Reasons for Not Reporting Among Sexual Assault Survivors Who Seek Medical Forensic Exams: A Qualitative Analysis

Abstract

After a sexual assault, survivors have the option of seeking a medical forensic exam, which includes medical evaluation and treatment, as well as forensic evidence collection. Forensic evidence is collected in a sexual assault evidence kit (SAEK) and typically released to police to aid in the investigation and potential prosecution of the assault. However, 20% to 25% of survivors who have a SAEK collected do not report their assault to police at that time and choose instead to have their SAEK stored for possible future use. This study sought to understand the reasons for not reporting among this group of survivors. We examined medical records of 296 individuals aged 18 and older who had documented their reasons for not reporting to police in their medical record and used a non-theory-driven coding framework to conduct a reflexive thematic analysis based on that data. We identified four themes: Reporting Won’t Help, Reporting Will Harm, Not Now, and Not What I’m Here For. These data illustrate that survivors are making an active choice which, for many, was based on concerns that reporting would not meaningfully help their situation or may even make their situations worse. For some survivors, the decision to have forensic evidence collected without a police report was based on their needs at that moment, whereas for other survivors it was based on their desire to move on from the assault more permanently. Practice and policy recommendations are discussed, including the importance of providing survivors information about what police reporting would look like in specific circumstances as well as ensuring that financial concerns are not a barrier to survivors receiving post-assault medical care without forensic evidence collection.

Sexual assault is a widespread social issue with a profound impact on survivors’ physical, mental, and emotional health (Campbell et al., 2009; Jina & Thomas, 2013). While anyone can be victimized, it is disproportionately perpetrated by men against women and gender diverse individuals (Planty et al., 2013; Wirtz et al., 2020). Nationally representative studies have found that approximately one in five women have experienced a completed or attempted rape, and 46% of women have experienced some type of unwanted sexual contact during their lifetimes (Smith et al., 2018). Survivors ¹ are often advised to seek out a medical forensic exam (MFE) after an assault, which includes medical evaluation and treatment as well as forensic evidence collection (Department of Justice, 2013). The forensic evidence and related documentation are placed in a sexual assault evidence kit (SAEK), which can be released to police for DNA testing and to aid in investigation and prosecution of the assault (Zweig et al., 2014, 2021).

However, sexual assault survivors have historically been treated poorly by the criminal legal system (Shaw et al., 2017; Tillman et al., 2010), and many express reservations about reporting their assaults. Quantitative analyses comparing case characteristics of reported versus nonreported assaults have found that survivors are more likely to report when their assault reflects stereotypical characteristics of rape, such as an unknown assailant, physical force, and victim injury; conversely, survivors are generally less likely to report their assaults when the assailant is known to the victim or when the victim was assaulted while incapacitated due to drugs or alcohol (Ceelen et al., 2019; Wolitzky-Taylor, 2011).

Qualitative research has expanded on these findings, indicating that survivors often do not report their assaults because they do not want others to know about the assault, want to handle it themselves, fear retaliation, fear being blamed or disbelieved by police, lawyers, or others involved in the criminal legal system, do not know if the incident was serious enough to report, or blame themselves for the assault (Ceelen et al., 2019; Cohn et al., 2013; Lorenz et al., 2021; Zinzow & Thompson, 2011). Cohn et al. (2013) distilled these reasons further with a principal component analysis that identified a three-factor solution: others knowing (i.e., not wanting family or others to know), nonacknowledgment (i.e., not knowing if it was serious, harmful, or criminal enough to report), and criminal justice concerns (i.e., concerns that reporting would lead to nonfavorable outcomes). These results are largely congruent with the typology of reasons for nonreporting proposed by Weiss (2011), who theorized that survivors’ nonreporting decisions were based on denying criminal intent, denying serious injury, denying victim innocence, and rejecting a victim identity.

In-depth qualitative interviews and focus groups have explored survivors’ perspectives in even greater depth. From interviews with 29 sexual assault survivors, Patterson et al. (2009) found that survivors frequently worried that police would not or could not help them, and the decision to not report was often made based on a desire to protect themselves from the pain that engaging with police was expected to cause. Zweig and colleagues’ (2014) focus groups similarly identified a theme of survivors not wanting to put themselves through the criminal legal process, as well as concerns related to shame, self-blame, fear of retaliation, and loss of privacy.

Until the mid-2000s, survivors who did not report were often unable to access post-assault medical-forensic care (Lonsway & Archambault, 2011; Zweig et al., 2014). In many jurisdictions, police were responsible for authorizing SAEK collection, meaning that survivors who did not report or were deemed uncooperative were unable to access those services. This changed with the Violence Against Women Act (VAWA) Reauthorization of 2005, which mandated that survivors have access to MFEs and SAEK collection regardless of whether they report the assault to police. The “alternative reporting options” now available to survivors vary by jurisdiction, but all require that survivors be able to access an MFE, have an SAEK collected, and have that SAEK stored for some period of time, during which the survivor can decide whether they want to report the assault (Lonsway et al., 2021). Because biological-forensic evidence can degrade within days, these alternative reporting options enable nonreporting survivors to capture time-sensitive forensic evidence so that it is available should they later decide to report their assault.

Research based on medical records indicates that 20% to 25% of sexual assault survivors who have an SAEK collected choose not to report their assault to police at that time (Campbell et al., 2021; Jones et al., 2009; Ledray, 2001), but relatively little is known about this population of survivors and their specific reasons for not reporting their assaults. Similar to what has been found in the larger reporting literature, the small body of research that has compared survivors who do not report their assault before or during SAEK collection to those who do has found that “stereotypical rape” characteristics often differentiate the two groups. Specifically, survivors who have an SAEK collected without reporting are more likely to have been intoxicated during the assault (Downing et al., 2022), and report that they knew the assailant (Schei et al., 2003; Stokbæk et al., 2021) and are less likely to have experienced an assault that involved penetration (Downing et al., 2022), physical force (Schei et al., 2003), or physical injury (Downing et al., 2022, Schei et al., 2003). Jones et al. (2009) queried these two groups of survivors directly by asking patients receiving medical-forensic care to complete a questionnaire after the exam had concluded. The questionnaire included a list of hesitations survivors may have about reporting the assault to police and respondents were asked to endorse any hesitations they had about reporting. Three differences emerged, with survivors who did not report before or during SAEK collection being significantly more likely to say they hesitated to report because they “knew the assailant” (54% vs. 23%), did “not want the assailant to go to jail” (66% vs. 9%), or were concerned that “police would be insensitive or blame” them for the assault (51% vs. 15%).

Largely missing from the literature are reasons for not reporting described by this group of survivors in their own words. Sexual assault survivors who have medical forensic evidence collected but choose not to release the evidence to police for investigation at that time are a sizable subgroup with potentially unique needs, and understanding their reasons for not reporting could inform what services are offered to survivors in the aftermath of sexual assault. Therefore, the purpose of the current study was to explore the reasons for nonreporting given directly by survivors who had an SAEK collected but declined to report the assault to police at that time.

Method

Project Setting and Sample

The setting for the current study was a medical forensic unit at a large, hospital-based forensic nursing program in the Mid-Atlantic United States. The program employs two nurse practitioners, and five registered nurses, and two certified nurse assistants who provide medical forensic services to all crime victims receiving services at the hospital. The number of nonreport SAEKs provided per year has increased over time, with n = 9 nonreport SAEKs provided by the forensic nursing program in 2010 and n = 62 provided in 2021 (M = 30.25, SD = 19.79). This increase coincides with an increase in the number of patients seen overall as the program grew; looking at the 2016 to 2021 period for which full-report SAEK comparison data are available, data indicate that a relatively consistent one-quarter of the adult sexual assault survivors who received an SAEK at the medical forensic unit chose a nonreport SAEK (range: 23%–29%).

The sample for the current analysis included all medical-forensic records connected to a nonreport SAEK that had been collected at that hospital from January 1, 2010, through December 31, 2021. As part of a supplement form specific to nonreport SAEKs, survivors were offered the opportunity to record offender or assault details that might be useful to a police investigation if they later decided to report the assault. The supplement form is completed in the exam room near the end of the exam and is filled out independently by the survivor unless they request assistance reading or writing answers to the questions. One of the questions on the supplement form is why the patient is choosing not to report the assault at that time, and survivors’ answers to that question provided the data for this analysis. A completed supplement form was included in the medical forensic records of 87.8% of sexual assault patients who had a nonreport SAEK collected. ²

The final sample included N = 296 medical records representing survivors who were 18 years or older, had medical decision-making capacity to consent to the exam, and had a completed nonreport SAEK supplement form in their medical forensic record. The sample reflected survivors who were primarily cisgender women (96%), with smaller proportions of cisgender men (4%) and transgender women (<1%). The most common racial and ethnic identities were White Non-Hispanic/Latino/a/x (38%), African American or Black (32%), and Hispanic/Latino/a/x (22%), with smaller percentages of survivors identifying as Asian/Pacific Islander (5%), Multi or Bi-racial (2%), or another racial and ethnic identity (1%). Survivors’ mean age was 26.90 (SD = 8.39; range 18–64) and most came to the hospital within 24 hours (49%) or between 24 and 48 hours after the assault (26%). The assaults described in the medical forensic records were primarily perpetrated by acquaintances or friends (44.2%), followed by individuals known only by sight or nickname (30.2%), complete strangers (13.6%), current or former partners (10.1%), or family members (1.9%). In 12.2% of the assaults, the survivor did not know their relationship to the offender, typically when the survivor was unconscious or had no memory of the assault. Most cases involved voluntary or involuntary consumption of alcohol or drugs (72.6%) and approximately half (54.4%) involved physical force.

Procedure

Nonreport SAEK medical forensic records for relevant years were gathered by hospital staff and reviewed by the first and second authors to confirm fit based on sampling criteria (i.e., to confirm that the medical record was associated with a nonreport SAEK and that the patient was 18 or older and had medical decision-making capacity). The first author then reviewed each record and recorded de-identified, IRB-approved variables, including demographic and assault variables and responses to questions on the nonreport SAEK supplement form. Responses to the question on the nonreport SAEK supplement form about why the survivor was choosing not to report at that time were typed verbatim into a spreadsheet and later uploaded into Atlas.ti (Version 9.1.7.0) for analysis. All data were saved to a secure research server and procedures were approved by the Institutional Review Boards at both Wichita State University and the hospital that houses the forensic nursing program.

Analysis

Our research project and subsequent analysis was grounded in a constructivist epistemological framework, which holds that knowledge is “constructed” by researchers (ideally in collaboration with participants) rather than “discovered” as pre-existing truth (Lincoln et al., 2011). Because our data were not generated through survivors’ participation in a research project, but rather their participation in an MFE and completion of related medical forms, we were not able to include survivors in the construction of our findings directly. However, we went through multiple rounds of descriptive coding with the goal of retaining as much survivor voice in the data as possible at each stage of analysis. We utilized thematic analysis (Braun & Clarke, 2012), specifically reflective thematic analysis (Braun & Clarke, 2021), for its alignment with our goal of identifying and making sense of patterned meaning. Our coding was inductive, meaning that no a priori theory or framework was applied. The coding and theme generation process reflected the hallmarks of reflexive thematic analysis, namely that coding did not rely on a codebook or coding framework, theme generation occurred late in the analysis process, and researcher subjectivity was viewed as an asset rather than a bias to be controlled (Braun & Clarke, 2021).

The first step in the analytic process—data familiarization—involved the first and second authors reading the data and noting initial thoughts and ideas. The first author read each piece of data multiple times—first while extracting data from the medical records, then when typing each response into a separate word document, and finally when uploading each word document into Atlas.ti. The second stage of the analysis—generating initial codes—was undertaken in multiple iterations with the goal of ensuring that codes (and ultimately themes) were constructed with as much survivor voice as possible, given the limitations of the data. The first iteration of coding was descriptive and relied only on semantic interpretation (e.g., “I’m in the middle of a custody battle” was coded as “custody concerns”). A second round of semantic, descriptive coding was then completed for data reduction purposes (e.g., “custody concerns” and “divorce concerns” codes were merged into a single “divorce/custody related concerns” code). A third round of coding was then conducted by the first and second authors in which initial codes were merged based on conceptual similarity. Braun and Clarke (2021) encourage recognition that semantic and latent codes should be viewed as ends of a continuum rather than as entirely separate concepts, and within that framing, this third round of coding shifted our analysis from purely semantic to a midpoint between semantic and latent meaning. For example, the code “divorce/custody related concerns” was merged with other theoretically similar codes such as “housing concerns” and “fear of being deported” to create the code “negative spillover effects.”

The next step in the analysis—generating themes—was carried out by the first author, who sorted the collated codes with the goal of identifying “patterns of shared meaning, united by a central concept or idea” (Braun & Clarke, 2021, p. 14). For example, the code “negative spillover effects” was grouped with the code “fear of harm/retaliation” as part of the theme Reporting Will Harm. All authors collaboratively engaged in the fourth step of the thematic analysis—reviewing themes—by reviewing and discussing potential thematic groupings and contributing input to the final list of candidate themes. The authors also collectively evaluated the candidate themes in relation to the data extracts, the content codes, and the dataset as a whole. The first author then initiated step five of the thematic analysis—defining and naming themes—by writing theme definitions that were then revised based on co-author feedback. The final step of the analysis—producing the report—was contributed to by all authors, who selected data excerpts to illustrate and elucidate the identified themes. A researcher positionality statement is included as Appendix A.

Results

Our analysis resulted in four primary themes that described sexual assault survivors’ complex reasons for having an SAEK collected but not reporting their assault to police: (1) Reporting Won’t Help, (2) Reporting Will Harm, (3) Not Now, and (4) Not What I’m Here For. Each theme is described in detail below.

Reporting Won’t Help

Survivors frequently shared the sentiment that reporting their assaults to police was unlikely to benefit them or improve their situations in a meaningful way. Often, this reflected what survivors perceived to be limitations of their potential cases. One survivor explained, “I don’t know what information to give [the police] because I don’t remember anything.” Another survivor echoed this sentiment, stating, “I don’t feel like I have enough information . . . I passed out that night and don’t remember much.” A third survivor summarized the concern clearly, referring to her lack of memory and saying, “I would not win a [court] case.” Survivors believed that investigation and possible prosecution of their case would require a great deal of information from them and when they did not feel they could provide that information, they were hesitant to make a report.

In other instances, survivors remembered the assault but did not have what they felt would be sufficient information to help police apprehend the offender. One survivor stated, “I didn’t see his face. It could be any Hispanic man” and another expressed the concern that she didn’t “know him or how to find him.” Even when survivors felt confident in their ability to give a full account of the assault and assailant, they sometimes decided against reporting because they did not believe the circumstances of their assault would produce enough evidence to prosecute the assailant. One survivor explained, “he used a condom and I’m not sure if there is enough evidence to prove my case.” Another survivor highlighted the potential costs of reporting without a strong case, explaining that it was “not worth reliving it” when she did not see a high likelihood of her case moving forward.

The perception that reporting the assault would be unlikely to help was also informed by survivors’ perceptions of police. Sometimes, these were general expressions of skepticism or fear, such as “they’re not going to do anything” and “I feel I will be the one questioned.” Other times, survivors referenced having experienced previous sexual assaults in which the police response was ineffective, at best, and traumatizing, at worst. One survivor spoke of a past assault in which she felt her case had not been pursued, saying, “I was sexually assaulted as a sophomore in college and went to the police, but it never went anywhere. I don’t want to do that again.” Another survivor recounted having been explicitly told she was making up her assault when she tried reporting to police: “I was raped in [my home country] and when I went to police, they told me I lied and didn’t do anything but make it worse.”

Survivors were discouraged from reporting not just by negative police interactions they had experienced themselves but also by negative police interactions they had heard about or witnessed. One survivor drew parallels between a friend’s case and her own, stating, “The police couldn’t help a friend I know when she was raped, and she at least knew who did it.” This survivor indicated that if police had been unable to help a friend whose case she perceived to be stronger than her own, there would be no benefit to her making a report. Regardless of whether the negative perceptions were specific to their own previous sexual assault, a previous sexual assault of someone known to them, or more general feelings of distrust, negative feelings toward police often contributed to the belief that reporting the sexual assault was unlikely to help them in a meaningful way.

Reporting Will Harm

Beyond the belief that reporting their assault would not make things better, many survivors believed that making a police report would actively make things worse. We identified two subthemes: Reporting Will Harm Me and Reporting Will Harm Others.

Reporting Will Harm Me

Survivors who expressed that reporting the assault would do them harm frequently referenced the emotional toll that participating in the criminal legal system would take. One woman explained, “Just repeating the story [is] emotionally draining” and another expressed that participating in an investigation “would draw out the process of grief.” Other survivors decided against reporting based on what would be required of them as their case moved forward, such as having to “face him again” in court. Survivors were also concerned about how they would be treated throughout the process, with one expressing “a huge fear of being in court and having a lawyer try to make it sound like it was my fault.” Across these concerns, survivors reflected that reporting the assault was likely to require that they disrupt their own healing process in order to provide the criminal legal system what was needed for investigation and prosecution. One survivor explained in-depth:

I would not like to involve the police at this time because I fear for my own mental health. I want to handle this situation on my own terms and at my own pace. Involving myself in a criminal investigation this early in my processing period may compromise my degree of control over this situation.

When survivors considered what would be required of them if they participated in the criminal legal system, the anticipated emotional toll was often enough to dissuade them from reporting. Concerns that reflected this theme often built on the concerns raised as part of the Reporting Won’t Help theme described above. Whereas those concerns frequently referenced the responses survivors expected from police as a reason not to report, they framed the expected response as a reason that reporting was not worthwhile and was unlikely to lead to a meaningful outcome. In contrast, when similar concerns were grouped as part of the Reporting Will Harm theme, they identified distinct harms of the reporting and prosecution process independent of the outcome. Regardless of whether their case moved forward, these survivors felt that reporting would do them harm.

Survivors were also concerned that reporting the assault would make them vulnerable to physical harm or disrupt their life in other concrete ways. One survivor expressed a fear of being physically harmed by her assailant, stating, “He is threatening me. I am scared about it and afraid of him.” Another survivor took little comfort in the idea that police intervention could reduce the threat to her safety, raising the possibility that he could “make bail and come after me.” Survivors described other tangible harms that could come from reporting their assault, as well. One survivor stated, “I work with [the perpetrator] and I am worried about my job.” Another woman, who was assaulted by her intimate partner, explained, “If I call the police, I will be on the street. The house is in his name only.” Divorce and child custody cases were raised as issues, as well, with survivors voicing the concern that their assaults could be used against them. One survivor explained this fear, stating, “I’m going through a divorce and it’s really nasty. My ex-husband has been looking for anything to take my [child] away from me.” One survivor summarized these concerns as the “domino effect,” which she explained as all the possible repercussions of reporting to police. These sentiments highlighted that, for many survivors, the current assault was one of many life stressors and they had to be cognizant of the way that reporting the assault could negatively impact other parts of their lives.

Reporting Will Harm Others

Survivors were also concerned about the ways that reporting the assault could harm others. One survivor described how difficult it would be for her family to learn about the assault, stating that she did not want to report “because of my family, relatives, and especially my mother. It would destroy her.” Another woman, whose assault was perpetrated by her child’s father, explained the negative impact a police report could have on her relationship with her child: “If I call the police, my [child] will hate me . . . the most important thing is that your child will hate you.” Other survivors worried about the impact reporting the assault would have on the perpetrator’s family. One woman stated that she did not “want his family to go through anything like this” and another explained that she did not want to report her assailant because “he is my ex’s older brother and without his older brother he has nobody to be there for him.” Concerns about the ways that reporting would harm others were particularly strong when the perpetrator had children. A survivor whose assailant was undocumented expressed concern about what his arrest and resulting deportation would mean for his child, explaining, “He doesn’t have [immigration] papers . . . He has a [teenage child] here and won’t be able to see [them] anymore.”

Some survivors also shared concerns about the ways that a police report would harm not only the perpetrator’s family but the perpetrator themselves. This was especially common when the survivor could not remember parts or all of the assault. Often, survivors had reason to think they had been assaulted by someone they had been with but could not remember the assault clearly and were uncomfortable making a report with that level of uncertainty. One woman described this hesitancy, saying, “I don’t know if I was raped or not, I just have this soreness and he was the only person I was with. If I was not raped, I don’t want to falsely accuse someone.” Even when survivors remembered the assault, concerns of harming the perpetrator sometimes remained. One woman explained that the perpetrator apologized after the incident, and she did not want to “ruin his life” by reporting him to police.” Another survivor echoed this statement, drawing a connection between the perpetrator’s life circumstances and why she did not want to make a report: “I feel bad because he just came back from deployment and I do not want to ruin his life.” While their specific concerns varied, many survivors saw ways that reporting could harm themselves or others and decided that it was simply not worth it to make a police report.

Not Now

For some survivors, the focus was not on whether to make a police report, but whether to make a police report now. These survivors often referenced the exhaustion and overwhelm that follow sexual assault. One woman explained that she was “too exhausted [to make a report] but might follow through later” and another similarly stated that she was ready to be “done with the incident for today.” Often, survivors chose to meet their basic needs before considering a police report. One woman explained, “I might [report] soon. I just want to go home and shower and eat and sleep.” Some survivors also wanted to wait to make a report until they had loved ones available to support them. For example, one survivor explained that she did not want to report at that time because she was “waiting for my mom to get here so I don’t have to do this alone.”

Many survivors were also explicit about needing more time to decide whether they would report their assault to police. One survivor explained, “I’m not sure about pressing charges yet. I want to sleep on it and then give an OK . . . I need a little more time to process.” Another survivor echoed this statement, stating, “I need to process what happened and decide what is best for my future.” Survivors often recognized that SAEK collection was time sensitive and therefore chose to seek out that care before they were ready to decide about reporting. One survivor described her thought process, saying, “I just want to get the exam out of the way and see how I feel in a couple of days.” Other survivors were leaning away from reporting but felt that having an SAEK collected would keep their options open. This sentiment was captured by a woman who was assaulted by her coworker and stated, “I . . . don’t feel like [reporting] is necessary at this time. If he begins to start things at work and if he tries to contact me then I will pursue charges and follow up.” Regardless of whether they were leaning toward or away from reporting in the future, these survivors shared a certainty that they did not want to report at the time of the MFE.

Not What I’m Here For

This final theme reflected that, for some survivors, reporting to police was not what they had come to the hospital for, nor was it an option they were interested in considering. Survivors who expressed this perspective emphasized that their goals for the hospital visit were to address their physical and emotional needs, not make a police report. One survivor explained that “the main reason I came here today was for a vaginal exam.” Another survivor echoed this perspective, stating, “I just want to focus on my body right now.” In each of these instances, survivors were clear about their desire to focus solely on their physical health at that time.

Other survivors explained that their mental health was the factor that drove them to seek services, as was the case for one woman who stated that she “came for depression.” At times, it was a combination of mental and physical health concerns that led away from making a police report. One survivor explained, “I’m putting my mental and physical health first and don’t want to get into reporting and pressing charges.” Among survivors who expressed that making a police report was not what they were there for, the purpose of the MFE was seen as entirely distinct from the reporting process. In this way, it was unique from the Not Now theme, as these survivors were not waiting to report until another time so much as expressing a desire to not think about reporting at all. One survivor summarized this sentiment clearly, saying, “I just want to make sure I’m OK health wise and forget this happened.” Another survivor echoed this statement, saying that they “would like to ensure medical wellbeing and move on.” For these survivors, receiving sexual assault-related care at the hospital was framed as a concluding step, and they were uninterested in opening a new chapter through reporting the assault to police.

Discussion

The goal of this study was to understand reasons for not reporting among sexual assault survivors who chose to have forensic evidence collected but not report their assault to police at that time. While reasons for not reporting have been a frequent topic of study, to our knowledge, this research is the first to analyze the concerns of this subset of survivors using their own words. Between 20% and 25% of survivors who seek MFEs choose the nonreport SAEK option (Campbell et al., 2021; Jones et al., 2009), and the ultimate goal of this study is to ensure that post-assault response systems are aware of and responsive to these survivors’ needs.

Two of the themes identified in these data—Reporting Won’t Help and Reporting Will Harm—reflect reasons for not reporting that have been documented in the nonreporting literature more broadly. Specific concerns that contributed to these themes, such as fear of physical retaliation and the low likelihood of receiving justice through the criminal legal system, have been raised, as well (Cohn et al., 2013; Zinzow & Thompson, 2011; Zweig et al., 2014). In perhaps the most similar set of findings, Patterson et al. (2009) found that survivors often worried that police could not help them, would not help them, or would make things worse. Interestingly, Patterson’s sample was quite different from our own. While Patterson’s team interviewed survivors who had not engaged with any formal systems, including police, medical, or advocacy, our current sample includes survivors who all engaged with medical help-seeking systems and chose to have forensic evidence collected that could be used if they later decided to make a report. That these concerns emerge across a range of survivor experiences emphasizes that while law enforcement agencies have worked to improve their responses to sexual assault in recent years (Campbell et al., 2020; Lathan et al., 2019), many sexual assault survivors remain hesitant to trust the police and a great deal of work is left to be done if that is to change.

Our findings also have notable similarities to the small body of literature that has specifically studied nonreporting among survivors who had nonreport SAEKs collected. Jones et al. (2009) found that not wanting the perpetrator to go to jail and believing that police would be insensitive or blame them significantly differentiated survivors who chose a nonreport SAEK from those who reported before or during the MFE. Those concerns arose in our data, as well, as ways in which survivors feared reporting would cause harm. This alignment is particularly noteworthy given that our analysis relied on survivors’ responses to an open-ended question and Jones quantitatively analyzed responses to a closed-ended list of potential concerns. The similarities in these two sets of findings indicate that concerns related to the perpetrator going to jail and concerns related to treatment by the police resonate deeply with at least some survivors who choose to have nonreport SAEKs collected.

While the Reporting Won’t Help and Reporting Will Harm themes reflect concerns about reporting that have been found in the general nonreporting literature, the themes Not Now and Not What I’m Here For may be more specific to survivors who had a nonreport SAEK collected. The Not Now theme reflects one of the primary reasons that the nonreport SAEK option was created, namely that many survivors are not ready to engage with the reporting system in the immediate aftermath of an assault (Lonsway et al., 2021; Zweig et al., 2014). There has been little research done with survivors who have a nonreport SAEK collected to confirm that this option is perceived as offering time and space as intended, and our data suggest that this is indeed the case.

Yet if the Not Now theme shows that alternative reporting options are working as intended, the theme Not What I’m Here For indicates that room for improvement remains. Survivors whose reasons for not reporting were captured by this theme communicated that their reasons for seeking post-assault medical care were entirely unrelated to making a police report. This theme, therefore, raises the question: would some survivors’ needs have been better met through a medical exam, carried out with the sole purpose of ensuring their physical health, rather than a medical forensic exam, carried out with the joint goals of physical health and evidence collection? Sexual assault patients at our study site are informed about all three options—a medical only exam, an MFE/nonreport SAEK, and an MFE/SAEK with a police report—so why did some survivors who expressed not wanting to report choose the nonreport SAEK rather than the medical only exam option? One uncomfortable reason could be financial cost. While exams that include forensic evidence collection are required to be financially covered through VAWA funds, medical only exams are not. The forensic nurses at our study site are passionate patient advocates and assure patients that they will connect them with the hospital’s financial assistance program, but the possibility of receiving a hospital bill for a medical only exam does exist. This possibility may lead some survivors to choose an option that is guaranteed to be financially covered, even if it includes forensic evidence collection they do not actually want. To our knowledge, this concern has not been previously documented in the research literature, and additional research is needed to explore and potentially confirm these dynamics.

Limitations

These findings should be interpreted in light of their limitations. Survivors’ written responses to the question about why they were not reporting at that time were quite short, usually a few words to a couple of sentences in length. It is very likely, therefore, that survivors’ reasons for not reporting are more complex than the data were able to represent. The lack of anonymity in survivors’ responses (i.e., that their responses were tied to their medical records) also could have impacted what they wrote. Additionally, use of archival data meant that we were unable to ask follow-up questions to clarify data that were unclear or ensure that we understood the survivor’s meaning. Finally, while the sample was diverse in age, race, and ethnicity, there was little representation of cisgender men, nonbinary, or transgender survivors. It should not be assumed that the reasons for not reporting identified here reflect the experiences of survivors who are cisgender men or survivors in transgender and gender diverse communities.

Implications for Research, Practice, and Policy

There is relatively little research focused on sexual assault survivors who have forensic evidence collected but do not report the assault to police at that time, and these findings emphasize that they have unique experiences and perspectives that warrant future study. Although the current study takes a meaningful step toward understanding these survivors’ experiences in their own words, future research should consider data collection methods likely to elicit a greater depth of information and provide survivors more control over the narratives they share. Zweig et al. (2014) gained important insights from focus groups that included survivors who chose the nonreport SAEK option, and these insights could be expanded with focus groups or individual interviews fully focused on this population. Research that seeks survivors’ input on questions such as how long nonreport SAEKs should be kept, whether and how survivors should be notified prior to their SAEK’s destruction, and what support would feel meaningful if they decided to convert their nonreport SAEK into a full report could be especially beneficial in ensuring that system responses are informed by survivor needs.

These findings also provide opportunities for practitioners to reflect on and potentially improve or better communicate their responses to sexual assault. The concerns reflected by the theme Reporting Won’t Help, in particular, represent instances in which survivors believed the criminal legal system could not or would not offer them meaningful help. Sometimes, these data reflected general distrust of police and that is trust that many agencies have been working, and must continue working, to earn. Other times, the data reflected circumstances in which survivors thought they did not have enough information to warrant making a police report, such as when they did not know the identity of the perpetrator or had limited memory of the assault. These findings should raise the question for police agencies: if sexual assault survivors are not reporting these types of assaults because they think there is nothing we can or will do, do we agree with that assessment? If not, agencies should consider developing and sharing how they investigate reports in which the survivor lacks complete information about the assault so that survivors can incorporate that information into their reporting decisions.

Informational pamphlets kept at help-seeking locations are one option for how such information could be communicated. Police agencies could use the themes identified through this analysis to communicate an understanding of survivors’ concerns and explain the actions they take to mitigate those concerns when possible. For example, a brochure could have a section that explains how the agency responds to reported assaults in which the survivor has a limited memory of the assault or does not feel they could find or identify the offender. Information about the process of ending an investigation if the survivor decides they do not want to move forward could also be included to address survivors’ concerns about an investigation negatively impacting their mental health. For agencies that have developed specific trauma-informed practices, these should be communicated, as well. Our results indicate that many survivors have had or know someone who has had a negative experience with police previously, and in the absence of evidence to the contrary, these previous experiences may be enough to dissuade survivors from reporting. The purpose of such informational materials should not be to dismiss survivors’ concerns or convince them to report, but rather to provide information about the current practices at local law enforcement agencies so that survivors can make the most informed decision possible.

The breadth and depth of survivors’ concerns, particularly those related to the Reporting Will Harm theme, also highlight the potential value of community-based advocacy services. Survivors referenced ways that reporting could negatively impact their employment, housing, custody, and close relationships. These are not short-term problems with easy solutions, and advocacy agencies are often the only response system able to provide the type of long-term support it would take to navigate them (Macy et al., 2009; Wegrzyn et al., 2023). Because community-based advocates are not affiliated with police agencies, they can also provide a neutral space to talk through the advantages and disadvantages of reporting and be there to support survivors regardless of what they decide (Patterson & Tringali, 2015).

Implications for policy are found most directly in the theme Not What I’m Here For. This theme reflected that some survivors were not at the hospital for anything related to a police report. Rather, they were there to have their physical health cared for and to potentially be connected with resources to support their emotional and mental health, as well. There is currently no national policy in place mandating that sexual assault survivors have access to a free medical only exam, and these data encourage exploration of such a policy. While there would be a financial cost associated with providing coverage for medical only exams in addition to MFEs, there are also costs to not providing that coverage. These costs are financial via the higher cost of forensic evidence collection compared to medical only examination, logistical via the burden of storing and tracking SAEKs that survivors may not have wanted collected in the first place, and moral via the possibility of survivors feeling financially pressured to have an invasive evidentiary exam when their health and healing could have been better served by something simpler.

Conclusion

Understanding sexual assault survivors’ reasons for not reporting their assaults can highlight areas where improvement is needed and also areas in which improvements have already been made. That survivors who wanted to have an SAEK collected and then go home to eat, sleep, or gather their thoughts before deciding whether to make a report had the option of doing so demonstrates one such success. That survivors expressed concerns that reporting would not help or would cause additional harm demonstrates the need for more. Policies and practices that offer support and resources to those who disclose sexual assault, regardless of whether they decide to report the assault to police, are likely to offer long-term benefits for survivors and their communities.

Author Biographies

Rachael Goodman-Williams, Ph.D., is an Assistant Professor at Wichita State University. Her research focuses on how communities develop and implement survivor-centered responses to sexual assault. Additional areas of work include posttraumatic stress, social support, and methodological and ethical considerations involved in gender-based violence research.

Jessica Volz DNP, CRNP, is a nurse practitioner and the Clinical Director of the Forensic Medical Unit at Adventist HealthCare Shady Grove Medical Center in Rockville, Maryland. She is a Ph.D. student and NIOSH fellow at the University of Alabama at Birmingham, where she is studying workplace violence and adverse childhood experiences.

Kathryn Fishwick, MA, is a Ph.D. student at Wichita State University. She conducts research related to the prevention of domestic violence and sexual assault, specifically related to primary prevention programming, teen or adolescent dating violence prevention, and school dating violence prevention policy.

Appendix A

Researcher Positionalities

Congruent with the constructivist epistemological framework of the research, we find it important to acknowledge our positionalities as knowledge producers in this project (Holmes, 2020; Sultana, 2007). This research project took place within a larger researcher-practitioner partnership that includes the first author, the second author, and other practitioners in Montgomery County, Maryland, including victims’ services providers and police officers. We approach our work from an action-research perspective, in which research is carried out with the goal of direct community application and change. The first and third authors have (R.G.W.) or are pursuing (K.F.) their doctorates in Community Psychology and have extensive training in qualitative research, including previous experience conducting qualitative research with survivors of sexual assault or service providers. Both also have experience working at sexual assault or domestic violence agencies. The second author has a doctorate in nursing practice and has more than 10 years of experience providing trauma-informed services to patients seeking medical-forensic care after sexual assault. The authors include both cisgender and genderqueer women, and all members of the research team are white and able-bodied. Our research is informed by a variety of feminist theories, including intersectionality theory (Crenshaw, 2017), which explores how the intersections of various identities shape experiences of inequality and oppression, and Neuman’s Systems Model of Nursing (Neuman, 1995), which considers the influence of physiological, psychological, sociocultural, developmental, and spiritual factors on a person’s response to stressors, adaptive behaviors, and wellness. Throughout this and other projects, we strive to actively engage with the ways that our varied identities and professional experiences impact us as researchers and our research.