Surprising second thoughts on the effectiveness of coitus interruptus

But now, four reproductive health researchers contend that the withdrawal method, commonly known as pulling out or, more delicately, coitus interruptus, has gotten a bad rap.

They cite evidence indicating withdrawal is almost as reliable as condoms over the course of a year. And while interrupting intercourse before ejaculation has obvious drawbacks, it's a reasonable strategy for monogamous couples who aren't worried about venereal diseases and have difficulty with other methods.

"Health-care providers should discuss withdrawal as a legitimate ... contraceptive method in the same way they do condoms and diaphragms," wrote Rachel K. Jones, lead author of the opinion piece in the June issue of the journal Contraception.

The article has aroused ardent reaction in the blogosphere and on the street _ most of it derisive.

"That's pretty much the most absurd thing I've ever heard," Linda Heffelfinger, 23, said as she took a break at Community College of Philadelphia. "There's no contraception in that method, so it's not contraception."

Family planning advocates were also skeptical.

"I'm certainly not outraged by the article, but I'm concerned about how it could be interpreted," said Dayle Steinberg, CEO of Planned Parenthood of Southeastern Pennsylvania. "The whole thing about withdrawal is that it's hard to control yourself when you're in the middle of the act. For someone who has no access to anything else, sure, it's better than nothing."

The "better than nothing" rap is one of several misconceptions about withdrawal, Jones and her co-authors say.

Several studies have found that pre-ejaculate fluid usually does not contain sperm, contrary to what generations of youths learned in sex ed class.

And while 85 percent of couples will get pregnant in a year using nothing, about 18 percent will get pregnant with "typical" use of withdrawal. (Typical is defined as imperfect, real-world use.) In comparison, 17 percent of condom users wind up pregnant because typically, the prophylactic slips, breaks _ or sits on the nightstand.

Those withdrawal and condom estimates come from a 2002 federal survey of women that was analyzed by the Guttmacher Institute, an authoritative reproductive-health research center. Jones is a researcher there, but wasn't part of the institute's analysis.

The thing is, contraceptive practices are moving targets. Previous versions of this national survey, also analyzed by Guttmacher, suggested 25 to 27 percent of couples who used withdrawal got pregnant per year, compared with 14 to 15 percent with condoms.

That 27 percent figure is cited by numerous family-planning groups.

What are the right rates?

It depends, said Jones' co-author Julie Fennell, a sociology professor at Central Connecticut State University.

"Estimates are never perfect. And people's ability to use these methods is constantly changing. People are better at it when they're married; we're not sure why. It looks like people genuinely are better at using withdrawal today than 20 years ago."

In the 2002 federal survey, more than half the women, ages 15 to 44, reported ever using withdrawal. The researchers suspect many more actually did.

"People are embarrassed or they don't consider it a real method," Jones explained.

That was clear from Fennell's interviews with 30 couples who were cohabiting or married. Several are quoted in the Contraception article:

"Sometimes we use condoms," one woman said. "But for the most part, just the withdrawal method. Which I know is, like, the worst."

"We didn't use anything," another woman said. "Wait a minute. He pulled out. I can't believe we didn't use anything, but I guess withdrawal is better than nothing."

The authors focused on the role of the method in mature, monogamous relationships. Withdrawal is often a backup strategy for couples who rely on condoms and track the woman's fertile period. As one woman told Fennell, "It doesn't smell bad and it doesn't have chemicals in it."

Nonetheless, critics of the article have focused on teenagers. Ironically, fans of all-inclusive sex education shudder at the idea of telling teens that withdrawal actually is better than nothing.

They warn that interrupting coitus doesn't protect against sexually transmitted diseases, and it requires more self-control and perceptiveness than young men tend to possess.

Besides, guys can't be trusted.

"For plenty of young couples using withdrawal, it doesn't take long to get to a time when a male partner decides to go without withdrawing on purpose _ often without consulting his partner," wrote Heather Corinna, a Seattle sex educator who runs Scarleteen.com, a popular sex advice Web site.

Martha Kempner of the Sexuality Information and Education Council of the United States, sought common ground.

"It's never appropriate to lie to teenagers, or withhold information to control their behavior. That's what we've criticized with the abstinence education movement," she said. "We have to give teens accurate information. But then we have to take it a step further and say: Now, think about this."

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