What is the recommended timeframe for conducting a medical forensic examination with a victim, following a sexual assault?

For sexual assault victims, we encourage obtaining a medical forensic exam as soon as possible, both to address medical issues and to maximize evidence collection and documentation. Emerging DNA research and advancing technologies have demonstrated that it is possible to obtain results from ever-smaller DNA samples, within ever-increasing timeframes.

We now know that viable evidence can exist well beyond the historical 72-, 96-, or 120-hour timeframes that have been used in many jurisdictions (National Protocol for Sexual Assault Medical Forensic Examinations, p. 73). In fact, a 7-day (168-hour) guideline is now being used in some jurisdictions, and jurisdictions may begin moving toward a 10-day guideline in the future (Speck & Ballantyne, 2015).

However, medical forensic care can be beneficial for victims and case investigations, even when it is delayed for a longer period of time. Victims should always be presented with information about their various options, and provided assistance in enacting their choices. Victim advocates can be extremely helpful and supportive during this process.

Also, please note that the determination of when to conduct a forensic examination should not be based solely on a jurisdiction’s timeframe for evidence collection. Rather, the answer should also be influenced by the facts of the specific case, the likelihood of recovering evidence given case circumstances, and the types of evidence needed for a successful investigation and prosecution. To illustrate, evidence may be available beyond even 168 hours after a sexual assault in cases where:

• The victim has not bathed, or only washed minimally

• The victim was seriously injured, or a great deal of force was used

• The victim continues to report pain or discomfort

• The victim is a minor, or a dependent adult, or was unconscious or physically incapacitated during the assault, or

• Multiple suspects were involved in the sexual assault.

There may be additional circumstances where it is wise to conduct a medical forensic examination beyond a jurisdiction’s standard timeframe; the above examples simply illustrate the need for flexibility when making these determinations. However, it is important that this decision not be based on any evaluation of the victim’s personal characteristics, or the perceived likelihood that the victim will participate in the investigation or potential prosecution, or that the case will be successfully prosecuted.

For more information, please see EVAWI’s training bulletin entitled, Time Limits for Conducting a Forensic Examination: Can Biological Evidence be Recovered 24, 36, 48, 72, 84 or 96 Hours Following a Sexual Assault?

Also see the US Department of Justice, National Institute of Justice (NIJ) publication entitled Extending the Time to Collect DNA in Sexual Assault Cases.

Should a Sexual Assault Forensic Examiner (SAFE) have follow-up contact with the victim, after the medical forensic exam is completed?

Yes, if possible, according to the National Protocol for Sexual Assault Medical Forensic Examinations (p. 117) published by the US Department of Justice, Office on Violence Against Women (OVW). Specifically, the National Protocol recommends that SAFEs follow-up by phone within 24-48 hours of an exam (if the patient consents). This allows the SAFE to check on the patient’s physical and emotional well-being, address any remaining medical concerns, and determine the patient’s level of compliance with the medications and medical treatment. At some point during the exam process, SAFEs should ask the patient for consent to this follow-up contact, and determine an optimal day, time, and location for both the patient and the SAFE.

Follow-up examination of the patient can be particularly critical when genital trauma is identified during the medical forensic examination. A follow-up appointment can be used to evaluate the status of this genital trauma as well as the general physical well-being of the patient. It can also be used to strengthen the documentation of evidence regarding genital and non-genital injuries sustained by the sexual assault victim. For example, the follow-up examination can be used to document the resolution of any injury, and in cases where there may be a question of whether an observation from the examination might be related to injury or normal anatomical variants. Photo-documentation at the time of the follow-up examination can be very helpful for comparison purposes.

There are also situations where the SAFE is unsure whether suspected injury of a female patient is due to the victim’s medical history or another gynecological condition. In these cases, a follow-up examination can be used to evaluate whether the suspected injury appears the same at this later point, which would suggest that it was in fact due to a gynecological condition of some kind, or if it healed as an injury naturally would.

Finally, the National Protocol also encourages follow-up care to address any issues regarding the testing and treatment of sexually transmitted infections (STI’s) as well as HIV (p. 112-114). Unfortunately, many SAFEs do not have the capacity for routine follow-up contact with patients. This may be for a variety of reasons, including a lack of program funding for time, or other limitations due to facilities or resources. For example, follow-up exams or contact with victims may not be reimbursable in every state. Follow-up contact is therefore a best practice that communities can strive to implement.

Thanks to Kim Day, RN, FNE, SANE-A, SANE-P for her assistance with this response. She serves as the SAFE Technical Assistance Coordinator for the International Association of Forensic Nurses (IAFN).

Who pays for medical forensic examinations in my jurisdiction?

There is considerable variation across jurisdictions in terms of who pays for medical forensic examinations conducted with a sexual assault victim. Some jurisdictions use the Crime Victim Compensation (CVC) program or other state funds, while other states require individual law enforcement agencies or counties to cover these costs.

In 2021, the Urban Institute published a report entitled Paying for Sexual Assault Medical Forensic Exams: How States and Jurisdictions Pay for Exams So Survivors Do Not Have To. The report is based on a survey conducted with sexual assault nurse examiner programs (SANEs), victim advocates, sexual assault coalitions, and Violence Against Women Act (VAWA) administrators. Results support four primary conclusions:

1. Most sexual assault victims seeking SAMFEs receive the exams free of charge and without being required to report assaults to the police.  
2. VOCA funds are the most common public payer for SAMFE costs. 
3. Many states have expanded the services provided as part of free SAMFEs beyond the narrow federal definition of a forensic examination.  
4. Payment levels from public payers often fall short of the full cost of the SAMFE. 

This report updates the 2014 publication, Sexual Assault Medical Forensic Exams and VAWA 2005: Payment Practices, Successes, and Directions for the Future.

To find out what the payment process is in your jurisdiction, the International Association of Forensic Nurses (IAFN) Sexual Assault Forensic Examination Technical Assistance (SAFEta) project offers an interactive US map with Exam Payment Resources. Users can click on each state or territory, to find a detailed summary of the exam payment process, Crime Victim Compensation (CVC), and related information.

Another helpful document was produced by AEquitas and EVAWI entitled, Summary of Laws and Guidelines with Charts: Payment of Sexual Assault Medical Forensic Examinations. Users can download the entire 228-page document, which includes laws and guidelines for each US state and territory, and charts summarizing the complex provisions. A 13-page Summary of Laws and Guidelines is also available.

What does VAWA require for payment of medical forensic exams?

Under the Violence Against Women Act (VAWA), US states, territories, and tribes must meet certain conditions to remain eligible for the STOP Violence Against Women Formula Grant Program. One of these requirements is to certify that the state, territory, tribe, or other governmental entity “incurs the full out-of-pocket cost of forensic medical exams” for victims of sexual assault.

What is a “medical forensic exam” for this purpose? VAWA defines it as:

(a) Examination of physical trauma

(b) Determination of penetration or force

(c) Patient interview, and

(d) Collection and evaluation of evidence [28 C.F.R. § 90.2(b) (1)]

Does VAWA require payment for the costs of medical testing and treatment?

No, VAWA does not require US states, territories, or tribal governments to cover the costs of medical testing or treatment associated with a medical forensic exam (including treatment of injuries, pregnancy, sexually transmitted infections, etc.).

This means there is variation in how these medical costs are covered, based on state laws and regulations, as well as local policies, protocols, and practices. For example, these costs may be billed to the victim’s private insurance, or the victim may be eligible to apply for Crime Victim Compensation for reimbursement. Because medical testing and treatment is a critical component of a medical forensic examination, the National Protocol for Sexual Assault Medical Forensic Examinations recommends that some basic medical services be included in the exam for free (p. 55-56).

For more information, please see the Online Training Institute (OLTI) module, The Earthquake in Sexual Assault Response: Implementing VAWA Forensic Compliance.

Additionally, The International Association of Forensic Nurses (IAFN) Sexual Assault Forensic Examination Technical Assistance (SAFEta) project provides many valuable resources on medical forensic exams and exam payment. One section of the website allows users to click on each state or territory, to find a detailed summary of the exam payment process, Crime Victim Compensation (CVC), and related information.

Can the victim’s private insurance be billed for the cost of a medical forensic exam?

Yes, according to the Violence Against Women Act (VAWA), a victim’s private insurance can be billed as long as there are no out-of-pocket costs for the victim.

As a result, some states require that a victim’s private insurance be billed for the cost of the exam, but they have instituted procedures to ensure there is no direct billing of the victim or co-pay required. Other states give victims the option of whether or not to have their private insurance billed for the exam, and still others prohibit billing the victim’s private insurance for the exam costs.

Yet insurance billing can present complications for some victims, including a potential loss of confidentiality. This is why the practice was originally discouraged by the Office on Violence Against Women (OVW):

We urge States to keep in mind that, in some cases, insurance billing can present a hardship for victims. For example, a victim of spousal rape may not want her husband to find out that she got a forensic exam. If the victim is forced to submit the claim to her insurance company and she is on her husband’s insurance, he may receive a statement from the insurance indicating that she got the exam. For this reason, the Office on Violence Against Women strongly encourages States to not require victims to file a claim with their insurers (OVW, 2007, pp. 24–25).

Even in the absence of abuse, partners or parents who receive an insurance statement will likely have questions about the purpose of any medical treatment, and this may eliminate the victim’s choice regarding whether or not to disclose the sexual assault. Insurance billing is thus one example of a practice that may meet the letter of the law for VAWA forensic compliance, but may fail to achieve the spirit of the law – which is to provide victims with prompt and unobstructed access to a medical forensic exam.

For more information, please see the Online Training Institute (OLTI) module, The Earthquake in Sexual Assault Response: Implementing VAWA Forensic Compliance.

US Department of Justice, Office on Violence Against Women (2007). Frequently Asked Questions Regarding STOP Formula Grant Program Forensic Exam Payment Requirement.

How many sexual assault victims have a medical forensic exam?

There are no exact figures for the number of sexual assault victims who obtain a medical forensic examination. There are only estimates for the number who seek medical care of any kind. Specifically, estimates range from 19-40% for the percentage of victims who seek medical care following their sexual assault (for review, see Campbell, 2008; also Kilpatrick et al., 2007; Zinzow et al., 2012). Of those who report their sexual assault to law enforcement, approximately half (44-55%) have a medical forensic exam (McEwan, 2011; Peterson et al., 2010).

Campbell, R. (2008). The Psychological Impact of Rape Victims’ Experiences with the Legal, Medical and Mental Health Systems. American Psychologist, 63 (8), 702-717. 

Kilpatrick, D.G., Resnick, H.S., Ruggiero, K.J., Conoscenti, M.A., & McCauley, J. (2007). Drug-Facilitated, Incapacitated, and Forcible Rape: A National Study. Washington DC: National Institute of Justice, US Department of Justice (NCJ 219181). 

Zinzow, H.M, Resnick, H.S., Barr, S.C., Danielson, C.K., & Kilpatrick, D.G. (2012). Receipt of Post-Rape Medical Care in a National Sample of Female Victims. American Journal of Preventive Medicine, 42 (2), 183-187. 

McEwan, T. (2011). The Role and Impact of Forensic Evidence in the Criminal Justice Process. Washington, DC: National Institute of Justice, US Department of Justice (NCJ 236474). 

Peterson, J., Sommers, I., Baskin, D., & Johnson, D. (2010). The Role and Impact of Forensic Evidence in the Criminal Justice Process. Washington, DC: National Institute of Justice, US Department of Justice (NCJ 231977).