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A transformative change

Rikki Bates (pictured drumming at a Cambridge block party earlier this month) says learning of MassHealth’s decision to cover gender reassignment surgery was “like my life’s dream coming true, really.”Kayana Szymczak for the Boston Globe

A memory more than 50 years old haunts Rikki Bates.

Growing up in East Springfield with no playmates her age, Bates, who was born male, never felt different from other children until age 4, when a baby sitter encouraged her to play with a group of boys in a sandlot across the street.

“They were roughhousing, and they were doing all kinds of stuff that I just didn’t get,” the longtime rock drummer recalled recently in her eclectic Orleans apartment. “They just targeted me right away. They thought I looked girlish, and . . . they just pounced on me.”

Since that day, Bates has struggled to accept herself and find understanding from others. Now 60, she hopes to finally live fully as a woman through an upcoming change in MassHealth regulations.

The state's public insurance program for low-income residents announced Friday that it plans to revoke a longstanding exclusion for gender reassignment surgery that placed it in a category of "experimental, unproven, or otherwise medically unnecessary procedures or treatments."

The administration of Governor Deval Patrick has directed MassHealth to provide coverage for hormone therapy and gender reassignment surgery, and the administration said it will recommend similar changes to the Group Insurance Commission, which provides coverage for thousands of state and municipal employees and their dependents.


Bates learned of the change amid a months-long appeal process following MassHealth's denial of her request for coverage for gender reassignment surgery earlier this year. Despite months of optimism, the insurer's shift came as a surprise.

"It's like my life's dream coming true, really," Bates said. "I never thought this day would come."

Though sudden, the MassHealth decision was not unheralded. The past several years, and even recent weeks, have brought meaningful shifts in the perception of transgender people within both the medical profession and the broader society, as well as expanded access to treatment.

Last year, the American Psychiatric Association identified gender reassignment surgery as an appropriate treatment for gender dysphoria, a condition defined by "a marked difference between the individual's expressed/experienced gender and the gender others would assign him or her."

Earlier this month, as it adopted a policy supporting change of sex designations on birth certificates for transgender persons irrespective of surgical interventions, the American Medical Association wrote, "The only effective treatment of [gender dysphoria] is medical care to support the person's ability to live fully consistent with one's gender identity."


Governmental agencies and political bodies are also shifting. In May, the federal Department of Health and Human Services ended a 1981 ban on coverage for gender reassignment surgery under Medicare, insurance that covers those 65 and older and some people with disabilities.

And earlier this month, the Boston City Council unanimously supported an ordinance that guarantees access to gender reassignment surgery, hormone therapy, and mental health services for municipal employees and their dependents who are transgender.

Bates's primary care physician, Dr. Patricia Raney, said in a phone interview that she supported Bates's request for gender reassignment surgery because the treatment is medically necessary.

"She's a woman, and her body doesn't match that, and so it's very uncomfortable for her to have abnormal genitals," Raney said. "The only treatment that has been shown to be effective is to help the patient affirm the gender that they are, that they feel."

Raney said the medical understanding of why some people are transgender is still "in its infancy," but studies have shown "physical differences and biochemical differences in the brain of transgender people."

Raney hopes the change in MassHealth policy will spur even more progress, including changes in medical school curricula so that more surgeons will be trained in gender reassignment. "Right now they're not, and there's nobody in the state of Massachusetts doing this surgery," she said.

Bennett H. Klein, a senior attorney at Gay & Lesbian Advocates and Defenders, who helped prepare Bates's appeal when she was denied coverage for the surgery, said the time had come for MassHealth to become the third state Medicaid program, following those in California and Vermont, to cover treatments doctors deem medically necessary for transgender patients.


"This exclusion . . . reflects antiquated thinking based on stereotypes and unscientific information," Klein said, "and that's not where Massachusetts has historically been in terms of health care for its citizens."

The old policy, Klein said, caused unnecessary harm to transgender residents covered by MassHealth.

"I think that there are a lot of transgender people who are really suffering because they're not getting the medical care that they really need," he said.

Bates said her suffering included bullying and physical abuse throughout elementary school, an almost friendless adolescence, and a string of failed relationships as an adult, including a divorce that led to a crippling depression.

A drummer since her teens, Bates said a lifelong love of music helped keep her going through hard times, but in the late 1980s even that passion came into conflict with reactions to her gender identity.

Bates had then been a member of the Cape Cod band The Incredible Casuals for more than a decade, but a rift formed when, amid the turmoil that followed the collapse of her marriage, she began performing dressed as a woman.

Chandler Travis, a bassist who formed The Incredible Casuals with Bates and guitarist Steve Shook around 1980, said he didn't care what Bates wore so long as she remained the drummer he admired, but he had concerns about public reaction.


"It certainly was confusing for some of us, and I wish we had handled that differently," he said.

Bates said she was highly emotional and sometimes argumentative with her bandmates during that period, but being forced to leave the band felt like a rejection, an adult parallel to the experience of being bullied on the sandlot.

She later formed a band with drag performer Ryan Landry, in which gender ambiguity was the norm.

And after Travis invited her to join another of his projects, the Chandler Travis Philharmonic, The Incredible Casuals invited Bates back, finding that fans accepted her enthusiastically.

Bates and Travis, who met more than four decades ago, said their shared love of music and respect for each other's talents have sustained them through the conflicts that inevitably arise.

"I think it's like a marriage," Travis said. "Once you go into double digits, it gets harder because there's skeletons in the closet. . . . But I think our working relationship has always been pretty good."

Still, despite many friendships built through music, Bates feels isolated, unable to form a romantic relationship while her body remains incompatible with her identity.

With gender reassignment surgery no longer a dream but a valid option, Bates hopes to overcome that isolation, and perhaps more importantly, the sense that she is not as she was meant to be.

"I feel like all this turmoil that I went through will come to an end, and I'll . . . have an inner peace," she said.


Jeremy C. Fox can be reached at