Jeffrey A. Singer
Cato adjunct scholar and California State University-Northridge economics Professor Shirley Svorny (1951–2022) passed away nearly three years ago after a long battle with multiple myeloma. Shirley devoted much of her career to showing how medical licensing laws raise costs and block access to care. Even near the end, she was still trading ideas with Cato’s health policy team. After she passed, Michael F. Cannon reviewed the notes she had left behind. One cryptic note simply read “SANEs.”
Michael shared the note with the rest of us—Cato research associate Akiva Malamet, former research associate and ICU nurse Spencer Pratt, and me—explaining that SANEs are sexual assault nurse examiners. None of us knew much about the field, but once we started digging, we discovered there was very little scholarship tracing the origins and development of this vital specialty. That journey led the four of us to co-author the policy analysis we’re releasing today, Licensing Requirements Would Block Care and Justice for Sexual Assault Victims.
When survivors of sexual assault arrive at emergency departments, they require immediate, compassionate care—not bureaucratic obstacles. The SANEs profession began when entrepreneurial nurses, starting in the 1970s, saw a need to deliver trauma-informed care to sexual assault victims and collect forensic evidence that enhances prosecution success. By the 1990s, SANEs assembled at the University of Minnesota to create a professional organization for education, certification, and credentialing—the International Association of Forensic Nurses (IAFN). It was the first of several similar third-party certification and educational organizations.
The evidence demonstrates that SANEs are more effective than other health professionals in providing care, collecting forensic evidence, and testifying in court. SANEs are linked to higher conviction rates.
However, in states like Alabama, Illinois, Kentucky, Maryland, New Jersey, and North Carolina, licensing requirements force skilled nurses to jump through costly, unnecessary hoops before they can treat victims. The result: fewer SANEs, longer waits, and deeper trauma for people already enduring the worst moments of their lives.
Licensing not only adds red tape, but it also stifles innovation, such as tele-SANE programs that connect rural victims to qualified examiners. Worst of all, as shown in our paper, licensing boards have a history of reinstating physicians convicted of sexual misconduct even as they prevent qualified nurses from practicing.
To be sure, licensing laws are not the only obstacle SANEs face. Certificate-of-need laws and restrictions on nurses practicing independently also limit access, while inadequate funding makes training programs less affordable. (Government funding of SANEs programs is justifiable from a libertarian perspective as a law enforcement measure expenditure.) But our paper focuses on licensing because it directly blocks victims from receiving timely care. We argue that states should eliminate these barriers and rely on voluntary certification, employer oversight, and professional accountability—tools that already do a better job of ensuring quality.
We dedicate this paper to Shirley Svorny, who spent her career pushing to remove government obstacles to health care. Honestly, if not for the sparse note she left behind, we would not have known about this vital and compassionate profession—or the needless barriers that state lawmakers have placed in its path.