Helen had her eyes on David since college. They’d never quite been friends, but they kept up with each other’s exploits online. When David’s first film came out he did the festival circuit, bringing him to obscure ski towns and, finally, to Helen. After his film won Best Director that night they celebrated together in formal wear until the bars of the sleepy town closed at 12:30.

Back at David’s hotel they ended up on the Egyptian cotton sheets with a room service cart of Champagne. Falling all over each other in half undone bathrobes, Helen licked her hand, grabbed David and put him inside of her.

They had both been in committed relationships before this. But then he wondered, “Is this OK?”

“What we do know is that the failure rate is between 18 and 28 percent. Some argue that under perfect circumstances, a 4 percent failure rate is possible to achieve. But, when are circumstances perfect?”

“I’ll make you a deal,” Helen wrapped her legs around David. “I want to come with you inside of me, as long as you promise not to come inside of me.”

And that, folks, is birth control for many millenials—the unlikely but marvelous offspring of a generation raised on sex education and porn. And science is having trouble keeping up.

“Withdrawal is sometimes referred to as the contraceptive method that is ‘better than nothing.’ But, based on the evidence, it might more aptly be referred to as a method that is almost as effective as the male condom.” So says the sex researcher with the awesomest name, Dr. Annie Dude. Her recent survey found that 1 in 3 sexually active women between ages 15 and 24 have used The Method. We’re gonna go ahead an up that figure to just about 100 percent for guys.

You can argue almost either way (doing withdrawal 100 percent correctly is technically 100 percent effective), and it’s hard (sorry) to compare a half-assed attempt with perfect use of hormonal or barrier methods (condoms and pills).

Luckily, we have an expert to call for these situations. Gail Ingram is a primary care nurse practitioner in New York City and shares health information via the fascinating real-talk website NurseGail.com. She is not only an incredible resource, but a gifted nurse. (I once called her from an ER with my leg in sixteen pieces and—no exaggeration—she got me walking within a week.) She seemed like a great source with whom to explore this trend.

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Nurse Gail Weighs In

How come there’s next to zero data on the oldest form of birth control?
Research is limited because pulling out doesn’t involve the need for product marketing data or human trials for FDA drug approval.  What we do know is that the failure rate is between 18 and 28 percent. Some argue that under perfect circumstances, a 4 percent failure rate is possible to achieve. But, when are circumstances perfect?

What makes it fail?
Failure occurs most often in cases of poor timing. When this happens, Plan B or emergency contraception is a viable backup. When used alone, spermicide has the same failure rate as the withdrawal method, but when combined, there is a better chance for success. However, spermicide is notorious for irritating skin and increasing the risk of UTIs (urinary tract infections) in women. Combining withdrawal with the rhythm method is a worthwhile practice to prevent pregnancy.

What can go wrong?
A better question is, what else can go wrong? Roughly 30 percent of healthy, sexually active men report some form of premature ejaculation. This usually affects younger men and can be lifelong or acquired (meaning short-term or situational). Causes can be related to psychiatric issues, genetic predisposition, prostatitis and stimulants like cocaine. (Prostatitis can occur in men with multiple partners when bacteria is introduced to the prostate through sex.)

Once and for all: Is there sperm in “pre-come?”
Pre-ejaculate or pre-seminal fluid is mucus produced by glands outside of the gonads and, therefore, does not contain sperm. Sperm has been found in pre-ejaculate when the urethra hasn’t been flushed between orgasms. To prevent sperm from finding its way into the pre-ejacualate, urinate between intimate sessions. The acidic nature of urine and the pressure of flow will disable and clear the sperm. Just be sure to drink water and stay hydrated so peeing isn’t a struggle.

So what’s the verdict?
Every situation is different and I advise patients on a one-to-one basis.  I don’t recommend withdrawal as first-line birth control for young people. Older men and women are more experienced, conscientious and able to cope with consequences.  In many cases they tend to be more comfortable having difficult conversations about STIs and pregnancy with their partners.  They are also statistically less likely to become pregnant which makes withdrawal a reasonable option for them.

What about for couples in a committed relationship?
The failure rate declines with age because older couples tend to be more responsible and understand the consequences to their actions. It becomes progressively more difficult for women beginning at the age of 30 to become pregnant. There are also issues with sperm count, motility and morphology in older men.

We’re concerned mostly with preventing unintended pregnancy. But is there a smaller chance of STI* transmission if the man pulls out before ejaculating semen?
There is a chance for some STIs to be transmitted simply by rubbing bare genitals together. Some STIs can be shared through skin-to-skin contact, without swapping body fluids.  However, both pre-ejaculate and semen carry STIs in addition to other bacteria and viruses.

After years of having to remember to take a pill or get the ring at the pharmacy, some women are happy to put the onus on the one doing the withdrawing. Is it seriously your girlfriend’s responsibility to keep your own semen out of her?

What Ladies Think

It’s important to note that all of these studies examine use of the Withdrawal Method by young women.  If they surveyed guys that age about unprotected sex, the researcher’s stat-hand would hurt from that many high-fives.

Millennials were raised by mothers who were told that chemical control of your fertility was true freedom. But a third of the women my age just say no.  “They are more driven by sexual pleasure—they see orgasms as a right, not a privilege—and hate the feel of condoms,” says NYMag. After years of having to remember to take a pill or get the ring at the pharmacy, some women are happy to put the onus on the one doing the withdrawing. Is it seriously your girlfriend’s responsibility to keep your own semen out of her?

But the women I spoke to were divided. On one hand: Wouldn’t it be nice if we all got tested regularly and could trust our sexual partners to know when to say when? To some this is a sign of our sex-positive times. But to other women, it’s just another thing they pretend to be OK with.

David and Helen?  They’re doing long distance now. Helen doesn’t see the point of taking a pill.  The last time she visited David she wrapped her legs around him and said, “Now I want you in my mouth.”  I love the way those two communicate.

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A Healthy Discussion

Like any method, it requires practice. But that doesn’t mean you need to have one of those Union shop signs over your bed: “108 Days without an Accident.”

Here’s the most interesting part to me: Everyone’s birth control hangups are their relationship hangups. Everything they do or do not like about dating gets expressed as anger against birth control. (“So I have to take a pill because I don’t know if you’ll be around next month?” “And I have to wear a condom because you don’t trust me?”) It is for that reason that we need to approach withdrawal with science and not judgement.

Contraception is the first discussion that couples need to have and come to an agreement on together. It’s good practice. Even for one-night stands. It is the absolute wrong time to make someone feel like they’re alone (“Did you take your pill?”).

Pulling out is just one more method that needs to be examined and practiced. And, yes, no one will say it, but: It’s healthy and it lowers the risk of pregnancy in combination with fertility tracking or hormonal therapy.  No form of birth control is foolproof.  Even women who’ve take the pill religiously since high school still buy pregnancy tests. And also, no one says you have to pull out like a fighter pilot. There are lots of fun and creative ways for guys to get off that don’t cause pregnancy.

And… we’ll let you take it from here.

 

*At the risk of using 2015’s most overused phrase: It’s 2015, stop saying STD. STD carries the stigma of someone being “diseased.” Syphilis ridden James Joyce lost his vision and his mind to an STD. Nurse Gail’s date who had antibiotic-resistant Chlamydia had an STI that got sorted out by the same doctor who diagnosed it.