms, on the other hand, is well known.
So reproductive experts were taken aback by a paper in the June issue of Contraception magazine
. Based on an analysis of studies, the paper pronounced withdrawal "almost as effective as the male condom — at least when it comes to pregnancy
prevention.""If the male partner withdraws before ejaculation every time a couple has vaginal intercourse, about 4 percent of couples will become pregnant over the course of a year," the authors write.
For condoms, used optimally, the rate is about 2 percent. But more significant, the authors say, are the rates for "typical use," because people can't be expected to use any contraception
method perfectly every time. Typical use of withdrawal leads to pregnancy 18 percent of the time, they write; for typical use of condoms 17 percent of the time.
(There are other, more effective methods. Failure rates for the pill and the patch are about 8 percent; for Depo-Provera injections, about 3 percent; and for diaphragms, about 16 percent. Intrauterine devices fail less than 1 percent of the time.)
The lead author, Rachel K. Jones, a senior research associate at the Guttmacher Institute, which studies reproductive health matters, said she and her co-authors were motivated to write the paper because it seemed to them the pullout method was getting short shrift.
"We had all noticed that social science researchers and health care providers just kind of dismiss withdrawal and don't seem to realize that it can prevent pregnancy," Ms. Jones said. "Most people seem to be under the impression that you might as well do nothing."
Even she used to think of withdrawal as "cheating," she said. But "most women have used withdrawal at some point in their lives" and it seemed logical to compare the method to condoms, because health care providers "have no problem advocating the use of condoms as a method even though those are flawed."
Some educators and physicians said they worried that putting out a message that withdrawal is effective would just give teenagers encouragement to have unprotected sex. And many underscored what the authors themselves point out: that unlike condoms, withdrawal does not protect against sexually transmitted diseases
, a strong reason to encourage condoms.
But Ms. Jones said the intention was not to advocate withdrawal, but to advocate talking about it.
"Health care providers and health educators should discuss withdrawal as a legitimate, if slightly less effective, contraceptive method in the same way they do condoms and diaphragms," the authors write. "Dismissing withdrawal as a legitimate contraceptive method is counterproductive for the prevention of pregnancy and also discourages academic inquiry into this frequently used and reasonably effective method."
Ms. Jones and her co-authors said they were dismayed to see that withdrawal had not been exhaustively studied.
"Despite its role in the European fertility decline, and relatively high levels of use, acceptability and effectiveness," they write, "most studies of withdrawal since that time have been small in scale (e.g., married Turkish men), or have focused on specific populations (e.g., Israeli Jews or Chinese Canadians obtaining abortions)."
The authors say there has been a bias against studying or legitimizing withdrawal, partly because of "preference for modern methods and the strongly held belief that pre-ejaculate fluid contains sperm, despite the lack of supporting evidence."
Studies may underreport withdrawal use "because respondents do not consider it a 'method,' " they write. "One study found that only 3 of 62 Turkish factory workers reported on a questionnaire that they used withdrawal. However, in face-to-face interviews, an additional 17 reported current use of this method."
Two of the authors also conducted their own interviews to gather anecdotal information on people's sexual practices. The interviews indicated that many people did not consider withdrawal a serious method. One woman, said she used no birth control
, adding: "Sometimes we use condoms. But for the most part just the withdrawal method. Which I know is, like, the worst thing."
Many people preferred withdrawal to condoms. As one said, "you can still have sex, it doesn't smell bad, it doesn't have chemicals in it."
The research convinced the authors that "it is unfortunate that some couples do not realize they are substantially reducing their risk of pregnancy when using withdrawal, as these misperceptions may cause unnecessary levels of anxiety
. More speculatively, if more people realized that correct and consistent use of withdrawal substantially reduced the risk of pregnancy, they might use it more effectively."
Some experts said they did not dispute the findings but worried that young people would construe the article's conclusion's too liberally. "Those data don't necessarily translate to youth today," said Dr. Melissa Gilliam, chief of family planning and contraceptive research in the University of Chicago
's Department of Obstetrics and Gynecology, who is on the board of the Guttmacher Institute. "In terms of a reliable method used over and over again, the risk of failure is quite high."
Martha Kempner, vice president for information and communications at the Sexuality Information and Education Council of the United States, said withdrawal, while less problematic for married or long-term monogamous couples, is not as acceptable in other circumstances because "well-intentioned young men can get it wrong, or somebody can just not do it after they said they would."
Spirited comments on blogs largely agreed. "I wouldn't want to trust a dude to get it right every time," read one comment on the blog CollegeCandy
Still, Ms. Kempner said: "It has made some classroom teachers nervous to give out the truth in this instance, but we do have to tell the truth. People, kids in particular, they're using it. It is better than nothing, and it is always available. You can't say, 'Oh, I didn't have one.' "Source