Exit Strategy

Editors' Note: This piece has been corrected.

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.

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 ScarletTeen. "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 recognize 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."

Correction: The piece originally stated that the TeenStar program teaches students to monitor vaginal mucus in order to avoid days of peak fertility. The program's goal is to get girls to recognize their fertility, not to avoid it.

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