Licensing Requirements Would Block Care and Justice for Sexual Assault Victims

Entrepreneurial nurses created the specialty of sexual assault nurse examiner (SANE) to provide high-quality, compassionate care for sexual assault victims and reliable evidence collection for prosecutors. These nurses have created voluntary, third-party educational and certifying organizations to develop and revise SANE professional standards. Research shows that sexual assault nurse examiners provide high-quality, compassionate care and that sexual assault prosecution rates rise after communities establish SANE programs.

Yet SANEs are in short supply. In some states, regulations block competent nurses from examining sexual assault victims. SANE licensing, mandatory training, or certification requirements increase barriers to care for sexual assault victims, slow the SANE profession’s development, and routinely subvert the needs of sexual assault victims to those of the practitioners they regulate. Worse, state licensing authorities have repeatedly and knowingly upheld or reinstated the licenses of physicians who have sexually assaulted patients. Some then go on to assault other patients.

Licensing is not the right model for protecting sexual assault victims. States should avoid creating barriers to nurses who wish to develop SANE certification programs or to specialize as SANEs. States that have already done so should remove those barriers.

Sexual assault inflicts profound trauma on survivors, encompassing not only an emotional and psychological toll but also physical trauma, including bruises, cuts, abrasions, sexually transmitted infections (STIs), damage to reproductive organs, chronic persistent pain, and sleep disturbances. The perpetrator’s violation of the victim’s bodily autonomy during an assault can result in unwanted pregnancy, which can further complicate, prolong, and intensify an already traumatic experience. The interplay of physical and emotional trauma can compound the initial harm, prolonging the experience and effects of an assault for years. Persistent psychological distress often haunts survivors long after their physical ailments have diminished or ceased.

The US Department of Justice’s Bureau of Justice Statistics estimates that 531,810 people experienced rape or sexual assault in the United States in 2022.² Although the national rate of sexual assault reports has decreased over the past 30 years (Figure 1), researchers at the University of Michigan detected a 15-fold increase in people seeking treatment for sexual assault in hospital emergency departments from 2006 to 2019. (Changes in hospital coding practices—such as the creation in 2015 of specific codes for sexual assault—as well as victims feeling less stigma when reporting sexual assault may have contributed to the findings.)³

Sexual assault victims typically seek care at hospital emergency departments mere hours after the most traumatic event of their lives. It is there that medical professionals—typically nurses—comfort and treat sexual assault victims and gather evidence for potential prosecutions. Until recently, registered nurses (RNs) in all states were free to perform such sexual assault forensic exams.

Entrepreneurial nurses responded to the need for skilled professionals to evaluate sexual assault victims by creating the nursing specialty of sexual assault nurse examiner (SANE). SANEs combine quality, compassionate care with evidence gathering for sexual assault victims. Furthermore, these nurses have created voluntary, third-party educational and certifying organizations to develop and revise professional standards. Hospitals and other employers select SANEs with qualifications that match the needs of the populations they serve. Only 17 to 20 percent of hospitals had SANEs on staff in 2022.⁴ Even in states with a relatively high number of SANEs per capita, evidence suggests there are not nearly enough to meet the need.

Initially, all states left these innovative nurses, third-party organizations, and employers free to determine and update the appropriate levels of education and training for SANEs generally and in specific settings. Most states still do.

In recent years, however, some states have substituted the judgment of legislators for the judgment of these health professionals and organizations. Those states have enacted laws that require RNs to obtain permission from the government—in the form of an additional license or functionally equivalent mandatory certification or training—before they can conduct sexual assault exams. To obtain a SANE license, RNs must comply with the state’s education and training requirements, which may vary by state, and with costly processes for demonstrating compliance with those requirements. (See the States Create Barriers to Competent Sexual Assault Examiners section.)

Such regulations perversely reduce access to quality sexual assault exams. Requiring RNs to comply with a single, rigid set of education and training requirements reduces access by increasing the cost of SANE training and reducing the number of practitioners, who are already in short supply. To the extent that mandatory training, certification, or licensing reduces the supply of people competent to perform sexual assault forensic exams, it forces sexual assault victims to wait longer for those services. In many states, sexual assault victims’ advocates note that it often takes many hours and sometimes days to connect victims to sexual assault forensic services. States that impose licensing exacerbate these challenges.⁵ During that time, “a victim must avoid bathing, showering, using the restroom, or changing clothes, or else risk damaging the evidence before it can be collected.”⁶ If possible, victims should also not eat.⁷ Requiring sexual assault victims to wait hours to eat or urinate or defecate can add further discomfort and pain to the most traumatic experience of their lives. Delaying urination and prophylaxis against STIs also increases the risk of infection.

Laws that require clinicians to obtain an additional government license (or the functional equivalent) before performing sexual assault forensic exams can exacerbate the psychological trauma of sexual assault. Restricting the supply of forensic examiners creates prolonged delays before victims may bathe or shower and change clothes. It requires victims to remain longer in the physical condition in which their assailants left them. Prolonging hunger increases physical pain and discomfort and hinders victims’ physiological and emotional recovery. Requiring victims to defer sanitizing stains or wounds also poses health risks. These restrictions may be important for successful exams, but they can make victims bear additional psychological burdens that can last for years. The longer victims must wait and the farther they must travel for testing and care, the greater the probability and depth of ongoing psychological harm.

Licensing also reduces innovation in the diffusion of competent sexual assault exams by reducing flexibility in the development of SANE education, training, and practice.

Licensing is a fundamentally flawed tool for promoting quality care for sexual assault victims. Licensing authorities have repeatedly and knowingly upheld or reinstated the licenses of physicians who sexually assaulted their patients. Reinstating those licenses means sex-offender physicians may lawfully continue to practice any area of medicine, including performing sexual assault forensic exams. Some sex-offender physicians then go on to assault additional patients.

Licensing is not the right model for protecting sexual assault victims. States should avoid using licensing to create barriers to nurses who wish to specialize as SANEs. States that have done so should remove those barriers.

Sexual assault nurse examiners are RNs who receive special education and training to care for patients who have experienced sexual assault, neglect, incest, or abuse. SANEs integrate clinical, legal, and advocacy services. They perform emergency medical triage of patients and provide emotional support to sexual assault victims.⁸ They administer medication to mitigate the risk of STIs, conduct pregnancy tests, offer emergency contraception, and provide prompt follow-up services along with medical referrals.⁹ A confidential survey of SANE programs in the United States found that 90 percent administered STI prophylaxis, 97 percent tested for pregnancy, and 97 percent provided emergency contraception.¹⁰

SANEs undergo special training to collect medical evidence and testify in court.¹¹ They collect a history of the incident and perform a head-to-toe physical examination—including a vaginal or anal exam—looking for evidence of trauma and sometimes photo-documenting injuries. For forensic evidence collection, they collect toxicology samples from urine and blood, swab the victim’s body for DNA testing, and gather items for potential DNA samples of the perpetrator.¹² SANEs use “rape kits,” consisting of the requisite materials and detailed instructions, including a comprehensive checklist, during forensic examinations. The protocols and contents of these rape kits vary across jurisdictions.¹³

SANEs connect patients to victim-advocacy organizations and law enforcement.¹⁴ The Health Insurance Portability and Accountability Act of 1996 requires SANEs to ensure patient and medical confidentiality.¹⁵ If courts call SANEs to testify as experts or fact witnesses, they provide neutral, impartial information.¹⁶

Most SANEs work in emergency and urgent care departments. However, they can work in a range of settings—such as community- and mobile-based programs and correctional facilities—and as independent contractors to small, often rural hospitals with few sexual assault victims.¹⁷

SANEs improve the quality of sexual assault exams. Studies indicate that when SANEs conduct exams, they deliver more comprehensive care than traditional emergency department care, expedite examination processes, and enhance forensic evidence collection, fostering improved collaboration with the legal system and higher prosecution rates.¹⁸

Studies suggest that SANEs provide comprehensive, compassionate care with clear explanations and choices.¹⁹ One survey’s respondents reported that SANEs provided them with support and resources, treated them with respect, and helped them reestablish a sense of control and agency.²⁰ Survey data showed that an overwhelming majority of victims “strongly agreed” that SANEs took their needs and concerns seriously (90 percent), without attributing blame (89 percent), and provided high-quality care across various domains.²¹

Analysis of forensic evidence collection found that SANEs demonstrated higher accuracy and adherence to protocols than nurses and physicians without SANE training. SANEs were more likely to maintain proper chain of custody (92 percent versus 81 percent), label specimen envelopes correctly (95 percent versus 88 percent), and collect appropriate samples for analysis, such as pubic hair (88 percent versus 74 percent), blood tubes (95 percent versus 80 percent), swabs (88 percent versus 71 percent), and a vaginal fluid sample for sperm motility (87 percent versus 72 percent).²²

An analysis of sexual assault prosecutions showed a significant increase in guilty pleas and convictions after the jurisdictions implemented SANE programs. The researchers attributed that outcome to SANEs’ preserving high-quality medical forensic evidence and providing ongoing case consultation with criminal justice practitioners.²³ Prosecutors report that SANEs contributed to convictions through detailed documentation, comprehensive physical examination, adept trial preparation and testimony, and credibility with jurors.²⁴ One SANE program “had a statistically significant impact in increasing the rate of sexual assault cases referred by police to prosecutors, the rate of cases prosecuted, and the rate of cases concluded with convictions or guilty pleas.”²⁵ Other studies find similar results.²⁶

The creation of the SANE specialty illustrates how markets foster specialization, the division of labor, and quality assurance. Specialization in the health professions occurs in the same way and for the same reasons as in other economic sectors. It results not from government direction but from entrepreneurs and innovators responding to incentives to reduce costs and increase productivity.²⁷ Health professionals spontaneously create specialties in response to evolving medical science, the expansion of the market, and changing health needs.

Over the past century, physicians went from almost all practicing as generalists to serving patients in more than 160 specialties and subspecialties.²⁸ In 1905, Connecticut dentist Alfred C. Fones created the profession of dental hygienist when he trained his assistant Irene Newman to be “the first lay woman to practice dental prophylaxis.”²⁹ Dentists in New Zealand created the dental therapist specialty in 1921.³⁰ Nurses have developed more than 100 specialties, including four categories of advanced practice registered nurses (APRNs): nurse practitioners (NPs), certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists.³¹ NPs, in turn, have developed 13 subspecialties to meet the various needs of different patient populations.³²

Private physician certification boards have established standards to promote the delivery of safe and high-quality care. As specialists in each discipline have grown in number, they have developed curricula, founded educational institutions, and established boards to train new specialists, create practice standards, and refine criteria to certify competence.³³ Specialty boards and private-sector certification programs continuously adapt to patient needs without government direction. This occurs across the health professions. For example:

• In 2023, the American College of Cardiology proposed a new medical board, unaffiliated with existing medical certification organizations, to pursue new approaches to certification.³⁴
• The American Board of Nursing Specialties continually updates national nursing certification criteria and actively monitors nurses’ competencies. Other professional boards advocate for changes to nursing curricula to enhance development of clinical judgment.³⁵
• The National Commission on Recognition of Dental Specialties and Certifying Boards continues to recognize new specialties such as orofacial pain (in 2020), oral medicine (in 2020), and dental anesthesiology (in 2019).³⁶

Throughout the health professions, when entrepreneurial clinicians develop specialties, they also develop private, voluntary standard-setting organizations to certify clinician competence within those specialties. For example, currently four specialty certification organizations offer educational programs, set qualification standards, and certify physicians as competent in specialties and subspecialties: the American Board of Medical Specialists, the American Board of Physician Specialties, the National Board of Physicians and Surgeons, and the American Osteopathic Association Bureau of Osteopathic Specialists.³⁷

These independent third parties arguably play a greater role than licensing boards in protecting patients from poor-quality practitioners.³⁸ For physicians, specialty board certification is voluntary.³⁹ Voluntary certification is a meaningful quality signal that employers and liability insurers value. States do not require doctors of medicine (MDs) or doctors of osteopathic medicine (DOs) to satisfy additional requirements to practice in a specialty. State licensing laws do not prevent specialist physicians from practicing outside their specialty.⁴⁰ However, hospital staff credentialing and admission committees, medical center employers, health plans, and liability insurance companies all screen physicians’ level of training and competence, including whether they have private specialty certifications. The American Association of Critical-Care Nurses (AACN), for example, offers the Critical Care Registered Nurse (CCRN) certification.⁴¹ No states require CCRN certification, but many hospitals and organizations reward certification with higher salaries, leadership opportunities, and exam reimbursement.⁴²

With nearly 100 private, voluntary RN-specialty certification boards, organizations often compete to provide certification in the same specialty. For example, the AACN, the American Academy of Nurse Practitioners, and the American Nurses Credentialing Center (ANCC) offer various certifications in gerontology. Similarly, the AACN, the Board of Certification for Emergency Nursing, the Pediatric Nursing Certification Board, and the ANCC, among others, offer various pediatric specialty certifications.⁴³

The boards compete on quality indicators of training and competence, enabling nurses and employers to select the programs they prefer.⁴⁴ With the sole exception of SANEs, however, no states require RNs to obtain an additional license to practice a specialty (Figure 2).

The nursing specialty of sexual assault nurse examiner emerged via the same market process. Beginning in the 1970s, entrepreneurial registered nurses recognized a need for higher-quality care for sexual assault victims. They believed nurses were ideal candidates to provide technical services compassionately to these victims. RNs have always been free to perform sexual assault examinations. Yet innovative RNs believed that with greater specialization and training, they could tailor care to sexual assault victims and better assist law enforcement in prosecuting rapists.

Those RNs began developing education and training programs for sexual assault examiners. The first SANE programs began in Memphis, Tennessee (in 1976); Minneapolis, Minnesota (in 1977), and Amarillo, Texas (in 1979). Nurses who attended these programs developed expertise at gathering forensic evidence and providing legal testimony.⁴⁵

Those RNs also launched private, voluntary certification of SANE competence. In 1992, a meeting of SANEs at the University of Minnesota formed the International Association of Forensic Nurses (IAFN), a private educational and certification organization.⁴⁶ The IAFN establishes practice standards and formalizes forensic nursing for RNs seeking to specialize in the field. It provides both SANE‑A certification for nurses to perform forensic exams for adults and SANE‑P (i.e., pediatrics) certification for nurses to perform forensic exams for children. It requires SANE-certification applicants to have a current, unrestricted RN or APRN license; to have at least two years’ experience as an RN for SANE‑A certification and three years’ experience for SANE‑P certification; to complete a minimum 40-hour educational course; to complete a SANE clinical apprenticeship; and to accrue 300 hours of SANE-related practice within three years of taking the certification exam. Of those 300 hours, 200 hours must be with the population for which the nurse seeks certification.⁴⁷ The IAFN has certified more than 2,500 SANEs.⁴⁸ Nurses can also obtain training and certification in sexual assault forensics from competing national organizations, including the Forensic Nursing Certification Board (FNCB) and the Academy of Forensic Nursing (AFN).⁴⁹

Other enterprising nursing organizations have since created state-specific programs. In 2008, nurses formed the Vermont Network Against Domestic and Sexual Violence. The Network houses the Vermont Forensic Nursing Program, which has certified more than 90 SANEs, which has certified more than 70 SANEs. The West Virginia Foundation for Rape Information and Services certifies SANEs. The Florida Council Against Sexual Violence offers SANE training.⁵⁰

Government entities also provide voluntary certifications to nurses wishing to practice as SANEs, because governments have an interest in collecting admissible forensic evidence in sexual assault prosecutions. In Texas, the Office of the Attorney General (OAG) created standards for nurses seeking SANE certification, yet “there is no legal requirement in Texas that you have an OAG SANE Certification” to conduct a sexual assault examination.⁵¹ The New York and Maine Departments of Health create standards and certify examiners to provide sexual assault examinations.⁵² The Massachusetts Department of Public Health (MDPH) operates the MA SANE Certification Training program. Individuals who successfully complete the training program are eligible to apply to work with the MDPH’s MA SANE Program, which provides examination services to hospitals across the state.⁵³ Massachusetts does not require medical professionals to obtain a state license before providing forensic medical examinations. IAFN-certified SANEs can work in Massachusetts hospitals and medical institutions. However, the MDPH works only with those it has directly trained, most SANEs operating in Massachusetts work with the MDPH, and Massachusetts hospitals primarily obtain SANEs through the MA SANE Program.⁵⁴

The existing, voluntary SANE-certification system allows “right-skilling” of sexual assault forensic exams. Right-skilling refers to the process of ensuring that clinicians have adequate training to provide quality services, while avoiding unnecessary investments in training that would make those services prohibitively expensive. It strikes a proper balance between too much and too little education and training. “A system that right-skills its clinician workforce continuously increases access to care by eliminating unnecessary education and training costs and allowing lower-cost paths to demonstrating competence to provide certain services.”⁵⁵

SANE certification creators designed education and training programs that prepare nurses to perform complex and specialized examinations on patients soon after those patients experience extreme emotional and physical trauma. Those education and training programs adjust and expand to meet changing technologies, as well as societal and legal needs—as the creation of those programs itself exemplifies.

Private-sector entities also promote quality services for sexual assault victims by advertising the value and importance of choosing a professional sexual assault forensic examiner over lower-quality options, such as at-home rape kits. The Maryland Coalition Against Sexual Assault “encourages all survivors to have evidence collected in a manner that they are comfortable with, and while at-home rape kits claim the ability to collect said evidence in private, they cannot replace the expertise and knowledge of a trained forensic nurse examiner.”⁵⁶

The fact that this certification system is private—and therefore the certifiers hold no monopoly power—gives the system the flexibility and incentive to respond nimbly to events. SANE certifiers are free to tailor their programs with varying levels of training for nurses working in different clinical settings. That flexibility frees nurses to acquire the level of training and experience suitable for the unique requirements of the communities they serve (e.g., rural areas).

When states require RNs (or MDs) to meet additional burdens before performing sexual assault forensic exams, those burdens may have value, as they may improve the quality of some exams beyond what voluntary certification would achieve. However, they may reduce the availability of sexual assault forensic exams by deterring RNs (or MDs) from obtaining any specialized training or performing exams.

The lack of additional licensing requirements leaves RNs free to find innovative ways to expand access to high-quality sexual assault exams. The freedom to expand access to SANE expertise is particularly vital in rural and underserved areas.

In areas where nurses with special training are scarce, for example, local nurses can perform forensic exams with the help of remote guidance from SANEs in their state or other states.⁵⁷ The tele-SANE model underscores the innovation, adaptability, and right-skilling that are possible in the absence of licensing. Tele-SANE services are currently available in several states, including Arizona, Arkansas, California, Colorado, Maine, Massachusetts, New York, Pennsylvania, and South Dakota.⁵⁸

This innovative model enabled a tele-SANE in New Hampshire to guide Amanda Shelley, an RN in rural Eagle County, Colorado, through a sexual assault forensic exam from 2,000 miles away. The tele-SANE used secure video technology to speak with the victim and direct Shelley through the two-hour exam, which included procedures such as endoscopically viewing the vagina. A camera on the examination device enabled the tele-SANE to observe what Shelley was viewing in real time. During the process, Shelley used a magnifying device to closely examine the victim’s vagina and cervix.⁵⁹

Research has found that tele-SANEs improve the way nurses perform forensic exams and collect evidence. A study in rural Northern California compared tele-SANE exams with examinations at hospitals that did not employ such guidance. Nurses with tele-SANE guidance scored higher on several measures, including documenting consent, general examination, genital and perianal examination, examination findings, and overall assessment.⁶⁰ In Pennsylvania, victims seeking sexual assault care at rural hospitals reported improved well-being following tele-SANE consultations (74 percent). On-site nurses expressed high levels of satisfaction with the tele-SANE program, particularly regarding their experience with telehealth technology (94.4 percent), the reliability of telehealth equipment (81.1 percent), and the level of support provided by the tele-SANE consultant (89.2 percent). Researchers concluded, “We believe this highlights that when experienced SANEs partner with less-experienced [local site nurses] to deliver patient-centered, trauma-informed, evidence-based care, it can be the first step in healing for a survivor of [sexual assault].”⁶¹

Licensing regulation in several states prevents these and other innovations that could help those states’ residents. In the case of tele-SANE consultations, licensing could prevent the local RN from conducting the exam whether or not the tele-SANE has a license from that state. Kentucky, North Carolina, and Maryland forbid RNs without a SANE license or other approved training from performing full forensic exams.⁶² In Kentucky, RNs can only assist a licensed SANE, but if one is unavailable, a physician, physician assistant (PA), or APRN must perform the exam.⁶³ Similarly, North Carolina permits RNs to collect only very limited evidence. Although Maryland recently liberalized teleforensics and forensic nurse examiner (FNE) virtual guidance, it continues to prohibit RNs from conducting exams.⁶⁴ These barriers also prevent out-of-state tele-SANEs from providing care and supporting victims in need. Kentucky, Maryland, and New Jersey block tele-SANEs from remotely guiding or supervising a local RN unless the tele-SANE has a license from the state where the victim and examining RN are.⁶⁵ As with explicit licensing regulation, states with training requirements—that is, Alabama and North Carolina—also block qualified tele-SANEs from guiding exams.⁶⁶ Unless a tele-SANE’s license or training meets the requirements of the state where the victim and examining clinician are, the tele-SANE cannot provide guidance. More radically, Illinois prohibits any medical provider from providing virtual supervision and support for sexual assault forensic exams.⁶⁷

Ideally, states would leave entrepreneurs free to find ways to make quality sexual assault forensic exams more widely available. For example, one can imagine programs that train clinicians solely to perform exams and to call on clinicians with more training (e.g., RNs or MDs) when a complex case exceeds their competence. Such a program would make forensic exam services more widely available by expanding the pool of examiners, reducing the cost of training examiners, and reducing the price of sexual assault forensic exam services. Such programs cannot exist if states require sexual assault forensic examiners to first obtain an MD or an RN license.

Many categories of clinicians—including advance practice registered nurses, physician assistants, doctors of medicine, and doctors of osteopathy—can lawfully provide sexual assault forensic examinations for both adults and children. Yet a survey of SANE programs in the United States found that most providers were RNs.⁶⁸

There are important reasons why nurses stepped forward to improve the quality of care for rape victims. The task of a sexual assault examiner requires clinicians to be immediately available, compassionate, delicate, and holistic. RNs are excellent candidates. They compose the largest number of hospital employees, at 30 percent.⁶⁹ Sexual assault victims typically encounter them before any other medical professional. According to a January 2023 Gallup poll, the American public trusts RNs more than any other profession. The public considers RNs more ethical than all other professions, a title they have held for more than two decades.⁷⁰

The nursing profession as a whole may be more empathetic and less threatening to sexual assault victims than other professions are. Men make up 92 percent of sexual assailants.⁷¹ Women make up 83 percent of victims.⁷² Eighty-six percent of nurses are women, whereas only 38 percent of physicians are.⁷³ Female nurses may also be more likely to empathize with sexual assault victims because, “compared to their male colleagues, female nurses are more likely to be sexually harassed at work by patients, their families, or colleagues.”⁷⁴

Registered nurses also have lower opportunity costs than MDs, PAs, and APRNs. There are more RNs than there are these other professionals, and it costs less to have RNs perform forensic exams. As one physician who declined to conduct a sexual assault forensic exam put it, “I cannot spend two hours in a room with one patient.”⁷⁵

Forty-four states and the District of Columbia leave RNs free to perform sexual assault forensic exams and leave entrepreneurs free to tailor training and quality certification to varying local needs. The exceptions are Alabama, Illinois, Kentucky, Maryland, New Jersey, and North Carolina. Those states block RNs from providing sexual assault forensic exams unless they obtain permission—a license or the functional equivalent, such as in training or private certification—from the government. Those six states now require all nurses, including SANEs who have already obtained private certification, to satisfy additional requirements before they may lawfully conduct forensic exams.⁷⁶ Appendix Table A1 details these restrictions. Illinois goes even further: It requires physicians to satisfy additional requirements and obtain an additional license to perform forensic exams.

States with SANE-licensing regulation first require all applicants to have at least an RN license. They then require would-be SANEs to complete training programs with between 40 and 64 hours of classroom instruction and between 16 and 40 hours of clinical experience.⁷⁷ They require clinicians who wish to perform both adult/​adolescent exams and pediatric exams to complete either two separate training programs or a combined program with many additional hours of instruction and clinical experience. The price of training programs, which can vary from $125 to $1,815, can pose a significant barrier, though some states provide training free of charge.⁷⁸ The IAFN charges nonmembers $600 for virtual SANE classroom training on both the adult/​adolescent and pediatric tracks. Local partner sites administer in-person clinical preceptorships, with varying fees. Some sites charge a flat fee of $300. Others bill participants $200 per day.⁷⁹

The problem is especially acute in rural areas. States with licensing or equivalent regulation require RNs to complete both the classroom and clinical training before providing exams. A 2021 study of SANE availability in rural areas suggested that the costs of IAFN certification ($275–$475 for the exam and $175–$575 in renewal fees every three years) can be a significant obstacle. It recommended that future research examine barriers to training and certification, especially for rural nurses.⁸⁰

License fees range from $25 to $200 and come on top of fees for training programs and private certification.⁸¹ License renewal fees range from $50 annually to $146 every two years.⁸² Some states require criminal background checks, which duplicate employer background checks.⁸³ License maintenance requirements range from 5 hours of SANE-related continuing education per year to 400 hours practicing as a SANE within the previous 24 months (plus 8–16 hours of continuing forensic education) and 300 hours of “SANE-related practice” every three years.⁸⁴ States typically set these requirements with heavy input from incumbent SANEs who have already met them.

Licensing regulation stifles innovations that competing certification organizations could otherwise provide. States that require SANEs to obtain a government license (or the functional equivalent) recognize only IAFN training guidelines and certifications. They do not recognize competing certifications or training programs by national organizations such as the FNCB or state-specific or regional groups. Those rules prohibit medical schools, hospitals, nursing organizations, and others from developing less burdensome certification programs that could expand access to forensic exams.

Licensing regulation also creates barriers to supply. When government restricts what training it recognizes, it compels nurses to choose programs that may be incompatible with their lives, needs, and aptitudes. In states with licensing regulation, prospective SANEs can obtain training only from approved programs. Since SANE training has in-person components, an RN must either live near the program site or spend time and money on travel, which makes combining work and study more difficult. The Carolina Public Press notes: “It costs money to send nurses to training—to travel to the training and pay for food and hotels. Those nurses also have to take time off from work, and other nurses need to fill those shifts for them.”⁸⁵ Limiting training options also increases disruptions to childcare and other familial responsibilities. In New Jersey, there are only two IAFN- and Board of Nursing–approved training programs, plus occasional training by the local IAFN chapter.⁸⁶

The additional cost of those requirements creates barriers to forensic exams and prevents many exams from occurring. The fact that government develops those requirements—and only government can change them—makes those requirements more rigid than voluntary private certification requirements.

The difficult and emotionally taxing nature of SANE certification and practice creates vicarious trauma, other forms of severe psychic distress, and a high burnout rate. A 2011 study of SANEs across multiple states found that 67 percent experienced vicarious trauma.⁸⁷ In 2018, the Government Accountability Office (GAO) found that fewer than 8 percent of Wisconsin SANEs (42 out of 540) who trained over a two-year period were still practicing by the end of that period. The GAO identified low SANE retention rates as a serious barrier to providing care.⁸⁸ A 2022 study of North Carolina SANEs found that 55.6 percent of former dual-role SANE and emergency nurses (a common career path) experienced burnout. SANEs with pediatric cases above the median were 48.78 percent more likely to meet the burnout threshold.⁸⁹

Licensing regulation (along with mandatory training/​certification requirements) adds to those psychic burdens, increases burnout risk, and decreases the likelihood that SANEs will continue to practice. It creates barriers to entry that restrict the number of available practitioners (including tele-SANEs), which results in fewer SANEs and a higher patient load for existing practitioners. If SANEs take a break for psychic recovery and let their license, certification, or continuing education lapse, the additional costs of relicensing can discourage them from resuming their practice. This situation reduces workforce flexibility and limits exam availability, particularly in rural areas.

The cumulative impact of these barriers forces practicing SANEs to overwork themselves while facing psychic challenges, significantly increasing their psychic distress and emotional exhaustion. Overall, licensure amplifies the psychic challenges and costs of providing sexual assault forensic exams.

Nevada’s experience illustrates the harms of licensing regulation and its functional equivalents. After compulsory certification created significant barriers to care, Nevada policymakers reversed course by making the requirements advisory instead.

The Nevada State Board of Nursing (NSBON) issued its first advisory opinion on SANEs as early as 1991. In 2004, the NSBON went beyond providing advice. The board ruled that RNs should not perform exams on victims under age 16, the Nevada age of consent. SANEs, law enforcement, district attorneys, and other parties testified in opposition. They emphasized that the restrictions would block vital care to children and young adults. They argued that existing SANE training ensured compassionate, high-quality care. Finally, they noted the troubling irony of denying care to sexual assault victims whose needs stemmed from consent violations. Some APRNs and MDs testified in favor of the NSBON decision. The board ultimately decided to allow SANEs to perform adolescent/​pediatric exams.⁹⁰

Yet the NSBON imposed a requirement that RNs wishing to perform forensic exams must complete mandatory training and certification that follow IAFN educational guidelines.⁹¹ As before, many victim-advocacy groups, SANEs, FNEs, and other medical professionals testified against these new requirements. Dr. Kristen J. MacLeod, a Nevada pediatrician working with child abuse victims, emphasized the downsides of imposing uniform IAFN standards. For example, multiple organizations train and certify RNs to provide forensic exams. Imposing uniform IAFN standards would bar competent RNs who had received certification from other organizations from providing forensic exams. Others noted that no other state imposed such a requirement.⁹²

In 2012, the Nevada State Board of Nursing’s Victims of Crime Subcommittee argued that the requirements for SANE‑A certification created “unnecessary roadblocks between potential nurses and SANE‑A certification,” resulting in a severe lack of access to forensic exams. In particular, the IAFN requires that SANE-As have “a physician or practicing SANE‑A … signify the trainee has demonstrated proficiency.” Nevada law made that requirement mandatory. The NSBON report explained that Nevada’s licensing regulations thus imposed a “financial impact [that] can be quite incredible.” Trainees without a supervising clinician in their area must travel to receive such training. They must bear costs including:

• Lodging while away from home;
• Additional family/​household expenses due to trainees’ absences; and
• Waiting, without pay, to be dispatched to a sexual assault exam.⁹³

The report continued: “Nurses could spend immeasurable amounts of money and time without achieving necessary practicum hours to complete the certification.” The NSBON concluded: “We cannot fill these vacancies, regardless of expressed interest by qualifying nurses, due to current certification requirements.” The report noted that NSBON requirements exceeded even IAFN guidelines and were “unlike any other state requirement.”⁹⁴

In 2012, Nevada Attorney General Catherine Cortez Masto (now a US senator from Nevada) petitioned the board to remove onerous prerequisites.⁹⁵ The IAFN also supported eliminating the requirements.

The petitions and testimonies succeeded. In 2016, the NSBON changed what had been a compulsory certification requirement into an advisory recommendation. Nevada no longer has mandatory certification requirements for RNs wishing to provide medical forensic exams.

Despite these improvements, Nevada continues to suffer from insufficient access to sexual assault forensic exams. As of 2023, only six locations statewide provided forensic exams.⁹⁶ The IAFN reports that in 2024, there were seven SANE-As and three SANE-Ps across Nevada, for ratios of 2.2 SANE-As and 0.9 SANE-Ps per million residents.⁹⁷

Geography complicates access. Seventy-five percent of Nevada’s population lives in the southern half of the state. Yet the only SANEs available in southern Nevada are in Clark County, the state’s largest county, which includes Las Vegas.⁹⁸ Only one hospital in Clark County (University Medical Center) has a SANE program. It has one primary SANE and two secondary fill-in SANEs serving a population of 2.4 million. Some sexual assault victims in Clark County reported having to wait 18 hours for an exam.⁹⁹ Rural victims must often drive 6 to 9 hours. Those traveling from a neighboring county to Clark County may not receive an exam for days. Liz Ortenburger is CEO of SafeNest, the largest domestic and sexual violence victim-advocacy and support organization in Nevada. She commented on the SANE bottleneck: “Transportation and child care, SafeNest can absolutely cover, but forensic nurses? I cannot create those.”¹⁰⁰

As a result of these shortages, Nevada continues to deregulate clinicians who provide sexual assault forensic exams. In 2023, Nevada removed regulatory barriers to the use of tele-SANEs.¹⁰¹ Yet shortages persist.

In addition to directly reducing the supply of forensic exams, licensing regulation also indirectly reduces the supply by reducing the underlying number of RNs who might undergo training and perform forensic exams. In 2022, Nevada had 7.5 nurses per 1,000 people, fewer than the national average of 9.2.¹⁰² In 2025, the Nevada Health Workforce Research Center estimated, “In order to meet national per capita employment rates, Nevada would need an additional 4,913 registered nurses, an additional 717 advanced practice registered nurses, an additional 3,154 licensed practical nurses, and an additional 5,372 [certified nurse anesthetists].”¹⁰³ Eliminating regulatory barriers to nursing practice would allow Nevada to expand the supply of nursing services and enhance access to forensic exams.¹⁰⁴

Unfortunately, not all state governments keep records of the number of licensed SANEs currently practicing in their state. In 2016, the GAO found that states rarely track how many SANEs are currently practicing.¹⁰⁵ This paucity of data creates significant challenges for researchers, particularly in states that require SANEs to obtain a license (or its equivalent). Particularly troubling is the fact that many states impose barriers to sexual assault forensic exams without monitoring the impact of those laws.

We have attempted to collect what data are available. Where state data are unavailable, we have included data from the IAFN and other sources, such as journalistic surveys. IAFN data do not reflect the total number of SANEs in each state, only those whom the IAFN has certified. A discrepancy exists between the number of IAFN-trained SANEs and total SANEs practicing for several reasons. A state may require prospective SANEs to obtain training that follows IAFN guidelines but not directly require them to obtain IAFN certification or training. An RN may obtain training or certification from the IAFN in one state but practice elsewhere. In addition, the IAFN records SANE-As and SANE-Ps separately. To the extent that individual SANEs offer both adult and pediatric exams, this estimate overstates the availability of SANE services. The IAFN states that “78 percent of those who hold a SANE‑P certification are also certified as SANE‑A. If people are not seeking certification for both at the same time, most often they complete the SANE‑A certification first, followed by SANE‑P.”¹⁰⁶

As of 2024, 1,948 IAFN-certified SANE-As and 844 IAFN-certified SANE-Ps were in the United States, or 5.7 SANE-As and 2.5 SANE-Ps per million residents.¹⁰⁷ These numbers also do not show the geographic distribution of SANEs within states, particularly urban–rural divides. The GAO found that rural areas especially have fewer SANEs per person and that rural nurses often have difficulty completing SANE training.¹⁰⁸

Since 2009, Alabama has required nurses to complete a mandatory educational program before providing sexual assault forensic exams.¹⁰⁹ Furthermore, if registered nurses wish to administer prophylactic medications for STIs or pregnancy, they must sign a collaborative practice agreement with a physician or nurse practitioner holding an Alabama license.¹¹⁰ RNs who wish to operate without a collaborative practice agreement must prove to the Alabama Board of Nursing that they have “no less than five years’ of experience as a SANE.”¹¹¹

These requirements can block even highly qualified SANEs from providing exams. Dr. Patricia M. Speck is a professor emeritus of nursing and former coordinator of the Advanced Forensic Nursing program at the University of Alabama at Birmingham School of Nursing. She is a past president of the IAFN (2004–2005) and the FNCB (2022–2024). She states:

Despite these restrictions, relative to other states Alabama has a higher-than-average number of SANEs per capita. The IAFN reports 35 SANE-As and 14 SANE-Ps serving a population of five million, or 7 SANE-As and 2.8 SANE-Ps per million.¹¹³

Nevertheless, the shortage of sexual assault forensic exams in Alabama shows that even an above-average number of SANEs can be inadequate. For example, those overall numbers can mask wide variation in the availability of SANEs in different parts of the state. Three out of four Alabama counties have no SANEs: Baldwin County, near Mobile, is an example. With a population of nearly 250,000, it is one of the fastest-growing areas of the state.¹¹⁴ Official state data indicate there were 54 reported rapes in Baldwin County in 2019.¹¹⁵ The actual number of sexual assaults may be four times as high: The US Department of Justice estimates 73 percent of sexual assault victims do not report the crime.¹¹⁶ Yet Baldwin County has no SANEs.

The dearth of SANEs dissuades sexual assault victims from getting treatment and reporting assaults to the police. In 2023, a victim from Fairhope told reporters she waited five hours in a Baldwin County emergency department for a forensic exam. Only then did hospital staff instruct her to drive 28 miles to Mobile for an exam—alone, after a traumatic assault. “Realistically,” the victim told a reporter, “I’m not gonna do that. I’ve already sat here five hours. I’m gonna go over there and sit there for five more hours?”¹¹⁷ Kathryn Loveless, a SANE in Mobile, explains:

Barriers to forensic exams create barriers to sexual assault prosecutions. In the case of the victim from Fairhope, local news reported that “being unable to get a rape kit in Baldwin County … discouraged her from reporting her assault. She decided not to pursue a police investigation.” Robert Wilters, a Baldwin County prosecutor, said that the lack of local clinicians who can conduct sexual assault forensic exams locally hamstrings his office’s efforts to prosecute rapists. If victims don’t make the journey to a city that has SANEs available, he explains, “We’ve got no way to prosecute somebody. We don’t have any evidence, we don’t have a report, we have nothing.”¹¹⁹

“It just feels like I’m helpless … just kind of powerless,” the victim from Fairhope said. “I’m just disappointed in humanity.”¹²⁰

Before 2019, any Illinois clinician who held an RN, APRN, PA, or MD license could legally perform sexual assault forensic exams. In 2019, Illinois prohibited anyone but “qualified medical providers” from performing exams.

To become a “qualified medical provider,” RNs and APRNs must complete state-approved training. Physicians and physician assistants must complete state-approved training as a sexual assault forensic examiner (SAFE).¹²¹ Illinois runs a training program through the Office of the Attorney General that trains both SANEs and SAFEs. It also recognizes any training program approved by the IAFN.¹²²

Before 2023, Illinois allowed applicants only one year to complete their clinical log requirements. Like Nevada, after recognizing the onerous nature of this requirement, Illinois eliminated it. However, Illinois continues to impose training requirements.

Laura Carson, a critical-care services manager in Illinois, noted that meeting clinical log requirements is especially challenging in smaller communities where meeting the requirement may take longer. She added that it can take about 18 months to obtain a SANE program certificate.¹²³ Carson works at Genesis Medical Center in Silvis, Illinois, part of the Quad Cities metropolitan area. Genesis Medical employs eight certified SANEs. Illinois blocks all but one of them from performing exams.¹²⁴

As of 2024, 579 SANE-As and 109 SANE-Ps were practicing in Illinois, as were 6 SAFE-As and 1 SAFE‑P. In a population of 12.6 million, those figures yield ratios of 46.6 adult examiners and 8.7 pediatric examiners per million residents.¹²⁵

As in Alabama, despite Illinois’s having more than the national average number of SANEs per capita, there remains widespread evidence of insufficient access to sexual assault forensic exams. Illinois law requires hospitals to provide exams without charge or to refer patients to a hospital that does. Yet a journalistic investigation found that from 2007 to 2024, “the number of hospitals transferring patients instead of treating them has more than tripled.” The investigation found widespread failures to connect victims with examiners and related breakdowns that affected more than 200 victims. An emergency room doctor at Jacksonville Memorial Hospital, for example, sent a four-year-old victim home without an exam. The doctor later told state investigators, “I cannot spend two hours in a room with one patient.” It took two days before the victim would receive an exam from a hospital an hour away in Springfield.¹²⁶ In 2023, the city of Anna, Illinois, had a population of 4,136.¹²⁷ An emergency room doctor at Union County Hospital in Anna told a 62-year-old victim, “We don’t do rape kits here,” then referred her to a hospital 70 miles away. The victim went home instead. She later learned that a hospital 25 minutes from her home performs exams. She received one there, nine days after her assault.¹²⁸ Illinois’s licensing regulations increased the barriers each of these victims faced.

Since 1997, Kentucky has required RNs to obtain a SANE license to perform forensic exams.¹²⁹ For many nurses, the principal barrier is less the licensing requirements than the income they forgo while meeting those requirements. Kentucky physicians are free to perform exams without any special training. Many physicians prefer not to perform exams, whether due to a lack of training or high opportunity costs.¹³⁰

As in other states, Kentucky’s licensing requirements harm both assault victims and many SANEs who treat them. In 2019, only 290 nurses held a SANE license in a population of 4.5 million, according to a Kentucky Center for Investigative Reporting survey. At least 10 percent of those nurses are “not actively practicing.” Many cite burnout as the primary cause.¹³¹ As in Alabama and Illinois, the resulting and apparently high ratio of SANEs per population—58 per million residents—still does not appear to provide adequate access:

Observers report that hospitals in Kentucky have been turning away sexual assault victims because the hospitals do not have licensed SANEs available.¹³³

Kentucky law requires emergency rooms to provide exams. It imposes no barriers on MDs providing them. Nevertheless, many hospitals without SANEs still refer victims elsewhere. One reason is that many believe that SANEs offer a higher level of sexual assault care than MDs or other clinicians. Another reason is that many Kentucky doctors feel uncomfortable or inadequate in conducting exams.¹³⁴ Some observers have called for stricter enforcement of the law or for subsidizing SANE training; however, few policymakers recognize or attempt to remove the unnecessary barriers that licensing regulation creates.

In 2014, the state of Maryland began prohibiting RNs from performing forensic exams unless they obtain a “forensic nurse examiner” license.¹³⁵

The Maryland Department of Health and Mental Hygiene and the Maryland Institute for Emergency Medical Services Systems reported that exam barriers included: “lack of 24/7 access to a forensic examination at some SAFE programs due to FNE staffing shortages,” even before the state imposed those additional barriers.¹³⁶ In 2017, after the state imposed licensing, Maryland’s attorney general reported “a shortage of forensic nurse examiners” such that “sexual assault survivors may be shuttled from place to place, sometimes giving up and not getting an exam to collect evidence of a sex crime.” The shortage of forensic exam services “jeopardizes potential criminal cases against assailants.”¹³⁷ Later that year, the legislature found that “There is a shortage of forensic nurse examiners qualified to perform sexual assault evidence collection.”¹³⁸ As of 2024, 123 FNE-As, 1 RN-FNE‑P, and 89 RN-FNE-A-Ps were practicing in Maryland, serving a population of 6.1 million residents.¹³⁹

Rather than free the hospitals and private certification entities to develop voluntary standards that could ameliorate that need, in 2017, the legislature established a Sexual Assault Evidence Kit Policy and Funding (SAEK) Committee. The SAEK Committee has a permanent subcommittee to examine the shortage of forensic exams, known as the Availability of Exams and Shortage of Forensic Nurse Examiners (FNE) Subcommittee.¹⁴⁰

In 2024, the FNE Subcommittee “continued efforts to address the FNE workforce shortage.” The subcommittee identified burnout as one of the factors reducing access. Unfortunately, it did not identify licensing regulation as contributing to the shortage or to FNE burnout. Yet the subcommittee did recommend that it “collaborate with the Board of Nursing’s FNE Stakeholder Group to … review licensure and training requirements and explore best practices in other states.”¹⁴¹ In 2024, the Maryland Senate passed legislation to subsidize telehealth services by sexual assault forensic examiners through the state’s Medicaid program and to fund a tele-SAFE pilot program.¹⁴² The bill introduced, for the first time, a legal definition of “peer-to-peer telehealth” that removed barriers to licensed FNEs remotely supporting a “qualified healthcare provider” during a sexual assault forensic exam.¹⁴³ The bill also directed the SAEK Committee to evaluate pilot program feasibility. The SAEK Committee’s working group on forensic telehealth has recommended a pilot program for FNE-to-RN forensic telehealth.¹⁴⁴

Although the legislation reflects progress in liberalizing telehealth, the reforms do not address the structural barriers created by FNE licensing. Maryland continues to prohibit RNs from performing sexual assault forensic exams, even when a licensed FNE remotely supervises and guides them.

In 2001, New Jersey began requiring RNs to obtain a SANE license to perform forensic exams. The attorney general and the Board of Nursing jointly establish the licensing process for forensic SANEs.¹⁴⁵ After RNs complete extensive educational and clinical training, they must meet state “Forensic Nurse–Certified Sexual Assault” requirements.¹⁴⁶ As of 2024, the IAFN records 18 SANE-As and 9 SANE-Ps serving a population of 9.3 million, yielding ratios of 1.9 SANE-As and 1 SANE‑P per million.¹⁴⁷

Consequently, exams become more difficult to obtain. US Representative Frank Pallone (D‑NJ) commented in 2020:

Pallone was describing the availability of SANE services in states without licensing regulation.¹⁴⁹ In New Jersey, which has fewer SANE-As and SANE-Ps per resident (1.9 and 1.0 per million residents, respectively) than the national average (5.7 and 2.5, respectively), the situation is arguably more dire.¹⁵⁰

Since 1981, North Carolina has forbidden RNs and NPs from providing sexual assault forensic exams unless they complete a state-approved training program.¹⁵¹

North Carolina prohibits nurses from performing forensic exams unless they complete state-mandated educational and clinical training requirements.¹⁵² The North Carolina Board of Nursing lists approved programs.¹⁵³ According to a 2021 survey by the Carolina Public Press, about 150 SANEs work throughout the state serving a population of 10.5 million, for a ratio of 14 SANEs per million. That survey found that rural areas especially suffer from a shortage of forensic exam services.¹⁵⁴ The Carolina Public Press found that no state government body tracks how many SANEs are practicing or where they are located.¹⁵⁵

In 2022, North Carolina Attorney General Josh Stein stated that North Carolina has a “shortage of SANE nurses” and approved special funding for SANE training.¹⁵⁶ However, Stein did not address any barriers created by the training requirements themselves.

Hospital administrators have lodged complaints against the state requirements. Brandy Popp, spokeswoman at CarolinaEast Medical Center of New Bern, stated:

According to a survey response from the University of North Carolina Medical Center in Chapel Hill, “Training and education of SANEs is difficult because it requires not only the didactic class but additional clinical hours.… In essence, a nurse training to be a SANE has to wait for someone to get raped to complete their training.”¹⁵⁸

Policymakers have begun to recognize that current restrictions cause sexual assault victims to lack adequate access to examinations. As of March 2024, they have freed RNs licensed in North Carolina to collect limited forensic evidence. Although the state forbids anyone but licensed SANEs to conduct full forensic medical examinations, it permits RNs to collect limited samples that include “fingernail scrapings or simple skin surface swabs but would not include vaginal swabs requiring insertion of a speculum.”¹⁵⁹

The existing voluntary education and certification system already assures the quality of SANEs. Private education and certification organizations such as the IAFN regularly update and adapt their criteria to meet market changes. In states that don’t license SANEs, health care facilities such as hospitals and health care systems can and do develop independent training and certification criteria that right-skill sexual assault care. The risk of liability lawsuits pushes these entities to ensure SANE quality. In rural and other areas where IAFN-certified nurses might be scarce, some facilities pay a select number of nurses to participate in an IAFN course or other 40-hour training program.¹⁶⁰

Whatever patient protections exist in the US health sector come not from clinician licensing but from other sources, including third-party certification organizations, health insurers, hospitals and other employers, competitive pressures, the threat of medical malpractice liability, and medical malpractice liability insurers.¹⁶¹ Private, nongovernmental entities provide the vetting and quality controls that provide whatever patient protection currently exists. Although licensing laws create no barrier to MDs practicing a specialty that they are not competent to practice, most hospitals and clinics will allow only board-certified specialists on their staff. Many health plans will allow only board-certified specialists on their provider panels.¹⁶² Malpractice insurance carriers often refuse to cover or charge higher premiums to physicians who lack certification in their specialty.¹⁶³ Skilled plaintiffs’ attorneys can point to physicians’ lack of board certification to diminish the physicians’ credibility in malpractice lawsuits.¹⁶⁴ These private entities have an economic interest in regulating provider competence and quality. They and the medical malpractice system—not licensing—are what protect patients from incompetent specialists.

Licensing SANEs reduces access to sexual assault exams, prevents innovation and right-skilling in quality certification, and ultimately harms sexual assault victims.

The IAFN reports that only 17 to 20 percent of hospitals employ SANEs. The unmet need is so dire that members of Congress have proposed subsidizing additional SANE training programs.¹⁶⁵ Licensing regulation may further reduce access to competent sexual assault examinations, particularly in rural or medically underserved areas.

Licensing SANEs would reduce the number of SANEs and the availability of sexual assault exams by imposing unnecessary barriers to entry into the specialty. It would require SANEs to meet government-prescribed educational and training milestones of questionable merit before helping sexual assault victims—and helping catch rapists. Research indicates that regulatory bodies that impose licensing restrictions diminish the number of qualified professionals, deterring the supply of practitioners and creating service bottlenecks.¹⁶⁶ So does real-world experience. During the COVID-19 pandemic, state officials from both political parties suspended scores of licensing regulations because they recognized those regulations block access to quality care.¹⁶⁷ Yet there is no indication that states removed barriers to sexual assault forensic exams.

The same would be true of licensing regulations that take currently voluntary quality-certification standards and make them compulsory. Similarly, consider the Board of Certification for Emergency Nursing, which offers Certified Emergency Nurse (CEN) certification to nurses working in emergency department settings.¹⁶⁸ No states require emergency nurses to obtain CEN certification. Were states to do so, it would reduce the number of emergency department nurses by 97 percent, from 1.18 million to approximately 41,000.¹⁶⁹

A 2021 study in Pennsylvania found that only 20.7 percent of rural hospitals had access to IAFN-certified SANEs. In other words, IAFN standards, which require SANEs to obtain an RN license, may themselves be too burdensome for many areas. The researchers concluded that “barriers to SANE certification may exist for rural SANEs” and “inconsistent SANE coverage may place rural sexual assault victims at risk of receiving lower quality sexual assault care.”¹⁷⁰ Were Pennsylvania lawmakers to require nurses to obtain IAFN certification, it would cement those barriers in place.

Licensing laws impede innovation as they favor standardization and regulatory compliance. Such rigidity reduces experimentation with different approaches to training and to expanding access to competent forensic exams.

The education or training requirements that states impose might have some merit. The fact that these requirements are a matter of law, however, means they are subject to political control and manipulation. It means established incumbents can influence lawmakers to retain or expand strict licensing requirements. It means unnecessary requirements will be harder to dislodge than under a system of voluntary certification. When the IAFN requires applicants to have a physician or practicing SANE certify their proficiency, hospitals and RNs can reject or adjust that standard if strict adherence would prevent forensic exams. When Nevada made the IAFN’s voluntary standard mandatory, then–Attorney General Catherine Cortez Masto noted the result was “extreme imbalance between the number of assaults and SANE-As.”¹⁷¹ Unnecessary requirements block entry by additional SANEs and block access to competent, compassionate sexual assault exams.¹⁷²

Licensing regulation is not the guarantor of quality that its supporters claim. In many ways, licensing actively reduces quality.

For instance, licensing laws prevent patients from using telehealth services to access high-quality care from practitioners in other parts of the country. During the COVID-19 pandemic, many states tacitly acknowledged that licensing blocks access to quality care when they suspended many licensing regulations. As of January 2024, seven states continue to suspend certain licensing regulations.¹⁷³ State licensing regulation further blocks access to high-quality international medical graduates.¹⁷⁴ Many states’ licensing laws block competent physicians, dentists, and nurses even from providing free medical care to the poor.¹⁷⁵

Worse, licensing boards do not actively monitor the quality of care that clinicians provide. Even when numerous patients file credible complaints with licensing boards, the boards often allow clinicians to continue practicing, seemingly without regard as to whether they are harming patients. Despite numerous complaints from patients about Dallas-based surgeon Christopher Duntsch (whom the media dubbed “Dr. Death”), the Texas licensing board bureaucracy took so long to act that Duntsch was able to keep maiming and killing patients. By the time the board revoked his license in 2013, Duntsch had maimed or killed nearly 40 patients in total. Three years later, he was sentenced to life in prison.¹⁷⁶

Duntsch’s case is an extreme one, but it illustrates how licensing regulation’s poor record of protecting sexual assault victims has serious implications. As we discuss next, licensing regulation often allows—and licensing boards defend allowing—physicians to continue practicing after boards find evidence of sexual misconduct with patients.

The clearest indication that licensing is not the right tool for protecting sexual assault victims is that licensing laws and authorities repeatedly prioritize the needs of the practitioners they regulate over the needs of victims.

For example, many physicians and other health care practitioners lack the training that an RN with even minimal SANE training may have. Yet SANE-licensing laws in Alabama, Kentucky, Maryland, New Jersey, and North Carolina literally block high-quality RNs but not lower-quality physicians from providing sexual assault exams.

Worse, state licensing authorities have repeatedly and knowingly upheld or reinstated the licenses of physicians who have sexually assaulted patients. Absent restrictions on their license, those sex-offender physicians are free to practice in any area of medicine—including performing forensic exams on sexual assault victims. Some sex-offender physicians then go on to assault additional patients. The physician lobby—including the American Medical Association—and some state licensing authorities have resisted efforts to increase protections against sex-offender physicians.

A 2021 investigation found that the California Medical Board had reinstated the licenses of 10 physicians it had suspended for sexual assault since 2013. New York State convicted physician Shahab Ataee of sexual abuse in 2001 and revoked his license. California’s licensing board subsequently rejected his application three times, citing his history of sexual abuse. In 2009, on Ataee’s fourth attempt, California’s licensing board relented. By 2012, he faced further accusations of sexual misconduct that led to a $1 million settlement—that is, the courts held him accountable where licensing authorities had not. The board took no action until 2016, when still more accusations emerged from multiple patients. The board ultimately revoked his license in 2019. The investigation found California’s board was more likely to reinstate a license if the physician had lost it because of sexual misconduct (59 percent of cases) than for “fraud, substance abuse, gross negligence,” or other reasons (45 percent).¹⁷⁷ In 2022, California lawmakers stripped the board of the power to reinstate licenses after sexual assault convictions.¹⁷⁸

The problem is nationwide. A 2016 investigation by the Atlanta Journal-Constitution found that although “many, if not most, cases of physician sexual misconduct remain hidden … of the 2,400 doctors publicly disciplined for sexual misconduct [with a patient], half still have active medical licenses.”¹⁷⁹ In some states, it is significantly more than half. “Georgia and Kansas … allowed two of every three doctors publicly disciplined for sexual misconduct to return to practice, orders on board websites show. In Alabama, it was nearly three out of every four. In Minnesota, it was four of every five.”¹⁸⁰

Examples include physician William Almon, who “admitted that he had sex with a hospitalized patient” while a psychiatric resident. The victim “was found immediately afterward on the floor of her hospital room, curled up and crying.” He faced multiple subsequent charges for sexual misconduct, including with a 14-year-old patient. He ultimately pleaded guilty to sexual battery but avoided jail time. The Georgia medical board took two years to sanction him, then forbade him to see female patients for four years. That restriction was lifted in 2011.¹⁸¹

Seventeen women accused Texas physician Philip Leonard of sexual misconduct. The medical board president called Leonard’s behavior “clearly an abuse of his power over these women.” The board initially suspended his license, then reversed itself, instead prohibiting him from seeing female patients for 10 years. That restriction was lifted in 2014.¹⁸²

As in California, state licensing officials in several states have often ignored other regulators’ findings of sexual misconduct and even their own findings:

Maryland physician Michael Rudman “managed to keep his license for [decades], despite a parade of patients who said they were molested, as he contested board orders.” In 2006, the board suspended, partially reinstated, then revoked his license. Since Rudman plea-bargained a sexual assault charge down to simple assault, however, Maryland’s licensing law allowed a judge to reinstate his license. By the time the board revoked his license again in 2012, seven more patients had accused Rudman of sexual abuse.¹⁸⁴

In 2006, Nevada police arrested physician Binh Minh Chung after accusations of “open and gross lewdness with a 15-year-old patient.” The Nevada board “issued only a ‘letter of concern’ that was supposed to be a nonpublic reprimand.… In 2015, Chung’s wife discovered video of him having sex with unconscious women and a minor in his office.”¹⁸⁵

Physician Jorge Ysacc Burgos “was permitted to return to practice … in Nevada after he was found guilty in 2017 of three misdemeanor charges of open or gross lewdness involving patients.”¹⁸⁶

North Carolina’s board lifted restrictions on physician Tuong D. Nguyen “in 2005, a year after being arrested and getting deferred prosecution for allegedly stroking a patient’s penis and [exposing] his own during two exams, telling one patient he wanted to ‘compare.’ … In 2016, Nguyen was criminally charged with touching another patient in a similar manner.”¹⁸⁷

In the same states that now regulate SANEs, the 2016 investigation found that licensing laws took an institutionally lax posture toward physician sexual misconduct. In Alabama, “state law does not require courts to report criminal convictions to the board.” Licensing laws in Alabama, Kentucky, Nevada, and New Jersey give boards discretion about whether to revoke licenses due to convictions for sexual misconduct, rather than make such revocations mandatory. Licensing laws in Alabama, Illinois, Kentucky, and North Carolina let boards decide whether to report criminal activity to law enforcement, rather than make such disclosures mandatory.¹⁸⁸ Illinois’s licensing law requires sexual assault victims to furnish “clear and convincing evidence to prove a disciplinary case against a doctor” rather than the lower “preponderance of evidence” standard most states require.¹⁸⁹ Licensing laws in Illinois, Kentucky, and Maryland let boards decide whether to deny licenses to physicians whom other states have sanctioned because of sexual misconduct, rather than make such denials mandatory. Licensing laws in Maryland and North Carolina do not require doctors to report possible violations by colleagues.¹⁹⁰

Efforts to adopt a zero-tolerance policy toward physician sexual misconduct encounter resistance from the physician lobby. The American Medical Association represents physicians and was instrumental in the establishment of clinician licensing.¹⁹¹ The organization “does not favor the automatic revocation of the medical license of every doctor who commits sexual abuse of a patient. It does not expel every offender from its membership rolls, and it has never independently researched the prevalence of sexual abuse in clinical settings.” On the contrary, it “fought to keep confidential a federal database of physicians disciplined for sexual misconduct and other transgressions.”¹⁹²

An investigation by the Atlanta Journal-Constitution found that some state licensing officials defend this lax posture:

A form of regulation that ignores, minimizes, and facilitates sexual assault is a poor tool for protecting sexual assault victims from low-quality forensic exams.

Licensing requirements for clinician specialties exhibit an odd pattern that provides further evidence that this form of regulation prioritizes something other than quality or patient safety. States frequently require advanced practice registered nurses to obtain additional licenses to practice in a specialty.¹⁹⁴ Yet states almost never require either physicians or RNs to do so, except for sexual assault exams. This pattern is more consistent with protecting incumbent physicians from competition than promoting quality.

States more often require mid-level clinicians to obtain an additional government license before practicing a specialty than they require RNs or physicians to do so. In contrast to Figure 2, Figure 3 shows that SANEs stand out as the only specialty for which some states require RNs to obtain an additional license to practice. Figure 4 shows that 46 states require APRNs to obtain an additional government license to practice in a specialty. Figure 5 shows that states do not require physicians to obtain an additional license to practice a specialty. In every state, a physician who has practiced psychiatry for 25 years can switch to surgery and advertise his or her surgical services without any formal training in the field. No state would require that physician to obtain an additional license. The same is true for surgeons who switch to psychiatry—or pathology, occupational medicine, or any other specialty. Figure 6 illustrates the exception that proves that rule. Only Illinois now requires physicians to obtain an additional license to perform sexual assault exams.

If lawmakers truly cared about promoting quality, and government licensing were a tool for promoting quality, one would expect states to be more likely to require physicians to obtain an additional license if they wished to practice in a specialty relative to other clinicians. Physicians have greater authority and make much higher-stakes decisions than other clinicians. Yet states are more likely to regulate mid-level clinicians, who have less authority and who make lower-stakes decisions. Curiously, states consider private, voluntary specialty certification sufficient where the stakes are higher (physicians) but insufficient where the stakes are lower (mid-level clinicians).

It is difficult to reconcile this pattern with the goal of quality assurance. Arguments that governments should license APRN specialties also apply to RN specialties. Yet states make specialty certifications compulsory for the former and not the latter. One might argue that compulsory licensing of physician specialties is unnecessary because physicians have already received so much more education than other clinicians. But if an MD or DO degree were sufficient to ensure competence across all specialties, voluntary certification for physician specialties would be unnecessary. There would be no need for hospitals, health insurance companies, or medical malpractice liability insurers to rely on such certifications. Yet scores of voluntary certifications exist, and private actors rely on those certifications.

Regardless of the intent of its supporters, government licensing behaves as if its actual purpose is not to promote quality but to protect incumbent physicians by erecting barriers to new physicians and mid-level clinicians who would compete with them. The notion that licensing serves the interests of patients carries less explanatory power than the idea that licensing primarily serves the interest of incumbent physicians by protecting them from competition from new entrants into their profession.

Ideally, states should repeal all health professional occupational licensing laws. Licensing laws do little to protect the public from poor-quality care. On the contrary, licensing reduces access to care by increasing prices and in many ways reduces health care quality.¹⁹⁵

Alternatively, states could accredit multiple competing third-party certification organizations to perform licensing boards’ functions.¹⁹⁶ Such organizations could review the credentials, education, and real-world experience of domestic and international applicants and certify them as competent to provide various health care services. Christina Sandefur, Byron Schlomach, and Murray Feldstein have proposed a voluntary alternative pathway involving third-party certification that could coexist with state licensing schemes and gradually replace them.¹⁹⁷

Alternatively, or concurrently, states can mimic a system of private third-party certification by recognizing clinician licenses issued by other states.¹⁹⁸ Arizona and many other states have taken steps in that direction.¹⁹⁹

At a minimum, states should refrain from regulating new health professions or specialties. Licensing regulation interrupts the natural market processes of specialization, division of labor, quality assurance, and right-skilling. The District of Columbia and the 44 states that do not require SANEs to obtain a government license should reject lawmakers’ efforts to impose such requirements. The six states that limit the availability of sexual assault forensic exams by requiring RNs to obtain an additional government license should remove those regulations. Just as states neither require MDs and DOs to obtain an additional government license to practice in a specialty nor require RNs to obtain an additional government license to practice in the other 100 or so nursing specialties, they should not require SANEs to obtain an additional government license.

Scientific advances have allowed entrepreneurs in the medical and nursing professions to develop specialties, subspecialties, and entities that train and credential clinicians in these fields as health care challenges evolve. Compassionate innovators in the nursing profession pioneered the SANE specialty. With national sexual assault rates exceeding 500,000 persons per year and far too few clinicians to perform sexual assault forensic exams, state lawmakers should avoid erecting barriers to nurses wishing to specialize as SANEs. States that have already installed these roadblocks should remove them.

A regulatory tool that allows sex offenders to perform sexual assault exams is not the right model for protecting sexual assault victims.

Table A1 details the restrictions that Alabama, Illinois, Kentucky, Maryland, New Jersey, and North Carolina impose on RNs who would perform sexual assault forensic exams.

The authors thank Emma Taylor, Lexie Stadler, Valeria Li, and Adetola Babalola for their contributions. The authors dedicate this study to the memory of Cato adjunct scholar Shirley V. Svorny, PhD, who identified and hoped to investigate this important topic.

Singer, Jeffrey A., Akiva Malamet, Spencer Pratt, and Michael F. Cannon. “Licensing Requirements Would Block Care and Justice for Sexual Assault Victims,” Policy Analysis no. 1005, Cato Institute, Washington, DC, October 1, 2025.