What is Withdrawal method (coitus interruptus): Purpose, Procedure, Results & Costs in India

In the diverse landscape of family planning options available today, various methods cater to different needs, beliefs, and circumstances. Among the oldest and most traditional forms of contraception widely practiced across the globe, including significant usage in India, is the withdrawal method, also known as coitus interruptus or simply the "pull-out method." This method relies on the man withdrawing his penis from the vagina before ejaculation to prevent sperm from entering the female reproductive tract and thus, theoretically, avoiding pregnancy.

While seemingly straightforward and requiring no external tools or hormones, the effectiveness and implications of the withdrawal method are subjects of extensive discussion among medical professionals. For couples in India, where access to or preference for other birth control methods can vary, the withdrawal method often becomes a default choice, particularly in regions like Kerala, where it has been reported as a commonly used contraceptive. However, understanding its nuances, effectiveness, and inherent risks is crucial for making informed decisions about reproductive health. This comprehensive guide, brought to you by Ayu, aims to shed light on all aspects of the withdrawal method, empowering you with the knowledge to navigate your family planning choices responsibly.

Why is Withdrawal method (coitus interruptus) Performed?

The decision to use the withdrawal method is influenced by a variety of factors, ranging from practical considerations to personal preferences. While medical professionals generally advocate for more effective contraception, many couples still opt for coitus interruptus for reasons that resonate with their specific circumstances.

The primary and overarching purpose of the withdrawal method is, unequivocally, to prevent pregnancy. Couples engage in this practice with the intention of avoiding conception, often seeking to space out births, limit family size, or simply delay pregnancy until a more opportune time.

Beyond this core objective, several underlying motivations contribute to its widespread adoption, especially in contexts like India:

• Lack of Access or Awareness of Other Methods: In many parts of India, particularly in remote or underserved areas, comprehensive sexual and reproductive health education and access to a full spectrum of contraceptive options might be limited. This can lead couples to rely on traditional methods they are familiar with or that require no external resources.
• Cost-Free Nature: The withdrawal method incurs no direct monetary cost. Unlike condoms, birth control pills, IUDs, or implants, there's no purchase price, consultation fee, or ongoing expense. This makes it an attractive option for economically constrained individuals or those who simply prefer to avoid spending on contraception.
• Desire for Spontaneity: Some couples find that other contraceptive methods, such as pausing to apply a condom or remembering to take a daily pill, can disrupt the spontaneity of sexual intimacy. The withdrawal method, when successfully executed, allows for an uninterrupted flow of intercourse, which some couples prefer.
• Avoidance of Hormonal Side Effects: Hormonal contraceptives (like birth control pills, injections, or patches) can come with a range of potential side effects, including mood changes, weight fluctuations, or headaches. Couples who are sensitive to hormones, have contraindications, or simply wish to avoid introducing artificial hormones into their bodies might choose the withdrawal method.
• Discomfort with Barrier Methods: While condoms are highly effective and offer STI protection, some individuals report reduced sensation or discomfort with their use. The withdrawal method eliminates the need for a physical barrier during intercourse.
• Perceived Naturalness: For some, the idea of using a "natural" method, without devices or chemicals, holds an appeal. They might view it as less invasive or more in tune with their body's natural processes, despite its reliance on a high degree of unnatural control.
• Temporary Solution: Couples who are not actively trying to conceive but are also not ready to commit to a long-term contraceptive solution (like an IUD or sterilization) might use withdrawal as a temporary measure.
• Religious or Cultural Beliefs: While not explicitly mentioned in the provided research, some cultural or religious viewpoints might subtly favor methods perceived as more "natural" or less "interfering" with the body's processes, indirectly contributing to the use of withdrawal.

However, it's crucial to acknowledge that while these reasons explain why couples choose the withdrawal method, they do not necessarily endorse its efficacy. Many couples overestimate its reliability, often due to a lack of complete understanding of reproductive biology and the method's inherent failure rates. The perception of ease and naturalness often overshadows the significant discipline and risk involved, making comprehensive education about this method paramount.

The Withdrawal method (coitus interruptus) Procedure

The procedure for coitus interruptus, while conceptually simple, demands extreme precision and timing for it to have even its limited chance of effectiveness. It is a sequence of events that requires the male partner to override a fundamental biological reflex at a critical moment.

Here's a breakdown of the procedure:

1. Initiation of Intercourse: Sexual intercourse begins as usual, with the penis inside the vagina. This phase is identical to any other form of vaginal intercourse, allowing for natural arousal and pleasure.
2. Recognition of Imminent Ejaculation: This is the most crucial phase and relies entirely on the male partner's self-awareness. As sexual excitement intensifies, the man experiences a series of physiological sensations leading up to orgasm and ejaculation. There's a distinct point of "no return" or "ejaculatory inevitability" – the moment just before semen is irreversibly expelled. The man must be acutely attuned to these pre-ejaculatory signals, which can include a sudden surge in pleasure, specific muscle contractions, or a sensation of fullness.
3. Prompt and Complete Withdrawal: The moment the man recognizes these signals of imminent ejaculation, he must immediately and completely withdraw his penis from the vagina. This withdrawal must be swift and decisive. The entire penis, including the tip, must be pulled out of the vagina and away from the woman's external genitalia (vulva) before any seminal fluid is released.
4. Ejaculation Outside the Body: Once the penis is fully withdrawn, ejaculation should occur entirely outside the woman's body. Critically, the semen must be released away from the woman's external genitalia, inner thighs, or any area where it could potentially trickle or be wiped into the vagina. Even a small amount of semen near the vaginal opening can potentially lead to pregnancy, as sperm are motile and can swim into the reproductive tract.

Challenges and Difficulties in Procedure:

• Difficulty in Timing: The window between recognizing imminent ejaculation and the actual expulsion of semen can be very narrow, often just a few seconds. In the heightened state of arousal, accurately perceiving and acting within this window can be incredibly difficult.
• Pre-ejaculate Fluid (Precum): One of the primary biological challenges is the release of pre-ejaculate fluid (Cowper's fluid or precum) from the penis before full ejaculation. This fluid acts as a lubricant and helps neutralize the acidity of the urethra. Crucially, precum can contain live sperm, even if the man hasn't fully ejaculated. If this fluid enters the vagina, pregnancy is possible. The man often doesn't feel the release of precum, making withdrawal after its release potentially ineffective.
• Premature Ejaculation: For men who experience premature ejaculation, the ability to withdraw in time is severely compromised, making the withdrawal method particularly unreliable.
• Loss of Control: The intense pleasure and physiological drive associated with impending orgasm can make it exceedingly difficult for a man to maintain the necessary self-control and focus required for timely withdrawal. The natural instinct is to continue, not to interrupt.
• Sperm Viability: Sperm are remarkably resilient. Even a small amount of semen deposited near the vaginal opening can potentially lead to conception, as sperm can survive for a period and actively swim into the vagina.
• Psychological Pressure: The constant pressure on the male partner to perform this delicate maneuver can create anxiety and impact sexual pleasure for both partners, potentially leading to a breakdown in communication or a rushed withdrawal that isn't fully effective.

Given these inherent challenges, the "perfect execution" of the withdrawal method is an ideal that is rarely achieved consistently in real-world scenarios, contributing significantly to its low effectiveness rates.

Costs in India

One of the primary appeals of the withdrawal method is its perceived lack of cost. Indeed, the method itself has no direct monetary cost as it requires no equipment, medication, prescription, or medical procedure. This "free" aspect often makes it a default choice for couples, particularly in India, where economic factors can significantly influence family planning decisions.

However, focusing solely on the direct cost overlooks the substantial financial and non-financial burdens that can arise from its high failure rate and lack of STI protection. The potential indirect costs associated with the failure of the withdrawal method can be significant in India.

Here's a breakdown of potential costs if the withdrawal method fails:

1. Emergency Contraception (EC):

   • Cost: If withdrawal fails (e.g., late withdrawal, suspected pre-ejaculate release, or ejaculation near the vulva), emergency contraception, commonly known as the "morning-after pill," can be used to reduce the risk of pregnancy. In India, EC pills are widely available over-the-counter at pharmacies without a prescription.
   • Price Range: A single dose of emergency contraceptive pill (e.g., containing levonorgestrel) typically costs between ₹70 to ₹150 per pill in India. While relatively inexpensive, this is a recurring cost if the method fails repeatedly or if multiple instances of unprotected intercourse occur.
   • Availability: EC is generally accessible in urban and semi-urban areas, but availability might be a challenge in very remote rural areas.

2. Medical Termination of Pregnancy (MTP / Abortion):

   • Cost: In the unfortunate event of an unintended pregnancy resulting from the failure of the withdrawal method, a couple might consider a medical termination of pregnancy (abortion). The cost of an MTP in India varies significantly based on several factors:
     • Stage of Pregnancy: Early-stage pregnancies (up to 9 weeks) can often be managed with medication (Medical Abortion), which is generally less expensive. Later-stage pregnancies (up to 20 weeks, and in specific cases up to 24 weeks) require surgical procedures, which are more complex and costly.
     • Type of Procedure: Medical abortion (pills) vs. surgical abortion (e.g., D&C, MVA).
     • Healthcare Facility: Government hospitals offer MTP services at very low or no cost, but availability, privacy, and wait times can be concerns. Private clinics and hospitals charge significantly more.
     • Location: Costs can vary between metropolitan cities and smaller towns.
   • Price Range:
     • Medical Abortion (pills): Approximately ₹1,500 to ₹4,000 for the medication and consultation in private clinics.
     • Surgical Abortion: Can range from ₹4,500 to ₹8,000 for early-stage surgical procedures, and potentially ₹10,000 to ₹25,000 or more for later-stage procedures in private facilities.
   • Insurance Coverage: Generally, health insurance policies in India do not cover voluntary abortions. Coverage might be considered only in specific medical emergencies where the mother's life is at risk or in cases of severe fetal abnormalities.
   • Non-Monetary Costs: Beyond the direct financial cost, an MTP can have significant emotional, psychological, and social costs, which are often far more impactful than the monetary expense.

3. Sexually Transmitted Infection (STI) Treatment:

   • Cost: Since the withdrawal method offers no protection against STIs, contracting an STI due to its use can lead to substantial medical expenses.
   • Diagnosis Costs: This includes consultation fees with a doctor (GP, gynecologist, urologist, dermatologist) and laboratory tests (blood tests, urine tests, swabs) to identify the specific STI. These can range from ₹500 to ₹3,000+ per set of tests, depending on the number and type of tests required.
   • Medication Costs: Treatment for STIs varies widely.
     • For bacterial STIs like Chlamydia or Gonorrhea, antibiotics can cost from ₹200 to ₹1,500 for a course.
     • For viral STIs like Herpes or HIV, treatment involves antiviral medications that might be required for long periods, potentially costing thousands of rupees per month for ongoing management.
     • Treatment for complications arising from untreated STIs (e.g., Pelvic Inflammatory Disease for women, infertility) can incur much higher costs, including hospitalizations and surgical procedures.
   • Long-Term Care: Some STIs, like HIV or chronic Hepatitis B, require lifelong management, leading to continuous and substantial medical expenses.
   • Non-Monetary Costs: Living with an STI can also lead to significant emotional distress, social stigma, and impact future relationships and reproductive health.

4. Costs of Raising an Unplanned Child:

   • This is the most significant long-term financial consequence of a failed contraceptive method. Raising a child in India, from birth through adulthood, involves substantial and continuous expenses including food, clothing, education, healthcare, and extracurricular activities. This cost can run into lakhs of rupees (hundreds of thousands) over two decades, representing a massive financial commitment that many couples using withdrawal may not be prepared for.

In conclusion, while the withdrawal method itself appears "free," the potential costs of its failure far outweigh the cost of more effective and reliable contraceptive methods. Medical professionals in India strongly advise considering safer and more effective options such as condoms (which also protect against STIs), birth control pills, IUDs, or implants, as these methods offer significantly higher protection against unintended pregnancy and, in the case of condoms, against STIs, thereby saving couples from potentially substantial financial, emotional, and health-related burdens.

FAQ (Frequently Asked Questions)

1. How effective is the withdrawal method in preventing pregnancy? The withdrawal method is one of the least effective forms of contraception. With typical use, about 20-22 out of 100 couples will experience an unintended pregnancy within a year. Even with perfect use, the failure rate is still around 4%.

2. Does the withdrawal method protect against STIs? No, the withdrawal method offers absolutely no protection against sexually transmitted infections (STIs), including HIV, Chlamydia, Gonorrhea, Herpes, and Syphilis. STIs can be transmitted through pre-ejaculate fluid and skin-to-skin contact, which occur before withdrawal.

3. What are the main reasons why the withdrawal method fails? The primary reasons for failure include the presence of sperm in pre-ejaculate fluid ("precum") that is released before ejaculation, and the difficulty for the man to withdraw his penis completely and on time before ejaculation occurs.

4. Is there any way to make the withdrawal method more effective? While no method can make coitus interruptus as effective as other modern contraceptives, some precautions like the man urinating before sex to clear residual sperm, and avoiding intercourse during the female partner's fertile window (if tracking ovulation), are sometimes suggested. However, these only marginally reduce the already high risk. Having emergency contraception on hand is a better preparation for failure.

5. What should I do if the withdrawal method fails (e.g., late withdrawal or suspected semen near the vagina)? If you suspect the withdrawal method has failed, consider using emergency contraception (morning-after pill) as soon as possible, ideally within 72 hours (some types up to 120 hours) of unprotected sex. Consult a healthcare professional for guidance.

6. What are the costs associated with the withdrawal method in India? The withdrawal method itself has no direct monetary cost. However, its failure can lead to significant indirect costs, including the price of emergency contraception (₹70-₹150), medical termination of pregnancy (abortion, ₹1,500-₹25,000+), and STI diagnosis and treatment (ranging from hundreds to thousands of rupees, potentially long-term).

7. Can women track their ovulation to improve the withdrawal method's effectiveness? Yes, women can track their ovulation to identify their fertile window. Couples may then choose to abstain or use a more reliable method (like condoms) during this high-risk period. However, this requires diligent tracking and still doesn't eliminate the risk during non-fertile periods if withdrawal fails.

8. Are there better contraceptive alternatives available in India? Absolutely. Medical professionals in India strongly recommend more effective and reliable contraceptive options such as male condoms (which also offer STI protection), birth control pills, contraceptive injections, intrauterine devices (IUDs), or implants. These methods offer significantly higher protection against unintended pregnancy.