How DARVO explains the war on the term obstetric violence
The Green Journal article that called obstetric violence a misnomer was itself a perpetrator’s pattern.
If you have ever advocated for a patient and been told you were being difficult, you already know what DARVO feels like even before you could name it.
DARVO is a pattern of response often used by people and institutions when they are held accountable for harm. Deny the harm happened. Attack the person naming it. Reverse Victim and Offender so that the one causing harm becomes the victim of a false accusation. Researcher Jennifer Freyd named and documented this pattern, and the evidence shows that it works. It generates enough confusion to make the person who was harmed start doubting themselves.
Nurses and families see this in birth rooms. It’s also a familiar, toxic scapegoating tactic in interpersonal and intimate relationships. And in 2024, the field of obstetrics published it in a peer-reviewed journal to avoid accountability and misplace blame.
When Chervenak, MD and colleagues argued that the term obstetric violence is a misnomer, citing that it introduces unnecessary hostility, that it vilifies providers, and it should be replaced with something softer, they were evading accountability and enacting a silencing tactic. And it followed the DARVO playbook exactly.
This piece is about what that silence protects, who it harms, and what it looks like in modern obstetrics.
When DARVO Goes Institutional
Cherise Doyley was twelve hours into labor at UF Health Jacksonville in 2024 when a nurse walked into her room holding a tablet. On the screen was a judge live on video. At the urging of her physician, the state of Florida had filed an emergency petition to force her into a cesarean she did not want. She didn’t have a lawyer or an advocate. She was in a labor gown in her labor bed – no time to prepare. She stated clearly that she understood the risk of uterine rupture was less than 2%, and she did not consent. The judge ordered the surgery anyway.
Brianna Bennett’s story is almost identical. She was at a different Florida hospital about a year and a half earlier. Nearly 20 people squeezed into her labor room over 24 hours into her labor process, because a doctor filed an emergency motion with the court. They placed a tablet on Bennett’s bedside table and pulled up a live video of a Florida judge. During her online hearing, the fetal heart rate changed, the judge ordered the surgery, and she was wheeled into the operating room.
Both individuals are Black women, had three prior cesareans, and arrived very prepared to fight for vaginal births, and both lost.
ProRepublica journalist, Amy Yurkanin, recently published a piece about these two Florida women and the harms brought to them by the healthcare systems, so the startling stories are all over news feeds and social media. And just last week I spoke to over 200 perinatal nurses who wanted answers. They shared that they were worried and asked: “Are those isolated instances in the South, or could that happen in our system in Maryland, too? “
During Doyley’s three-hour hearing, both the hospital’s doctors and Doyley herself cited recommendations from the American College of Obstetricians and Gynecologists on the safety of the mother and the fetus. ACOG’s Committee Opinion 664, however, states that court-ordered obstetric interventions are “ethically impermissible” and that obstetricians are “discouraged in the strongest possible terms” from using coercion, duress, or threats to involve the courts to motivate patients toward a clinical decision. ACOG is unambiguous: pregnancy is not an exception to a patient’s right to refuse treatment.
The organization’s own ethics position should have ended the argument. It’s stated plainly for obstetricians to reference in ethically challenging cases such as these, but the OB and legal teams willfully disregarded established professional standards, and two forced surgeries on Black mothers occurred.
These instances are not coincidences, nor are they shocking. As an obstetric violence researcher, speaker, L&D nurse, and survivor of gender-based violence and sexual violence, the through lines are warning signs that we must continue to call out.
The Control Framework Behind the Cases
To understand how courts end up ordering forced surgery on women and determine if it’s a broader warning sign, we have to understand the intellectual framework that makes it possible and the men who built it.
Firstly, Emma Katz’s research on coercive control in family systems shows how controlling behavior operates across relationships simultaneously, targeting the most vulnerable members of a system and removing their access to outside support, independent decision-making, and self-determination. This pattern doesn’t require physical violence. The current structural conditions make resistance and safety often impossible. Katz documents how coercive control works by limiting access to information, restricting options, and framing the controlled person’s choices within a predetermined set of acceptable, behaviors with ever-changing goal posts. The person believes they are choosing freely, but the controller has already eliminated everything outside the permitted range.
That framework maps directly onto what Frank A. Chervenak, MD and ethicist Laurence McCullough, PhD have spent more than three decades building in obstetric ethics.
Chervenak is chair of OB-GYN at Lenox Hill Hospital, associate dean at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and president of the International Society of the Fetus as a Patient. McCullough holds the Dalton Tomlin Chair in Medical Ethics and Health Policy at Baylor College of Medicine. Both are listed as previously on the advisory board of the American Journal of Obstetrics and Gynecology under Ethics.
Together, they have co-authored over 200 peer-reviewed papers and two books, building what they call the “fetus as patient” ethical framework. This framework positions the pregnant person and the fetus as two separate patients with potentially competing interests. When those interests conflict, their “professional responsibility model” gives the physician the ethical authority to decide what options the patient is even allowed to consider.
Their 2015 clinical practice chapter in the Global Library of Women’s Medicine details their disempowering framework. They write that “respect for autonomy” requires the physician to identify “medically reasonable alternatives” and that “there is no ethical obligation to offer a technically possible alternative” that does not meet the physician’s test for medical reasonableness.
The physician curates the menu. The patient chooses from what remains.
They call this autonomy. In fact, it’s the opposite of autonomy. It is the coercive control framework Katz describes, operationalized inside an ethics model and published in peer-reviewed literature.
Where does this moral compass come from to guide their menu list of options? Well, straight from medical traditions as they’ve always been done. That’s what they describe in a circular argument that protects the system from accountability by design. 
Here’s their logic:
Medical traditions are the source of physician morality.
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Physician morality defines what is ethical.
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What is ethical is what physicians have traditionally done.
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Therefore, medical traditions are ethical.
They state this plainly in the same chapter: The Professional Responsibility Model of Obstetric Ethics in Clinical Practice: “The traditions and practices of medicine constitute an obvious source of morality for physicians. These traditions provide an important reference point for professional medical ethics…”
There is no external check on that framework. The moral authority originates inside the profession and is validated by the profession. Which means when patients name obstetric violence, when they say what was done to them was harmful, that claim has no standing inside this framework because it originates outside the tradition. The tradition is the moral truth. The patient’s experience is a challenge to the tradition and goes unacknowledged.
Tema Okun’s analysis of white supremacy culture in institutions is instructive here. The characteristics she identifies: worship of the written word, paternalism, the belief that there is one right way, power hoarding, and the invalidation of knowledge that originates outside the tradition, are structural features of the professional responsibility model itself. The written tradition is the moral source. The physician knows best. There is one right way to manage a pregnancy. Power stays with the credentialed party. Patient experience that falls outside the documented tradition doesn’t count as evidence.
And the harm of de-prioritizing patient experience is not distributed equally. ACOG’s own data shows that coercive tactics and court-ordered interventions are disproportionately applied to Black patients, low-income patients, and patients of color. Cherise Doyley and Brianna Bennett are both Black women. The traditions Chervenak and McCullough cite as the moral north star of obstetric ethics were not built with Black women’s bodies or experiences as the reference point. They were built in spite of them, and they continue to operate against them.
The traditions they are protecting include their 1993 paper justifying forced surgery.
In 1993, they published “An Ethical Justification for Emergency, Coerced Cesarean Delivery Without a Court Order,” arguing directly that a pregnant person’s autonomy is constrained by obligations to the fetus as a patient, and that forced surgery is ethically justified. In 2012, they went on to publish “The Professional Responsibility Model of Respect for Autonomy in Decision Making About Cesarean Delivery” in the American Journal of Bioethics.
Runyon, Rojas Landivar, Pascucci, and I (2023) documented that labor and delivery nurses, the healthcare professionals who spend the most time at the point of care during childbirth, are uniquely positioned as active bystanders who can either prevent or perpetuate obstetric violence. That positioning only exists if obstetric violence has a name. Nurses cannot interrupt what they cannot identify. The framework Chervenak and McCullough built makes identification harder and therefore disruption impossible.
This is not a fringe position from 30 years ago. This framework continues to be cited and defended today. And when Florida hospitals brought Cherise Doyley and Brianna Bennett before judges in active labor, invoking the best interest of the fetus, they were using it.
Legal scholar Krista Stone-Manista identified this pattern as early as 2009, arguing that the “fetus as patient” model creates structural conditions in which physicians treat pregnant people as if there are two conflicting patients in one body, and courts defer to that framing without constitutional basis. Stone-Manista documented a Florida woman named Laura Pemberton who was forcibly returned to the hospital in active labor by county police for a forced cesarean at Tallahassee Memorial Regional Medical Center. A court later ruled that neither the hospital nor the county had violated her constitutional rights (Stone-Manista, Cardozo Journal of Law & Gender, 2010). Fifteen years later, Brianna Bennett found herself at that same Florida hospital system.
The harm hasn’t stopped, and these highly acclaimed, institutionally protected AJOG authors continue to defend the harmful practices of “the good ol’ days” into modern obstetric care.
Exploring DARVO aids in understanding how perpetrators are able to enforce victims’ silence through the mechanism of self-blame.
Harsey, S. J., Zurbriggen, E. L., & Freyd, J. J. (2017)
What is DARVO?
When people and institutions are held accountable for harm, some respond with a specific pattern of deflection. Jennifer Freyd named it DARVO: Deny, Attack, Reverse Victim and Offender.
Research by Harsey, Zurbriggen, and Freyd (2017) shows that DARVO causes increased self-blame in the person who raises the concern. When someone confronts harm and receives a DARVO response, they end up doubting themselves more than before they spoke up. That self-doubt is not a side effect of DARVO. Katz identifies it as a feature of coercive control itself, built into the relationship as a form of mental manipulation. DARVO doesn’t require a conscious plan. It functions as a pattern whether or not the person or institution deploying it recognizes what they’re doing.
Harsey and Freyd (2023) further showed that DARVO changes how observers perceive the situation. Offenders look less responsible, victims look less credible and often feel confused, less likely to protest and self-advocate.
DARVO works because it generates confusion about who the actual wrongdoer is. It shifts the focus from the harm that was done to prioritize the feelings of the person being held accountable.
In 2024, Chervenak and colleagues published “Obstetric Violence is a Misnomer” in the American Journal of Obstetrics and Gynecology.
Their paper is a textbook DARVO response.
Deny
The paper opens by redefining violence itself. The authors cite the WHO definition of violence as “the intentional use of physical force or power” and the US legal definition of crimes of violence, then argue that obstetric harm cannot be called violence because violence requires intent. If a provider did not mean to hurt you, it was not violence. If harm came from “systemic issues, lack of training, or misunderstandings,” the word violence does not apply.
This is the deny move. It does not deny that harm occurs. It denies that harm is serious enough to name accurately and serious harm isn’t possible without intent.
They also cite a LexisNexis search finding only 10 cases of “forced and coerced cesarean deliveries” in the United States over 24 years to suggest coercion is rare. Denying that it’s even common enough for language.
But LexisNexis captures legal cases, not clinical ones. It doesn’t count every patient who consented under duress, every provider who used the fetal heart rate monitor as leverage, or every woman who agreed to surgery because she was told her baby would die if she didn’t.
Attack
The authors describe the term “obstetric violence” as “quite strong and emotionally charged” and warn it “may lead to misunderstandings or misconceptions.” They call using it to advance accountability “political rhetoric” and “controversial scientifically unproven agendas.” They compare it to “psychiatric violence” and “neurosurgical violence” to make it sound absurd.
They warn that naming obstetric violence “vilifies the provider as an intentional perpetrator of interpersonal violence” and introduces “unnecessary hostility” into the patient-provider relationship.
This is the attack move. The language is the problem. They describe that people naming the harm are the problem, not the harm itself.
Reverse
Here is where the paper does its wildest work.
The authors write that “obstetricians frequently advocate and champion causes that empower the autonomy of women” and that it is “inappropriate” to define obstetric violence as a form of structural violence. They position the field of obstetrics as a protector of women, unfairly tarnished by inflammatory language.
The provider becomes the victim. The patient’s experience becomes an attack.
To support this, they cite their own prior paper, the professional responsibility model, as evidence of their commitment to patient autonomy. A joke.
That model is the same framework that allows physicians to pre-screen options, eliminate what they deem unreasonable, and call the resulting constrained choice an exercise of autonomy. They cite their commitment to autonomy using a paper that redefines autonomy as physician-curated compliance.
When Chervenak and colleagues warn in their 2024 paper that the term obstetric violence introduces “unnecessary hostility” into the patient-provider relationship, ask whose comfort that sentence is protecting.
This is coercive control logic operating at an institutional scale. The framework names itself as the antidote to paternalism while functioning as its mechanism. Katz documents exactly this pattern in intimate relationships: the controller presents themselves as caring and protective, uses the language of the victim’s wellbeing to justify control, and frames any resistance as irrational or dangerous.
The 2024 paper does this on behalf of an entire medical specialty, inside its most credible platform.
This is what it sounds like:
“I’m not controlling. I’m being protective because I care about you”
“If you hadn’t pushed back, none of this would have happened.”
“I know what’s best for us. You’re not thinking clearly right now. You’re not yourself.”
“I’m the only one who actually has your best interests at heart.”
“We’re not overriding your autonomy. We’re offering you medically reasonable options.”
“The term obstetric violence vilifies providers who are advocates for women.”
“We only involved the court because we were trying to save two lives.”
The ACOG Contradiction
ACOG Committee Opinion 664 states that court-ordered obstetric interventions are “ethically impermissible.” It states that obstetricians are “discouraged in the strongest possible terms” from using duress, manipulation, coercion, physical force, or threats to motivate patients toward clinical decisions. It states that pregnancy is not an exception to a patient’s right to refuse treatment. ACOG’s 2020 policy statement reinforces this: the College “opposes the use of the courts to mandate medical intervention for unwilling patients” and notes that coercive tactics are disproportionately applied to people of color and low-income patients.
The Florida hospital invoked ACOG’s clinical authority to justify surgery on a patient who refused it, while the same organization’s ethics committee had already declared that action ethically impermissible.
Chervenak and McCullough’s professional responsibility model directly contradicts ACOG’s ethics position. Their framework gives physicians authority to override patient refusal in the interest of the fetus. ACOG says that is never acceptable. Yet both men sat on AJOG’s advisory board listed under Ethics, positioned as voices of ethical authority within the same professional organization whose stated ethics their framework contradicts.
Court-ordered obstetric interventions are “ethically impermissible.”
ACOG Committee Opinion 664
What Obstetrics Loses When the Language Weakens
The coercive control framework, obstetric violence as a term, the naming of structural harm all exist because victim-survivors needed language powerful enough to match what happened to them. Researchers including Maggie Runyon, Paula Rojas Landivar, Cristen Pascucci, and myself documented obstetric violence culture as a distinct phenomenon operating within healthcare institutions, shaped by power hierarchies, normalization of coercive practices, and systemic silencing of patient experience. It exists inside a larger social environment where gender-based violence is normalized and rape culture exists.
When that language is refused in favor of “mistreatment in healthcare,” the harm becomes diffuse and vague. Mistreatment can mean anything. It doesn’t name a pattern or implicate a framework. And that’s the point.
What The Article Could Have Said
The harms Chervenak and colleagues describe in their own paper are true. They acknowledge nonconsensual procedures, verbal abuse, forced sterilizations, discrimination, and neglect. They acknowledge that 1 in 5 women reported mistreatment during maternity care. They acknowledge that Black, Hispanic, and multiracial mothers experience mistreatment at higher rates.
A paper that took that evidence seriously might have said: the term obstetric violence exists because patients needed language powerful enough to match their experience. It might have asked what it means that the field resists that language. It might have centered the millions of victim-survivors instead of the feelings of their providers.
It might have looked at the 1993 paper justifying coerced cesarean delivery and asked: what did we build, and who did it harm?
It might have cited ACOG’s own ethics position and asked why hospitals are taking laboring patients to court in direct violation of it.
That paper was not written, however.
They chose to prioritize their own comfort and DARVO on a public stage to argue that their profession is safe and trustworthy.
Court-Ordered Cesareans Are Not a Surprise
Court-ordered cesareans in Florida did not pop up out of nowhere. They emerged from decades of published ethical frameworks that positioned the fetus above the person carrying it. They emerged from journals that gave space to papers calling accountability “political rhetoric” and institutions who work to protect their own.
Obstetric violence is not a misnomer. It is uncomfortable for those who perpetrate it and liberating for those who survived it. If the term makes you squirm, that discomfort is an opportunity for radical self-reflection, question the ways in which it has shown up in your life and work, and to explore trauma-informed care.
And the people fighting to erase the term are exposing exactly why we need it.
References
- ACOG Committee Opinion No. 664. (2016). Refusal of medically recommended treatment during pregnancy. Obstetrics & Gynecology, 127(6), e175–e182.
- ACOG. (2020). Opposition to criminalization of individuals during pregnancy and the postpartum period. American College of Obstetricians and Gynecologists. https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2020/opposition-criminalization-of-individuals-pregnancy-and-postpartum-period
- Chervenak, F. A., McLeod-Sordjan, R., Pollet, S. L., De Four Jones, M., Gordon, M. R., Combs, A., Bornstein, E., Lewis, D., Katz, A., Warman, A., & Grünebaum, A. (2023). Obstetric violence is a misnomer. American journal of obstetrics and gynecology, 230(3S), S1138–S1145. https://doi.org/10.1016/j.ajog.2023.10.003
- Chervenak, F. A., & McCullough, L. B. (2012). The professional responsibility model of respect for autonomy in decision making about cesarean delivery. American Journal of Bioethics, 12(7), 1-DOI: 10.1080/15265161.2012.682639
- Chervenak, F. A., & McCullough, L. B. (2015). The professional responsibility model of obstetric ethics in clinical practice. Global Library of Women’s Medicine. DOI 10.3843/GLOWM.10449
- Chervenak, F. A., & McCullough, L. B. (1993). An ethical justification for emergency, coerced cesarean delivery without a court order. Obstetrics & Gynecology, 82(6), 1029–1035.
- Freyd, J. J. (1997). Violations of power, adaptive blindness, and betrayal trauma theory. Feminism & Psychology, 7(1), 22–32.
- Harsey, S. J., Zurbriggen, E. L., & Freyd, J. J. (2017). Perpetrator responses to victim confrontation: DARVO and victim self-blame. Journal of Aggression, Maltreatment & Trauma, 26(6), 644–663. https://psycnet.apa.org/doi/10.1080/10926771.2017.1320777.
- Harsey, S. J., & Freyd, J. J. (2023). The influence of deny, attack, reverse victim and offender and insincere apologies on perceptions of sexual assault. Journal of Interpersonal Violence, 38(17–18), 9985–10008.
- Katz, E. (2022). Coercive control in children’s and mothers’ lives. Oxford University Press.
- Okun, T. (2017). White supremacy culture. dRworks. https://www.sbctc.edu/resources/documents/about/edi/white-supremacy-culture-tema-okun.pdf
- Runyon, M. C., M. N. Irby, P. Rojas Landivar, and C. Pascucci. 2025. “ Reframing Obstetric Violence Culture: A Concept Analysis.” Journal of Advanced Nursing 1–31. https://onlinelibrary.wiley.com/doi/10.1111/jan.70323.
- Runyon, M. C., Irby, M. N., Pascucci, C., & Rojas Landivar, P. (2023). Exposing the role of labor and delivery nurses as active bystanders in preventing or perpetuating obstetric violence. Nursing for Women’s Health, 27(5), 330–336. https://doi.org/10.1016/j.nwh.2023.05.002
- Stone-Manista, K. (2010). In the manner prescribed by the state: Potential challenges to state-enforced hospital limitations on childbirth options. Cardozo Journal of Law & Gender, 16, 469–489.
- Yurkanin, A. (2026, March 16). Florida courts ordered them to have C-sections. ProPublica. https://www.propublica.org/article/florida-court-ordered-c-sections
