NMartinez 2

Nicole Ames, “Empty Nest”

an Essay by Josephine Ensign

One evening in 1996 at the homeless youth clinic in Seattle, where I worked as a nurse practitioner, I looked over the medical chart of a new patient. She was sixteen and went by her street name, Dazzle. I opened the door to find her sitting cross-legged on the exam table, undressed from the waist down, a paper sheet draped over her lower body. Dazzle was thin, olive-skinned, with black cascading wavy hair, a ruby red nose piercing, and a tattoo of a rose sprouting from the top of her tight-fitting camisole. She sat hunched over, chewing her nails, and she glanced up at me shyly as I greeted her.

“It says here on your chart you’re here to get a vaginal infection checked out. Can you tell me more of what’s going on?”

“Yeah. I think it’s a yeast infection. I’ve gotten ‘em before. This one’s so bad it hurts to have sex. My boyfriend, he’s gonna’ want to have sex tonight, so I was hoping you’d give me some pills to make it go away fast.”

When I examined her, the infection was so bad it hurt to look at. In response to my questions, Dazzle told me she lived with her boyfriend in a motel on Aurora Avenue. From what she said—and from what she didn’t say—I knew he was really her pimp, and she’d be working that night as a prostitute.

Aurora Avenue, old Highway 99, is a long established track for prostitutes in Seattle, lined with cheap hotels, adult sex shops, and motorcycle and gun stores. There’s even an exotic meat store that sells elk, buffalo, and rattlesnake. Built on top of an old wagon trail, this stretch of highway keeps Seattle firmly tethered to the remnants of the Wild West. On a stretch of road south of the city, Gary Ridgeway, the Green River Killer, picked up young prostitutes he would rape, strangle, and then toss from his truck, covering their bodies with trash or dumping them in the nearby river. In his court testimony, he admitted that he lost count of how many he killed. When I saw Dazzle in the clinic, Gary was still murdering prostitutes.

“Can I bring in someone to talk with you about safer places to stay tonight?” I asked after we had discussed treatment options. I wanted Dazzle to talk with our mental health counselor without using that specific title, since it made young people think I was labeling them as crazy. But she got increasingly agitated. “No, really, I’ll be fine, I just need those pills,” she said, and then left. She never returned.

A large number of our youth clinic patients worked in the sex industry as exotic dancers and prostitutes. Most came to the clinic by themselves, some were brought in by their pimps, and a few young females came in with their male high-school teachers who were fleeing to other states on criminal sex charges. I was never sure which I found more despicable: the pimps or the teachers. The prostitutes were mostly young women, although there were also young men and transgender youth. We called it survival sex or just plain sex work, and erred on the side of non-intervention and harm reduction, trying to keep them as safe as possible until they could exit “the life.” This was a laudable goal and one I believed in. But in reality we were sometimes supporting their lifestyle, enabling it, and becoming part of the problem. We mostly used the neutral term “sex worker” instead of “prostitute,” thinking it was more politically correct, more respectful of the young people involved.

I often asked myself if there was such a thing as a happy, healthy hooker. Is the character Julia Roberts plays in Pretty Woman based on any sort of reality, or is she just part of a twisted Hollywood fairytale? I know prostitutes who call it a profession, who say they freely choose their work. I’d like to believe them because it would make my own work easier. But their statements have the off-key clank of false bravado I know so well, having used it myself over the years. So many young prostitutes have histories of sexual abuse as children. Their bodies are not their own; their bodies have been stolen from them. In such situations, I doubt that free choice is possible.

I have a recurrent vision of working on an assembly line where the faceless broken bodies move past me and where my job is to patch them together. But I can’t keep up. They remain broken—and silent—and they fall off the end of the conveyor belt into a pile.

The truth is that not all of the bodies in my imagined assembly line are faceless or silent. Some have the distinct faces of homeless young women I have worked with—young women such as Dazzle and Dawn. Dawn is the homeless girl who haunts me the most.


It was June 1987 in my hometown of Richmond, Virginia. Another health clinic, this time a combination shelter, soup kitchen, social services agency, and clinic, located in a squat three-story brick warehouse on the edge of downtown. This was the summer I lost my faith; this was the summer I began my own spiral into homelessness.

I was twenty-six, married to a seminary student, and had just given birth to my first child. The agency I worked for, CrossOver Clinic, was a fundamentalist Christian organization with ties to the Moral Majority. The all-white male board of directors was composed of wealthy ministers, dentists, and physicians. I was hired because I played the roles of humble Christian wife, mother, and nurse—roles I played so well I had convinced myself they were true.

Dawn was fifteen when I met her. I was doing street outreach with the Richmond Street Team, which operated out of the Street Center. Dawn had been living on the streets for three months and was involved in prostitution. The street team’s social workers and mental health counselors were trying hard to get Dawn into Oasis House, the only teen shelter in Richmond. She refused, saying she didn’t want to live in a place with curfews.

The Richmond Street Team focused on identifying homeless adults and teens with mental health and substance abuse problems, and linking them with available services—mainly emergency shelter beds. There were only a dozen or so publicly funded drug and alcohol inpatient beds in the city, with long waiting lists. None of the available outpatient drug and alcohol treatment programs effectively dealt with people who had co-occurring mental health disorders. Most of our homeless patients fell into this category. The few available mental health treatment programs didn’t accept patients with active substance abuse problems.

Dawn had run away from home in a small coal-mining town in the Appalachian mountains of Virginia. She traveled to Richmond on a one-way Greyhound bus ticket, hoping to stay with an older sister. But her sister wouldn’t let Dawn live with her, fearing Dawn would steal her boyfriend. Instead, Dawn found a group of men staying in tents on the edge of an open area near the Greyhound bus station. They let her stay with them, eat their food, and drink Wild Irish Rose in exchange for sex. Dawn was used to taking care of herself. She was used to survival sex. Her mother was an alcoholic, and her mother’s live-in boyfriend had been sexually abusing Dawn for years.

Dawn told me pieces of her story as I worked with her over the next two years. Her story was an example of Greyhound Therapy, what we called Alcoholic Anonymous’ Geographical Cure: attempting to escape problems by moving somewhere else. The AA Big Book states that it doesn’t work, quoting the maxim, “Wherever you go, there you are.” For young people like Dawn, escaping damaging home situations made sense, but the alternatives awaiting them often weren’t much better.

The day I first met Dawn, she was standing with a group of young men in the parking lot of a take-out pizza place just a few blocks north of the Street Center. Dawn was big in the Matisse way: fleshy, voluptuous, exuding sexuality like an early-blooming flower. She had a small head, short, bowl-cut sandy hair, and glacier-blue eyes. Her voice was a loud baritone, out of sync with her large, sagging breasts. She was braless and wore a men’s undershirt, with a faded, cotton high school letter jacket and baggy, torn jeans. Dawn was laughing, sneaking up behind one of the taller men, jumping up and trying to knock the baseball cap off his head in a pesky, flirtatious way.

“Hey Dawn, I want you to meet Nurse Jo. She’s the one I told you about from the Street Center clinic.” One of the street team counselors was trying to get Dawn’s attention as she continued to jump after the man’s hat. Now that she had an audience, Dawn got even more boisterous.

“Damn it all, Dawn, quit it now!” The man with the hat finally had enough. “Leave me alone before I have to hurt you!” He pushed her away.

Dawn had a look on her face like a slapped puppy, stung by his words. Then she frowned and looked down at her feet, kicking loose gravel from a muddy pothole in the parking lot. I saw a fading yellow bruise on one side of her face.

I took the change in her mood as a cue. “Dawn, if you ever have any health questions, come on over to the clinic, OK?” As soon as I heard my words, they sounded lame. Striking up conversations with strangers, especially with homeless teens in a pizza parking lot, did not come easily to me.

Still looking down, Dawn nodded, turned to the group of men. “See you later, losers!” Hands stuffed into her jacket pockets, she walked off in the direction of The Block. The Block was the name for the perimeter around the main public library downtown, an area known for street prostitution. There were specific sections for white female prostitutes, black female prostitutes, and another section for both black and white male prostitutes, all arranged like items on a convenience store shelf.

The Virginia state laws weren’t helping the outreach workers with Dawn. The age of consent for sex was fifteen, and even though prostitution was illegal, cops looked the other way. Virginia had antiquated but still sporadically enforced sodomy laws: crimes against nature like oral and anal sex. The male descendants of the men who had made these laws were now lawyers who staunchly defended the sodomy laws in a state legislation hearing as having their roots in Judeo-Christian beliefs. They worked in offices near The Block. Some were Dawn’s customers. I was learning these sorts of things by doing outreach with the city’s street team of savvy social workers and mental health counselors. They were introducing me to a world much different from the one I had known.

In every city people live on the fringes, stuffed into nooks and crannies, living on the edge of homelessness. Richmond was no exception. There were cheap motels for prostitutes and for homeless people who occasionally scraped together enough money to buy a room for a few all-night parties with as many of their friends as they could smuggle in. Most of these motels were sprawling one-story buildings along the older car and trucking routes, like U.S. Route 301 that the Street Center was located on. They had beds with Magic Fingers vibrating massage, thin walls, stained carpeting, and leaky plumbing. Then there were the aging hotels, now turned into Single Room Occupancy housing units—SROs. These had once been respectable hotels but were now in decline, their owners renting cheap to anyone willing to pay.

The summer I met Dawn, there was one main SRO hotel where many of my patients lived. The Capitol Hotel was located downtown near the gleaming white Saint Paul’s Episcopal Church and the even whiter State Capitol building. City developers were working hard to get the hotel condemned. Many Richmonders considered the six-story Capitol Hotel an eyesore and a magnet for prostitution and drug dealing. Housing advocates I worked with referred to the owner, a physician, as Richmond’s worst slumlord. They, along with a series of newspaper articles by Robin Farmer, informed me that he rented rooms for $200 a month and kept a few rooms for nightly use only. He charged $20/night for these rooms, plus a $5 “visitor’s fee” in order to get a cut on the prostitution and drug dealing. Some families with children lived there; a Richmond Public School bus stopped in front of the hotel.

The Capitol Hotel was also a regular stop for the street team. One day soon after I had met Dawn, street team members asked me to accompany them to check on a man. He was in his seventies and was an alcoholic they had gotten off the streets, through detox, and into the Capitol Hotel. He had an injured knee and couldn’t get out of his room to see a doctor.

I followed the two outreach workers between a series of thick marble columns holding up the portico and in the heavy brass front doors. The inside was dark. The lobby stank of rotting garbage, mold, and urine. The outreach workers spoke with a muscular, T-shirt-clad black man who sat at the front desk behind protective bars. On the other side of the lobby was a caged elevator with a large hand-lettered sign taped to it: “Broke. Use stairs.” From the curled and yellowed paper, it looked as if the sign had been hanging there for years.

There was a wide central staircase lit by a tall window. The wine-colored wall-to-wall carpeting was tattered, stained, and oily-looking. I noticed thick black mold radiating from the bottom of the window, out over the wall, and onto the damp rug. We climbed the stairs to the fourth floor, each floor lit by a solitary light bulb illuminating lines of scarred wooden doors.

The outreach workers knocked on a door at the end of a hall. Inside the small room, a thin grey-haired black man lay on a bare ticking-stripe mattress. His right knee was propped up on a dingy pillow. He let me examine his knee, which was sprained and probably arthritic. I wrapped it with an elastic bandage and gave him some over-the-counter pain medication. I couldn’t imagine how he navigated the hotel stairs. His room was littered with fast food boxes and bags, but no alcohol cans or bottles, so maybe his sobriety was sticking. I wasn’t sure I’d be able to stay sober for long if I had to live in a place like this.

Once we’d finished our visit and were back in the lobby downstairs, a young woman, scantily clad in cutoff jeans and tank top, ran past us toward the front door. It was Dawn.

“Nurse, I gotta come see ya soon!” she yelled in my direction as the door slammed behind her.

The next week, Dawn showed up at the Street Center clinic accompanied by one of the street team counselors. “I hate this place. It creeps me out!” Dawn said loudly in lieu of a greeting. This didn’t surprise me. The waiting room was clean, sparsely furnished, with a row of orange plastic chairs, and a small wooden bookshelf full of patient education pamphlets alongside pocket-sized New Testaments. On the wall was a large colorful poster of the twenty-third Psalm, with a shepherd’s staff silhouetted in the background.

Maybe she was referring to our religious décor, but I assumed the entire building disturbed her. The Street Center clients were mostly men, and staff members frequently broke up fights.  By then, Dawn was living with her twenty-year-old boyfriend Red in a boarded up building downtown. Red had been the man I’d seen Dawn pestering on the sidewalk, trying to steal his hat, the day I met her.

“Dawn, come on in the room here so we can have some privacy.” I tried to sound welcoming but not overly so. She seemed skittish, ready to flee.

“Nurse, it hurts to pee!”

I sent her to the bathroom for a urine sample. She had a bladder infection, and she was pregnant. Standing in my small lab area, I stared at the blue plus sign on the plastic pregnancy stick, sighed, and walked back into the exam room to tell her.

“No way. No way! I can’t be. Red will kill me when he finds out!”

At that point, I didn’t have a lot of experience with either unwanted pregnancies or homeless teenagers. Dawn started sobbing, her shoulders heaving. Her crying was high-pitched, soft, like a kitten mewing. I grabbed a box of tissues, tore out a few, and handed them to her. She took them and blew her nose loudly. Staring at the sodden mass of tissues she said, “Red wants a baby, but not yet. We’re saving money for a car so we can get away from this damn place. Go to Florida!” Words tumbled out of her. “Oh God!” she said, raising her head to look at me. Her eyes widened and her mouth gaped open. “What if it’s not even Red’s baby! He’ll kill me for sure!” Through louder sobs, she told me she tried to get customers to use condoms but not all of them would. Some paid her extra not to use one.

I sat back on my stool and sighed. I was going to have to test Dawn for sexually transmitted infections, including HIV, and soon. Today. I was mentally making a medical checklist of things to do. This was beyond what I thought I could handle on my own. None of my medical manuals would be of any help, nor would the two male private practice physicians available by telephone for consults. This was a complex social, emotional, and health situation all wrapped up together. My direct supervisors at the clinic had made it clear that they were opposed to me doing any pregnancy options counseling, and especially to referring women for an abortion. “That’s just not what our faith tells us to do,” one of my supervisors said.  My back-up physicians were against me doing pregnancy options counseling with women, of referring them for an abortion. I considered pulling in the street team counselor at that point, but decided I should at least finish the visit with Dawn.

“Dawn, it’s early. You’re probably about six weeks right now, so you have a few weeks to decide what you want to do.” I tried to sound as neutral as possible, even though I was really thinking a baby was the last thing Dawn needed right now. As a nurse, I had to give her information on all her legal options: terminating the pregnancy with an abortion, giving the baby up for adoption or to family members, or trying to parent the baby herself—although the latter option didn’t seem realistic. As a woman, I wanted to give her the information and leave the decision to her. But it also brought back painful memories of my first pregnancy.


I had been a good girl growing up, a preacher’s kid. My parents didn’t let me cut my long hair, pierce my ears, wear makeup, or start dating until I was sixteen. Premarital sex was, of course, forbidden. It happened anyways.

I was a sophomore in college, and my fiancé was in graduate school. I visited him at Thanksgiving, and we had sex for the first time. Christmas break, I discovered I was pregnant. I kept thinking of the fact that I had had sex one time and had gotten pregnant. What were the odds of that happening? I took it as divine retribution, both for having premarital sex and for being in a relationship with an atheist who didn’t know how to use a condom correctly.

I didn’t tell anyone about my pregnancy, except for my fiancé, who promised me we would marry and have children after he finished graduate school and had established his career. I believed him, or at least I wanted to believe him since I thought I was in love. He arranged for me to have an abortion when I visited him in February.

About the abortion: I remember walking toward the front door of the Brookline clinic in Boston, my fiancé shielding me from the angry taunts of pro-life protesters lining the sidewalk. I remember the female intake counselor, especially her long pause and her eyes darting to my boyfriend’s when I told her I wasn’t 100% sure this was the right decision. I remember sipping the cool, sweet apple juice in a recovery room full of women. I remember furtively looking at some of the women who were there alone and wondering if it wasn’t somehow easier that way. I remember bleeding profusely while lying in my fiancé’s awful bedroom in a crowded graduate student rooming house. Outside, the snow lay in black melting drifts. Next to me lay my fiancé, who was eating a large bowl of ice cream and watching Hill Street Blues, a show he knew I hated. We broke up soon after.


I was rattled by Dawn’s in-your-face sexuality, coupled with descriptions of her work as a prostitute. When I met Dawn, I was married to a preacher. I didn’t allow myself to think of sex, except as procreation. It was easier that way. Dawn was too distraught to make a decision about her pregnancy options that day, so I treated her bladder infection and convinced her to let me check her for HIV, gonorrhea, and chlamydia. I sent her out the back door of the Street Center, accompanied by the outreach counselor. A week later, all her tests came back as negative.

Dawn came back to clinic for a check-up.  She’d had a miscarriage, but refused my offer of birth control.

“Red and me want a baby real bad. I’ll make sure it’s Red’s this time. Losing this one must a’ been God’s will. It must a’ not been Red’s baby, right?” She asked me this as I sat on a stool under the poster of the twenty-third Psalm. I wasn’t sure about God’s will, but I nodded in agreement. Whatever the cause, I found myself relieved Dawn had lost this pregnancy.


The last time I saw Dawn was two years later, at the end of the summer of 1989. I was out working with the street team. I didn’t know it at the time, but I was a month away from being fired from my clinic job for “no longer being a Christian woman with a humble and teachable spirit,” for referring women for abortions, for not calling AIDS patients in to account for their sins before they died. I had not known it was possible to be fired for such things. I was six weeks away from becoming homeless myself. I had never thought that was possible either.

Teetering on clear plastic high heels, Dawn was headed to The Block. She had lost so much weight, her collarbones jutted out over her pink puckered tube top. I wondered if she had AIDS. One of my favorite patients had died of AIDS just a few months before, so I knew what the disease could do—what the disease looked like. Dawn refused testing, saying she’d rather not know.

That fall I spiraled down, lost the vestiges of my faith, my marriage, my job, my home, and my sanity—more or less in that order. I didn’t drag my son down with me; he stayed with his father in the seminary housing where I’d lived as a good Christian wife and mother. So I also lost my son. I spent six months couch-surfing, living in my car and abandoned sheds, before moving to Baltimore to go to graduate school. Some geographical cures do work. Sometimes it takes radical change to get your life back. After graduation, I took a job in Seattle and got my son back full-time. I can now revisit Richmond—for a short time—and not get lost. The real truth is I no longer return.

But I realize I have the luxury of not returning. I was able to extract myself from my own downward spiral because I had more resources than Dawn did for working my way back out of poverty and homelessness. Unlike Dawn, my own family of origin was not as poor or dysfunctional. And, of course, I had the advantage of a good education and the ability to work as a nurse instead of relying on the dangerous—and deadly—‘work’ of prostitution.

In my assembly line nightmare, my body continues to lie between those of Dazzle and Dawn, but I am no longer mute. I cannot tell their stories. I can tell mine.

Josephine Ensign is a writer and a nurse. She teaches health policy and health humanities at the University of Washington in Seattle. Her essays have appeared in The Sun, The Oberlin Alumni Magazine, Pulse: Voices From the Heart of Medicine, Silk Road, The Intima, The Examined Life Journal, Johns Hopkins Public Health Magazine, and in the nonfiction anthology: I Wasn’t Strong Like This When I Started Out: True Stories of Becoming a Nurse edited by Lee Gutkind. ‘Greyhound Therapy’ is based on a chapter from her forthcoming book, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net (She Writes Press, August 2016).