# Licensing Requirements Would Block Care and Justice for Sexual Assault Victims October 1, 2025 • Policy Analysis No. 1005 By [Jeffrey A. Singer](https://www.cato.org/people/jeffrey-singer), Akiva Malamet, [Spencer Pratt](https://www.cato.org/people/spencer-pratt), & [Michael F. Cannon](https://www.cato.org/people/michael-f-cannon) ![Licensing Requirements PA Nurse](/sites/cato.org/files/styles/aside_3x/public/2025-09/GettyImages-2201681286.jpg?itok=T7Z2f46j) [ Download PDF ](https://www.cato.org/sites/cato.org/files/2025-09/PA%201005.pdf) Sexual assault is a deeply traumatic experience. The emotional toll often includes feelings of shame, guilt, and fear, contributing to a sense of powerlessness and vulnerability. Survivors may grapple with post-traumatic stress disorder, anxiety, depression, and other mental health challenges. Sexual assault victims typically seek care at hospital emergency departments mere hours after the most traumatic event of their lives. 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. ## Introduction > When Leah Griffin regained consciousness in her apartment on the morning of April 10, 2014, she knew she had been sexually assaulted. Bleeding from her groin and still feeling the effects of what she would later learn was Xanax placed in her drink the night before, she drove herself to the hospital.… > > But when she walked into Swedish Medical Center Ballard and told the staff at the \[emergency room\] desk she had been raped, she said she was informed that the hospital did not “do rape kits”—the forensic exams conducted after a sexual assault. The main hospital that did perform them, Harborview Medical Center, was more than six miles across town. > > Confused and exasperated, Griffin drove herself home.… > > Griffin ultimately did make her way to Harborview more than 12 hours later, when she was still bleeding. There, she said she waited several hours for a nurse trained in examining sexual assault patients to be available, before finally being examined.… > > Griffin’s attacker, who she met at a bar, was never charged.[1](#_edn1) 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](#_edn2) 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](#_edn3) ![Copy: Figure 1 SANE PA: Number of forcible rape and sexual assault victims in the US](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/b65ffc6d-b3d9-4064-a57c-2ef6ec302832.jpg) 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](#_edn4) 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](#states-create-barriers-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](#_edn5) 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](#_edn6) If possible, victims should also not eat.[7](#_edn7) 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 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. ## What Are SANEs? 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](#_edn8) 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](#_edn9) 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](#_edn10) SANEs undergo special training to collect medical evidence and testify in court.[11](#_edn11) 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](#_edn12) 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](#_edn13) SANEs connect patients to victim-advocacy organizations and law enforcement.[14](#_edn14) The Health Insurance Portability and Accountability Act of 1996 requires SANEs to ensure patient and medical confidentiality.[15](#_edn15) If courts call SANEs to testify as experts or fact witnesses, they provide neutral, impartial information.[16](#_edn16) 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](#_edn17) 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](#_edn18) Studies suggest that SANEs provide comprehensive, compassionate care with clear explanations and choices.[19](#_edn19) 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](#_edn20) 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](#_edn21) 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](#_edn22) 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](#_edn23) Prosecutors report that SANEs contributed to convictions through detailed documentation, comprehensive physical examination, adept trial preparation and testimony, and credibility with jurors.[24](#_edn24) 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](#_edn25) Other studies find similar results.[26](#_edn26) ## Creation of New Clinician Specialties 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](#_edn27) 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](#_edn28) 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](#_edn29) Dentists in New Zealand created the dental therapist specialty in 1921.[30](#_edn30) 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](#_edn31) NPs, in turn, have developed 13 subspecialties to meet the various needs of different patient populations.[32](#_edn32) 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](#_edn33) 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](#_edn34) - 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](#_edn35) - 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](#_edn36) ### Voluntary Certification Protects and Improves Quality 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](#_edn37) These independent third parties arguably play a greater role than licensing boards in protecting patients from poor-quality practitioners.[38](#_edn38) For physicians, specialty board certification is voluntary.[39](#_edn39) 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](#_edn40) 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](#_edn41) No states require CCRN certification, but many hospitals and organizations reward certification with higher salaries, leadership opportunities, and exam reimbursement.[42](#_edn42) 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](#_edn43) The boards compete on quality indicators of training and competence, enabling nurses and employers to select the programs they prefer.[44](#_edn44) With the sole exception of SANEs, however, no states require RNs to obtain an additional license to practice a specialty (Figure 2). ![Copy: Figure 2 SANE PA: Registered nurses do not require specialty certification](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/19ee2d46-958b-4a67-a00c-634f51b2e4b8.jpg) ## Creation of the SANE Specialty 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](#_edn45) 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](#_edn46) 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](#_edn47) The IAFN has certified more than 2,500 SANEs.[48](#_edn48) 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](#_edn49) 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](#_edn50) 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](#_edn51) The New York and Maine Departments of Health create standards and certify examiners to provide sexual assault examinations.[52](#_edn52) 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](#_edn53) 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](#_edn54) ### Voluntary Certification Enables Right-Skilling 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](#_edn55) 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](#_edn56) 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. ### Voluntary Certification Fosters Innovation, Regulation Blocks It 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](#_edn57) 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](#_edn58) 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](#_edn59) 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](#_edn60) 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](#_edn61) 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](#_edn62) 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](#_edn63) 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](#_edn64) 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](#_edn65) As with explicit licensing regulation, states with training requirements—that is, Alabama and North Carolina—also block qualified tele-SANEs from guiding exams.[66](#_edn66) 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](#_edn67) 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. ### Why Nurses? 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](#_edn68) 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](#_edn69) 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](#_edn70) 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](#_edn71) Women make up 83 percent of victims.[72](#_edn72) Eighty-six percent of nurses are women, whereas only 38 percent of physicians are.[73](#_edn73) 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](#_edn74) 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](#_edn75) ## States Create Barriers to Competent Sexual Assault Examiners 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](#_edn76) 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](#_edn77) 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](#_edn78) 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](#_edn79) 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](#_edn80) License fees range from $25 to $200 and come on top of fees for training programs and private certification.[81](#_edn81) License renewal fees range from $50 annually to $146 every two years.[82](#_edn82) Some states require criminal background checks, which duplicate employer background checks.[83](#_edn83) 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](#_edn84) 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. When government restricts what training it recognizes, it compels nurses to choose programs that may be incompatible with their lives, needs, and aptitudes. 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](#_edn85) 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](#_edn86) 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. ### Licensure Exacerbates SANE Burnout 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](#_edn87) 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](#_edn88) 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](#_edn89) 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: A Case Study in Reform 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](#_edn90) 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](#_edn91) 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](#_edn92) 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](#_edn93) 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](#_edn94) In 2012, Nevada Attorney General Catherine Cortez Masto (now a US senator from Nevada) petitioned the board to remove onerous prerequisites.[95](#_edn95) 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](#_edn96) 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](#_edn97) 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](#_edn98) 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](#_edn99) 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](#_edn100) 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](#_edn101) 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](#_edn102) 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](#_edn103) Eliminating regulatory barriers to nursing practice would allow Nevada to expand the supply of nursing services and enhance access to forensic exams.[104](#_edn104) ### SANE Data by State 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](#_edn105) 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](#_edn106) 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](#_edn107) 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](#_edn108) #### Alabama Since 2009, Alabama has required nurses to complete a mandatory educational program before providing sexual assault forensic exams.[109](#_edn109) 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](#_edn110) 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](#_edn111) 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: > I personally have decades of practice with thousands of patients, reviewing charts and photographs, and training and supervising nurses caring for tens of thousands of patients. I suspect I would have difficulty practicing in Alabama, even though I am certified thrice, and SANEs use my extensive research and publications to support their practices.[112](#_edn112) 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](#_edn113) 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](#_edn114) Official state data indicate there were 54 reported rapes in Baldwin County in 2019.[115](#_edn115) 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](#_edn116) 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](#_edn117) Kathryn Loveless, a SANE in Mobile, explains: > Making the journey from Baldwin County \[to Mobile\] is typically what’s going to dissuade somebody … to make that extra effort, especially when you’re bringing in other circumstances of transportation, getting all the way from wherever they present to across the bay over here, and then having to wait to see a physician to call the SANE nurse, which we typically get there in about an hour. It’s a day trip.[118](#_edn118) 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](#_edn119) “It just feels like I’m helpless … just kind of powerless,” the victim from Fairhope said. “I’m just disappointed in humanity.”[120](#_edn120) #### Illinois 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](#_edn121) 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](#_edn122) 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](#_edn123) 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](#_edn124) 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](#_edn125) 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](#_edn126) In 2023, the city of Anna, Illinois, had a population of 4,136.[127](#_edn127) 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](#_edn128) Illinois’s licensing regulations increased the barriers each of these victims faced. #### Kentucky Since 1997, Kentucky has required RNs to obtain a SANE license to perform forensic exams.[129](#_edn129) 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](#_edn130) 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](#_edn131) 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: > SANE nurses are working in just one-third of Kentucky’s 120 counties.… Many of the state’s SANE nurses are clustered at a few hospitals, leaving large swaths of the state without that specialized care.… Half of the hospitals with SANE nurses … rely on just one nurse to respond to all calls.… And sometimes, multiple hospitals in different counties rely on the same nurse.[132](#_edn132) Observers report that hospitals in Kentucky have been turning away sexual assault victims because the hospitals do not have licensed SANEs available.[133](#_edn133) 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](#_edn134) 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. #### Maryland In 2014, the state of Maryland began prohibiting RNs from performing forensic exams unless they obtain a “forensic nurse examiner” license.[135](#_edn135) 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](#_edn136) 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](#_edn137) Later that year, the legislature found that “There is a shortage of forensic nurse examiners qualified to perform sexual assault evidence collection.”[138](#_edn138) 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](#_edn139) 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](#_edn140) 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](#_edn141) 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](#_edn142) 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](#_edn143) 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](#_edn144) 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. #### New Jersey 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](#_edn145) After RNs complete extensive educational and clinical training, they must meet state “Forensic Nurse–Certified Sexual Assault” requirements.[146](#_edn146) 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](#_edn147) Consequently, exams become more difficult to obtain. US Representative Frank Pallone (D‑NJ) commented in 2020: > In some cases, victims must travel over an hour to a facility with a trained examiner. In 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. This is unacceptable, and we must find ways to make these services more widely available.[148](#_edn148) Pallone was describing the availability of SANE services in states without licensing regulation.[149](#_edn149) 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](#_edn150) #### North Carolina Since 1981, North Carolina has forbidden RNs and NPs from providing sexual assault forensic exams unless they complete a state-approved training program.[151](#_edn151) North Carolina prohibits nurses from performing forensic exams unless they complete state-mandated educational and clinical training requirements.[152](#_edn152) The North Carolina Board of Nursing lists approved programs.[153](#_edn153) 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](#_edn154) The Carolina Public Press found that no state government body tracks how many SANEs are practicing or where they are located.[155](#_edn155) 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](#_edn156) 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: > SANE training is not readily available, is costly and is difficult to complete while working full time.… Our organization is extremely supportive of staff attending SANE training and receiving this education, but once the classroom piece is complete, there are clinical requirements that must be done within a specified time frame, and oftentimes, those requirements can be a challenge.[157](#_edn157) 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](#_edn158) 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](#_edn159) ## Regulation Does Not Increase Protections for Sexual Assault Victims 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](#_edn160) 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](#_edn161) 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](#_edn162) Malpractice insurance carriers often refuse to cover or charge higher premiums to physicians who lack certification in their specialty.[163](#_edn163) Skilled plaintiffs’ attorneys can point to physicians’ lack of board certification to diminish the physicians’ credibility in malpractice lawsuits.[164](#_edn164) 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. ### Licensing Reduces Access 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](#_edn165) 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. 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](#_edn166) 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](#_edn167) 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](#_edn168) 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](#_edn169) 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](#_edn170) Were Pennsylvania lawmakers to require nurses to obtain IAFN certification, it would cement those barriers in place. ##### Related Media [ Download Episode ](https://feeds.acast.com/public/streams/5e28e0d8963f166217546493/episodes/67575322d59c6635eebb4495.mp3)Subscribe: [ Apple Podcasts ](http://itunes.apple.com/podcast/cato-daily-podcast/id158961219) [ Spotify ](https://open.spotify.com/show/4dHRhKEljj8zcLdl3Gvsv7) ### Licensing Prevents Innovation and Right-Skilling 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](#_edn171) Unnecessary requirements block entry by additional SANEs and block access to competent, compassionate sexual assault exams.[172](#_edn172) ### Licensing: Not the Guarantor of Quality That Supporters Claim 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](#_edn173) State licensing regulation further blocks access to high-quality international medical graduates.[174](#_edn174) Many states’ licensing laws block competent physicians, dentists, and nurses even from providing free medical care to the poor.[175](#_edn175) 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](#_edn176) 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. ### Blocking Good Nurses, Not Bad Doctors 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](#_edn177) In 2022, California lawmakers stripped the board of the power to reinstate licenses after sexual assault convictions.[178](#_edn178) 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](#_edn179) 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](#_edn180) 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](#_edn181) 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](#_edn182) As in California, state licensing officials in several states have often ignored other regulators’ findings of sexual misconduct and even their own findings: > Alabama revoked Dr. Oscar Almeida Jr.’s license in 2002 after four female patients complained of various improprieties, including fondling and kissing and inappropriate vaginal exams.… > > A year later, Almeida applied for a Mississippi license. His request was approved, with the State Board of Medical Licensure saying the doctor “would be an asset to the State of Mississippi.” In 2007, Alabama reinstated Almeida’s license. Its order cites his boundary training and says “it would be a great loss to the medical community, and to the public in general, if a physician of Dr. Almeida’s obvious skill and ability would never again be able to practice medicine.”[183](#_edn183) 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](#_edn184) 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](#_edn185) 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](#_edn186) 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](#_edn187) 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](#_edn188) 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](#_edn189) 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](#_edn190) 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](#_edn191) 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](#_edn192) An investigation by the *Atlanta Journal-Constitution* found that some state licensing officials defend this lax posture: > Larry Dixon, the executive director of the Alabama Board of Medical Examiners, has heard the argument that doctors who engage in sexual misconduct should be barred from practice. He doesn’t buy it. > > “If you graduate a class of more than 100 people out of the University of Alabama medical school, the resources that have been poured into that education almost demand that you try to salvage that physician—if it’s possible,” said Dixon, who has led the Alabama board for 35 years.[193](#_edn193) 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. ### The Odd Pattern of Specialty Licensing 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](#_edn194) 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. ![Copy: Figure 3 SANE PA: Sexual assault nurse examiners require state licensure](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/da1c546d-85d0-469d-b8fa-c26950ba5689.jpg) ![Copy: Figure 4 SANE PA: Advanced practice registered nurses require national certification](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/f7024ab4-a9d2-4fb0-8b14-f97847361d5d.jpg) ![Copy: Figure 5 SANE PA: Physicians do not require board certification](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/afc7bd17-8cf9-4c0e-a6e6-41e150bb7636.jpg) ![Copy: Figure 6 SANE PA: Physicians do not require sexual assault forensic examiner licensure](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/7858e716-9b56-4ec2-bfc0-05f7d80e93be.jpg) 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. ## Policy Recommendations 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](#_edn195) Alternatively, states could accredit multiple competing third-party certification organizations to perform licensing boards’ functions.[196](#_edn196) 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](#_edn197) Alternatively, or concurrently, states can mimic a system of private third-party certification by recognizing clinician licenses issued by other states.[198](#_edn198) Arizona and many other states have taken steps in that direction.[199](#_edn199) Licensing regulation interrupts the natural market processes of specialization, division of labor, quality assurance, and right-skilling. 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. ## Conclusion 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. ## Appendix 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. ![Copy: Appendix 1 SANE PA: State-specific barriers to SANEs](https://infogram-thumbs-1024.s3-eu-west-1.amazonaws.com/765756ab-2304-4be2-9a65-3c366f25f18e.jpg) ## Acknowledgments 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. ## Citation Singer, Jeffrey A., Akiva Malamet, Spencer Pratt, and Michael F. Cannon. “[Licensing Requirements Would Block Care and Justice for Sexual Assault Victims](https://www.cato.org/policy-analysis/licensing-requirements-would-block-care-justice-sexual-assault-victims),” Policy Analysis no. 1005, Cato Institute, Washington, DC, October 1, 2025. [![PA 1005 Cover](/sites/cato.org/files/styles/serial_cover_phone/public/2025-09/policy-analysis-1005-cover.png?itok=9IEn-My8)](https://www.cato.org/sites/cato.org/files/2025-09/PA%201005.pdf) ### Download This Policy Analysis ##### Licensing Requirements Would Block Care and Justice for Sexual Assault Victims [ Download PDF ](https://www.cato.org/sites/cato.org/files/2025-09/PA%201005.pdf) ##### About the Authors [![jeff-singer-cropped.jpg](/sites/cato.org/files/styles/author_picture/public/2024-05/jeff-singer-cropped.jpg?itok=G_0nEnx7)](/people/jeffrey-singer) ##### [Jeffrey A. Singer](/people/jeffrey-singer) Senior Fellow, Cato Institute [ ](https://x.com/dr4liberty) [ ](mailto:jsinger@cato.org) ![Akiva Malamet Cropped](/sites/cato.org/files/styles/author_picture/public/2025-07/Akiva%20Malamet%20Cropped.png?itok=noJs8kSK) ##### Akiva Malamet Former Research Associate, Cato Institute [![spencer-pratt-cropped](/sites/cato.org/files/styles/author_picture/public/2023-04/spencer-pratt-cropped.jpg?itok=PQtB8DuE)](/people/spencer-pratt) ##### [Spencer Pratt](/people/spencer-pratt) Research Associate, Cato Institute [![Michael F. Cannon](/sites/cato.org/files/styles/author_picture/public/2021-01/Michael%20Cannon.jpg?itok=0UROn8Dc)](/people/michael-f-cannon) ##### [Michael F. Cannon](/people/michael-f-cannon) Director of Health Policy Studies, Cato Institute [ ](https://x.com/mfcannon) [ ](mailto:mcannon@cato.org) Show Endnotes Hide Endnotes ##### Notes [1](#_ednref1). Adiel Kaplan et al., “After a Sexual Assault, Where Can You Get a Medical and Forensic Exam?,” NBC News, January 23, 2021. [2](#_ednref2). Alexandra Thompson and Susannah N. Tapp, [*Criminal Victimization, 2022*](https://bjs.ojp.gov/document/cv22.pdf) (US Department of Justice, 2023), p. 3. The US Department of Justice’s Bureau of Justice Statistics combines rape and sexual assault into one victimization measure. It defines “sexual assault” as encompassing “a wide range of victimizations, separate from rape or attempted rape,” including completed or attempted attacks, with or without force, that involve “unwanted contact between the victim and offender.” Bureau of Justice Statistics, “NCVS Dashboard (N‑DASH): Terms and Definitions,” US Department of Justice. [3](#_ednref3). Emily L. Vogt et al., “[Trends in US Emergency Department Use After Sexual Assault, 2006–2019](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797504),” *JAMA Network Open* 5, no. 10 (2022): 1–11. [4](#_ednref4). Rape, Abuse, and Incest National Network, “[Congress Moves to Address Critical Shortage of Sexual Assault Nurse Examiners; RAINN Partners on Bipartisan Legislation](https://www.rainn.org/news/congress-moves-address-critical-shortage-sexual-assault-nurse-examiners-rainn-partners),” news release, February 15, 2022. [5](#_ednref5). Camalot Todd, “[Nevada Among Handful of States Funding Strangulation Exams for Domestic Violence Victims](https://nevadacurrent.com/2023/10/19/nevada-among-handful-of-states-funding-strangulation-exams-for-domestic-violence-victims/),” *Nevada Current*, October 19, 2023; Serena Evans, policy director for the Nevada Coalition to End Domestic and Sexual Violence, “[Testimony on AB 276](https://www.leg.state.nv.us/App/NELIS/REL/82nd2023/ExhibitDocument/OpenExhibitDocument?exhibitId=64917&fileDownloadName=0320_AB276_evans.s_testsup.pdf)” before the Nevada State Assembly, March 20, 2023; Kate Martin, “[Rape Victims Need Help from Specialized Nurses, but No One in NC Keeps Track of Them](https://carolinapublicpress.org/41683/rape-victims-need-help-from-specialized-nurses-but-no-one-in-nc-keeps-track-of-them/),“ Carolina Public Press, January 25, 2021; Alex Stern, “[The Health Care Shortage That Impacts Victims of Sexual Assault](https://www.washingtonpost.com/gender-identity/the-health-care-shortage-that-impacts-victims-of-sexual-assault/),” *Washington Post*, June 27, 2017 (“… sexual assault victims may end up having to travel up to two hours to obtain an exam”); “[Some North Alabama Rape Victims Must Drive More Than 1 Hour for Rape Exam](https://www.waff.com/story/29620571/some-north-alabama-rape-victims-must-drive-more-than-1-hour-for-rape-exam/),” WAFF, July 23, 2015; and Joce Sterman et al., “[Sexual Assault Survivors May Lack Access to Specially Trained Nurses Due to National Shortage](https://upnorthlive.com/news/spotlight-on-america/sex-assault-survivors-may-lack-access-to-specially-trained-nurses-due-to-national-shortage),” UpNorthLive, November 5, 2020. [6](#_ednref6). Joce Sterman et al., “[Sexual Assault Survivors May Lack Access to Specially Trained Nurses Due to National Shortage](https://upnorthlive.com/news/spotlight-on-america/sex-assault-survivors-may-lack-access-to-specially-trained-nurses-due-to-national-shortage),” UpNorthLive, November 5, 2020. [7](#_ednref7). Camalot Todd, “[Nevada Among Handful of States Funding Strangulation Exams for Domestic Violence Victims](https://nevadacurrent.com/2023/10/19/nevada-among-handful-of-states-funding-strangulation-exams-for-domestic-violence-victims/),” *Nevada Current*, October 19, 2023; and Serena Evans, policy director for the Nevada Coalition to End Domestic and Sexual Violence, “[Testimony on AB 276](https://www.leg.state.nv.us/App/NELIS/REL/82nd2023/ExhibitDocument/OpenExhibitDocument?exhibitId=64917&fileDownloadName=0320_AB276_evans.s_testsup.pdf)” before the Nevada State Assembly, March 20, 2023. [8](#_ednref8). Kathleen Gaines, “[How to Become a Sexual Assault Nurse Examiner (SANE)](https://nurse.org/resources/SANE-nurse/),” Nurse​.org, January 9, 2024. [9](#_ednref9). Office for Victims of Crime, “[Are SANE Programs Effective?](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/are-sane-programs-effective/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [10](#_ednref10). Rebecca Campbell et al., “[Responding to Sexual Assault Victims’ Medical and Emotional Needs: A National Study of the Services Provided by SANE Programs](https://onlinelibrary.wiley.com/doi/10.1002/nur.20137),” *Research in Nursing and Health* 29, no. 5 (2006): 384–98; “[Medical Forensic Exam](https://aurora.umn.edu/get-help/medical-forensic-exam),” Aurora Center, University of Minnesota; Kathleen Gaines, “[How to Become a Sexual Assault Nurse Examiner (SANE)](https://nurse.org/resources/SANE-nurse/),” Nurse​.org, January 9, 2024; Office for Victims of Crime, “[Are SANE Programs Effective?](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/are-sane-programs-effective/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016); and A. C. Ciancone et al., “[Sexual Assault Nurse Examiner Programs in the United States](https://pubmed.ncbi.nlm.nih.gov/10736121/),” *Annals of Emergency Medicine* 35 , no. 4 (2000): 353–57. [11](#_ednref11). Nurse​.org Staff, “[How to Become a Forensic Nurse](https://nurse.org/resources/forensic-nurse/),” Nurse​.org, September 29, 2023; and A. C. Ciancone et al., “[Sexual Assault Nurse Examiner Programs in the United States](https://pubmed.ncbi.nlm.nih.gov/10736121/),” *Annals of Emergency Medicine* 35, no. 4 (2000): 353–57. [12](#_ednref12). “[Medical Forensic Exam](https://aurora.umn.edu/get-help/medical-forensic-exam),” Aurora Center, University of Minnesota. [13](#_ednref13). Rape, Abuse, and Incest National Network, “What Is a Sexual Assault Forensic Exam?” [14](#_ednref14). Office for Victims of Crime, “[Are SANE Programs Effective?](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/are-sane-programs-effective/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [15](#_ednref15). Health Insurance Portability and Accountability Act of 1996, [Pub. L. No. 104–191, 110 Stat. 1936 (1996)](https://www.congress.gov/104/plaws/publ191/PLAW-104publ191.pdf). [16](#_ednref16). Office for Victims of Crime, “[SANE Testimony](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/identifying-essential-components-of-a-sane-program/sane-testimony/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [17](#_ednref17). Office for Victims of Crime, “[Program Models](https://web.archive.org/web/20241229053628/https:/www.ovcttac.gov/saneguide/building-a-sustainable-sane-program/program-models/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [18](#_ednref18). Office for Victims of Crime, “[Are SANE Programs Effective?](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/are-sane-programs-effective/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [19](#_ednref19). Giannina Fehler-Cabral et al., “[Adult Sexual Assault Survivors’ Experiences with Sexual Assault Nurse Examiners (SANEs)](https://journals.sagepub.com/doi/abs/10.1177/0886260511403761),” *Journal of Interpersonal Violence* 26, no. 18 (2011): 3618–39; and Meredith Hollender et. al., “[Sexual Assault Nurse Examiners Lead to Improved Uptake of Services: A Cross-Sectional Study](https://pmc.ncbi.nlm.nih.gov/articles/PMC10527845/),” *Western Journal of Emergency Medicine* 11, no. 5 (2023): 974–82. [20](#_ednref20). Rebecca Campbell et al., “[A Participatory Evaluation Project to Measure SANE Nursing Practice and Adult Sexual Assault Patients’ Psychological Well-Being](https://pubmed.ncbi.nlm.nih.gov/18387006/),” *Journal of Forensic Nursing* 4, no. 1 (2008): 19–28. [21](#_ednref21). Megan Lechner et al., “[Perceived Care Quality Among Women Receiving Sexual Assault Nurse Examiner (SANE) Care: Results from a 1 Week Post Exam Survey in a Large Multisite Prospective Study](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122032/),” *Journal of Emergency Nursing* 47, no. 3 (2021): 449–58. [22](#_ednref22). Valeria Sievers et al., “[Sexual Assault Evidence Collection More Accurate When Completed by Sexual Assault Nurse Examiners: Colorado’s Experience](https://pubmed.ncbi.nlm.nih.gov/14631337/),” *Journal of Emergency Nursing* 29, no. 6 (2003): 511–14. [23](#_ednref23). Rebecca Campbell et al., [*Systems Change Analysis of SANE Programs: Identifying the Mediating Mechanisms of Criminal Justice System Impact*](https://nij.ojp.gov/library/publications/systems-change-analysis-sane-programs-identifying-mediating-mechanisms) (National Institute of Justice, 2009). [24](#_ednref24). Thaddeus Schmitt et al., “[Qualitative Analysis of Prosecutors’ Perspectives on Sexual Assault Nurse Examiners and the Criminal Justice Response to Sexual Assault](https://www.researchgate.net/publication/318019111_Qualitative_Analysis_of_Prosecutors%27_Perspectives_on_Sexual_Assault_Nurse_Examiners_and_the_Criminal_Justice_Response_to_Sexual_Assault),” *Journal of Forensic Nursing* 13, no. 2 (2017): 62–68. [25](#_ednref25). Rebecca Campbell, “[Impact of SANE Programs on Adult Sexual Assault Investigation and Prosecution—Presentation to NIJ](https://www.ojp.gov/ncjrs/virtual-library/abstracts/impact-sane-programs-adult-sexual-assault-investigation-and),” National Institute of Justice, March 2009. [26](#_ednref26). Nesa E. Wasarhaley et al., “[Mock Juror Perception of Sexual Assault Nurse Examiner Testimony](https://knowledgebank.criminaljustice.ny.gov/system/files/documents/2021/02/wasarhaleyetal.2012mockjurorperceptionofsanetestimony.pdf),” *Violence and Victims* 27, no. 4 (2012): 500–511; and Rebecca Campbell et al., “[The Impact of Sexual Assault Nurse Examiner Programs on Criminal Justice Case Outcomes: A Multisite Replication Study](https://pubmed.ncbi.nlm.nih.gov/24875379/),” *Violence Against Women* 20, no. 5 (2014): 607–25. [27](#_ednref27). See Michael Munger, “[Division of Labor](https://www.econlib.org/library/Enc/DivisionofLabor.html),” Library of Economics and Liberty, Liberty Fund Network, 2024. [28](#_ednref28). “[Specialty Profiles](https://careersinmedicine.aamc.org/explore-options/specialty-profiles),” Association of American Medical Colleges, 2025. [29](#_ednref29). Alfred C. Fones, “[The Origin and History of the Dental Hygienist Movement](https://www.sciencedirect.com/science/article/pii/S1048636426120143),” *Journal of the American Dental Association* 13, no. 12 (1926): 61. “I commented on the inordinate amount of time that such a system \[of prophylaxis\] would require in dental practice, and suggested that it might be possible to train a woman specially to perform this operation.… It was not until 1905 that, having evolved in 1901 a system of prophylactic treatments for use in my own office, I found it no longer feasible to carry on these treatments without aid, and I undertook the instruction of my office assistant, Mrs. Irene Newman.” In 1907, Fones secured legislation ensuring that Connecticut licensing laws “should not prevent dentists from employing assistants for the ‘so-called operation of cleaning teeth’” (p. 61). Fones credits C. M. Wright, DDS, with developing the idea of dental hygienists a quarter-century earlier, in 1877. See also C. M. Wright, “[A Plea for a Sub-Specialty in Dentistry](https://pmc.ncbi.nlm.nih.gov/articles/PMC10156230/),” *International Dental Journal* 23, no. 4 (1902): 235–38. [30](#_ednref30). Andrew I. Spielman, “[The Dental Therapist: A Century of Controversy](https://dental.nyu.edu/faculty/academy-of-distinguished-educators/jade/2023/a-century-of-controversy.html),” *Journal of the Academy of Distinguished Educators* 9, no. 1 (2023). [31](#_ednref31). Kasia Kovacs, “Guide to Nursing Specializations and Concentrations,” *NurseJournal*, updated October 3, 2023. [32](#_ednref32). “Advanced Practice Registered Nurse (APRN) Career Guide,” Nursing License Map, last updated October 21, 2023. [33](#_ednref33). American Board of Medical Specialties, “[What Is the Value of ABMS Board Certification?](https://www.abms.org/board-certification/value-of-board-certification/),” 2025. [34](#_ednref34). American Board of Medical Specialties, “[What Is the Value of ABMS Board Certification?](https://www.abms.org/board-certification/value-of-board-certification/),” 2025; Julie K. Johnson et al., “[Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work](https://www.ncbi.nlm.nih.gov/books/NBK43731/),” in *Advances in Patient Safety: New Directions and Alternative Approaches*, vol. 2, *Culture and Redesign*, ed. K. Henriksen et al. (Agency for Healthcare Research and Quality, 2008); and American College of Cardiology, “[Cardiovascular Organizations Pursue New, Independent Medical Board](https://www.acc.org/About-ACC/Press-Releases/2023/09/21/15/02/Cardiovascular-Organizations-Pursue-New-Independent-Medical-Board),” news release, September 21, 2023. [35](#_ednref35). American Board of Nursing Specialties, “[Resources and Research Initiatives](https://www.nursingcertification.org/resource/research),” 2025; and Lisa S. Lewis et al., “[Nursing Education Practice Update 2022: Competency-Based Education in Nursing](https://journals.sagepub.com/doi/full/10.1177/23779608221140774),” *SAGE Open Nursing* 8 (2022): 2. [36](#_ednref36). Leland Humbertson and Caitlin Davis, “[A Seat at the Table: The Story of the Growing Recognition of Dental Specialties](https://www.agd.org/constituent/news/2020/11/16/a-seat-at-the-table-the-story-of-the-growing-recognition-of-dental-specialties),” Ontario Academy of General Dentistry, November 16, 2020. [37](#_ednref37). Website of the American Board of Medical Specialties; website of the [American Board of Physician Specialties](https://www.abpsus.org/); website of [the National Board of Physicians and Surgeons](https://nbpas.org/); and American Osteopathic Association, “[AOA Board Certification](https://osteopathic.org/life-career/aoa-board-certification/),” 2025. [38](#_ednref38). See “[Jeffrey A. Singer Is the Speaker and Guest of Honor at the 14th Biannual Illinois Association of Prescribing Psychologists Networking Dinner](https://www.cato.org/multimedia/media-highlights-tv/jeffrey-singer-speaker-guest-honor-14th-biannual-illinois),” Media Highlights TV, Cato Institute, October 6, 2023. [39](#_ednref39). Brendan Murphy, “Licensing and Board Certification: What Residents Need to Know,” American Medical Association, April 8. 2025. [40](#_ednref40). Debra Beaulieu-Volk, “[Docs Practicing Outside Specialties Stir Controversy](https://www.fiercehealthcare.com/practices/docs-practicing-outside-specialties-stir-controversy),” *Fierce Healthcare*, February 1, 2012; and Kate Murphy, “[Ear Doctors Performing Face-Lifts? It Happens](https://www.nytimes.com/2012/01/31/health/non-specialists-expand-into-lucrative-cosmetic-surgery-procedures.html?_r=2),” *New York Times*, January 30, 2012. [41](#_ednref41). American Association of Critical-Care Nurses, “[CCRN (Adult)—Direct Care Eligibility Pathway](https://www.aacn.org/certification/get-certified/ccrn-adult),” 2025. [42](#_ednref42). Critical Care Academy, “[What Is the CCRN Certification and Why You Should Do It](https://www.ccrnacademy.com/what-is-the-ccrn-certification-and-why-you-should-do-it/),” 2025. A survey of nurse managers by the American Nurses Credentialing Center found “86 percent said they would hire a certified nurse over a non-certified nurse.” ANA Career Center Staff, “[Recruiters Look For](https://www.nursingworld.org/resources/individual/recruiters-look-for/),” ANA Enterprise, September 2014. In a study of the rate of falls in 48 intensive care units from a random sample of 29 hospitals, researchers found that the unit proportion of certified nurses inversely relates to the rate of falls. Deborah Kendall-Gallagher and Mary A. Blegen, “[Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units](https://pubmed.ncbi.nlm.nih.gov/19255100/),” *American Journal of Critical Care* 18, no. 2 (2009): 106–13. Lisette Hilton, “[Emergency Nurse Certification Helps Nurses Stand Out](https://www.nurse.com/blog/emergency-nurse-certification-helps-nurses-stand-out/),” *Nurse​.com* *Blog*, November 25, 2019. Board-certified acute and critical-care RNs receive a 10 percent discount on malpractice premiums from Mercer Health and Benefits Insurance Services, the world’s largest insurance broker. American Association of Critical Care Nurses, “[Certification Benefits Patients, Employers and Nurses](https://www.aacn.org/certification/value-of-certification-resource-center/nurse-certification-benefits-patients-employers-and-nurses),” 2025. [43](#_ednref43). ShiftMed Team, “[The Complete List of Specialty Nursing Certifications](https://www.shiftmed.com/blog/complete-list-of-specialty-nursing-certifications/),” ShiftMed, December 12, 2022; and Nurse​.org Staff, “[Complete List of Common Nursing Certifications](https://nurse.org/articles/nursing-certifications-credentials-list/),” Nurse​.org, March 8, 2024. [44](#_ednref44). “[Top Nursing Certifications You Should Have in 2022](https://nightingale.edu/blog/nursing-certifications.html),” *Nightingale College Blog*, January 5, 2022. To establish and maintain standards among certification boards, the National Commission for Certifying Agencies accredits specialty boards. Institute for Credentialing Excellence, “[NCCA Accreditation](https://www.credentialingexcellence.org/Accreditation/Earn-Accreditation/NCCA),” 2025. [45](#_ednref45). Office for Victims of Crime, “[History and Development of SANE Programs](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/history-and-development-of-sane-programs/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016). [46](#_ednref46). Office for Victims of Crime, “[History and Development of SANE Programs](https://web.archive.org/web/20241222224406/https:/www.ovcttac.gov/saneguide/introduction/history-and-development-of-sane-programs/),” in *SANE Program Development and Operation Guide* (US Department of Justice, Office of Justice Programs, 2016); International Association of Forensic Nurses, “[History of the Association](https://www.forensicnurses.org/page/AboutUS/),” 2025. [47](#_ednref47). International Association of Forensic Nurses, “[Exam Details](https://www.forensicnurses.org/page/ExamDetails),” 2025. [48](#_ednref48). International Association of Forensic Nurses, “Certification Central,” 2025. [49](#_ednref49). Forensic Nursing Certification Board, “[FNCB Certifications](https://goforensicncb.org/certification-types/),” 2024; and Academy of Forensic Nursing, “[AFN Learn](https://www.goafn.org/goafn-learn),” 2024. [50](#_ednref50). Vermont Forensic Nursing Program, “[About Us](https://www.vermontsane.org/about-2),” 2025; West Virginia Foundation for Rape Information and Services, “Sexual Assault Nurse Examiner (SANE),” 2020; and Florida Council Against Sexual Violence, “[Sexual Assault Nurse Examiner (SANE) Training](https://www.fcasv.org/sane),” 2021. [51](#_ednref51). Office of the Attorney General of Texas, “[Sexual Assault Nurse Examiner (SANE) Certification](https://www.texasattorneygeneral.gov/crime-victims/information-victim-services-professionals/sexual-assault-prevention-and-crisis-services-sapcs/sexual-assault-nurse-examiner-sane-certification),” 2025. [52](#_ednref52). New York State Department of Health, “[Sexual Assault Forensic Examiner (SAFE) Program Overview](https://www.health.ny.gov/professionals/safe/docs/program_overview_and_standards.pdf),” last revised October 2019; and State of Maine Sexual Assault Forensic Examiner Advisory Board, “[Standards to Obtain a Certificate of Completion for Sexual Assault Forensic Examiners Adult/​Adolescent and Pediatric](https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/State%20of%20Maine%20SAFE%20Standards%20for%20Credentialing%202024%20-%202027.pdf),” revised October 19, 2023. [53](#_ednref53). Commonwealth of Massachusetts, “[Apply for the Sexual Assault Nurse Training Certification Program](https://www.mass.gov/how-to/apply-for-the-sexual-assault-nurse-training-certification-program),” 2025. [54](#_ednref54). Information received through correspondence with the Massachusetts SANE Program (copy in author’s files). [55](#_ednref55). Shirley Svorny and Michael F. Cannon, “[Health Care Workforce Reform: COVID-19 Spotlights Need for Changes to Clinician Licensing](https://www.cato.org/policy-analysis/health-care-workforce-reform-covid-19-spotlights-need-changes-clinician-licensing),” Cato Institute Policy Analysis no. 899, August 4, 2020. [56](#_ednref56). Maryland Coalition Against Sexual Assault, “[Getting Medical Attention](https://mcasa.org/survivors/getting-medical-attention),” 2025. [57](#_ednref57). Kaiser Health News, “[Telehealth Brings Expert Sexual Assault Exams to Rural Patients](https://carolinapublicpress.org/58602/telehealth-brings-expert-sexual-assault-exams-to-rural-patients/),” Carolina Public Press, January 9, 2023; and Kristen J. MacLeod et al., “[Using Telemedicine to Improve the Care Delivered to Sexually Abused Children in Rural, Underserved Hospitals](https://publications.aap.org/pediatrics/article-abstract/123/1/223/71918/Using-Telemedicine-to-Improve-the-Care-Delivered?autologincheck=redirected),” *Pediatrics* 123, no. 1 (2009): 223–28. [58](#_ednref58). Commonwealth of Massachusetts National TeleNursing Center, “About the National TeleNursing Center,” last updated September 21, 2023; Institute for Digital Health and Innovation, “[Hospitals/​Clinics](https://idhi.uams.edu/telesane/providers/hospitals-clinics/),” University of Arkansas for Medical Sciences; Sheridan Miyamoto et al., “[Impact of Telemedicine on the Quality of Forensic Sexual Abuse Examinations in Rural Communities](https://www.sciencedirect.com/science/article/abs/pii/S014521341400146X?via%3Dihub),” *Child Abuse and Neglect* 38, no. 9 (2014): 1533–39; Kaiser Health News, “[Telehealth Brings Expert Sexual Assault Exams to Rural Patients](https://carolinapublicpress.org/58602/telehealth-brings-expert-sexual-assault-exams-to-rural-patients/),” Carolina Public Press, January 9, 2023; Northeast Telehealth Resource Center, “[Telehealth in the Northeast, Field Report: Sample Stakeholder Challenges, Solutions, and Lessons Learned](https://netrc.org/stories/UNE%20Tele-SANE%20Program.pdf),” monthly report, March 2021; TeleSAFE, “[About TeleSAFE](https://telesafe.org/about/),” 2022; SAFE‑T System, “[About SAFE‑T System](https://safe-tsystem.com/about-us/)”; Avel eCare, “[Emergency: SANE Program](https://www.avelecare.com/services/emergency/),” 2025; and Avera Health, “[Sexual Assault Nurse Examiners (SANE)](https://www.avera.org/services/emergency-trauma/sexual-assault-nurse-examiners-sane/),” 2025. [59](#_ednref59). Kaiser Health News, “[Telehealth Brings Expert Sexual Assault Exams to Rural Patients](https://carolinapublicpress.org/58602/telehealth-brings-expert-sexual-assault-exams-to-rural-patients/),” Carolina Public Press, January 9, 2023. [60](#_ednref60). Sheridan Miyamoto et al., “[Impact of Telemedicine on the Quality of Forensic Sexual Abuse Examinations in Rural Communities](https://www.sciencedirect.com/science/article/abs/pii/S014521341400146X?via%3Dihub),” *Child Abuse and Neglect* 38, no. 9 (2014): 1533–39. [61](#_ednref61). Sheridan Miyamoto et al., “[The Implementation of the Sexual Assault Forensic Examination Telehealth Center: A Program Evaluation](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387343/),” *Journal of Forensic Nursing* 17, no. 3 (2021): E24–E33. [62](#_ednref62). Correspondence with Med Center Health SANE Training Program (Kentucky), the North Carolina Board of Nursing, and Shady Grove Medical Center Forensic Medical Unit (Maryland) (copy in author’s files). See also [201 Ky. Admin. Regs. 20:411](https://www.law.cornell.edu/regulations/kentucky/201-KAR-20-411); North Carolina Board of Nursing, “[Sexual Assault Nurse Examiner](https://www.ncbon.com/practice-sexual-assault-nurse-examiner),” last changed March 15, 2024; [Md. Ch. 659, 2017 Md. Laws 734 (2017)](https://mgaleg.maryland.gov/2017RS/Chapters_noln/CH_659_sb0734t.pdf); and Maryland Board of Nursing, “[Forensic Nurse Examiner](https://health.maryland.gov/mbon/Pages/forensic-nurse-examiner.aspx),” updated December 13, 2024. [63](#_ednref63). Correspondence with Med Center Health SANE Training Program (Kentucky) (copy in author’s files). [64](#_ednref64). [S.B. 950, 2024 Leg., 446th Sess. (Md. 2024)](https://mgaleg.maryland.gov/2024RS/Chapters_noln/CH_833_sb0950t.pdf); Maryland Sexual Assault Evidence Kit Policy and Funding Committee, “[Annual Report](https://oag.maryland.gov/our-office/Documents/pdfs/2025_SAEK_Committee_Annual_Report.pdf),” January 2025. [65](#_ednref65). [NJ Rev Stat § 45:1–62 (2024)](https://law.justia.com/codes/new-jersey/title-45/section-45-1-62/); [201 Ky. Admin. Regs. 20:411](https://www.law.cornell.edu/regulations/kentucky/201-KAR-20-411); Maryland Board of Nursing, “[Forensic Nurse Examiner](https://health.maryland.gov/mbon/Pages/forensic-nurse-examiner.aspx)”; and correspondence with Med Health Center SANE Training Program (Kentucky) and Shady Grove Medical Center Forensic Medical Unit (Maryland) (copy in author’s files). [66](#_ednref66). Correspondence with the North Carolina Board of Nursing (copy in author’s files); correspondence with Dr. Patricia M. Speck, professor emeritus in Nursing, University of Alabama at Birmingham School of Nursing, former coordinator of the Advanced Forensic Nursing program, and past president of the IAFN (2004–2005) and the FNCB (2022–2024) (copy in author’s files); [Ala. Admin. Code r. 610-X-6-.16](https://admincode.legislature.state.al.us/administrative-code/610-X-6-.16); and North Carolina Board of Nursing, “[Sexual Assault Nurse Examiner](https://www.ncbon.com/practice-sexual-assault-nurse-examiner),” last changed March 15, 2024. [67](#_ednref67). Correspondence with the Illinois Office of the Attorney General SANE Program; and [410 Ill. Comp. Stat. 70/1 et seq. (2024)](https://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1531&utm) (copy in author’s files). [68](#_ednref68). A. C. Ciancone et al., “[Sexual Assault Nurse Examiner Programs in the United States](https://pubmed.ncbi.nlm.nih.gov/10736121/),” *Annals of Emergency Medicine* 35, no. 4 (April 2000): 353–57. [69](#_ednref69). US Bureau of Labor Statistics, “Registered Nurses Made Up 30 Percent of Hospital Employment in May 2019,” April 27, 2020. [70](#_ednref70). Megan Brenan, “[Nurses Retain Top Ethics Rating in U.S., but Below 2020 High](https://news.gallup.com/poll/467804/nurses-retain-top-ethics-rating-below-2020-high.aspx),” Gallup, January 10, 2023. [71](#_ednref71). US Sentencing Commission, “[Quick Facts: Sexual Abuse Offenders](https://www.ussc.gov/sites/default/files/pdf/research-and-publications/quick-facts/Sexual_Abuse_FY18.pdf),” FY 2014 through FY 2018 Datafiles, USSCFY14–USSCFY18. [72](#_ednref72). Statista Research Department, “[Number of Forcible Rape and Sexual Assault Victims in the United States from 1993 to 2021, by Sex](https://www.statista.com/statistics/251923/usa-reported-forcible-rape-cases-by-gender/),” Statista, October 20, 2023; and authors’ calculations. [73](#_ednref73). US Census Bureau, “[Certified Nurses Day: March 19, 2023](https://www.census.gov/newsroom/stories/certified-nurses-day.html),” news release no. CB23–SFS.36, March 19, 2023; and authors’ calculations. [74](#_ednref74). Marco Clari et al., “[Prevalence of Workplace Sexual Violence Against Healthcare Workers Providing Home Care: A Systematic Review and Meta-Analysis](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731391/),” *International Journal of Environmental Research and Public Health* 17, no. 23 (2020): 8807. [75](#_ednref75). Kate Martin, “[Survivors Sidelined: How Illinois’ Sexual Assault Survivor Law Allows Hospitals to Deny Care](https://19thnews.org/2024/04/illinois-sexual-assault-survivor-law-hospitals/),” The 19th, April 2, 2024. [76](#_ednref76). Office for Victims of Crime, “[Sexual Assault Nurse Examiners](https://web.archive.org/web/20241231012814/https:/www.ovcttac.gov/saneguide/management-of-sane-programs/sexual-assault-nurse-examiners/),” in *SANE Program Development and Operations Guide* (US Department of Justice, Office of Justice Programs, 2016). The Office for Victims of Crime lists eight states that require SANEs to meet a state standard of certification: Kentucky, Maryland, Massachusetts, New Jersey, New York, North Carolina, Oregon, and Texas. New York State Department of Health, “[Sexual Assault Forensic Examiner (SAFE) Program Overview](https://www.health.ny.gov/professionals/safe/docs/program_overview_and_standards.pdf),” last revised October 2019, p. 13. In New York, “a sexual assault medical forensic exam can be performed by any registered nurse, nurse practitioner, physician’s assistant, or physician in any New York State hospital emergency department.” Oregon State Board of Nursing, “[The Registered Nurse Who Performs Sexual Assault Examinations](https://www.oregon.gov/osbn/documents/IS_Sane.pdf),” revised September 15, 2022, p. 1. In Oregon, the Board of Nursing released an interpretive statement clarifying that it is within the scope of practice of RN licensure to perform a sexual assault exam (SAE), but not for licensed practical nurses (LPNs), according to the Nurse Practice Act (NPA). “While Oregon’s NPA does not specifically prohibit the LPN from performing a SAE, the comprehensive examination and interpretation of collected data necessary to perform a prosecutable SAE exceeds the parameters of focused assessment allowed with LPN licensure.” Office of the Attorney General of Texas, “[Sexual Assault Nurse Examiner (SANE) Certification](https://www.texasattorneygeneral.gov/crime-victims/information-victim-services-professionals/sexual-assault-prevention-and-crisis-services-sapcs/sexual-assault-nurse-examiner-sane-certification),” 2025. “There is no legal requirement in Texas that you have an OAG SANE Certification. Some jurisdictions and medical providers require the certification.” Heather Coleman, “[In Re: Petition for Declaratory Statement](https://www.floridahealth.gov/licensing-and-regulation/declaratory/_documents/nursing/fo-doh-04-0039.pdf),” Final Order no. DOH–04–0039–DS–MOA, State of Florida Board of Nursing, filed January 20, 2004. According to a Petition for a Declaratory Statement to the Florida Board of Nursing (2004), it is within the scope of practice for a nurse to perform sexual battery examinations if they received training as a SANE. However, no information regarding SANE requirements was available on the Board of Nursing website. Correspondence with the Massachusetts Department of Public Health clarified that medical practitioners do not need to be certified as SANEs to conduct forensic medical exams and that SANEs do not need to be certified with the Department of Public Health or Board of Nursing to offer services (copy in author’s files). [77](#_ednref77). Ala. Admin. Code r. 610–X–7.05 (2016); Shelby Shepherd, “[Updated Law Requires Illinois Emergency Department to Have SANE Nurses](https://www.kwqc.com/content/news/Updated-law-requires-Illinois-emergency-department-to-have-SANE-nurses-491514831.html),” KWQC, August 22, 2018; Office of the Illinois Attorney General, “[Illinois Sexual Assault Nurse Examiner (IL SANE) Program](https://illinoisattorneygeneral.gov/Page-Attachments/SANEProgramFactSheet.pdf),” January 2024; Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019; Maryland Coalition Against Sexual Assault, “Nursing & Medical,” 2025; Nevada Board of Nursing, “Nevada State Board of Nursing Practice Decision,” revisions adopted by the board March 23, 2018; New Jersey Division of Consumer Affairs, “[Sexual Assault Nurse Examiner Program](https://www.njconsumeraffairs.gov/Adoptions/nurado_031504.pdf),” March 15, 2004; and North Carolina Board of Nursing, “[Sexual Assault Nurse Examiner](https://www.ncbon.com/practice-sexual-assault-nurse-examiner),” North Carolina Board of Nursing, last changed March 15, 2024. [78](#_ednref78). See Med Center Health, “[SANE Training](https://medcenterhealth.org/sane-training/),” 2025; Crisis Services of North Alabama, “[Sexual Assault Nurse Examiner Training](https://csna.org/upcoming-training),” 2024; Rutgers School of Nursing, “[Forensic Nurse Examiner Course](https://nursing.rutgers.edu/ce/course-catalog/forensic-nurse-examiner-course/),” 2025; Maryland Coalition Against Sexual Assault, “[Forensic Nurse Examiner Adult/​Adolescent (FNE‑A) Clinical Training](https://mcasa.org/events/event/forensic-nurse-examiner-adult-adolescent-fne-a-clinical-training-july-17-20),” 2025; Maryland Coalition Against Sexual Assault, “[Certified Forensic Nurse Examiner–Adult/Adolescent Course](https://mcasa.org/events/event/certified-forensic-nurse-examiner-adult-adolescent-course),” 2022; and Office of the Illinois Attorney General, “[Responding to Sexual Assault: Sexual Assault Nurse Examiner (SANE)](https://www.illinoisattorneygeneral.gov/Safer-Communities/Responding-to-Sexual-Assault/SANE/),” 2025. [79](#_ednref79). International Association of Forensic Nurses, “[Online SANE Training](https://www.forensicnurses.org/page/40HourSANE/),” 2025; and International Association of Forensic Nurses, “[SANE Clinical Preceptorship](https://www.forensicnurses.org/page/ClinicalPreceptor),” 2025. [80](#_ednref80). Elizabeth Thiede and Sheridan Miyamoto, “[Rural Availability of Sexual Assault Nurse Examiners](https://pmc.ncbi.nlm.nih.gov/articles/PMC9326872/),” *Journal of Rural Health* 37, no. 1 (2021): 81–91. [81](#_ednref81). Maryland Board of Nursing, “[Application Instructions for Initial Certification Registered Nurse–Forensic Nurse Examiner](https://mbon.maryland.gov/Pages/adv-prac-rn-fne-instructions.aspx),” 2025; and New Jersey Board of Nursing, “[Official Application for Forensic Nurse Examiner–Certified Sexual Assault](https://www.njconsumeraffairs.gov/nur/Applications/Application-for-Forsenic-Nurse-Certified-Sexual-Assualt.pdf),” 2025. [82](#_ednref82). Maryland Board of Nursing, “[Schedule of Fees](https://mbon.maryland.gov/Pages/services-fees.aspx),” updated June 2, 2025; Kentucky Board of Nursing, “[Fees for Licensure Applications and Services](https://kbn.ky.gov/KBN%20Documents/fees-for-licensure-applications-and-services.pdf),” last revised August 2021; New Jersey Board of Nursing, “[Application for Forensic Nurse Examiner—Certified Sexual Assault](https://www.njconsumeraffairs.gov/nur/Applications/Application-for-Forsenic-Nurse-Certified-Sexual-Assualt.pdf),” 2025; and New Jersey Division of Consumer Affairs, “[License Renewals: New Jersey Board of Nursing](https://www.njconsumeraffairs.gov/renewals/Pages/Nurse.aspx),” 2022. [83](#_ednref83). Maryland Board of Nursing, “[Forensic Nurse Examiner](https://mbon.maryland.gov/Pages/forensic-nurse-examiner.aspx),” updated August 20, 2021; New Jersey Board of Nursing, “[Application for Forensic Nurse Examiner–Certified Sexual Assault](https://www.njconsumeraffairs.gov/nur/Applications/Application-for-Forsenic-Nurse-Certified-Sexual-Assualt.pdf),” 2025; and Kentucky Board of Nursing, “[How to Obtain, Renew, or Reinstate a SANE Credential](https://kbn.ky.gov/sexual-assault-nurse-examiner/Pages/Apply.aspx),” 2025. The IAFN states in correspondence: “We do not perform background checks. If employed, their employer does this” (copy in author’s files). [84](#_ednref84). [201 Ky. Admin. Regs. 20:411 (2023)](https://apps.legislature.ky.gov/law/kar/titles/201/020/411/); Kate Martin, “[No State Oversight of Where Sexual Assault Nurse Examiners Work in NC, but Models for Change Exist](https://www.northcarolinahealthnews.org/2021/01/30/no-state-oversight-of-where-sexual-assault-nurse-examiners-work-in-nc-but-models-for-change-exist/),” *North Carolina Health News*, January 30, 2021; and [COMAR 10.27.21.07](https://dsd.maryland.gov/regulations/Pages/10.27.21.07.aspx). [85](#_ednref85). Kate Martin, “[Sexual Assault Nurse Examiners Can Be Hard to Find in NC](https://qcnerve.com/nc-sexual-assault-nurses/),” *Queen City Nerve*, January 25, 2021. [86](#_ednref86). Rutgers School of Nursing, “[Forensic Nurse Examiner Course](https://nursing.rutgers.edu/ce/course-catalog/forensic-nurse-examiner-course/)”; International Association of Forensic Nurses, “[New Jersey Clinical Skills Training](https://www.forensicnurses.org/page/NJclinskills/),” 2025; New Jersey Chapter of the International Association of Forensic Nurses, “[Education and Events](https://www.nj-iafn.org/education-events/),” 2023; and Monmouth University, “[Sexual Assault Examination across the Lifespan](https://www.monmouth.edu/school-of-nursing-health/documents/2019/10/sane-june.pdf/),” 2020. Not all of these options are available annually. [87](#_ednref87). Shana L. Maier, “[The Emotional Challenges Faced by Sexual Assault Nurse Examiners: ‘ER Nursing Is Stressful on a Good Day Without Rape ](https://journals.lww.com/forensicnursing/abstract/2011/12000/the_emotional_challenges_faced_by_sexual_assault.4.aspx)Victims,’” *Journal of Forensic Nursing* 7, no. 4 (2011): 161–72. [88](#_ednref88). A. Nicole Clowers, managing director, health care, Government Accountability Office, Testimony on “[Sexual Assault: Information on the Availability of Forensic Examiners](https://www.gao.gov/assets/gao-19-259t.pdf)” before the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce, 115th Cong., 2nd sess., December 12, 2018, pp. 9–10. [89](#_ednref89). Stacie Zelman et al., “[Burnout and the Sexual Assault Nurse Examiner: Who Is Experiencing Burnout and Why?](https://www.sciencedirect.com/science/article/abs/pii/S0099176721002865),” *Journal of Emergency Nursing* [48, no. 2](https://www.sciencedirect.com/journal/journal-of-emergency-nursing/vol/48/issue/2) (2022): 202–10. [90](#_ednref90). Based on correspondence with Debbi Robison, BSN, RN, SANE-A‑P FNE, forensic nurse examiner, Washoe County Child Advocacy Center Forensic Medical Team, Washoe County, NV; member of the IAFN, AFN, Nevada Coalition to End Domestic and Sexual Violence, California Sexual Assault Investigators Association, and the American Professional Society on the Abuse of Children (copy in author’s files). Robison was among the medical-forensic practitioners testifying on mandatory certification requirements in both 2004 and 2012. [91](#_ednref91). Nevada Board of Nursing, “Nevada State Board of Nursing Practice Decision,” revisions adopted by the board March 23, 2018; and Nevada Board of Nursing, [report](https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/6643) of the Sexual Assault Nurse Examiner Certification and the Nevada State Board of Nursing Victims of Crime Subcommittee, June 20, 2012. [92](#_ednref92). Correspondence with Debbi Robison, BSN, RN, SANE-A‑P FNE, forensic nurse examiner, Washoe County Child Advocacy Center Forensic Medical Team, Washoe County, NV; member of the IAFN, AFN, Nevada Coalition to End Domestic and Sexual Violence, California Sexual Assault Investigators Association, and the American Professional Society on the Abuse of Children (copy in author’s files). [93](#_ednref93). Nevada Board of Nursing, [report](https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/6643) of the Sexual Assault Nurse Examiner Certification and the Nevada State Board of Nursing Victims of Crime Subcommittee, June 20, 2012, p. 2. [94](#_ednref94). Nevada Board of Nursing, [report](https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/6643) of the Sexual Assault Nurse Examiner Certification and the Nevada State Board of Nursing Victims of Crime Subcommittee, June 20, 2012, pp. 1–2. [95](#_ednref95). Nevada Board of Nursing, [report](https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/6643) of the Sexual Assault Nurse Examiner Certification and the Nevada State Board of Nursing Victims of Crime Subcommittee, June 20, 2012, p. 1. [96](#_ednref96). Serena Evans, policy director for the Nevada Coalition to End Domestic and Sexual Violence, “[Testimony on AB 276](https://www.leg.state.nv.us/App/NELIS/REL/82nd2023/ExhibitDocument/OpenExhibitDocument?exhibitId=64917&fileDownloadName=0320_AB276_evans.s_testsup.pdf)” before the Nevada State Assembly, March 20, 2023. [97](#_ednref97). Data obtained through correspondence with the IAFN (copy in author’s files). [98](#_ednref98). Camalot Todd, “[Nevada Among Handful of States Funding Strangulation Exams for Domestic Violence Victims](https://nevadacurrent.com/2023/10/19/nevada-among-handful-of-states-funding-strangulation-exams-for-domestic-violence-victims/),” *Nevada Current*, October 19, 2023. [99](#_ednref99). Anjali Patel, “[‘It’s Simply Not Enough’: More Forensic Nurses Needed to Help Survivors of Domestic, Sexual Violence](https://www.ktnv.com/news/its-simply-not-enough-more-forensic-nurses-needed-to-help-survivors-of-domestic-sexual-violence),” KTNV Las Vegas, March 19, 2024. [100](#_ednref100). Camalot Todd, “[Nevada Among Handful of States Funding Strangulation Exams for Domestic Violence Victims](https://nevadacurrent.com/2023/10/19/nevada-among-handful-of-states-funding-strangulation-exams-for-domestic-violence-victims/),” *Nevada Current*, October 19, 2023. [101](#_ednref101). Camalot Todd, “[Nevada Among Handful of States Funding Strangulation Exams for Domestic Violence Victims](https://nevadacurrent.com/2023/10/19/nevada-among-handful-of-states-funding-strangulation-exams-for-domestic-violence-victims/),” *Nevada Current*, October 19, 2023. [102](#_ednref102). Charmaine Robinson, “[The U.S. Nursing Shortage: A State-by-State Breakdown](https://nursejournal.org/articles/the-us-nursing-shortage-state-by-state-breakdown/),” *NurseJournal*, March 28, 2024. [103](#_ednref103). John Packham et al., [*Nursing Workforce in Nevada—2025*](https://ppc.nv.gov/uploadedFiles/ppcnvgov/content/Meetings/2025/ADA%20NWIN%20Report%20FINAL%20V2%203-13-25.pdf) (Nevada Health Workforce Research Center, 2025), p. 2. [104](#_ednref104). State regulations create barriers at the county and municipal levels. The NSBON does not allow RNs to practice independently. That means RNs may not provide SANE services except in collaboration with a hospital or under the supervision of an MD or APRN. The RN may not offer this service if a hospital or higher-level practitioner does not wish to support a SANE program. Certificate-of-need laws in Nevada also prevent the expansion or creation of medical facilities that may wish to support SANE practice. Nevada should consider allowing RNs to operate fully independently and eliminate certificate-of-need regulation. Nevada is not a member of the Nurse Licensure Compact (NLC), which helps nurses overcome the barriers to interstate practice and mobility that state licensing regulations create. Given Nevada’s history of decentralization and frequent deferral to private certification, Nevada should consider eliminating medical licensure. More modest reforms, such as joining the NLC or otherwise recognizing licenses from other states, would also improve matters. See Michael F. Cannon, “[Clinicians](https://www.cato.org/sites/cato.org/files/ebookfiles/michael-f-cannon-recovery.pdf),” in *Recovery: A Guide to Reforming the US Health Sector* (Cato Institute, 2023), pp. 19–26. [105](#_ednref105). A. Nicole Clowers, managing director, health care, Government Accountability Office, Testimony on “[Sexual Assault: Information on the Availability of Forensic Examiners](https://www.gao.gov/assets/gao-19-259t.pdf)” before the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce, 115th Cong., 2nd sess., December 12, 2018, p. 4. [106](#_ednref106). Correspondence with the IAFN (copy in author’s files). [107](#_ednref107). Data obtained from the IAFN (copy in author’s files); and United States Census Bureau, “[US and World Population Clock](https://www.census.gov/popclock/).” [108](#_ednref108). A. Nicole Clowers, managing director, health care, Government Accountability Office, Testimony on “[Sexual Assault: Information on the Availability of Forensic Examiners](https://www.gao.gov/assets/gao-19-259t.pdf)” before the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce, 115th Cong., 2nd sess., December 12, 2018, findings summary and pp. 6–7. [109](#_ednref109). Ala. Admin. Code r. 610–X–7.05 (2016). [110](#_ednref110). Ala. Admin. Code r. 610–X–7.05 (2016). [111](#_ednref111). Ala. Admin. Code r. 610–X–7.05 (2016). [112](#_ednref112). Quote obtained through correspondence with Dr. Patricia M. Speck, professor emeritus in Nursing, University of Alabama at Birmingham School of Nursing, former coordinator of the Advanced Forensic Nursing program, and past president of the IAFN (2004–2005) and the FNCB (2022–2024) (copy in author’s files). Used with permission. [113](#_ednref113). Data obtained from the IAFN (copy in author’s files); Data USA, “[Alabama](https://datausa.io/profile/geo/alabama).” [114](#_ednref114). Mary Helene Hall, “[In Alabama’s Fastest-Growing County, It Is Nearly Impossible to Get a Rape Kit](https://www.al.com/news/2023/08/in-alabamas-fastest-growing-county-it-is-nearly-impossible-to-get-a-rape-kit.html),” Advance Local Media, August 17, 2023. [115](#_ednref115). “[Statewide Crimes](https://web.archive.org/web/20240922014319/https:/crime.alabama.gov/Data/StatewideCrime),” Crime​.Alaba​ma​.gov, archived September 22, 2024, at Wayback Machine. [116](#_ednref116). Rachel E. Morgan and Alexandra Thompson, “[Criminal Victimization, 2020](https://bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/cv20.pdf),” US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, October 2021, p. 8; and authors’ calculations. [117](#_ednref117). Mary Helene Hall, “[In Alabama’s Fastest-Growing County, It Is Nearly Impossible to Get a Rape Kit](https://www.al.com/news/2023/08/in-alabamas-fastest-growing-county-it-is-nearly-impossible-to-get-a-rape-kit.html),” Advance Local Media, August 17, 2023. [118](#_ednref118). Mary Helene Hall, “[In Alabama’s Fastest-Growing County, It Is Nearly Impossible to Get a Rape Kit](https://www.al.com/news/2023/08/in-alabamas-fastest-growing-county-it-is-nearly-impossible-to-get-a-rape-kit.html),” Advance Local Media, August 17, 2023. [119](#_ednref119). Mary Helene Hall, “[In Alabama’s Fastest-Growing County, It Is Nearly Impossible to Get a Rape Kit](https://www.al.com/news/2023/08/in-alabamas-fastest-growing-county-it-is-nearly-impossible-to-get-a-rape-kit.html),” Advance Local Media, August 17, 2023. [120](#_ednref120). Mary Helene Hall, “[In Alabama’s Fastest-Growing County, It Is Nearly Impossible to Get a Rape Kit](https://www.al.com/news/2023/08/in-alabamas-fastest-growing-county-it-is-nearly-impossible-to-get-a-rape-kit.html),” Advance Local Media, August 17, 2023. [121](#_ednref121). Illinois College of Emergency Physicians, “[Illinois Law Changes in Care of Sexual Assault Patients—2019](https://www.icep.org/advocacy-key-issues/illinois-law-changes-in-care-of-sexual-assault-patients-2019/).” [122](#_ednref122). Office of the Illinois Attorney General, “[Responding to Sexual Assault: Sexual Assault Nurse Examiner (SANE)](https://www.illinoisattorneygeneral.gov/Safer-Communities/Responding-to-Sexual-Assault/SANE/)”; additional details obtained through correspondence with the Illinois Office of the Attorney General (copy in author’s files). [123](#_ednref123). Shelby Shepherd, “[Updated Law Requires Illinois Emergency Department to Have SANE Nurses](https://www.kwqc.com/content/news/Updated-law-requires-Illinois-emergency-department-to-have-SANE-nurses-491514831.html),” KWQC, August 22, 2018. [124](#_ednref124). Shelby Shepherd, “[Updated Law Requires Illinois Emergency Department to Have SANE Nurses](https://www.kwqc.com/content/news/Updated-law-requires-Illinois-emergency-department-to-have-SANE-nurses-491514831.html),” KWQC, August 22, 2018. [125](#_ednref125). Correspondence with the Illinois Board of Nursing. Data are from the Illinois Office of the Attorney General (copy in author’s files). Data USA, “[Illinois](https://datausa.io/profile/geo/illinois).” [126](#_ednref126). Kate Martin, “[Survivors Sidelined: How Illinois’ Sexual Assault Sexual Assault Survivor Law Allows Hospitals to Deny Care](https://19thnews.org/2024/04/illinois-sexual-assault-survivor-law-hospitals/),” The 19th, April 2, 2024. [127](#_ednref127). United States Census Bureau, “[City and Town Population Totals: 2020–2023](https://www.census.gov/data/tables/time-series/demo/popest/2020s-total-cities-and-towns.html),” last revised April 23, 2025. [128](#_ednref128). Kate Martin, “[Survivors Sidelined: How Illinois’ Sexual Assault Sexual Assault Survivor Law Allows Hospitals to Deny Care](https://19thnews.org/2024/04/illinois-sexual-assault-survivor-law-hospitals/),” The 19th, April 2, 2024. [129](#_ednref129). [201 Ky. Admin. Regs. 20:411](https://apps.legislature.ky.gov/law/kar/titles/201/020/411/). [130](#_ednref130). Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019; and Kentucky Board of Nursing, “[Sexual Assault Nurse Examiner](https://kbn.ky.gov/sexual-assault-nurse-examiner/Pages/default.aspx),” 2025. [131](#_ednref131). Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019; and America Counts Staff, “[Kentucky Population Topped 4.5 Million in 2020](https://www.census.gov/library/stories/state-by-state/kentucky.html),” US Census Bureau, August 25, 2021. [132](#_ednref132). Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019. [133](#_ednref133). Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019. [134](#_ednref134). Eleanor Klibanoff, “[Lacking Sexual Assault Nurses, Some Ky. Hospitals Illegally Turn Victims Away](https://www.lpm.org/investigate/2019-09-03/lacking-sexual-assault-nurses-some-ky-hospitals-illegally-turn-victims-away),” Louisville Public Media, September 3, 2019. [135](#_ednref135). Maryland Board of Nursing, “[Forensic Nurse ](https://mbon.maryland.gov/Pages/forensic-nurse-examiner.aspx)Examiner.” [136](#_ednref136). “[Report on the Improved Access to Sexual Assault Medical Forensic Examinations](https://health.maryland.gov/phpa/documents/sexual-assault-forensic-exam-report-2015.pdf),” Maryland Department of Health and Mental Hygiene, and the Maryland Institute for Emergency Medical Services Systems, December 1, 2015, p. 3. [137](#_ednref137). Brian E. Frosh, “[Statewide Accounting of Untested Sexual Assault Evidence Kits in the State of Maryland](https://www.marylandattorneygeneral.gov/Reports/Rape_Kit_Report.pdf),” Office of the Maryland Attorney General, January 1, 2017, p. 12. [138](#_ednref138). [Md. Ch. 659, 2017 Md. Laws 734 (2017)](https://mgaleg.maryland.gov/2017RS/Chapters_noln/CH_659_sb0734t.pdf). [139](#_ednref139). Data obtained through correspondence with the Maryland Board of Nursing (copy in author’s files); and Data USA, “[Maryland](https://datausa.io/profile/geo/maryland).” [140](#_ednref140). Maryland Sexual Assault Evidence Kit Policy and Funding Committee, “[Preliminary Recommendations](https://www.marylandattorneygeneral.gov/Pages/Groups/SAEK_Committee_Preliminary_Recommendations_April_2018.pdf),” April 2018. [141](#_ednref141). Maryland Sexual Assault Evidence Kit Policy and Funding Committee, “[Annual Report](https://www.marylandattorneygeneral.gov/Pages/Groups/2024_SAEK_Committee_Annual_Report.pdf),” January 2024, pp. 26, 30, 32. [142](#_ednref142). [S.B. 950, 2024 Leg., 446th Sess. (Md. 2024)](https://mgaleg.maryland.gov/2024RS/Chapters_noln/CH_833_sb0950t.pdf). [143](#_ednref143). Maryland Sexual Assault Evidence Kit Policy and Funding Committee, “[Annual Report](https://www.marylandattorneygeneral.gov/Pages/Groups/2025_SAEK_Committee_Annual_Report.pdf),” January 2025, pp. 22–23. The “qualified healthcare provider” provision does not appear to eliminate barriers to RNs performing forensic exams. [144](#_ednref144). Maryland Sexual Assault Evidence Kit Policy and Funding Committee, “[Annual Report](https://www.marylandattorneygeneral.gov/Pages/Groups/2025_SAEK_Committee_Annual_Report.pdf),” January 2025, p. 59. [145](#_ednref145). [N.J. Rev. Stat. § 52:4B–53 (2022)](https://law.justia.com/codes/new-jersey/2022/title-52/section-52-4b-53/); [N.J. P.L. 2001, ch. 81 (2001)](https://pub.njleg.state.nj.us/Bills/2000/PL01/81_.PDF). [146](#_ednref146). New Jersey Board of Nursing, “[Application for Forensic Nurse–Certified Sexual Assault](https://www.njconsumeraffairs.gov/nur/Applications/Application-for-Forsenic-Nurse-Certified-Sexual-Assualt.pdf),” 2025. [147](#_ednref147). Data obtained through correspondence with the IAFN (copy in author’s files); Data USA, “[New Jersey](https://datausa.io/profile/geo/new-jersey).” [148](#_ednref148). Joce Sterman et al., “[Sexual Assault Survivors May Lack Access to Specially Trained Nurses Due to National Shortage](https://upnorthlive.com/news/spotlight-on-america/sex-assault-survivors-may-lack-access-to-specially-trained-nurses-due-to-national-shortage),” UpNorthLive, November 5, 2020. [149](#_ednref149). Pallone was commenting on a GAO report that examined shortages in states without SANE-licensing regulation. See A. Nicole Clowers, managing director, health care, Government Accountability Office, Testimony on “[Sexual Assault: Information on the Availability of Forensic Examiners](https://www.gao.gov/assets/gao-19-259t.pdf)” before the Subcommittee on Oversight and Investigations of the House Committee on Energy and Commerce, 115th Cong., 2nd sess., December 12, 2018. [150](#_ednref150). Data obtained from the IAFN (copy in author’s files); and US Census Bureau, “[US and World Population Clock](https://www.census.gov/popclock/).” [151](#_ednref151). North Carolina Board of Nursing, “[Sexual Assault Nurse Examiner](https://www.ncbon.com/practice-sexual-assault-nurse-examiner),” last changed March 15, 2024; and correspondence with the North Carolina Board of Nursing (copy in author’s files). [152](#_ednref152). North Carolina Board of Nursing, “[Sexual Assault Nurse Examiner](https://www.ncbon.com/practice-sexual-assault-nurse-examiner),” last changed March 15, 2024; and North Carolina Board of Nursing, “[FAQ Sexual Assault Nurse Examiner (SANE)](https://www.ncbon.com/faq-sexual-assault-nurse-examiner-sane),” last changed March 15, 2024. [153](#_ednref153). North Carolina Board of Nursing, “[List of NCBON-Approved Sexual Assault Nurse Examiner (SANE) Programs Offered in North Carolina](https://www.ncbon.com/sites/default/files/documents/2024-03/sane-program-listings_0.pdf),” March 18, 2025. [154](#_ednref154). Kate Martin, “[No State Oversight of Where Sexual Assault Nurse Examiners Work in NC, but Models for Change Exist](https://www.northcarolinahealthnews.org/2021/01/30/no-state-oversight-of-where-sexual-assault-nurse-examiners-work-in-nc-but-models-for-change-exist/),” *North Carolina Health News*, January 30, 2021; and Staff Reports, “[Finding Nurses](https://carolinapublicpress.org/finding-nurses/),” Carolina Public Press, February 5, 2021; and Data USA, “[North Carolina](https://datausa.io/profile/geo/north-carolina).” [155](#_ednref155). Kate Martin, “[No State Oversight of Where Sexual Assault Nurse Examiners Work in NC, but Models for Change Exist](https://www.northcarolinahealthnews.org/2021/01/30/no-state-oversight-of-where-sexual-assault-nurse-examiners-work-in-nc-but-models-for-change-exist/),” *North Carolina Health News*, January 30, 2021; Staff Reports, “[Finding Nurses](https://carolinapublicpress.org/finding-nurses/),” Carolina Public Press, February 5, 2021; and Data USA, “[North Carolina](https://datausa.io/profile/geo/north-carolina).” [156](#_ednref156). Office of the North Carolina Attorney General, “[Attorney General Josh Stein Announces Sexual Assault Nurse Examiner Training for 50 North Carolina Nurses](https://ncdoj.gov/attorney-general-josh-stein-announces-sexual-assault-nurse-examiner-training-for-50-north-carolina-nurses/),” news release, April 7, 2022. [157](#_ednref157). Kate Martin, “[No State Oversight of Where Sexual Assault Nurse Examiners Work in NC, but Models for Change Exist](https://www.northcarolinahealthnews.org/2021/01/30/no-state-oversight-of-where-sexual-assault-nurse-examiners-work-in-nc-but-models-for-change-exist/),” *North Carolina Health News*, January 30, 2021. [158](#_ednref158). Kate Martin, “[No State Oversight of Where Sexual Assault Nurse Examiners Work in NC, but Models for Change Exist](https://www.northcarolinahealthnews.org/2021/01/30/no-state-oversight-of-where-sexual-assault-nurse-examiners-work-in-nc-but-models-for-change-exist/),” *North Carolina Health News*, January 30, 2021. [159](#_ednref159). North Carolina Board of Nursing, “[FAQ Sexual Assault Nurse Examiner (SANE)](https://www.ncbon.com/faq-sexual-assault-nurse-examiner-sane),” last changed March 15, 2024. [160](#_ednref160). Elizabeth Thiede and Sheridan Miyamoto, “[Rural Availability of Sexual Assault Nurse Examiners (SANEs)](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9326872/),” *Journal of Rural Health* 37, no. 1 (January 2021): 81–91. [161](#_ednref161). Shirley Svorny, “[Medical Licensing: An Obstacle to Affordable, Quality Care](https://www.cato.org/policy-analysis/medical-licensing-obstacle-affordable-quality-care),” Cato Institute Policy Analysis no. 621, September 17, 2008; Shirley Svorny, “[Could Mandatory Caps on Medical Malpractice Damages Harm Consumers?](https://www.cato.org/policy-analysis/could-mandatory-caps-medical-malpractice-damages-harm-consumers),” Cato Institute Policy Analysis no. 685, October 20, 2011; and “[Jeffrey A. Singer Is the Speaker and Guest of Honor at the 14th Biannual Illinois Association of Prescribing Psychologists Networking Dinner](https://www.cato.org/multimedia/media-highlights-tv/jeffrey-singer-speaker-guest-honor-14th-biannual-illinois),” Media Highlights TV, Cato Institute, October 6, 2023. [162](#_ednref162). B. Gardner Laurence, “[Who Holds Physicians Accountable?](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1863596/),” *Transactions of the American Clinical and Climatological Association* 118 (2007): 57–68. See also Elaine Cox, “[Board Certification for Doctors: What Does It Really Mean?](https://health.usnews.com/health-care/for-better/articles/2017-04-26/board-certification-for-doctors-what-does-it-really-mean),” *U.S. News and World Report*, April 26, 2017; and Credentialing Resource Center, “Verifying Board Certification During Your Provider Enrollment Process,” *Credentialing Resource Center Digest*, January 24, 2023. [163](#_ednref163). Nexus Insurance Services, “Who Pays the Most for Malpractice Insurance?,” 2025. [164](#_ednref164). Relias Media, “[Hospitals Could Face Legal Exposure If EPs Are Not Board-Certified](https://www.reliasmedia.com/articles/148041-hospitals-could-face-legal-exposure-if-eps-are-not-board-certified),” *ED Legal Letter*, June 1, 2021. [165](#_ednref165). Rape, Abuse, and Incest National Network, “[Congress Moves to Address Critical Shortage](https://www.rainn.org/news/congress-moves-address-critical-shortage-sexual-assault-nurse-examiners-rainn-partners),” news release, February 15, 2022. [166](#_ednref166). Peter Q. Blair, “[New Frontiers in Occupational Licensing Research](https://www.nber.org/reporter/2022number1/new-frontiers-occupational-licensing-research),” *NBER Reporter*, no. 1 (March 2022): 5–8; and Morris M. Kleiner and Evgeny S. Vorotnikov, [*At What Cost? State and National Estimates of the Economic Costs of Occupational Licensing*](https://ij.org/report/at-what-cost/costs-of-occupational-licensing/) (Institute for Justice, 2018). [167](#_ednref167). Shirley Svorny and Michael F. Cannon, “[Health Care Workforce Reform: COVID-19 Spotlights Need for Changes to Clinician Licensing](https://www.cato.org/policy-analysis/health-care-workforce-reform-covid-19-spotlights-need-changes-clinician-licensing),” Cato Institute Policy Analysis no. 899, August 4, 2020. [168](#_ednref168). Board of Certification for Emergency Nursing, “[Eligibility](https://bcen.org/cen/eligibility/).” [169](#_ednref169). Zippia, “[Emergency Department Registered Nurse Demographics and Statistics in the US](https://www.zippia.com/emergency-department-registered-nurse-jobs/demographics/),” updated July 21, 2023; and Board of Certification for Emergency Nursing, “[FAQs](https://bcen.org/cen/faqs/).” [170](#_ednref170). Elizabeth Thiede and Sheridan Miyamoto, “[Rural Availability of Sexual Assault Nurse Examiners (SANEs)](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9326872/),” *Journal of Rural Health* 37, no. 1 (January 2021): 81. [171](#_ednref171). Nevada Board of Nursing, [Report](https://www.leg.state.nv.us/App/InterimCommittee/REL/Document/6643) of the Sexual Assault Nurse Examiner Certification and the Nevada State Board of Nursing Victims of Crime Subcommittee, June 20, 2012, p. 1. [172](#_ednref172). Patrick McLaughlin et al., “[The Effects of Occupational Licensure on Competition, Consumers, and the Workforce](https://www.mercatus.org/research/public-interest-comments/effects-occupational-licensure-competition-consumers-and),” Mercatus Center at George Mason University, November 2017. [173](#_ednref173). The seven states are Arizona, Delaware, Florida, Indiana, Kansas, Minnesota, and West Virginia. See Amanda Hagerman, “[Who Is Using Telehealth? A Groundbreaking State-Based Reform Is Bringing Help to Those Who Need It Most](https://www.goldwaterinstitute.org/policy-report/who-is-using-telehealth/),” Goldwater Institute, January 31, 2024. See also Jeffrey A. Singer, “[HHS Authorizes Some Telehealth Services across State Lines—Temporarily](https://www.cato.org/blog/hhs-authorizes-some-telehealth-services-across-state-lines-temporarily),” *Cato at Liberty* (blog), December 4, 2020; Jeffrey A. Singer, senior fellow, Cato Institute, [Testimony on “State of Telehealth: Removing Barriers to Access and Improving Patient Outcomes”](https://www.cato.org/testimony/statement-record-hearing-state-telehealth-removing-barriers-access-improving-patient) before the Subcommittee on Communications, Media, and Broadband of the Senate Committee on Commerce, Science, and Transportation, 117th Cong., 1st sess., October 7, 2021; and Vittorio Nastasi and Sal Nuzzo, “[Expanding Access to Telehealth in Florida: Recent Progress and Opportunities for Improvement](https://www.jamesmadison.org/wp-content/uploads/2021/03/Telehealth_Policy_Brief_Mar2021_v02_print-1.pdf),” Policy Brief, Reason Foundation and James Madison Institute, March 19, 2021. [174](#_ednref174). Jeffrey A. Singer, senior fellow, Cato Institute, Testimony on “[Flatlining Care: Why Immigrants Are Crucial to Bolstering Our Health Care Workforce](https://www.cato.org/testimony/statement-record-flatlining-care-why-immigrants-are-crucial-bolstering-our-health-care)” before the Subcommittee on Immigration, Citizenship, and Border Security of the Senate Committee on the Judiciary, 117th Cong., 2nd sess., September 14, 2022. [175](#_ednref175). Lauren Petty, “[Hold-Up with State Rules Prevents Free Dental Clinic from Expanding](https://www.nbcchicago.com/news/local/hold-up-with-state-rules-prevents-free-dental-clinic-from-expanding/3026370/),” NBC Chicago, December 19, 2022; Zachary Paikin, “[An Illogical Monopoly over Those Without Care: Volunteer Licensure Restrictions in the State of Georgia](https://emorywheel.com/an-illogical-monopoly-over-those-without-care-volunteer-licensure-restrictions-in-the-state-of-georgia/),” *Emory Wheel*, September 6, 2023; and “[Medical Volunteers Not Free to Cross States](https://www.lubbockonline.com/story/lifestyle/health-fitness/2012/07/22/medical-volunteers-not-free-cross-states/15142447007/),” *Lubbock Avalanche-Journal*, July 21, 2021. [176](#_ednref176). Matt Goodman, “[Dr. Death](https://www.dmagazine.com/publications/d-magazine/2016/november/christopher-duntsch-dr-death/),” *D Magazine*, October 24, 2016; and Mahita Gajanan, “[Peacock’s Dr. Death Is Based on a Chilling True Crime Podcast about a Murderous Surgeon. Here’s What to Know](https://time.com/6080714/dr-death-true-story/),” *Time*, July 16, 2021. See also Laura Beil, “[A Surgeon So Bad It Was Criminal](https://www.propublica.org/article/dr-death-christopher-duntsch-a-surgeon-so-bad-it-was-criminal),” ProPublica, October 2, 2018. [177](#_ednref177). Jack Dolan et al., “[These Doctors Sexually Abused Patients. Their Medical Board Gave Them Their Licenses Back](https://www.latimes.com/california/story/2021-12-15/california-medical-board-doctor-patient-sexual-abuse-license-reinstate),” *Los Angeles Times*, December 15, 2021. [178](#_ednref178). California Medical Association, “[Governor Signs CMA Bill to Protect Patients and the Sanctity of the Physician–Patient Relationship](https://www.cmadocs.org/newsroom/news/view/ArticleId/49888/Governor-signs-CMA-bill-to-protect-patients-and-the-sanctity-of-the-physician-patient-relationship),” news release, September 22, 2022. [179](#_ednref179). Carrie Teegardin et al., “[License to Betray: A Broken System Forgives Sexually Abusive Doctors in Every State, Investigation Finds](https://doctors.ajc.com/doctors_sex_abuse/?ecmp=doctorssexabuse_microsite_nav),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016; James M. Dubois et al., “[Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases](https://journals.sagepub.com/doi/10.1177/1079063217712217),” *Sexual Abuse* 31, no. 5 (2017): 503–23; Azza AbuDagga et al., “Time to End Physician Sexual Abuse of Patients: Calling the U.S. Medical Community to Action,” *Journal of General Internal Medicine* 34 (2019): 1330–33; and “[Some High-Profile Doctors Who Sexually Abused Their Patients](https://doctors.ajc.com/sex_abuse_doctors_profiles/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [180](#_ednref180). Carrie Teegardin et al., “[License to Betray: A Broken System Forgives Sexually Abusive Doctors in Every State, Investigation Finds](https://doctors.ajc.com/doctors_sex_abuse/?ecmp=doctorssexabuse_microsite_nav),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [181](#_ednref181). Danny Robbins, “[Repeat Offender Still Licensed to Treat Georgia Patients](https://doctors.ajc.com/georgia_doctor_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [182](#_ednref182). Carrie Teegardin et al., “[License to Betray: A Broken System Forgives Sexually Abusive Doctors in Every State, Investigation Finds](https://doctors.ajc.com/doctors_sex_abuse/?ecmp=doctorssexabuse_microsite_nav),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [183](#_ednref183). Carrie Teegardin et al., “License to Betray: A Broken System Forgives Sexually Abusive Doctors in Every State, Investigation Finds,” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [184](#_ednref184). “[Maryland State Report Card](https://doctors.ajc.com/states/maryland_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017. [185](#_ednref185). “[Nevada State Report Card](https://doctors.ajc.com/states/nevada_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017. [186](#_ednref186). Carrie Teegardin and Danny Robbins, “[Still Forgiven: New Cases of Doctors Accused of Sex Abuse, Kept License](https://doctors.ajc.com/still_forgiven/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, April 26, 2018. [187](#_ednref187). Carrie Teegardin and Danny Robbins, “[Still Forgiven: New Cases of Doctors Accused of Sex Abuse, Kept License](https://doctors.ajc.com/still_forgiven/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, April 26, 2018. [188](#_ednref188). “[Alabama State Report Card](https://doctors.ajc.com/states/alabama_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “[Illinois State Report Card](https://doctors.ajc.com/states/illinois_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “[Kentucky State Report Card](https://doctors.ajc.com/states/kentucky_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “[Nevada State Report Card](https://doctors.ajc.com/states/nevada_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “[New Jersey State Report Card](https://doctors.ajc.com/states/new_jersey_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; and “[North Carolina State Report Card](https://doctors.ajc.com/states/north_carolina_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017. [189](#_ednref189). “[Illinois State Report Card](https://doctors.ajc.com/states/illinois_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017. [190](#_ednref190). “[Illinois State Report Card](https://doctors.ajc.com/states/illinois_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “[Kentucky State Report Card](https://doctors.ajc.com/states/kentucky_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; “Maryland State Report Card,” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017; and “[North Carolina State Report Card](https://doctors.ajc.com/states/north_carolina_sex_abuse/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, 2017. [191](#_ednref191). Margaret Vigil-Fowler, “[The History Behind America’s Devastating Shortage of Black Doctors](https://time.com/6333653/black-doctors-racism-history/),” Made by History, *Time*, November 23, 2023. “Between 1870 and 1910, the white physicians who controlled the \[American Medical Association\] began demanding that states adopt licensing laws that required physicians to pass an exam and meet educational requirements to legally practice medicine.” [192](#_ednref192). Alan Judd, “[Condemnation Without Action](https://doctors.ajc.com/ama_sex_abuse_doctors/),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [193](#_ednref193). Carrie Teegardin et al., “[License to Betray: A Broken System Forgives Sexually Abusive Doctors in Every State, Investigation Finds](https://doctors.ajc.com/doctors_sex_abuse/?ecmp=doctorssexabuse_microsite_nav),” Doctors and Sex Abuse, *Atlanta Journal-Constitution*, July 6, 2016. [194](#_ednref194). In all cases where states require clinicians to obtain an additional license to practice a specialty, they require clinicians to obtain certifications from private organizations. Mandatory private certification is functionally equivalent to compulsory government licensing. [195](#_ednref195). Michael F. Cannon, “[Clinicians](https://www.cato.org/sites/cato.org/files/ebookfiles/michael-f-cannon-recovery.pdf),” in *Recovery: A Guide to Reforming the US Health Sector* (Cato Institute, 2023), p. 20. “Clinician licensing also reduces access to quality care in several ways.” [196](#_ednref196). Shirley V. Svorny, “[Beyond Medical Licensure](https://www.cato.org/regulation/spring-2015/beyond-medical-licensure),” *Regulation* 38, no. 1 (2015): 26–29; Shirley V. Svorny, “[Medical Licensing: An Obstacle to Affordable, Quality Care](https://www.cato.org/policy-analysis/medical-licensing-obstacle-affordable-quality-care),” Cato Institute Policy Analysis no. 621, September 17, 2008; and Shirley Svorny and Michael F. Cannon, “[Health Care Workforce Reform: COVID-19 Spotlights Need for Changes to Clinician Licensing](https://www.cato.org/policy-analysis/health-care-workforce-reform-covid-19-spotlights-need-changes-clinician-licensing),” Cato Institute Policy Analysis no. 899, August 4, 2020. [197](#_ednref197). Christina Sandefur et al., “[A Win‐​Win for Consumers and Professionals Alike: An Alternative to Occupational Licensing](https://www.goldwaterinstitute.org/wp-content/uploads/2018/11/Occupational-Licensing-Win-Win-Final.pdf),” Goldwater Institute and 1889 Institute, November 15, 2018. [198](#_ednref198). Michael F. Cannon, “[Clinicians](https://www.cato.org/sites/cato.org/files/ebookfiles/michael-f-cannon-recovery.pdf),” in *Recovery: A Guide to Reforming the US Health Sector* (Cato Institute, October 16, 2023), p. 20. [199](#_ednref199). See Institute for Justice, “[State Reforms for Universal License Recognition](https://ij.org/legislative-advocacy/states-reforms-for-universal-recognition-of-occupational-licensing/)”; and National Center for Interstate Compacts, “[Interstate Licensure Compacts and Universal Licensure Recognition Laws Fact Sheet](https://compacts.csg.org/wp-content/uploads/2022/07/OL_8_Page_Graphic_JUNE_22_V-2_FINAL-1.pdf),” May 2022. [![Creative Commons License](/build/cato_2020/images/creative-commons.svg)](http://creativecommons.org/licenses/by-nc-sa/4.0/) This work is licensed under a [Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License](https://creativecommons.org/licenses/by-nc-sa/4.0/). [ Download PDF ](https://www.cato.org/sites/cato.org/files/2025-09/PA%201005.pdf)