About once per month, Marcia Clennon spends her weekend on-call and ready to respond to victims of sexual assault.

While travelling to whatever hospital the victim is at, she likes to spend that time mentally preparing.

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"We usually ask whoever called about it so we kind of know how to prepare, whether it's a traumatic stranger assault versus somebody they know or some sort of incest," Clennon said. "You would approach each one of those differently."

Her colleague Amanda Paull agreed.

They're both nurses at Mercy Hospital in Moose Lake. On the weekends, they work as sexual assault nurse examiners, or SANEs, for WINDOW Victim Services, which serves Carlton, Pine and Kanabec counties.

The SANE program started operation in June 2016. As of this week, it has responded to 75 victims among the three counties; 34 of those were in Carlton County. Two SANEs have also testified in court as expert witnesses; both cases resulted in the abuser receiving conviction.

SANEs collect forensic evidence using a sexual assault evidence-collecting kit. They also assess injury of their patients - not that physical injury has to be present for the assault to have occured, which Clennon said is a common misconception.

The SANEs can collect evidence DNA using cervical, vaginal and oral swabs. They then seal everything in a box and hand it over to law enforcement.

Having that evidence makes all the difference if a sexual assault victim ever chooses to prosecute, said Lisa Lilja, executive director of WINDOW Victim Services, based in Carlton.

"It makes the case much stronger and I think it gives our systems more courage to move forward with these cases," Lilja said.

When a sexual assault is reported in one of the three counties, Erica Heesaker, the program manager at WINDOW, is the first line of contact within SANE.

She also responds as an advocate to support victims throughout the examination process at the hospital, as well as during interviews with law enforcement, court proceedings or anonymous reporting.

"The nice thing about an advocate and nurses working in tandem is once the nurse cracked that box and started collecting evidence, they can't leave it, but we can," Lilja said. "So we can run and get the victim."

"Crackers and socks, a blanket if they're cold," Heesaker chimed in.

Maybe the patient says they haven't eaten since the assault happened a couple days ago. Heesaker said she would go find them something to eat if they asked for it. Or, maybe the patient really would rather be alone. It's always the victim's choice, Heesaker said.

"I always offer," Heesaker said. "I say, 'You know this is completely up to you. I'll sit over there, whatever it is that you want, or I can leave.'"

Advocates also refer victims to mental health services or support groups and explain the entire criminal justice process to victims so they can decide whether they want to proceed with a case.

Nurses and advocates within SANE have to complete 40 hours of training, while also continuing training throughout the year, Lilja said. Often, the nurses, like Paull and Clennon, use their vacation time to attend training.

It's one of the barriers that makes it difficult for rural areas to have a SANE program, Lilja said, since rural hospitals can't always afford to pay their nurses to attend the sexual assault training.

Another major roadblock preventing similar services from serving more people is getting program funding in rural areas. Depending on the county, the sheriff's office or the county attorney's office typically funds the service.

"While they're supportive and they like the program, they just can't contribute the funds to it," Lilja said.

Patients do not foot the bill of the exam, but the county where the assault occurred does.

At least 29 of 87 Minnesota counties are served by a SANE program, according to the International Association of Forensic Nurses.

Without a SANE program, or a similar service, victims who arrive at a hospital emergency room aren't guaranteed the same immediate response SANEs can provide.

"When we respond to an assault, we are focused on them only, no matter how long it takes, even if it's six or eight hours," Clennon said. "Whereas, if a hospital uses one of their nurses, that's taking a nurse off the ER floor for however long it takes, so they tend to go through it quicker because they have to get back to their other patients."

Or, as Heesaker has observed as an advocate, because of the time it can require to complete a forensic exam on a sexual assault victim, those patients might have to wait hours before a nurse has time to provide the exam.

SANES also bring a victim-centered approach to the medical process, Heesaker said. They describe everything they do and they let the patient know that at anytime, they can ask them to stop the exam.

As of January, 85 percent of victims a SANE nurse responded to chose to follow through with completion of the exam. The rest only consulted with the nurse. And, at least 86 percent of victims reported the sexual assault to law enforcement.

During the week, when SANEs aren't on call, Heesaker still takes calls from hospital emergency rooms and dispatches advocates. If a SANE is available, they will often agree to provide the exam, Lilja said, otherwise, the hospital follows its own policy procedure.

Growing awareness

For 19 years, Lilja has worked with WINDOW Victim Services. She was hired as a children's advocate in Hinckley. A month or two in, the director resigned and the board of directors hired her.

Throughout her years in the field, she has bore witness to the changing ways in which we think about sexual assault, even just within WINDOW. The biggest difference she's noticed is the way we've flipped the conversation from blaming the victim to holding the abuser responsible.

"We've switched the dialogue and conversation around so that we're not saying, 'What did you do to make him do this?' It's now, 'Why did you choose to rape her?'" Lilja said.

She's also noticed law enforcement has become more victim-sensitive in interviews, and education around consent has heightened. Still, the work continues.

"We're very lucky in our counties that we're allowed a seat at the table," Lilja said. "So we can be sure to be the voice of the victims and talk about how the system needs to improve to be more victim-oriented as well as trauma-informed."