The withdrawal method of family planning, also called coitus interruptus, is a male-controlled method that has been used for centuries but has not been rigorously studied scientifically.
It is used by substantial numbers in a few countries, including Turkey, Rumania and the Czech Republic. Most couples in those countries cite concerns about health and side effects of modern methods as a major reason for using withdrawal, according to an analysis by Dr. Howard Goldberg, a demographer at the U.S. Centers for Disease Control and Prevention. Other reasons for using withdrawal are partner preference, lack of knowledge and access to modern methods, and the cost of modern methods.1
Family planning programs generally focus on promoting modern methods. "Withdrawal has largely been left out as a method today," says Meena Cabral of Geneva, who works with the Family Planning and Population Unit of the World Health Organization (WHO). "But it should be discussed with those who are interested in it and, for various reasons, are not able to use another method."
WHO has not formulated recommendations on the use of withdrawal, primarily due to a lack of research on efficacy and on how service providers can support the method in a reliable way. "There are so many difficulties in studying withdrawal because it is so culturally bound and user-dependent," says Cabral.
"It's very unpredictable how it's going to work," says Dr. Carlos Huezo of London, medical director of the International Planned Parenthood Federation (IPPF). "Using withdrawal takes commitment, discipline and motivation. For those who have experience and find it effective, it should be one of the choices." IPPF does not promote the method, which has a relatively high failure rate, but provides information on it. "We don't think it is appropriate to move people away from using withdrawal if they are using it well," explains Dr. Huezo.
To use withdrawal correctly, the man must remove his penis from the woman's vagina before ejaculation. This requires a high level of motivation and awareness during intercourse. He must pull out as sexual excitement is nearing its peak and move his penis away from contact with the woman's vagina or external genitalia where cervical secretions can carry the sperm up the genital tract. Experts estimate withdrawal to have a typical pregnancy rate of 19 percent, but acknowledge this estimate is based on little research.2
If given proper attention in research and program policies, this method has potential for greater use, says Deborah Rogow, who has written an analysis of the literature on withdrawal.3 "Scientists generally do not recognize how widely it is used and do not know how effective it is," she says.
Regional popularity
Withdrawal is a popular method in some regions. National surveys indicate that withdrawal is the most widely used method in Rumania (35 percent), Turkey (27 percent) and the Czech Republic (24 percent). Other countries with substantial use are Mauritius (16 percent), Sri Lanka (8 percent), and, at 5 percent, Brazil, Colombia, the Philippines, Trinidad and Tobago, and Zimbabwe.
Researchers have found that withdrawal is frequently used in conjunction with other methods, is not always recognized as a method by the person being surveyed, and may not be reported in traditional surveys of contraceptive use. A 1991 study in Sri Lanka, for example, found that 28 percent of women relied on withdrawal as their primary method, with many others reporting that they use it as a secondary method. "In Sri Lanka, there is high likelihood of undernumerating traditional methods with the conventional survey approach," write Dr. Amy Tsui of the U.S.-based Carolina Population Center and Dr. Victor de Silva of the Family Planning Association (FPA) of Sri Lanka, who followed 300 randomly-chosen women in five villages for 35 days. They asked them about menstrual and lactational status, perception of pregnancy risk, coital activity and pregnancy avoidance behavior.4
Another study found that some women may not want to "admit to themselves, let alone to an interviewer, that they have been party to the taking of precautions."5 Also, women may not report that they use withdrawal since they perceive it as something men use, or they don't think of it as a method of contraception, explains Dr. Malcolm Potts of the University of California at Berkeley, who lectures widely on family planning issues.6
While experts estimate typical failure rates for withdrawal at 19 percent, this figure is based on only four studies since the 1960s.7 One of those, a prospective study conducted by Dr. Martin Vessey and colleagues in England, found only a 7 percent failure rate, based on 674 women-years of withdrawal use and 45 unintended pregnancies. (The nine-year study followed thousands of women who were using modern methods. Some of them used withdrawal sporadically, such as between the use of other methods.)8
The Vessey and Sri Lanka studies suggest that withdrawal is most frequently used between other methods or only during parts of a woman's fertility cycle.
Some have assumed that withdrawal is not reliable because pre-ejaculate fluid contains viable sperm -- an assumption that two small studies have questioned. One study found no sperm in the pre-ejaculatory fluid of 16 men.9 The other found a few small clumps of sperm in this fluid from five of 15 men, but the sperm appeared to be inactive.10
Counseling on withdrawal
Policy-makers and researchers vary in how much emphasis they think modern family planning programs should put on withdrawal. "We do not think providers should encourage successful withdrawal users to switch to modern methods systematically," says Cabral of WHO.
The Sri Lankan FPA, an IPPF affiliate, always includes withdrawal as a method in medical lectures and training. But the FPA does try to shift couples away from traditional methods to modern methods. "The traditional methods are believed to have much higher failure rates," says Dr. Sriani Basnayake, the FPA's medical director.
One type of counseling that would be helpful is fertility awareness. "If women know their menstrual cycle and are aware of pregnancy high-risk periods, then withdrawal can work with modern NFP [natural family planning]," says Dr. Aysen Bulut of the University of Istanbul, who recently completed a survey of 867 women in Istanbul. She found that about one of four withdrawal users said they did not know their fertile period and another third identified their fertile time incorrectly. Almost half of contraceptive users were using withdrawal, either alone or in combination with other methods.
Male involvement
In her literature analysis, Rogow views arguments for shifting away from withdrawal as a bias that "contemporary family planning professionals place on marginal differences in effectiveness over other aspects of contraceptives." Because of the need to involve men more in family planning and to provide effective male methods, "withdrawal must be included among those methods urgently needing attention and research," she writes.11
In one sense, men's use of withdrawal could become a means of reinforcing their sexual control in a relationship, Rogow and others point out. But withdrawal could also engage men to take greater responsibility for the consequences of their sexual actions. "Communication [between a couple about] using withdrawal, as with a condom, can lead to more respect for women by men," says Judy Norsigian of the Boston Women's Health Book Collective. "But it's not a simple process and not instantaneous."
Education about fertility awareness is especially important for young, sexually active men and women, a group that tends to use withdrawal. Withdrawal can result in high pregnancy rates particularly for this group, because using the method successfully requires sexual experience.
Another important area of counseling involves the transmission of STDs, including AIDS. Sexually active couples at risk of STD/HIV transmission should be counseled to use condoms. Couples practicing withdrawal are not protected from the transmission of STDs. Pathogens such as those causing chlamydial infection, gonorrhea and syphilis are not limited to semen. "Gonorrhea and chlamydial infection come from urethral shedding and discharge, not from the seminal vesicles and prostate gland," says Ron Roddy of FHI, whose research focuses on STDs. "The pressure on the penis during intercourse before ejaculation could cause a discharge containing the bacteria."
Whether counseling about STDs, fertility awareness, or informed choice, providers need to understand the overall pattern of fertility control within their communities. "Their professional wisdom will be greater and their usefulness to the couple increased if they have a general understanding of coitus interruptus and some of the characteristics of those who use the method," Dr. Potts writes. "Coitus interruptus is like a bicycle or buffalo cart; no doubt there are better methods of transport or better methods of contraception, but for a great many people it represents a practical solution to an everyday problem. Instead of criticizing the method, one should capitalize on it. When those who use it feel the need, they will move to more modern methods."12
-- Willam R. Finger
References
- Goldberg HI. The use of non-supplied contraceptive methods in high prevalence countries. Poster session, Population Association of America Annual Meeting, 1995, San Francisco, CA; Goldberg HI, Toros A. The use of traditional methods of contraception among Turkish couples. Stud Fam Plann 1994;25(2):122-28.
- Trussell J, Kost K. Contraceptive failure in the United States: A critical review of the literature. Stud Fam Plann 1987;18(5):246.
- Rogow D, Horowitz S. Withdrawal: A review of the literature and an agenda for research. Stud Fam Plann 1995;26(3):140-53.
- Tsui AO, de Silva SV, Marinshaw R. Pregnancy avoidance and coital behavior. Demography 1991;28(1):114.
- Santow G. Coitus interruptus in the twentieth century. Popul Dev Rev 1993;19(4):773.
- Potts DM. Coitus interruptus. In Fertility Control, eds. Corson, SL, Derman RJ, Tyrer LB. (Boston: Little, Brown and Company, 1985) 299-305.
- Trussell, 246.
- Vessey M, Lawless M, Yeates D. Efficacy of different contraceptive methods. Lancet 1982;8276:841-42.
- Ilaria G, Jacobs JL, Polsky B, et al. Detection of HIV-1 DNA sequences in pre-ejaculatory fluid. Lancet 1992;340(1833):1469.
- Pudney J, Oneta M, Maer K, et al. Pre-ejaculatory fluid as potential vector for sexual transmission of HIV-1. Lancet 1992;340(1833):1470.
- Rogow, 148-9.
- Potts, 304.
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