Every year thousands of adults in the United States experience rape and sexual violence. Few studies have examined and compared the nuances of sexual assault narratives from the survivors at the time of the sexual assault medical examination, especially among survivors who did not report to police. This thematic analysis compared the descriptive narratives of survivors who voluntarily used substances and survivors who did not at the time of their medical examination. Results indicated five overarching themes with corresponding subthemes: nonprototypical characteristics, disruption, gaps in narratives, safety consequences, and distrust and neglect in systems.