In many ways, 2016 is an exceptionally good time to be a woman in need of birth control. The IUD, a method that works more than 99 percent of the time, is more popular than ever; birth control is covered under the Affordable Care Act; and in a few states, pharmacists can now give women a full year's worth of the pill without a doctor's prescription. Women's access to a range of reliable contraceptive options is arguably the best it's ever been.
Why, then, do many straight women still turn to the "pull-out method," the world's oldest, most rudimentary form of birth control?
Estimates suggest that nearly 60 percent of American women have relied on their partners to withdraw before ejaculating at some point in their lives, and around 3 percent of 15 to 44-year-old women are currently using coitus interruptus at any given time -- though researchers believe the actual number is likely much higher. Despite its relative popularity, sex educators tend to dismiss pulling out as outdated and irresponsible -- not so much a contraceptive method as a foolish afterthought. And yet the women who regularly rely on the pull-out method insist that it's not only a good option; it's the best option for them.
"I definitely feel shame from others online about my method of choice," said Rachel, 26, who has been using withdrawal with her partner for more than four years. "People seem to be pretty vocal against it." Rachel feels that women who rely on the method are judged as irresponsible, apathetic and downright negligent.
But perhaps surprisingly, research indicates that pulling out is about as effective as condoms at preventing pregnancies -- though of course, not sexually transmitted infections. The perfect-use failure rate for condoms is around 3 percent; for withdrawal, it's 4 percent. One investigation found that 18 percent of couples who use withdrawal for a year will get pregnant, compared to 17 percent among couples who use condoms, although Planned Parenthood puts the chances of pregnancy higher, saying that 27 out of 100 women whose partners use withdrawal will get pregnant. Of course, neither method comes close being as effective as the birth control pill or IUD, but the numbers do suggest that pulling out suffers from an unfairly negative reputation.
"There are still a lot of health care providers who are like, 'Yeah, but it's not really a method,'" said Rachel Jones, principal research scientist at The Guttmacher Institute, which studies sex and reproductive health.
"Over half of women have had a partner who has used withdrawal, so just the sheer fact that most women are going to be exposed to it is reason to be talking about it more," she added. "Both the pros and the cons."
Jones worked on a 2014 study of more than 4,600 18 to 39-year-old women in the United States that found 33 percent had used withdrawal at least once in the past month, lending credence to the claim that current use estimates are low. (Jones cautioned, however, that her study was not nationally representative.) Notably, she and her co-authors found that many women used withdrawal in conjunction with the pill or IUD (13 percent) or condoms (11 percent), basically as a back-up form of contraception. Which suggests that many of the women who identify as "pull-out users" are actually more vigilant about pregnancy prevention.
“Obviously one of the major benefits is that it requires no prescription, no equipment, and it’s an option that’s right there all of the time.”
Withdrawal is sometimes used in conjunction with "natural family planning" or "fertility awareness-based" methods, in which women track their menstrual cycles -- as well as bodily changes that occur throughout -- in order to determine when they're most fertile. Fertility awareness-based methods have long been viewed as a decidedly crunchy, but the emergence of fertility tracking smartphone apps also suggest there is real interest from a range of women.
But even women who rely specifically on withdrawal as their primary method of birth control disagree with the narrative that they're simply ill-informed or ill-prepared.
"I'm not naive," said Tamara, 26, who has a 7-year-old daughter. "I know it's probably a less effective method, and I still chose it. I was on birth control before, I missed a week, and I got pregnant."
For three years in her early 20s, Tamara used withdrawal with her boyfriend. She's not sexually active right now, but she said she would consider using the method again. Nothing about it feels irresponsible to her. On the one or two occasions that Tamara's boyfriend didn't pull out in time, she took the morning-after pill. She and her ex-boyfriend were very clear on what would happen if they got pregnant (she'd get an abortion), and Tamara had money set aside in case.
"I think that there's a misconception. It wasn't because of laziness," Tamara said. "For me it was access." Tamara was on the pill for years, but then she moved and had to drive 45 minutes to her local clinic once a month -- an ordeal that cost her half a day's work. She didn't use condoms because of a latex allergy that makes her break out in a rash.
Women have a lot of reasons why they opt for withdrawal with their partners. The birth control pill has been widely studied and is very safe, but there are a lot of women who simply prefer not to use hormones, said Kelly Blanchard, president of Ibis Reproductive Health, a non-profit that conducts clinical and social science research. Religious objections are another common reason, she said.
Then, of course, there's ease.
"Obviously one of the major benefits is that it requires no prescription, no equipment, and it's an option that's right there all of the time," Blanchard said.
When discussing pulling out, Blanchard was very clear to point out the risks associated with the method, and to explain that she was not advocating for it. But she also believes the discussion should be more nuanced than pulling out is always bad. In 2008, Blanchard co-authored a research commentary with Jones arguing that for all its flaws, health care providers should do a better job of acknowledging withdrawal as a contraceptive method in order to advise their patients and do a better job of studying how often it is being used. It got a lot of feedback, Blanchard said, more so than any paper of her career.
"I heard a lot of negative reactions from sex educators and health care providers who work with young people who said it's dangerous to suggest that it could be used," she said, "and I heard a lot of comments from young people about having used it."
Julia, 22, is one such woman. She has been using the pull-out method since she lost her virginity as a teenager, after discovering she had a latex allergy that caused her to break out in a localized rash. When she was 19, she had an IUD implanted, but she hated it and had it removed six months later.
Julia isn't in a committed relationship, and is currently sleeping with a few men, most of whom are friends she also has sex with. She gets tested for STIs every three months, and expects her partners to do the same. Julia generally trusts that the men she sleeps with are being honest with her about their STI status, but if she feels at all uneasy, she asks to see their results. And she has had a few partners say they're uncomfortable pulling out, in which case they simply do other things together, like oral sex. Julia prefers it when her partners ejaculate on her chest or butt, which keeps things "kinky" she said -- and her sheets clean.
Julia is a true devotee to the pull-out method, and says that for her, for now, there really are no downsides to it. Maybe three times in her life, her partners have been too caught up in the moment and accidentally ejaculated inside her, and in those cases, she used Plan-B.
"If they don't communicate well, and if they don't let me know they're going to ejaculate, how am I supposed to know?" Julia said. "It's a hard thing to read, and that's why communication is key."
"I know women have different reactions to different types of birth control," she added, "but other options weren't a positive experience for me."
Names have been changed to protect anonymity.