Jeffrey Epstein was in some respects fastidious. As he managed an international sex-trafficking operation, the size of which is likely yet to be comprehended, he was careful that the young women in his orbit were sexually healthy — ready to be used for his purposes. The latest cache of emails, texts, and other documents released by the DOJ reveals that Epstein had an established system for making sure the women were tested for STDs, prescribed birth-control pills, and inoculated against HPV. As a part of this system, he regularly made payments to at least three New York City gynecologists, as well as a dermatologist and his own personal physician.

For the moment, it’s difficult to tell whether the involved women, whose names are largely redacted by the DOJ, are among those who have been considered victims. It’s also unclear, to varying degrees, if the named physicians were aware of Epstein’s criminal activity, though by the time of the earliest relevant messages, he had been convicted for solicitation of a minor. What is certain, however, is that Epstein paid for many of these medical appointments directly via check or credit card. It is also clear, from messages with his close contacts, that he was sending women to gynecologists and other physicians so frequently that it was common knowledge among some in his circle. In one December 12, 2012, email, an associate whose name is redacted but whose email address matches that of Mark Epstein, Jeffrey’s brother, asks Epstein, “Do you remember the name of the Gynocologist [sic] that you used to send your victims to?”

“Many years ago you used to send them to a gyno in NY who once commented something to the effect that you were keeping him in business singlehandedly,” the sender writes. The message does not name the specific physician, but the new files offer potential clues about the involvement of a number of doctors.

In one 2015 email, when an unidentified person asks which gynecologists Epstein regularly uses for “the girls,” Epstein’s former staff member Bella Klein replies, “S. Yale and Romoff.” “S. Yale” appears to be Suzanne Yale, an OB/GYN who practiced in Manhattan for more than 45 years. She previously shared an office with fellow OB/GYN Adam Romoff, who is cited in the emails as the physician for a number of the women associated with Epstein, including Karyna Shuliak, his longtime girlfriend and reported beneficiary of his $100 million fortune.

For years, Romoff and Yale practiced out of an expansive townhouse on 82nd Street, off of Fifth Avenue, and were affiliated with Lenox Hill Hospital (now Northwell Health). Though Yale retired years ago, according to a colleague of both doctors who asked not to be identified, Romoff is still practicing and regularly presents at academic conferences. His name shows up in the Epstein files 38 times, though he is never shown to be in direct communication with Epstein himself. “They’re both very well respected, had very busy practices,” the colleague said of Yale and Romoff. “There were no shades of improprieties or anything like that.”

The colleague did not believe that Yale or Romoff knew they were treating women associated with illegal activities. And this may be true. The majority of the appointments referred to in the files appear to have been made by the young patients directly or by one of Epstein’s assistants — in multiple emails, he instructs them to schedule “pussy swab[s]” or “pussy test[s].” But the source of the money was unambiguous. Between 2011 and 2019, according to the released files, Epstein made more than half a dozen direct payments to Romoff and Yale. On March 14, 2019, just four months before he was arrested for the last time, he wrote a $375 check to Women’s Health of Manhattan, Romoff’s current practice. A receptionist at that office declined to speak, and neither Romoff nor Yale responded to emails requesting comment.

Alexander Shifrin, an OB/GYN and women’s integrative health specialist in Manhattan and Brooklyn, is also repeatedly cited in the emails and text messages. In one 2019 exchange, a woman whose name is redacted sends Epstein an ultrasound performed by Shifrin before soliciting advice about treatment for her ovarian cysts. (“Send me a sexy photo as a thank you,” Epstein says in response.) Shifrin also did not respond to a request for comment.

Beyond New York City practitioners, the emails make reference to physicians in West Palm Beach, New Mexico, and Ohio, where Epstein had homes. Earlier this month, Ohio State University announced it was investigating the chair of its department of obstetrics and gynecology, Dr. Mark Landon, after his name appeared in the DOJ dump; Epstein reportedly gave thousands of dollars in payments to Landon for unspecified work between 2001 and 2005. In a statement issued via the Ohio State Wexner Medical Center, Landon denied knowing anything about Epstein’s illegal activities or treating any of the young women in his sphere. “I did not provide any clinical care for Jeffrey Epstein or any of his victims,” it said. “I was a paid consultant for the New York Strategy Group regarding potential biotech investments from 2001 to 2005. I had no knowledge of any criminal activities; I find them reprehensible and I feel terrible for Epstein’s victims.”

None of the other doctors revealed to have treated women associated with Epstein have publicly commented on their relationship with him, nor have they clarified whether they found it peculiar that a well-connected billionaire was sending young women, often from Eastern Europe, to their practices to be checked for STIs. The anonymous peer of Romoff and Yale said that if the doctors had known of Epstein’s involvement, it would have posed a “dilemma.” Having sex with a slew of young yet ostensibly adult women may be creepy but is not necessarily illegal. “We put ourselves in these positions where we want to take care of the patients and give them confidentiality,” they said. “And if you don’t notice any obvious signs of abuse, and the patient isn’t going to bring up anything, why would you suspect anything? It’s a judgment call, for sure.”

In the case of at least three doctors, however, there is evidence that Epstein communicated with them directly. In one May 2019 text exchange, Epstein tells an unidentified woman that she will see a new gynecologist, Dr. Isabel Blumberg — a physician associated with Mount Sinai — after she receives her “shots” from Shifrin. “I spoke to her and told her you are my new assistant and to take special care,” he wrote. “Her clients are the wealthiest families in New York and she is very kind.” (Blumberg did not respond to requests for comment.) Another physician, Dr. Steven Victor, a New York City–based dermatologist whose name pops up in the DOJ drop hundreds of times, appears to have believed that seeing Epstein’s “girls” gave him a form of leverage. In one 2009 email, he seems to take Epstein to task for failing to support him financially in exchange for treating his “girl friends” for free and not speaking to the media about him. “I have been loyal to you about the magazines calling me over and over about you. I have asked you over and over about investing and helping and not just loaning me … I have lived up to my bargain as I promised,” Victor wrote. (According to the emails, Victor continued to see Epstein’s “girls” for years afterward; in a 2012 email, one unnamed woman discussed seeing Victor to treat her molloscum contagiosium, a viral skin infection that can be spread through sexual contact.)

In a lengthy email responding to a request for comment, Victor wrote that he had agreed to treat Epstein and a limited number of associated individuals without charge in exchange for a loan helping him to start a “cosmeceutical company.” He continued, “Most of the patients referred were adults. There were also some younger patients, including minors. In every such instance, they were accompanied by a legal adult guardian … No patient ever disclosed any inappropriate conduct by Mr. Epstein to me or to my staff. Had anyone done so, I would have immediately reported it to the authorities.” He wrote that he “did not view Mr. Epstein’s personal legal matters in 2008 as relevant” to his role as a dermatologist and that he was not certain he was even “aware of the details” at the time. In regard to his reference in the emails to not speaking to magazines, he said, “I never agreed to silence as a condition of anything.” He added, “I am appalled and heartbroken by what Mr. Epstein did to young women and children … My involvement with Mr. Epstein was limited to providing dermatologic care to him and patients referred to my practice. I did not participate in, enable, or have knowledge of any criminal conduct.”

There is evidence that Bruce Moskowitz, Epstein’s own physician, made an effort to cover up his patient’s sexual activities on at least one occasion. Texts from 2016 between Epstein and Moskowitz show that Epstein was diagnosed with gonorrhea that year and placed on a rigorous antibiotic course. In 2018, Epstein texted Moskowitz again, informing him that two of his “friends” might have also contracted gonorrhea. “I think to be safe my two friends should get shot by you tomorrow or send them somewhere close,” he wrote. Moskowitz agreed, proposing a location for him to treat them. “That way I do not have to report the cases to health department including contacts,” he wrote. (Moskowitz also did not respond to a request for comment.)

Meanwhile, the young female patients — whom Epstein sometimes refers to as his “assistants” — were subject to humiliating messages regarding their health. In one 2017 text exchange, Epstein requests that an unnamed woman send him a photo of her genital sores. “You need famvir,” he says, naming an antiviral medication commonly used to treat herpes. In one particularly gross email, from 2012, he advises an unnamed woman, “make sure you take some form of antibiotic for the pussy, Cleocin or some such, you’ve had many dicks in just a few weeks.” In a series of emails from 2017, he berates one of his partners for having unprotected sex with another man, accusing her of concealing a herpes outbreak from him. “I was crystal clear that the real risk for casual sex in New York, with boys, is disease,” he wrote. “I believe you either chose to carelessly disregard what I had said, or intentionally ignored it.” It was not uncommon for these young women to balk at Epstein’s testing protocols. In texts from June 2019, Epstein mocks an unnamed young woman for being “too afraid” to let a male gynecologist examine her.

Remarkably, Epstein appears to have taken pride in his knowledge of female sexual health, offering it to his rich and powerful friends like other bits of supposed expertise he used to curry favor. In one 2017 email, he asks a friend, the billionaire Ariane de Rothschild, if her own daughters — the youngest of whom would have been 15 at the time — had received their HPV shots.

“Sorry what is HPV?” de Rothschild replies.

“It protects against cancer,” Epstein writes. “I have all the assistants get a full health check.”