What's the Typical Use Effectiveness Rate of Abstinence?
Heather Corinna replies:What's the typical use effectiveness rate for abstinence? All I can find anywhere, even at organizations that teach abstinence, or say it's the only effective method of contraception, is the perfect use rate. How well does it really work for people in real life? Why doesn't anyone have that information on this method when we do for every other method?
That question probably either sounds like a really important one or a really stupid one, depending on your view. But I want the answer regardless, and am seriously tired of waiting for it. That's why I went ahead and asked it myself.
As an organization that provides information on all methods of contraception and other aspects of sexual decision-making, we include talking about abstinence (or celibacy, or not having certain kinds of sex, terminology we prefer because they're more clear) as a method. We are supportive of our users who choose to be celibate, in whole or in part, as their method of birth control, just as we're supportive of our users choosing any other method of contraception. We know full well that there is no one best method of contraception for all people and would never suggest that there is.
For every other method, we provide perfect and typical use rates of effectiveness. Those are two pieces of information, combined with additional info on each method, we provide for those making choices about contraception; two pieces of information that play a big part in most people's decision-making process when choosing a method or methods.
That given, it really sucks that I can never provide a typical use rate for celibacy.
...or can't I?
The people promoting abstinence clearly haven't wanted to study effectiveness and failure of abstinence as a method of contraception so we can all know what the typical use rates are. They want to frame it as contraception, which is already problematic, because contraception is defined as things we actively do or use to prevent pregnancy, not as things we don't do or avoid using: contraceptive reference books won't show rates for abstinence because people not having sex don't need contraception. But if you're going to put it out there as a method of birth control, you have to also treat it like one when it comes to the kind of study we have for all other methods. Alas.
For all the promotion of abstinence, we still don't have studied, published typical use rates for abstinence as a method: the rate that shows us, for every method of contraception, how frequently a method does and doesn't result in pregnancy when used by people in daily life.
But that doesn't mean we can't get a good idea of what that rate is ourselves. This rate won't be as sound as we could get with a specific study, but I think we can use plenty of data we have on abstinence, as well as on other methods and use of no method, to get a good idea of what typical use probably is.
Before I get started, let me explain what a typical use rate for any method is. This is confusing, even though it's referenced all the time for methods. What "typical use" means is that a group of people, in a study, are asked what method they used in the last year. They reply that they used X method. Then they are asked about if a pregnancy or pregnancies occurred in the last year with that method. A rate is then figured from that data.
We call this typical use because this isn't study done in a lab or in a way where we can have any idea of how well a given person was using that method: this is what people are reporting with uncontrolled use. Additionally, as you probably know, when someone says they use a given method, they don't necessarily mean all the time or properly. Some people may say they use condoms, and yet only used them once or twice in the last year, only put them on halfway through intercourse or didn't use them at all. Non-use, weird as it may seem, is factored into typical use for every contraceptive method's rates. And yes, ease of use or comfort with using is obviously part of that equation: in other words, if a method is really tough to use or access, that's going to be reflected in the typical use rate: it's harder to use some methods perfectly than it is with others. For instance, the Depo-Provera injection has a near-identical perfect and typical use rate, because it's pretty goof-proof. But the pill's two rates have just over a 7% difference between them; condoms' typical and use rates differ by around 11%: these methods are easily to mess up. We always have to consider how hard or easy a method is to use when looking at typical use rates, and the rate alone often tells us something about that.
Perfect use of abstinence, as a method of birth control, is, at most, not having any kind of sex at all in the year one is using this as a method, or, at least, not having ANY of the kinds of sex which can pose a risk of pregnancy. That's genital intercourse and/or direct genital-to-genital contact between two (or more) people where one has a uterus and fallopian tubes and the other has testes.
Perfect use isn't only having anal sex, nor is it mostly not having vaginal intercourse, but having it every once in a while. There is no technical virginity at play when we're talking about abstinence per the prevention of pregnancy. Typical use of abstinence, per the definition of abstinence, can only mean that you're not abstaining completely in that same year. While with most other methods, what's typical use and what's perfect can be a bit blurry sometimes: with abstinence from the standpoint of abstinence-as-contraception, it's crystal clear. Using abstinence perfectly isn't about what may or may not be part of your values around sex, it's about biology, not psychology. As well, we're not going to consider that condom use sometimes, but abstinence other times, should be factored into typical use rates, because adding a second method isn't factored into typical use rates for any other methods.
Okay, then. Here's sound and relevant data we can look at to help provide the answer to this burning question of typical use:
1) The typical (and perfect) use rate for using no method at all when having intercourse and/or other direct genital-to-genital contact between opposite-sexed and fertile people is 10 - 20%. (AHRP, FWHC, Contraceptive Technology)
2) The typical use rate for using natural family planning without another method as a backup, which includes abstaining from direct genital-to-genital contact and intercourse during fertile times as well as tracking fertility in at least one of several ways, is 75 - 80% (Merck, AHRP, FWHC, Contraceptive Technology).
3) We know that most people, on the whole, have sex. And that the vast majority do and have always done so before or without marriage, and the majority, regardless of orientation, will have sex that poses a risk of pregnancy. The average age of first marriage right now in the states is 26-27. By ages 22-24, 92% of women have had vaginal intercourse (Mosher, Chandra, & Jones, 2005).
Abstaining from intercourse or other genital-to-genital contact before marriage is something very few people have ever done. "Trends in Premarital Sex in the United States, 1954–2003," (Lawrence B. Finer, January/February 2007, Public Health Reports) found that even among women born in the 1940s, nearly nine in 10 had sex before marriage. Using data from several rounds of the federal National Survey of Family Growth, Finer found that by age 44, 99% of respondents had had sex (intercourse), and 95% had done so before marriage.
It's stating the obvious, but we also know that pregnancy being unwanted or untenable isn't something that only happens to nonmarried or unmarried people. In the United States, over 30% of unintended pregnancies occur to married women (Unintended Pregnancy in the United States, Stanley K. Henshaw, Family Planning Perspectives, Volume 30, Number 1, January/February 1998). So, if abstinence is framed only as a method to use until marriage, and once married, those who chose to use abstinence both no longer abstain from sex and do not choose to use other methods of birth control, we can apply the typical use rate for using no method to married people who are not abstaining, but are also not using any other method.
4) For the first time in ten years, after consistent decreases since the 70's, unintended pregnancy rates for teens are up. Abstinence-only got it's start in the states in 1996, but only began to become as widespread as it did...umm, around 10 years ago. That may be coincidental, but probably not, especially since abstinence-only education programs not only state abstinence until marriage is the only acceptable choice, they often state that other methods of contraception are ineffective (which is a pretty wacky thing to do when your method has no published typical use rate), and other countries without these programs aren't seeing this kind of increase. Experts on teen pregnancy, contraception and sexuality near-unilaterally agree that abstinence-only education likely has played a key role in this change.
5) Studies which have been done about those who pledge abstinence have found that those who pledge abstinence do not have intercourse at lower rates than those who do not pledge, nor do they have lower rates of pregnancy and STIs. Based on interviews with more than 20,000 young people who took virginity pledges, one study found that 88 percent of them broke their pledge and had sex before marriage (Brückner H, Bearman P. After the promise: the STD consequences of adolescent virginity pledges. Journal of Adolescent Health 2005; Bearman PS, Brückner H. Promising the future: virginity pledges and first intercourse. American Journal of Sociology 2001). Bearman did also find that in his study, those who pledged often delayed vaginal intercourse, some for even as long as as 18 months. Now, for those who do NOT have any kind of sex which poses a pregnancy risk (important, as "sex" in this case doesn't include anal intercourse) for one full year, abstinence would be 100% effective. However, that's not typical according to studies as a whole.
A study by Janet Elise Rosenbaum, PhD, AM (Patient Teenagers? A Comparison of the Sexual Behavior of Virginity Pledgers and Matched Nonpledgers, PEDIATRICS Vol. 123 No. 1 January 2009) found that teens who pledge to abstain from sex have just as much sex as those who don't, and that those who pledge not to have sex until marriage don't wait longer to have sex than those who don't make that pledge. Pledgers did not differ in lifetime sexual partners and age of ﬁrst sex. Fewer pledgers than matched nonpledgers also used birth control and condoms in the past year and birth control at last sex. She also found that five years after the pledge, 82% of pledgers denied having ever pledged at all. Central to the information we're looking for, on typical use in a year, "pledgers reported an average of 1.09 past-year vaginal sex partners, 0.11 fewer than nonpledgers." In other words, on average, those who report using abstinence are not using abstinence perfectly each year.
Rosembaum's study was fantastically done, by the way, with a far sounder and stricter methodology than the Bearman and Brückner studies. She even ensured, via 128 different factors, that her samples of those who pledged and those who didn't had similar attitudes towards sexual activity to begin with.
Lastly, of the ten studies identified by the Heritage Foundation as providing proof that their respective programs reduced early sexual activity, nine of them failed to provide credible evidence that they delayed the initiation of sex or reduced the frequency of sex ("Do Abstinence-Only Programs Delay the Initiation of Sex Among Young People and Reduce Teen Pregnancy?," Douglas Kirby, Ph.D, The National Campaign to Prevent Teen Pregnancy).
Here are a few of the studies on abstinence (mostly on ab-only sex ed programs) and reports on them:
- Patient Teenagers? A Comparison of the Sexual Behavior of Virginity Pledgers and Matched Nonpledgers
- Understanding 'Abstinence': Implications for Individuals, Programs and Policies
- Five Years of Abstinence-Only-Until-Marriage Education: Assessing the Impact
- Many Teens Don't Keep Virginity Pledges
- Taking The Pledge
- What the Research Shows: Government-Funded Abstinence-Only Programs Don’t Make the Grade
- How Effective is Abstinence Education?
If you want to look at what's published by those who strongly support not just abstinence, but abstinence being put forth as the only right method of birth control, I'll give you a few links. I would, however, encourage you to consider that the studies above do this funny thing where they create and explain a methodology, something you'll note tends to be conspicuously absent from the links below. You also may notice that some of them report things from other studies linked above which are dubious, incomplete or suggest the studies were incorrect without putting forth any sort of sound critique, or offering up their own controlled study.
- Virginity Pledges Are Highly Effective, Study Says
- The Effectiveness of Abstinence Education Programs in Reducing Sexual Activity Among Youth
- Abstinence-only programs effective in protecting teens from consequences of unwed sex
- Study Claims Abstinence Classes Don't Work
I want to make a distinction between abstinence-only education and programs and abstinence used as a method of birth control. Because of the billions of dollars which have gone into ab-only education (more money than has ever gone into developing or honing any birth control method), and the breadth of what ab-only programs can impact, including STI rates and GLBT invisibility and discrimination, much of the study and reporting we have on abstinence is about abstinence-only education or pledge programs. By all means, some people choosing abstinence as a method are doing so via abstinence-only or abstinence-pledge programs. Some people are choosing abstinence based in moral or religious beliefs. But not everyone choosing to be celibate or abstain from sex that poses the risk of pregnancy is a member of any or all of those groups. There are also people who choose to be abstinent for other reasons and with different motivations, and they may well present very different outcomes.
But let's get back to the main question at hand. Considering all that data, what is the typical use rate for abstinence at preventing pregnancy?
At first glance, the rates for natural family planning/periodic abstinence may look plausible as the typical use rate for abstinence. However, FAM/NFP is a method all by itself of which abstinence is only one part. Someone who was using abstinence as a sole method isn't using NFP/FAM: if they're not doing any kind of fertility awareness, they're only using abstinence. If they are doing any kind of fertility awareness, they're using NFP/FAM, not abstinence. Using NFP and FAM, includes, and is centered around calculating fertility in some way: either by the calendar method, or more efficiently, with daily tracking of cervical mucus and/or basal temperatures, then fertility predictions based on charting one or both over time. That's not part of how abstinence is defined.
However, in that method there is a shared motivation to those using abstinence, which is the motivation to abstain from sex, even though it's not a constant. I don't think that typical use rate is irrelevant, because motivation isn't irrelevant in typical use, and NFP rates do give us some information on abstinence: but it's also only part of the picture.
Given the study we have on abstinence shows us the amount of sex and lifetime partners had appears to be no less than those who don't report using abstinence as a method, we can presume that when it comes to figuring out the typical use rates, we're not considering a group of people whose sex lives -- when it comes to having sex, and to frequency of sex -- are that different than we'd find when considering any other group. In other words, if someone who is using abstinence doesn't use it perfectly, but typically, meaning they did not abstain from sex or the kinds of sex which have the potential to create a pregnancy, and we are ONLY considering abstinence as a sole method, not other methods they may use (which would then be about rates for combining methods), then they may be the same, practically speaking, as those who do not use any method at all.
It may be sound and accurate to state that the typical use rate for abstinence as a sole method is probably the same as the typical use rate for no method: 10-20%. However, I'm not willing to dismiss that intention of use, and motivation to use, is a factor in the use of any method, including abstinence. I also can't dismiss that rates for NFP, while they involve a built-in backup method abstinence alone does not, do also take some abstinence into account. Using abstinence sometimes in a year, but not all the time or for the whole of a year, is consistent with the studies we have on abstinence, and what I hear from young people who have been using it as a method or taken a pledge.
My theory is that the typical use rate for abstinence is the average of the typical use rate for using no method at all, and the typical use rate for periodic abstinence, which lands us at a rate of 42.5 - 50%. I may be overly generous in that estimate, but I don't think so. If you think I am, and want to play it as safe as possible, then you'll want to consider it to be the 10-20% figure, instead. (I'd also be really interested in reading your own comments on this, and seeing your own theories.)
Even with that potentially generous estimate of 42.5 - 50%, abstinence has the lowest effectiveness rate in typical use of all methods. That's important information for people considering any method to have, especially if this method is touted as being foolproof by someone who says condoms, with around an 85% typical use rate, are said to never or only infrequently be effective.
For the record, I know that some people have a beef with abstinence being assigned a 100% perfect use rating, arguing that even in perfect use, all other methods fail. I don't share that beef. The complaints about that claim are usually a) that we have no studies to show that (I disagree: we have plenty of study to show how pregnancy happens, so can know clearly that with no sex, it won't), b) that plenty of people don't understand what perfect use of abstinence even means (yes, but plenty of people don't know that for all methods), and c) that we know full well abstinence fails (true, but in typical use, since perfect use means not having sex, so unless you're counting Mary and Jesus, who we're told abstinence failed in perfect use, it's 100% in perfect use). The reason all other methods fail even with perfect use is that those perfect use rates still include people who are having genital intercourse: perfect use for those methods does not require or account for a lack of any intercourse whatsoever.
When I'm doing a contraception consult with someone, be that online or in-person, a tactic I often suggest when choosing a method is for people to figure that as someone who is getting good education on using a method with me, but also has a harried life like anyone else where we'll goof things sometimes, they'll probably wind up with an effectiveness rate somewhere between perfect and typical use. So, for example, if we were taking about the pill, used alone, I'd ask them to think about if 96% effectiveness (the average between perfect and typical use), was a rate they felt comfortable with. If it wasn't, then I'd bring up both other methods which are more effective as well as how combining more than one method can increase effectiveness. For example, even with just typical use for both, adding condoms to the pill would net them 98.8% protection.
So, I'd pose the same proposition to anyone considering abstinence as their sole method. If perfect use is 100%, and typical use is, in fact, 45-50%, then we're talking about an average between them of 72.5-75% effectiveness at preventing pregnancy. Are you okay with those levels of protection/risk? If so, okay: I'm not going to say that's not okay for someone who tells me that's a level of protection they're okay with, just like I wouldn't for any other method. (But if, for instance, I see someone at one of the clinics or other sites I do consultations for, or on the site, who is saying they're okay with it, but either keeps having pregnancies they don't want, or keeps freaking out worrying about pregnancy all the time, I am going to suggest they rethink, since it seems clear they're really not okay with it, after all.)
If you're not okay with that level of protection against unwanted pregnancy, and want a higher one, then just like with the consideration of any other method you have two choices: you can either choose a more effective method, or you can combine abstinence with a second method. In practice, what the latter would mean is that if there are times you choose not to abstain, and you want to prevent unwanted pregnancy at those times, that you use a second method of contraception, like a condom, a pill, a ring, an injection, withdrawal or natural family planning.
I also want to share an observation about celibacy as a method that I've made over the decade-and-change I've been doing my job. What I've observed is that celibacy seems to be more effective at preventing pregnancy for those who choose it without making pledges to g-d some other authority figure, or making a big to-do about it and without feeling that it is their only right, moral, or religiously-sanctioned contraceptive choice to make. If a study was done which compared those making abstinence pledges until marriage versus those people choosing celibacy for now, without those kinds of conditions, I think we'd find the latter group had lower rates of pregnancy and more positive sexual outcomes. I don't think we'd see, as we did in the Rosenbaum study, the latter group outright denying they had chosen to be celibate, either. The people I've spoken with in work and in life who just choose not to have sex, or certain kinds of sex, as a way to prevent pregnancy (or just because they don't want to have those kinds of sex), and do so feeling they'd be supported if they chose a different method, seem to be pretty relaxed about it, and not at all ashamed or defensive around that choice. They also don't seem to make that choice out of fear.
In other words, I think if the folks pushing abstinence so freaking hard would stop pushing and shoving the way they do, and would treat it like any other method, giving every method the respect and plausibility they give it, doing studies on it like the kind done with other method, including providing some studied typical use rate, not only would the typical use rate of abstinence likely be higher in time than I theorize it is now, the rate of unwanted pregnancy -- something they say they really want -- would also start declining again, the way it was before the advent of abstinence programs. There are other potential bonuses with that change of approach: for instance, treating abstinence differently would support more folks who want to decline sex for any number of reasons in doing so better, would likely help get our STI rates down, would result in less shame and fear (which never helps with sound decision-making, sexual or otherwise), would address people who can't get married at all or just don't want to, and a whole plethora of positive outcomes. If what many abstinence-proponents tend to say they want -- lower STI and unwanted pregnancy rates and happier, healthier people -- isn't a pile of hooey to mask a religious or political agenda, they'll hop right on board with that.
But I expect to be waiting as long for that to happen as I expect to continue waiting for them to give me a typical use rate.
P.S. Should you read this and strongly disagree with my theory, thinking abstinence as a method is far more effective in typical use, I encourage you to lobby abstinence organizations to do some actual study on typical use of abstinence as a method. I would far rather have sound data from study on typical use to post here, too. The only reason I'm doing this the way that I am if that I've got no other options, and I don't find "?" an acceptable permanent answer for an effectiveness rate for any method of contraception. Especially one that's gotten billions of our tax dollars, so goodness knows they can certainly afford to do the studies.
Thanks to Dr. Logan Levkoff for letting me toss these ideas at her and for her helpful input!