Abstinence, Birth Control, And The Difference Between Theory And Practice

This piece was originally published on the Blowfish Blog.

So how effective -- really -- is abstinence as a birth control method?

Bristol Palin, Sarah Palin's famously "unmarried and pregnant at 17 and an unmarried mother at 18" daughter, went on a tour of the TV talk shows earlier this year, advocating -- in an irony so massive I feel puny standing next to it -- abstinence for teenagers.

And one of the arguments she made -- with her baby on her lap -- was that abstinence is the only 100% effective way to prevent pregnancy.

Now, if Bristol Palin, or anyone else, had gone on the TV talk show circuit arguing that, say, birth control pills were the only 100% effective way to prevent pregnancy -- and they’d done so with their unplanned baby on their lap -- they'd have been laughed off the stage. But people tend to see abstinence as different. People -- and not just right-wing ideologues -- tend to see a failure of abstinence as a failure of the people practicing it... not as a failure of the method.

So today, I want to talk about how we do -- and do not -- measure the effectiveness of any given method of birth control.

Many years ago, I worked as a counselor and educator at a birth control and abortion clinic. And I learned a standard way of measuring the effectiveness of any birth control method that's absolutely crucial to this discussion. It's this:

When you're evaluating how effective a birth control method is, you have to look at the difference between how effective it is in theory... and how effective it is in practice. You have to look at the difference between how often women using this method would get pregnant if they used it perfectly every time... and how often women who use this method actually do get pregnant.

And the reason you have to do that is the reality of human imperfection.

Example. A diaphragm is about 95% effective if it's used perfectly every time. But humans aren't perfect. We can, in our haste to start fucking, put the diaphragm in wrong, or not put in enough spermicidal goop, or something. And we can also, in our haste to start fucking, decide, "To hell with it, just this once let's not bother." A diaphragm that gets left in the nightstand drawer while its owner boffs is a diaphragm with a very good chance of, shall I say, bringing down the effectiveness rate of diaphragms. Therefore, while they're 95% effective in theory, diaphragms are only about 85% effective in practice.

Ditto with every other birth control method. People can forget to take birth control pills; put condoms on wrong; miss their appointment to get their Depo-Provera shot. Even supposedly foolproof birth control methods have some degree of disconnect between theory and practice. (How many women with IUDs actually check the string every month like they're supposed to? I know I don't.)

In fact, when you're deciding which birth control method is best, this gap between theory and practice is one of the most important things to pay attention to -- whether you're a birth control educator or just a person using birth control. For people who are highly self-motivated and organized, methods like diaphragms can work very well, and the gap between theory and practice won't be all that wide; for people who are more impetuous or whose lives and schedules are more unpredictable, methods like the pill and the IUD, which are less likely to be used incorrectly or not at all, are generally a better choice.

Fine. So what does all this have to do with abstinence?

I bet you can see where I'm going with this.

In theory, Bristol Palin is absolutely right. In theory, abstaining from penis- in- vagina intercourse is the only 100% effective method of preventing pregnancy.

But in practice?

It's difficult to find hard numbers on this. While other birth control methods have had their practical failure rates studied extensively, abstinence hasn't received the same attention, and most of the sources I found just said "We know it fails a lot, but we don't know exactly how often." But the one source that I found with hard numbers puts the "in practice" failure rate of abstinence among teens at between 26 and 86%.

That's huge. Even the lowest number on that scale is huge. That's one of the highest failure rates of any birth control method we know of. That ranks just above "crossing your fingers."

Of all the birth control methods available, abstinence is probably the one that's most likely to be left in the nightstand drawer. Sex is, among other things, a fundamental and powerful physical drive, deeply ingrained in us by millions of years of evolution. If your birth control method depends on your ability to just say no to sex until you're ready to have kids... it's a bit like having a birth control method that depends on your ability to refuse to eat. For a week. In a bakery.

So where does this idea come from that abstinence is 100% effective, even though it fails more than just about any other method of birth control?

It comes -- I think -- from the fact that people tend to see a failure of abstinence, not as a failure of the method, but as a failure of the people practicing it.

If you put the condom on wrong or forget to take your birth control pill, people tend to see that as a human mistake that could happen to anyone. But if you go ahead and have sex when you swore to yourself that you wouldn't, people are more likely to see that as a personal failure, a failure of will power and self control.

Now, from a purely philosophical perspective, I suppose you could make that argument. I certainly wouldn't -- I consider it grossly sex-negative to think that abstaining from sex until you want kids is a reasonable thing to expect people to do. But in an abstract, "angels fucking on the head of a pin" sense, I'd be happy to debate the question of whether the failure of a birth control method that relies entirely on the free will of the people practicing it should be seen as a failure of the people or the method.

But from a practical viewpoint?

It makes no sense at all. From a practical viewpoint, if what you care about is preventing unwanted pregnancy -- especially unwanted teenage pregnancy -- then we need to treat abstinence like a condom that rips 26-86% of the time; like birth control pills where, out of every four packets, one to three packets is filled with placebos. We need to treat abstinence like what it is: a birth control method that results in pregnancy in 26-86% of the teenagers who practice it.

And when it comes to making sure that teenagers don't get pregnant?

I, for one, don't give a damn about philosophy.

I want them to not get pregnant.

(P.S. Apparently, the Obama administration agrees. The new budget eliminates funding for the conspicuously failed abstinence- only sex education programs, and re-directs it towards evidence- based programs to prevent teen pregancy. Yay!)

Comments

[the chaplain]

Great post.

Abstinence-As-Birth-Control is one of the areas in which the gap between theory and reality has long-lasting consequences for a lot of people. It's important to give people the information they need to make the right decisions regarding their sexuality. The costs of failing to do so are horrendous for society, as well as for couples and their families.

[MD]

If someone using abstinence as a birth control method gets pregnant from rape is that a failure of the method or the application? I was happily abstinent by choice until age 29, but had an extreme irrational fear of pregnancy from the risk of rape and was on hormonal birth control for some of the time (even though I hated the side effects) just because of this fear.

It wasn't until my tubal ligation that I more fully relaxed although that method is also not 100%, and my irrational but life-impacting fear of pregnancy prompted my surgeon to take internal photos of the ligation to help assure me.

[jemand]

MD, I'm certain rape caused pregnancies are a failure of the abstinence METHOD itself.

To be more specific it's a failure of someone to meet minimal decent-human standards... as is the case in one third of abortions for which the woman's partner sabotaged her birth control...

So there's:

Failure of method
Failure of application of method
and
Failure to be a minimally decent human being

[Rose]

I'm very happy about the Obama administration redirecting funds! And this is an excellent post, agree all the way.

[Chakolate]

A useful analogy for this is found in diabetic treatment. If a diabetic is diagnosed reasonably early, then all he/she has to do to remain healthy is to exercise strict control over what he/she eats.

Since this method is the most effective, we should just stop giving people advice on other ways to help keep their sugar under control - those other ways are just not needed.

So we should use food-control-only education for diabetics, and not tell them that exercise will help, not give them any of the (very effective) drugs available, and if they get even sicker, don't tell them about injecting insulin. It's just not necessary, since the most effective treatment is... well, abstinence.

[Sebastian Conolly]

But the one source that I found with hard numbers puts the "in practice" failure rate of abstinence among teens at between 26 and 86%.

That's huge. Even the lowest number on that scale is huge. That's one of the highest failure rates of any birth control method we know of. That ranks just above "crossing your fingers."

It's not clear to me whether that's the number of people having sex anyway, or the actual failure rate of the contraception. If the latter, then the higher figure seems implausible, since "trying to get pregnant" only has a failure (or, success given the different intent) rate of 85%. I suppose it's possible that people who are trying to abstain actually have more sex on average than people who are trying to get pregant, but really not very likely.

[Eclectic]

An excellent argument that nicely undercuts the "moral failing" argument.

Sebastaian: generally, what are quoted are relative failure rates, basically scaled so "no birth control" is 100%. (You can, by actively trying to get pregnant, do better than 100% by watching for signs of ovulation. If course, when discussing that, I'd prefer to talk about the "relative pregnancy rate".)

This reminds me: I remember a kinky friend in SF telling me about her neighbourhood pharmacy, where the owner deliberately places the condoms in a hard-to-see corner of the store so the kids who are too embarrassed to buy condoms can steal them.

To this day, I have never heard a better definition of "quiet heroism."

[naath]

Quoted rates> all the bc failure rates I have seen were quoted as "pregnancies per 100 women using this method"; relative failure might be used, but not in public health information leaflets in the UK.

Abstinence is very effective for people not interested in having sex; much less useful for people who are very interested in having sex. I think it's stupid to try to force all people into one model of sexuality and sexed class clearly should cater to all the people in it (I don't think it should teach "abstinence" since said teaching appears to be largely "sex is bad mmmkay" but I do think it should teach "it's OK to say no" and "PiV is not the only sort of sex people have").

[JL]

...but I do think it should teach "it's OK to say no" and "PiV is not the only sort of sex people have"

Are there actually a non-negligible number of people who support some form of sex ed other than abstinence-only, who are opposed to either of these points?

I wasn't under the impression that comprehensive sex ed programs discourage those who wish to abstain.

[Dale]

Ever wonder if theistic groups who promote abstinence-only education already know all this stuff and are out to create more babies to indoctrinate, no matter the cost? And they accuse us of running a conspiracy!

I kid, I kid.

Great piece as usual. I agree wholeheartedly; abstinence is a method that only works on paper.

[Ramel]

Dale that is the big question, do they no know that it doesn't work, or do they just not care?

[CybrgnX]

Abstinence fails on even more fronts then Greta presented.
If the insert or tube or pill is not perfect it will still give some pretection. If the abstinence is not perfect it plain fails.
In the rape example it you are on birth control then rape will not cause pregnancy but abstinence fails again.

[ade]

Although Dale's conspiracy theory is a lot more fun, I've always wondered if there aren't a lot of people in the Absinence Only movement conspiring to make money. After all, why does abstinence education cost anything at all? How much can it possibly cost to find someone to tell kids not to have sex? I'm sure there are plenty of Christian volunteers who would do it for free.

[Laura]

I love the way you organize your thoughts because it makes so much f-ing sense! :D

[Claire B]

..but I do think it should teach "it's OK to say no" and "PiV is not the only sort of sex people have"

"Are there actually a non-negligible number of people who support some form of sex ed other than abstinence-only, who are opposed to either of these points?"

It's not so much being opposed to them. It's not drawing any attention to them whatsoever. I know people whose children were being taught abstinence-only sex ed, and the focus was all on how having sex was bad and wrong, with, appallingly, a sidebar on why women who dress "provocatively" and get raped have to "take responsibility" for what happened to them. The focus for the girls was on being pure and modestly-dressed enough to not "tempt" a boy into wanting to sleep with her. There was no mention whatsoever of the fact that, if a boy did want to sleep with them, it was okay to make him stop, with force if needed. Possibly because that might have given the impression that it was okay for a woman not to do as a man tells her or something (the teaching was apparently very traditonal-gender-role focused in many ways).

And there was certainly no-one saying, "hey kids, if you feel horny and don't want to get pregnant, have you considered oral sex?" In fact, I've read an interview with a prominent advocate of abstinence-only sex education who expressed horror at the fact that a teacher had told kids that, if they felt horny, it was okay to masturbate. Even masturbation was a problem, for this woman. Even if you did it when there was no-one else in the room.

That's not about preventing pregnancy. That's about a deep-seated dislike of the very idea of teens having sexual desires and acting on them in any way.

[Dale]

Claire B: "That's not about preventing pregnancy. That's about a deep-seated dislike of the very idea of teens having sexual desires and acting on them in any way."

I agree wholeheartedly, and would push further to say that some Christians would rather that no one ever have sex at all unless it's for the sole purpose of creating babies. They'd rather not think about their own "less presentable parts", nor their childrens', and they'll go to any lengths to push that topic away whenever it springs up (no pun intended).

Moreover, most denominations of Christianity I can think of (Catholicism jumps immediately to mind) are against masturbation--often because of the whole "spilled seed" passage--and thus refuse to teach their youth that it is an acceptable, safe, and perfectly natural outlet for sexual energy.

What are they expecting? That their poor teenage son, whose brain is literally swimming in hormones, will be able to dissolve his frequent arousals with a few heartfelt prayers? That each time their daughter spots a cute boy with a hot body, she'll transfigure his pecs into the bloodied torso of Jesus on the cross in her mind's eye?

Please theist. Get real.

Oh wait, that's right. You believe in an invisible man in the sky who grants wishes. My mistake.

[Annie]

My husband just send me a link to your blog and 5 min later I am a fan already! :-)
Kudos for this post!!!

[Valhar2000]

Claire B: "That's not about preventing pregnancy. That's about a deep-seated dislike of the very idea of teens having sexual desires and acting on them in any way."

Yes, I often come across people who are partial to abstinence only sex education who are horrified when they discover just what a cesspit of lies, repression and indoctrination the whole exercise actually is, in the real world.

In fact, many people assume that abstinence-only sex education consists of doing on of the things you advocate, telling kids that "it's okay to say no", whereas in fact it goes much further than that, deep into fundamentalist lunacy.

[Cynthia]

The birth control pill. Yaz, has been linked to life-threatening side effects such as strokes, blood clots, and heart attacks. Since 2004, at least 50 deaths have been reported in women taking Yaz and contraceptives made with similar ingredients. There is more information on this disturbing problem at http://www.yaz-may-cause-strokes.com/.

[El Suscriptor Justiciero]

With your permission, miss Cynthia, let's give a look to your facts before we start to spread fear-mongering.
At Snopes
10 myths about the pill busted
Side effects of Drospirenone
It looks like there might be a grain of truth about this particular brand, Yasmine/Yaz, so let me ask: is Drospirenone proved or suspected by the medical community of having greater risk of stroke than other birth-control pills?

[condoms]

great post
abstinence? no, thanks
I choose condoms