Though misconceptions about prostitution often lead to mistreatment in hospitals and law enforcement, in Worcester, that story is slowly changing. Officials and community leaders say that the city is increasingly looking at prostitution as a public health issue, rather than a moral failing.

Nationwide, women are much more likely to be punished for charging for sex than men are for buying it. Between 2000 and 2014, prostituted women were around twice as likely to be arrested than the men paying for sex with them, according to statistics from the U.S. Bureau of Justice.

But recent data show that Worcester is starting to buck this trend. In 2010, 98 women were arrested for prostitution, while only nine men were arrested for paying for sex. In 2018, 33 women were arrested compared to 96 men. Medical professionals in Worcester are also starting to change their training to reduce bias against prostituted women and provide better care to help women exit prostitution. This shift follows — and may be partially thanks to — a shifting mindset towards people struggling with drug addiction in the midst of the opioid crisis.

Prostituted women often face discrimination and bias when interacting with doctors or members of law enforcement, according to Nikki Bell, a survivor of commercial sexual exploitation in Worcester. During the 10 years she was trapped in prostitution, Bell said trips to the hospital and interacting with police were traumatizing.

Once, in her late 20s, she went to the emergency room after being raped, and a nurse suggested that treating her was a waste of time.

“It was horrible,” said Bell. “Somebody has just been assaulted, and you’re basically saying, ‘Why are we even doing this?’”

Bell is the founder and director of Living in Freedom Together, orLIFT, an organization in Worcester that helps women exit the cycle of commercial sexual exploitation. Among other things, Bell’s organization is working to change the narrative around prostitution, particularly in medical systems and in law enforcement. Bell said women stuck in the violent cycle of prostitution need help and recovery services — not judgment or punishment.

Most prostituted women in Worcester struggle with poverty, homelessness and addiction, according to Marianne Sarkis, a professor at Clark University who researches sexual exploitation in the region.

“Women enter prostitution as a result of having a lot of trauma in their background,” said Sarkis. “They stay and get stuck in prostitution is because of things like homelessness, domestic violence and substance use.”

A majority of prostituted women experience violent crime committed by johns or traffickers, particularly rape, according to a report by the U.S. Department of Justice. The report also found that up to 80 percent of women were forced into prostitution by pimps or traffickers.

Bell’s organization has been working with local law enforcement to reduce the effects of criminalization on prostituted women. When LIFT was founded in 2014, prostituted women in the city were being arrested five times more than the men who were buying them. Last year, women were arrested less than half as many times as the men.

These numbers reflect a change in attitude in the Worcester County District Attorney’s office, according to Worcester DA Joseph Early Jr. He said that his office is focusing on buyers and plans to use sting operations and undercover officers to target buyers and traffickers.

“We’d rather prevent crime than have to solve crime,” said Early. “It falls into philosophy with what we’re trying to do in this office — show compassion and stay within the law.”

The DA's office has worked with LIFT and the Worcester Police Department to create a diversion program that allows women to avoid charges as long as they get recovery services from LIFT. Around 25 women have taken part in the program since it started in July. Bell said that so far, the program is working well.

The change in attitude toward prostituted women is also entering medical systems in Worcester. Jennifer Bradford, a doctor of family medicine, said judgmental or insensitive words and actions from doctors or nurses can make the difference between life and death for some prostituted women.

“People are actually avoiding going to the hospital when they have serious conditions,” said Bradford. “Individuals are deciding they would rather die than get treated in the hospital where they feel like they’re going to get treated without respect, without dignity.”

Involvement in prostitution can increase a woman’s risk of many health issues, such as tuberculosis, HIV, sexually transmitted diseases, hepatitis and other infectious diseases, according to Bradford. When women are treated well by doctors or officials, she said, they will be more likely to connect with resources and get help.

Bradford treats women once a week at LIFT’s drop-in center, and she uses an approach known as “trauma-informed care,” in which doctors try to create safe spaces for patients who have experienced trauma. Bradford said it’s about respecting her patient’s decisions non-judgmentally and “meeting them where they are.”

“They’re telling me what they need,” said Bradford. “So, when I go into their space, they can tell me, 'I feel comfortable with this treatment' or 'I don’t feel comfortable with another treatment.' I become a familiar face within their space.”

Bradford said "trauma-informed care" combats bias and mistreatment of prostituted women and helps lower the power differential between doctors and patients. And this approach is gaining traction in the medical system, she added. She teaches it to her University of Massachusetts Medical School residents in Worcester.

Changing people’s attitudes around prostitution goes hand in hand with changing attitudes about addiction — two issues full of misconceptions.

An ironic upside of the nation's opioid epidemic is that people addicted to drugs — and those trapped in prostitution to feed their addiction — are increasingly seen as needing treatment and support as opposed to punishment, according to John Kelly, director of the Recovery Research Institute at Massachusetts General Hospital.

“We’ve had 50 years now of the ‘War on Drugs,’” said Kelly. “We’ve shifted the needle in terms of moving towards a broader public health approach [and] away from the more punitive rhetoric.”

Around the country, and especially in Boston, said Kelly, medical schools are updating their curriculum around substance use and recovery to reflect this new approach.

In Worcester, the culture is changing for the better, said Bell, but there are still issues. The women her organization serves complain about their treatment in local hospitals, and law enforcement is still arresting prostituted women. So far in 2019, 20 women have been arrested for prostitution in Worcester. Bell said ideally that number would be zero.

Early said that for now, arresting prostituted women is necessary, but there could be a future where women are not arrested at all and brought directly to LIFT instead.

Bell thinks that as more people in positions of authority are better educated about addiction and sexual exploitation, more women will get the help they need.

“People that end up in prostitution are the people with the least amount of choices,” said Bell. “If people can better understand the process of entry, and the vulnerabilities these women have, it’s much easier to look at the person standing in front of you with compassion and empathy.”

Correction: Due to a source error, an earlier version of this story incorrectly stated that Marianne Sarkis will be monitoring the efficacy of the DA's diversion program. That reference has been removed from this article.