In mid-May, Chrissi Bates placed an order at a Market Basket bakery counter — a marble cake with orange flowers and the words “WELCOME TO WOMANHOOD” piped in pink icing across the top.

The cake was Bates’ final preparation for a long-awaited gender-affirmation surgery, a significant turning point in her own life and a new chapter for transgender healthcare in western Massachusetts.

Hours later, Bates became the first patient to receive a gender-affirming vaginoplasty, or bottom surgery, at UMass Memorial Hospital in Worcester, the first known procedure at a Massachusetts hospital outside of Boston. As Bates was wheeled to the operating room on a gurney, hospital staff buzzed, nurses stopped to share their excitement and medical residents gathered to observe the seven-hour surgery.

“It’s really just about trying to be my most authentic self,” Bates said. “I feel like I’m making history, I really do. I know it happens in Boston, but for this area, it significantly changes the landscape for access to care.”

Bates is one of a growing number of people in Massachusetts and across the country to undergo gender-affirming surgeries as insurance coverage has expanded for transgender care over the last decade. Between 2016 and 2020, nearly 50,000 patients underwent gender-affirming surgery, according to a Columbia University study published last year.

But transgender healthcare is still limited, particularly outside of major city centers. More than a quarter of transgender patients in rural areas, including parts of Massachusetts, reported that they had no access to gender-affirming primary care, and more than half said they had to travel two hours or more to see a doctor, according to a 2022 Fenway Health/Harvard University study.

Bates’ surgeon, Dr. Ashley Alford, says she came to UMass last summer with a plan to address that gap. With Bates as the first patient and a slate of some 15 people in line behind her, Alford is working to establish a clinic at UMass for gender-affirming surgical and psychological care, tentatively named the TRANScend Clinic.

“It’s all about accessibility,” Alford said. “I’m hoping to build it and they will come.”

Chrissi Bates, 29, applies makeup in her bathroom mirror, April 17, 2024
Chrissi Bates, 29, applies makeup in her bathroom mirror, April 17, 2024.
Tori Bedford GBH News

Dallas Ducar — who founded the Northampton-based healthcare center Transhealth in 2021 in response to a call for more resources for trans people in rural areas — says Bates’ surgery is reflective of needed change.

“This is really a historic moment, a milestone for gender affirming care in the state,” she said. “There’s really an importance in expanding care beyond major urban centers.”

Becoming Chrissi Bates

Bates says she knew she was different as a child but didn’t see a way out.

She said she had a conservative Catholic upbringing that provided little space for gender expression. In her senior year of high school, she came out as gay to a few close friends.

“I would look in the mirror and I just always felt like I was in the wrong body,’’ she said. “It wasn’t until later in high school, when I started dressing in women’s clothes.”

She also was a victim of commercial sexual exploitation. Bates experienced homelessness and poverty as a child and sexual assault as a teenager, when she engaged in survival sex work. She was featured in a GBH News investigation focused on boy victims of the sex trade and became an advocate for exploited youth.

She now works with homeless youth at a nonprofit in Worcester, using her lived experience to help other young people access housing.

Chrissi Bates, 29, in Kelvingrove Park, on a trip to London Saturday June 8, 2024
Chrissi Bates, 29, in Kelvingrove Park, on a trip to Scotland Saturday June 8, 2024.
Courtesy Chrissi Bates Courtesy Chrissi Bates

After years of therapy, she began to seek gender-affirming care. UMass Memorial in Worcester was the logical choice. The hospital is about 15 miles from her home. As a child, she used to go there to see a pediatrician. And it’s where she already has gone for hormones, voice surgery and a facial feminization operation as she’s continued her transition over the last few years.

Bates says the whole process has made her feel affirmed — especially by the way doctors took her seriously and treated her with respect.

“I broke down,” she said, “because it’s just so nice to see doctors actually hearing my concerns.”

Across the country, mistreatment from medical providers continues to be an issue for transgender and nonbinary patients. A 2022 report from the U.S. Transgender Survey found that nearly half of all respondents who saw a doctor in the previous year reported at least one negative experience with a provider, including physical or emotional abuse.

Chrissi Bates with Dr. Ashley Alford at UMass Memorial Hospital in Worcester, May 30, 2024
Chrissi Bates with Dr. Ashley Alford at UMass Memorial Hospital in Worcester, May 30, 2024.
Tori Bedford GBH News

Bates says she feels privileged for the treatment — and she’s hoping she can open the door for other people to feel safe and get the care they need.

“It just makes me want to advocate for so many other people that are lost and really stuck,” she said. “I’ve been there, and it was really dark at one point.”

A surgery milestone

Alford, Bates’ surgeon, found herself drawn to gender-affirming surgery during a urology residency at the University of Minnesota. She worked with older patients who waited years for surgery, including one who waited 65 years for a vaginoplasty.

“It’s a much more emotional kind of satisfaction, seeing patients, for the first time in their life, being happy to see themselves naked,” she said. “It’s just life-changing for patients, and they come back as completely different people. Finally their body aligns with how they’ve always felt.”

Alford says she became motivated to expand transgender care into more rural areas during a year-long fellowship at the NYU Langone Health medical center, where she saw patients who had to travel long distances and spend considerable amounts of money to access care.

“It made me realize that if I could bring services just up north three hours, it would make it so much more accessible to so many more people, ” she said.

At UMass, Alford also is bringing with her a modern process developed in 2017 at NYU. The process, which uses abdominal tissue and an assist from robotic technology, aims to achieve a more realistic and functional vagina than more commonly-practiced procedures.

Bates is the first patient in New England to undergo this kind of gender-affirming surgery, medical experts say.

Chrissi Bates, 29, prepares for her surgery at UMass Memorial Hospital in Worcester, May 13, 2024
Chrissi Bates, 29, prepares for her surgery at UMass Memorial Hospital in Worcester, May 13, 2024.
Tori Bedford GBH News

Dr. Alex Keuroghlian, who founded and leads the psychiatry gender identity program at Massachusetts General Hospital, says it’s important to have these kinds of options outside of Boston.

Keuroghlian identified “dramatic needs” among transgender patients in rural areas of Massachusetts in a 2021 study. The study found transgender patients in rural areas faced a lack of healthcare providers, were refused treatment and were more likely to experience discrimination.

“I love the fact that a cutting-edge vaginoplasty would be available outside of the Boston area. It’s important to have options within the state,” Keuroghlian told GBH News. “People will often travel as far as they need to, to have the gender-affirming surgical procedure that’s right for them. So having new surgical options in Massachusetts and having these not necessarily all be concentrated in Boston is wonderful.”

Though the record of gender-affirming bottom surgeries in the United States dates back to the early 20th century, barriers persist. Roughly a quarter of transgender patients are denied healthcare services, leading to a 73% higher risk of attempted suicide, according to research from Wright State University in Ohio.

An anti-trans political movement also has gathered steam in recent years. In 2023, state legislators across the country introduced more than 100 pieces of legislation banning aspects of gender-affirming medical care, according to data from the American Civil Liberties Union.

Alford says there are still women in certain areas of the country who have to buy hormones through the black market because they can’t get a doctor to prescribe them the drugs they need.

“Even now, there’s still an underground transgender health care movement,’’ she said. “It’s very, very sad, but that is the unfortunate state of this country right now.”

Getting approved

Patients who manage to access medical care have to navigate policy hurdles to get insurance coverage.

Bates worked with Alford to make sure her insurance applications reflected guidelines laid out by the World Professional Association for Transgender Health, or WPATH. That includes a doctor’s note proving that she’d been on hormones for at least a year and that any medical issues were under control.

She also needed letters of support from mental health providers diagnosing her with gender dysphoria, a medical term for the state of psychological distress experienced when a person’s gender identity doesn’t match the sex they were assigned at birth.

WPATH urged medical providers and insurers to move away from “gender dysphoria” as a prerequisite for approval.

Doctors like Keuroghlian have pushed for insurers to stop requiring a psychological diagnosis of gender dysphoria as part of a movement to “uncouple the inherent stigma” and modernize the process.

“When you require letters by mental health professionals, that automatically creates an additional set of barriers,” he said. “There’s this implication that this is somehow a mental health problem, which we know it absolutely isn’t.”

Chrissi Bates with her partner Andrew, preparing for surgery at UMass Memorial Hospital in Worcester, May 13, 2024
Chrissi Bates with her partner Andrew, preparing for surgery at UMass Memorial Hospital in Worcester, May 13, 2024.
Tori Bedford GBH News

Bates says, for her part, she never felt comfortable with the parts of her body that didn’t match who she was inside.

“I just never identified with it or felt satisfaction from it,” she said. “But it doesn’t make people any less trans, if they do like it or they don’t. It’s just really about how you identify on the gender spectrum and about letting people do what they want.”

She says she will continue to follow up with Alford over the next six months and work on a series of exercises to strengthen her pelvic floor and adjust to the change. As she continues to heal, she says she’s feeling more and more confident in her new body.

When she saw herself for the first time after her surgery, Bates was overjoyed.

“Every time I wake up, I’m just like, 'wow, this is even more me. I’m becoming more me,'’’ she said. “It’s an honor and a privilege to be able to be who I actually am.”