When a survivor of sexual assault seeks help at a hospital, every minute counts — for both healing and justice. Yet, out of 48 hospital emergency departments in Maryland, only half have forensic nurses as of 2024, and even fewer serve patients aged 12 and under. Survivors often must visit multiple hospitals to get the forensic exam they need. Maryland’s shortage of Sexual Assault Nurse Examiners (SANEs) is so severe that a state committee recently suggested a telehealth solution: a pilot program allowing licensed examiners to guide non-specialist nurses remotely through rape kit evidence collection.

That temporary fix highlights the problem. Maryland is one of only six states that requires nurses to obtain a special license to perform these exams. This barrier keeps capable professionals on the sidelines, leaving victims waiting when they need care most.

The profession of SANEs began when entrepreneurial nurses, starting in the 1970s, recognized the need to provide trauma-informed care to sexual assault victims and to collect forensic evidence that supports prosecution. By the 1990s, SANEs gathered at the University of Minnesota to establish a professional organization focused on education, certification and credentialing — the International Association of Forensic Nurses. It was the first among several similar third-party certification and educational organizations.

In a recent Cato Institute policy analysis, my colleagues and I present evidence showing SANEs are more effective than other health professionals in providing care, collecting forensic evidence and testifying in court. SANEs are also associated with higher conviction rates.

However, in Maryland and five other states — Alabama, Illinois, Kentucky, New Jersey and North Carolina — licensing requirements force skilled nurses to undergo costly and unnecessary steps before they can treat victims. The result: fewer SANEs, longer waits and more trauma for people already enduring the worst moments of their lives. Yet, except for Illinois, all these states allow licensed physicians to perform sexual assault forensic exams, even if they lack training or experience.

Licensing not only adds bureaucratic hurdles, but it also hampers innovation. For example, tele-SANE programs connect rural victims with qualified examiners based at medical centers in other parts of the country. However, even Maryland’s own telehealth pilot program is limited by licensing rules that prevent qualified out-of-state examiners from assisting.

The consequences go beyond delays and inefficiency. Our paper shows that licensing boards have a history of reinstating physicians convicted of sexual misconduct even as they restrict qualified nurses from practicing. A regulatory tool that allows sex offenders to perform sexual assault exams is not the right model for protecting sexual assault victims.

In 2014, Maryland began restricting RNs from conducting sexual assault forensic exams unless they have a “forensic nurse examiner” license. In 2017, the Maryland General Assembly established the Sexual Assault Evidence Kit Policy and Funding Committee (SAEK), which pointed out a shortage of forensic nurse examiners — leaving many sexual assault survivors without timely access to evidence collection.

Instead of following the path of 44 other states that rely on voluntary standards, the SAEK committee recommended a pilot program where licensed SANEs within the state would assist unlicensed ones via telehealth technology. In 2024, the Maryland General Assembly passed legislation requiring the committee to evaluate the feasibility of developing a telehealth pilot program and set aside funding if the idea proved workable. By the end of the year, the committee concluded the pilot was indeed feasible.

Although the legislation shows progress in liberalizing telehealth, the reforms do not address the structural barriers caused by forensic nurse examiner licensing. Maryland still prohibits RNs from performing sexual assault forensic exams, even when a licensed forensic nurse examiner remotely supervises and guides them.

To be sure, licensing laws are not the only obstacle SANEs face. Certificate-of-need laws also limit access by restricting and slowing the process of opening new hospitals and health care facilities. Inadequate funding makes training programs less affordable. Government funding of SANEs programs is justifiable as a law enforcement expenditure. But our paper focuses on licensing because licensing directly blocks victims from receiving timely care.

Maryland survivors should never be left waiting or turned away because lawmakers chose red tape over care. Lawmakers should end SANE licensing, allowing hospitals and professional bodies to ensure quality, and let nurses return to helping victims when every minute counts.