Erica Worthington [email protected] Patent Counsel 650-533-6008

I Transitioned at Qualcomm: A Lesson in Trans* Self-Advocacy

1 The path from Eric to Erica Ð the beginning 1961 Ð 2007 “big hetero dude” Engineer, MBA, Patent Lawyer

Everything’s great, so why was I so unhappy?

…in 2007 first thought to myself: “maybe I’m gay?”

Lots of learning & self-introspection followed

Got involved with QCOM LGBT group in 2008

February 2009 2 The path from Eric to Erica - exploring My first boyfriend was a makeup artist!

Began occasional crossdressing & exploring my femininity in 2009

…and started counseling to unravel the confusion, self- doubt, self-loathing, and stress that resulted March 2009 from not being whole… 3 The path from Eric to Erica Ð first time out!

1st Light of Day, after being paralyzed by fear for months by the thought of going out “en femme”

Trans* support group (and my GF) helped me handle the fear

June 2011

4 The path from Eric to Erica Ð the middle years?

March ’12 Ð Androgynous - Oct 2011 TG Week confusing to most people, and to me too

5 Eric to Erica Ð coming out at work

March 2012 Ð “heads up” email to Senior Execs & HR re upcoming transition ¥ Thanks for positive, supportive comments regarding diversity ¥ Advance notice of a significant personal change …. my appearance will continue changing, I am transitioning from male to female, a long process ¥ People have treated me wonderfully so far ¥ HR has been fully supportive and very helpful ¥ I offer myself as a resource on transgender or LGBT issues ¥ I am glad to share my story, provide support, help others understand, engage other resources, etc ¥ I’m open to talk about this and answer any questions 11/10/15 Qualcomm Confidential and Proprietary 6 Eric to Erica Ð coming out at work April 2012 Ð email to workgroup re upcoming transition I’ll be out on medical leave A further evolution in my appearance—facial feminization surgery as part of my ongoing transition to female My gender transition will be gradual Eventually I will legally change my name to Erica, until then feel free to refer to me as Eric or Erica (or my gender-neutral nickname, Ricky/Ricki) I won’t care if you refer to me as “he” or “she”—pronouns can be challenging, I still confuse myself sometimes I appreciate that my transition affects those around me, and I will gladly give you space to grow with me. Transition is not the kind of thing most of us encounter and I can understand if you may want to know more. I’m open to talk and would be delighted to answer any questions you might have, share my story, provide links to resources, etc

11/10/15 Qualcomm Confidential and Proprietary 7 Eric to Erica Ð coming out

Responses to “coming out” email were fabulous & congratulatory! ¥ “you have my complete support“ ¥ “I come from an extremely conservative background and have grown so much from people here. You have silently been a part of that growth for me. When I first saw your changes, I told myself that I would get the courage to ask you about it. What I’ve learned is that we are all very different people and it takes a tremendous amount of courage to be who we are. I wish you the best of luck, and would love to hear your story” ¥ “hoping for no bigotry or other such challenges, and most important Ð happiness and a sense of fulfillment knowing that you have chosen what is best for you. For whatever it’s worth, my support is guaranteed” ¥ “What a courageous step you are taking! I wish you all the best for your surgery, a fast recovery, and a smooth transition into your new gender.”

11/10/15¥ “in the UK I worked withQualcomm someone Confidential who and Proprietary went on to be the UKs first 8 transgender mayor. I was very happy to see her flourish in her new identity.” Eric to Erica Hair transplants (Dec ‘12) Scalp Face lift, advancement neck lift Upper & lower Brow bone blepharoplasty re-contour Cheek Nose job & implants deviated septum fix Chin re-contour

Trachea shave

April ’12: 13 hours of Facial Feminization Surgery

(started hormones & t-blockers too) 9 A very happy Erica Happier than ever!

November 2015 September 2013 10 Erica - from then to now

Facial Feminization Surgery $35k Hair transplant surgery $12k Electrolysis (700+ hours) $35k Body hair removal (several years) $10k Total ~$92k

Covered by insurance - Mental health counseling - Hormone replacement therapy - Breast Augmentation ~$7k

11/10/15 Qualcomm Confidential and Proprietary 11 Lessons Learned What went well - Open communication, being open to explaining something that many are oblivious to - Working closely with HR really helped - Making myself available as a resource in the company - Giving a heads-up to coworkers with guidance on how to transition along with me What could have been better - 1 or 2 people needed to be told after 1-2 years to get with the program on name/pronoun - HR/Benefits could have been more proactive on transition healthcare (I did much of the work)

11/10/15 Qualcomm Confidential and Proprietary 12 2013 QCOM transgender exclusion

QC PPO: Section 2: What’s Not Covered Ð Exclusions R. All Other Exclusions 15. Sex transformation operations.

Kaiser: General Exclusions, General Limitations, Coordination of Benefits, and Reductions 58. Sexual reassignment surgery

11/10/15 Qualcomm Confidential and Proprietary 13 Why provide TG-inclusive healthcare? It’s medically necessary It’s cost effective It’s the right thing to do.

11/10/15 Qualcomm Confidential and Proprietary 14 Is TG healthcare medically necessary?

YES, says: − The IRS Tax Court (O'Donnabhain v. Commissioner, 134 T.C. No. 4, 2010) − The American Medical Association − The American Psychological Association & American Psychiatric Association − The World Professional Association for Transgender Health − American College of Obstetricians and Gynecologists − American Association of Clinical Endocrinologists & The Endocrine Society − American Academy of Family Physicians − The National Association of Social Workers − CA Dept. of Managed Healthcare − Colorado Division of Insurance ! “medical− Oregon necessity” Dept. of rests Consumer with medical and Business provider Services & patient Ð not insurance11/10/15 − Washington companies DC Dept.Qualcomm of Insurance Confidential and Proprietary 15 − Vermont Div. of Insurance

What kinds of treatments can be medically necessary for transgender folks? Mental health services Hormone replacement therapy Testosterone and/or Puberty blockers Breast/chest reconstruction Facial reconstruction Gonadal surgery Genital reconstruction / Sex reassignment surgery Hair removal (electrolysis)

Typically, each patient will not utilize all treatments

11/10/15 Qualcomm Confidential and Proprietary 16 Who else offers TG-inclusive health plans? Many competitors for talent: >200 employers in HRC’s Corporate Equality Index ~30% of Fortune 100 companies - Apple, Intel, Google, Cisco, Microsoft, HP, AT&T, Oracle, EA, IBM…

Where many of our recruits graduate: Entire U of California system, U Michigan, Yale, Harvard, Duke, Brown, U Penn… à New recruits increasingly expect TG-inclusive healthcare

Where many of our recruits have lived: New York, San Francisco, Seattle, Minneapolis, Portland… CA, CO, OR, DC … Why provide TG-inclusive healthcare? It’s medically necessary It’s cost effective It’s the right thing to do.

11/10/15 Qualcomm Confidential and Proprietary 18 Is TG healthcare coverage costly? NO.

Distributed costs are extremely low, annualized costs are typically negligible San Francisco - no discernible cost increase. − 3 years after at start of San Fran coverage, they paid out only $156k, then they lowered the PEPM cost and paid out $44k for 19 claims, and in 2007 they declared the cost de minimis and stopped charging for it. Portland OR’s cost increase was 0.08% Employers generally report zero or miniscule initial premium increases, extremely low utilization at low payouts Not every TG person covered will use every option of care— some require relatively little to feel satisfied, or stretch out their procedures over long timeframes

11/10/15 Qualcomm Confidential and Proprietary 19 Why provide TG-inclusive healthcare? It’s medically necessary It’s cost effective It’s the right thing to do.

11/10/15 Qualcomm Confidential and Proprietary 20 It’s the right thing to do Joe Biden (VP of US) said TG discrimination is "the civil rights issue of our time“ (10/30/2012) GLAAD, HRC have committed to prioritize trans issues Allies are increasing their support of trans issues Celebrities are coming out as trans: Caitlyn Jenner, Chaz Bono, Lana-Wachowski (The Matrix director), Candis Cayne (Nip/Tuck, Necessary Roughness), Isis King (America’s Next Top Model), Jenna Talackova (Miss Universe Canadian), Lea T (Brazilian Model), DC Comics has trans characters…

! Reflects QCOM’s commitment to inclusion, fairness, and diversity ! Makes a huge impact in TG people’s lives! − 41% of transgender people have attempted suicide -- 25x the general population − 2 out of 3 transgender people have thought about suicide Ð 11/10/15 about 10x the generalQualcomm population Confidential and Proprietary 21 Discrimination is rampant in healthcare of TG’s

28% of TG’s postponed medical care when sick or injured due to discrimination, and 48% due to inability to afford it. Those with private insurance less likely to postpone care because of inability to afford it (37%) than those with public (46%) or no insurance who postponed care (86%). 19% reported being refused care due to being TG. 28% reported verbal harassment in a doctor’s office, ER, or other medical setting 2% reported being physically attacked in a doctor’s office Only 28% of TG’s are “out” to all of their doctors, 18% were out to most, 33% were out to a few, and 21% were not out to ANY of their doctors. PRIVACY IS VERY IMPORTANT! 50% of respondents reported having to teach their doctor about appropriate care (61% for female-to-male, 61% for those who are full- Source:time) National Transgender Discrimination Report on Health and Health Care, Oct 2010, based on responses from 6,450 people 11/10/15 Qualcomm Confidential and Proprietary 22 Why provide TG-inclusive healthcare? It’s medically necessary It’s cost effective It’s the right thing to do.

11/10/15 Qualcomm Confidential and Proprietary 23 What should TG-inclusive insurance include, ideally? TG people are a diverse bunch and medical providers give care based on the patient’s needs and choices All medically necessary transition-related health care services should be covered, including but not limited to consultation, follow-up, and repair (if necessary) All deductibles, co-pays, benefit maximums or other restrictions should be commensurate with those offered to non-TG individuals Medical leave for transition-related care should be applied in the same manner as for any other medical treatment Wide communication to employees on TG coverage so that they need not “out” themselves to determine coverage

11/10/15 Qualcomm Confidential and Proprietary 24 Since QC is self-insured, what about coverage on a case-by-case basis?

NO! Privacy should be respected - would require disclosure of profoundly sensitive or personal information Coverage should be handled as any other medical service would be, through claims process Should communicate TG-inclusive coverage during open enrollment process—to avoid the need for workers to “out” themselves or their dependents to QC directly

11/10/15 Qualcomm Confidential and Proprietary 25 How many TG individuals are there? Prevalence estimates vary widely, from 0.2% to 1% of the overall population − San Francisco middle schools lists 1.5% as trans TG people often don’t share their identity − Pervasive stigma and discrimination − Personal choice and privacy − I was once told by a TG person to NEVER talk about being trans, for fear of reprisal, discrimination, etc. Employers generally report zero or miniscule initial premium increases, extremely low utilization at low payouts

11/10/15 Qualcomm Confidential and Proprietary 26 Do QC Insurance Carriers have experience with this?

YES. Both UHC and Kaiser have experience with TG coverage for at least one employer or student plan

E.g., Kaiser: The Multi-Specialty Transitions Clinic (MST) at Kaiser Permanente Oakland Medical Center is deeply committed to providing equitable, compassionate and high-quality medical care to our transgender patients and their families. Our specialist team consists of providers from surgery, internal medicine, gynecology, and psychiatry, who work together to provide comprehensive healthcare for Kaiser Permanente members needing hormone consultations, gynecologic care, psychological services and surgical evaluations for transition and sexual reassignment surgeries.

11/10/15 Qualcomm Confidential and Proprietary 27 Qualcomm covers *some* TG healthcare Psychotherapy Hormone replacement therapy & laboratory testing Surgery to change the genitalia and specified secondary sex characteristics: − Reduction of the Adam's Apple − Bilateral mastectomy Augmentation mammoplasty Limited to $75,000 max benefit

We still have some room to improve Facial feminization surgery Hair transplantation Electrolysis/laser

11/10/15 Qualcomm Confidential and Proprietary 28 Resources Transgender Law Center National Center for Lesbian Rights National Center for Transgender Equality Human Rights Campaign (HRC) CA Gender Nondiscrimination Act - January 1st, 2012. Clarifies existing legal protections by making gender identity and gender expression their own protected categories in specified non-discrimination laws. California Department of Fair Employment and Housing (DFEH) Equal Employment Opportunity Commission

11/10/15 Qualcomm Confidential and Proprietary 29 Any Questions?

11/10/15 Qualcomm Confidential and Proprietary 30 Thank you

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