UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN)
UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)

Withdrawal popular in some cultures

Network, vol. 17(1), Fall 1996: Fertility Awareness







Copyright 1996, Family Health International







Contraceptive Update



Withdrawal Popular in Some Cultures



While widely used in some countries, little research has been done

on efficacy or service issues.



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.1Family 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.2If 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 "We need to acknowledge

that withdrawal is a method and talk to women about it as an option,"

she says. "Scientists generally do not recognize how widely it is

used and do not know how effective it is, especially in specific

populations. Withdrawal is the biggest blind spot in contraceptive

technology."Regional popularityWithdrawal 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.4Another 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 writes and

lectures widely on family planning issues.6While 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.)8The 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.10Counseling on

withdrawalPolicy-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 provider needs to evaluate how they are using their chosen

method. Complete information should be available on a variety of

choices, then people can make an informed choice."The Sri Lankan FPA,

an IPPF affiliate, always includes withdrawal as a method in medical

lectures and training. "When counseling clients, if they still wish

to practice a traditional method after having heard the pros and cons

of the method, we will do our best to teach them how to practice the

chosen method correctly," says Dr. Sriani Basnayake, the FPA's

medical director. 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."



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.11In 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."



Both of the small studies that found no sperm in pre-ejaculatory

fluid did find HIV from many of those who were infected with HIV. The

fluid contained HIV from six of nine infected men in one study12 and

from six of 14 infected men in the other.13 Hence, even successful

use of withdrawal could result in the transmission of HIV. Another

study, however ( this one among discordant partners, where the man

was infected with HIV and the woman was not ( showed that consistent

use of withdrawal before ejaculation appeared to provide the woman

with some protection against transmission of HIV.14Whether 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."15



( William R. Finger)



                  References





1 Goldberg HI. The use of

non-supplied contraceptive methods in high prevalence countries.

Poster session, Population Association of America Annual Meeting,

1995, San Franciso, CA; Goldberg HI, Toros A. The use of traditional

methods of contraception among Turkish couples. Stud Fam Plann

1994;25(2):122-28.



2  Trussell J, Kost K. Contraceptive failure in the United States:

a critical review of the literature. Stud Fam Plann 1987;18(5):246.



3  Rogow D, Horowitz S. Withdrawal: a review of the literature and

an agenda for research. Stud Fam Plann 1995;26(3):140-53.



4  Tsui AO, de Silva SV, Marinshaw R. Pregnancy avoidance and coital

behavior. Demography 1991;28(1):114.



51  Santow G. Coitus interruptus in the twentieth century. Popul Dev

Rev 1993;19(4):773.



6 Potts DM. Coitus interruptus. In Fertility Control, eds. Corson,

SL, Derman RJ, Tyrer LB. (Boston: Little, Brown and Company, 1985)

299-305.



7 Trussell, 246.



8 Vessey M, Lawless M, Yeates D. Efficacy of different contraceptive

methods. Lancet 1982;8276:841-42.



9 Ilaria G, Jacobs JL, Polsky B, et al. Detection of HIV-1 DNA

sequences in pre-ejaculatory fluid. Lancet 1992;340(1833):1469.



10 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.



11 Rogow, 148-9.



12Pudney.



13Ilaria.



14 de Vincenzi I. A longitudinal study of human immunodeficiency

virus transmission by heterosexual partners. N Engl J Med

1994;331(6)341-46.



15Potts, 304.







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