It works, so why are doctors so against it?

At a recent appointment, Laura didn’t think twice about giving her gynecologist an honest answer about what kind of birth control she uses: the pullout method.

Laura, age 29, explained that she and her partner feel perfectly satisfied with withdrawal, which they’ve been using for four years without a hitch. But the gynecologist was flabbergasted, Laura recalls, and told her that this was an “accident waiting to happen.” She sent her home with internal condoms and spermicides—neither of which Laura plans to use.

The latter suggestion left a particularly bad impression. With side effects like burning, abdominal pain, trouble urinating, and an efficacy rate of only 70–80 percent, spermicides are widely considered to be one of the least effective forms of contraception.

As far as preventing pregnancy goes, the pullout method is actually a much better choice, if not, among the limited birth control options out there, a near-perfect one. Sexual health experts have known for years that it’s about as effective as male condoms when used correctly—the two have near-identical failure rates of 4 percent and 3 percent, respectively. And in a large national study, 18 percent of couples who relied solely on withdrawal experienced an unplanned pregnancy, compared with the 17 percent who used only condoms. In other words, when it comes to noninvasive forms of birth control, pulling out is a pretty safe bet.

It’s also very common. The latest data from the Centers for Disease Control and Prevention, released in December, shows that about two-thirds of women have, at some point, relied on withdrawal as their primary form of birth control. It’s the third-most-common option behind male condoms and the pill and is much more widely used than IUDs or contraceptive implants. Some people choose it as a last-ditch effort when nothing else is available, or because they can’t access or afford methods like hormonal birth control or IUDs (which are the most reliable forms of birth control). But for others—particularly those who live in states where abortion is legal, and who trust their partner’s STI status—withdrawal is simply a superior method. Not only is it free and always available, it has no side effects and does not necessitate a doctor’s visit. So why are doctors like Laura’s so against it?

The most obvious reason, of course, is that not everyone uses it correctly. According to Planned Parenthood, about 1 in 5 people will get pregnant if they use withdrawal imperfectly—that is, if their partner ejaculates before pulling out, during or around the time of ovulation. But that alone doesn’t explain the stigma. If withdrawal is relatively effective with proper use—a technique that should be easy for providers to teach—it should have a place on the contraceptive menu.

But in some cases, the bias against it is just too strong. Many of us have teenage memories of sexual educators strongly cautioning us against pulling out, and even for adults, anti-withdrawal messaging is widespread—it’s sometimes referred to as the “pull-and-pray method,” a label insinuating that it works about as well as appealing to God. Sexual and reproductive health providers often write about the “human error” involved, and caution women that pulling out can require “a lot of self-control and self-awareness on your partner’s part.” The penis, in this view, is like an unpredictable volcano: at risk of exploding with sperm at any time.

As such, many providers and educators portray withdrawal as a sort of surprise-filled roll of the dice. Kathleen Broussard, a sociology professor at the University of South Carolina, collects sexual health education materials for her reproductive health course. She has seen some neutral depictions of withdrawal, like clocks and exit signs, but also more stigmatizing design choices, like crossed fingers or party poppers with confetti. Images like these imply that pulling out involves chance, luck, or an utter lack of self-control. It’s an odd way to portray a contraceptive method that even Planned Parenthood calls “pretty effective” when used correctly.

Still, beliefs like these often make their way into exam rooms. “There’s a broader medical culture of not considering withdrawal to be a contraceptive,” Brian Nguyen, an OB-GYN and researcher at the University of Southern California, told me. “They would say, ‘That’s not a method of contraception—you’re going to get pregnant. Here are other options you might consider instead.’ ” One of those methods doctors might recommend instead is condoms, which Nguyen confirmed are ranked “third-tier,” along with withdrawal.

Rather, Nguyen says, the clinical community tends to trust and prefer contraceptive methods that they can prescribe. “Withdrawal is a behavior,” he said. “It’s not necessarily a product that you can sell or a technique you can teach that can be billed.”

This is ironic because the very people who counsel against withdrawal also often use it themselves. In a study of 340 sexual and reproductive health experts, 76 percent had relied on withdrawal at some point in their lives. Liza Fuentes, director of health equity research at Boston Medical Center, says reproductive health experts likely use withdrawal for the same reasons non-experts do. “It’s low cost, it’s convenient, you don’t have to plan ahead,” she said.

And ideally, there are options if withdrawal fails. Plan B can help prevent pregnancy when used within five days of unprotected sex. For those who can access it, abortion can relieve the burden of having to prevent a pregnancy no matter what. And though it’s not always cheap or free of side effects itself, abortion can also allow people to sidestep the occasionally intense side effects and costs of other, more effective birth control methods, which Fuentes said may also color people’s decision to use withdrawal in the first place.

Rachel Jones, a reproductive health expert and research scientist at the Guttmacher Institute, published a survey on contraceptive use in 2014 that included withdrawal at the top of the list of options for study participants so they wouldn’t overlook it. She recalls getting a lot of antagonism from peers who complained that it was “irresponsible” for someone from the Guttmacher Institute to promote the pullout method as a legitimate contraceptive. But her study found that many people were actually using withdrawal responsibly. Some were even using it in tandem with other contraceptive options, which makes them even more effective. “Everyone uses it, but no one talks about it,” she said.

Critics of her research did bring up one interesting question: What about pre-cum? Many pointed out that withdrawal isn’t much good if the pre-ejaculatory fluid some men release before orgasm contains sperm—in that case, pulling out before ejaculation wouldn’t help, even if they did it at the exact right moment. It’s a valid argument, but it’s not entirely factual—research on pre-ejaculate fluid is sparse, and it’s typically based on small numbers of men. Some studies have found no sperm in pre-cum and others have.

Thus, researchers still don’t know whether pre-cum has active sperm in it. The only current conclusion is that some men’s pre-ejaculate fluid does, while others’ does not. “Statistically speaking, it’s an even smaller likelihood than if there’s a full load of sperm,” Jones said. Perhaps if the pullout method had more respect, researchers would be eager to figure out how much of a pregnancy risk pre-cum truly poses.

The fact is that the nonhormonal birth control options out there are few and far between. Though it’s seldom talked about other than as an irresponsible act, many people have weighed the risks and benefits of pulling out and decided it’s right for them. Whether they live in states with protected abortion access, and/or are willing to risk an unwanted pregnancy, they view the risks as being outweighed by the benefit of not having to spend years of their lives taking a daily pill, having an IUD inserted, or using one of the other imperfect birth control options on the market—all of which also have the capacity to fail. For Laura, avoiding the depression and weight gain that the pill brought on for her was enough to make the decision alone.

In response, some providers and sexual health educators are shifting their practices to account for withdrawal use. “I think most people’s reaction is to shame folks for practicing the withdrawal method,” Gabrielle Kassel, co-host of Bad in Bed: The Queer Sex Podcast, told me. “But the real shame is the fact that our sex education programs do not teach people when they can actually become pregnant.” Indeed, there are only a handful of days one can get pregnant every month, which is a biological reality many are unfamiliar with due in part to anti–teen pregnancy campaigns. To counter this gap in education, Kassel encourages people who use withdrawal to also track their ovulation windows and basal body temperatures in order to avoid sex without a barrier during their fertile days. This strategy more closely aligns with “fertility awareness methods,” which Nguyen said the medical community might be more supportive of because they involve marketable products and educational materials—namely, an app, a thermometer, and a tracking technique.

It might run counter to decades of cultural messaging, but pulling out is not the enemy of public health it’s been made out to be. As long as people are using withdrawal correctly—i.e., not during ovulation—and because they want to, not because they can’t access something better, providers and sex educators shouldn’t have an issue. Laura and her partner, for one, do not.