In October, Admiral Rachel Levine gave the keynote address at the national convention for the Parents, Families, and Friends of Lesbians and Gays, or “PFLAG,” as it’s been known since its founding in the 1970s. Standing before a backdrop patterned with rainbow hearts and queer rights slogans, Levine’s long gray hair was tied back in a bun, and she wore a dark blue skirt-suit uniform befitting her role as Assistant Secretary for Health, in which she oversees the US Public Health Service Commissioned Corps, a 6,000 member agency that leads the charge on a wide range of initiatives, from family planning clinics to toxic waste clean-up. (Though Levine does not serve in the armed forces, her title is still Admiral.) Levine is the first trans woman to ever serve in a Senate-confirmed office, and the most prominent trans official in any branch of government—a position that forces her to balance the responsibilities of being a bureaucrat with the burdens of being a symbol.
The PFLAG audience had gathered at a hotel in Arlington Virginia amid an ugly backlash against trans Americans, and during the Q&A, Levine was asked for tips on keeping ones cool. “My clinical training as a pediatrician has always been very helpful,” she said. “You have to take whatever emotions come up and put them aside, to compartmentalize them, and then treat the patient and the family in front of you. That’s what I do when I am at a Senate confirmation hearing or other challenging situations,” she said. In an earnest if somewhat clipped cadence, she called her audience to action. “We need all of you to work at the local and state level,” Levine said. “Teacher by teacher, county commissioner by county commissioner, superintendent by superintendent — to educate them about all of our collective humanity,” she said, stopping for applause. She asked her audience to engage with the sympathetic but uninformed, and cited statistics showing that just one supportive adult can keep a queer kid from trying to kill themselves. It was rousing, but also an admission of the limits of her power: Levine, perhaps better than any other Biden official, shows what representation can and can’t do.
Rachel Levine grew up in Boston in the 1970s, the child of two lawyers. On Saturdays she went to Hebrew school; during the week she attended the elite all-male Belmont Hill prep school. She was involved in theater, and still remembers her parents suffering through her performance in a 3-hour Chekhov play. Levine’s mother, among the first generation of women to graduate law school, represented widows and orphans of Boston dock workers who’d died from asbestos exposure. After graduating from Harvard, Levine attended Tulane Medical School, and fell in love with pediatrics. She moved to New York City for residency at Mt. Sinai, where in 1986, she was selected as chief resident of her pediatrics program. It was the early years of the AIDS crisis, so in addition to performing well-child exams and discussing immunization schedules, Levine also saw many newborns with a rare and aggressive pneumonia that resisted all treatment. The disease was initially labeled a “gay-related” immunodeficiency, but Levine saw many mothers pass the illness on to their children.
“There was a siege mentality,” Levine told me. “Every single one of those babies died. Every single one of those mothers died.” she said. Residency forced her to compartmentalize; Levine learned to shelve societal concerns, as she went room to room, patient to patient, addressing one problem at a time.
After finishing training, she moved with her family to Hershey, Pennsylvania for a position at Penn State. She became chief of their adolescent medicine division, running the eating disorder clinic for two decades. She became active in the Pennsylvania Medical Society and participated in community theater. (Levine jokes that she hopes someday to be the first person in Hershey to ever play both Captain Von Trapp and Fraulein Maria, before conceding that she doesn’t have Maria’s soprano range.)
Though Levine knew that she was trans from the time she was a child, she didn’t come out and begin her transition until 2011, when she was in her mid 50s. In conversations with her therapist, she compared her feelings about transitioning to Alice in Wonderland and The Matrix — journeys of exploration and self-reflection from which there is no return. She couldn’t compartmentalize anymore, and her family and colleagues were supportive as she began wearing more feminine clothes, growing her hair out. Her hospital even expanded its non-discrimination policy to include gender expression, despite the fact that trans issues were still peripheral to national gay rights groups. (President Obama hadn’t yet endorsed same-sex marriage, which remained illegal in many states.) “I was told I was going to lose everything. My job. My family. Everything. I was determined not to do that. And I was successful,” Levine told me. She says she has “no regrets” about when she transitioned, but acknowledged falling through the looking glass comes with tradeoffs. “I never got to be a 25-year-old woman.” Levine told me, but “I cannot imagine a life without my children,” While she believes gender affirming care should be available to all people who want it, she says young peoples’ reproductive potential needs to be carefully considered.
Levine’s rise in public life happened entirely after her transition. In 2015, Democratic Gov.-elect Tom Wolf asked her to join his transition team, and later nominated her to be the state’s physician general. She was unanimously confirmed by the GOP-controlled state Senate.
Levine quickly established herself as a creative and capable bureaucrat. At the height of the opioid epidemic, she expanded access to naloxone, a behind the counter overdose medication, by personally prescribing it to every person in the commonwealth. “It was an out of the box concept,” Levine told me. “Why can’t I do that?” When the state’s health secretary stepped down in 2017, Levine got the job. “People trusted her because she was straightforward,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Public health is often done through a political lens, but she was not a partisan.” Like many queer trailblazers, Levine got ahead by being consummately respectable.
When Covid hit and the governor began daily press conferences, she appeared at his side, quickly becoming one of the state’s most recognizable and influential officials. As ICU beds dwindled, Levine was praised for her “unflappable” demeanor, as she issued masking orders and mandated tests for out-of-staters.
Being a trans woman enforcing pandemic restrictions put Levine in the crossfire of two culture wars. One bar in Tioga County protested statewide closures by printing menus offering “Levine balls,” while a fair in Columbia County had a dunk tank where attendees could soak a wigged man impersonating the state health secretary. Levine addressed the abuse at one of the daily press conferences. “I want to emphasize that while these individuals may think they are only expressing their displeasure with me, they are in fact hurting the thousands of LGBTQ Pennsylvanians who suffer directly from these current demonstrations of harassment.” It was a lesson in doing a job while being a symbol.
After Biden won the 2020 election, Levine submitted her name for a role in the administration. “I literally got a text,” Levine told me. When she answered it, her life quickly began to change, as she left her job, prepared a replacement, and submitted herself to senate confirmation hearings, where Senator Rand Paul (R-Ky.) accused her of supporting “surgical destruction of a minor’s genitalia.” She was confirmed with every Senate Republican, save Lisa Murkowski and Susan Collins, voting against her. While Levine likened her confirmation process to a colonoscopy, she was never too concerned: “I’ve only ever had one secret in my life,” she told me.
The Assistant Secretary for Health can’t hire or fire staff or move money—let alone give anyone rights. Yet Levine does administer public programs funded with billions of dollars, while advising many people who have more power. When she shows up in uniform, there’s no escaping that she represents the government, and people are excited she’s there.
Like any middle manager, her job entails turning an endless parade of meetings into results. In June, I tagged along with Levine on a three-day trip to St. Louis, It was the one-year anniversary of the Dobbs decision, and just a week after Missouri state legislators had banned gender affirming care for minors, and she was doing panels with her boss, HHS Sec. Xavier Becerra, and Rep. Cori Bush (D-Mo.) at two area Planned Parenthoods. She also met with residents of Cahokia Heights, a Black neighborhood outside St. Louis, to address the summer rains that fill their houses with sewage, and with Jackie Joyner-Kersee and officials from the Department of Agriculture to discuss ways to expand nutrition programs in the Olympian’s East St. Louis neighborhood.
At most of these meetings Levine would introduce herself and then listen for long stretches, occasionally nodding or adjusting her glasses with an index finger. When she did finally speak, she often gave her diagnosis of the problem, suggested a few possible avenues of reform, and then—like so many doctor’s appointments—left with a promise to follow up, but with few sure solutions.
So it went at Vivient Health, where Levine appeared on another panel with Rep. Bush. After a tour of the LGBTQ clinic, we settled into a sterile meeting room with Diet Coke cans and wheeled office chairs. Though it was a bright, hot day, the mood was grim. Ben Greene, a 24-year-old trans activist, said that the trans children he works with had been despondent since Missouri passed its gender affirming care ban. “Kids have reached out to me to say that they don’t want to be here. They feel like they aren’t wanted.” Greene had helped the kids testify against the bill, and was shocked by the contempt Republican legislators showed, either by leaving the chamber or scrolling on their phones as the kids pleaded and cried. “The trans kids I work with don’t know that trans people live into our 30s,” said Greene. “They call me a ‘trans elder.’ That’s horrifying.”
Michaela Joy Kraemer, executive director of St. Louis’s Metro Trans Umbrella Group, said that she had felt hollow after a friend’s suicide, and was bogged down in finding a health insurance program that would cover gender affirming care for the group’s employees.
Levine waited 20 minutes before speaking. “Well, I’m actually a trans elder,” she began, and the room let out a laugh. Then she launched into her spiel—part diagnosis, part policy prescription, part call to action. “I think that it is important to push back in the state legislature, but I would not expect that to be successful at this time. But I think that other people can be educated, and that we can change the narrative.” As the meeting wrapped up, she listed sources of funding at HHS and new policy initiatives — anything that might be able to help. “I don’t mean to put the onus on you,” she said. But she was. It was a stark example of the limits of representation: the most powerful trans bureaucrat in the country was, literally, offering people fighting for their rights and lives the chance to fill out paperwork.
In November, I checked back with Greene and Joy Kraemer on whether anything—funding, support—had come of the meeting. Both said no. “But that’s not a fair expectation to have,” Kraemer told me. Greene agreed: “When we have someone on the inside we have these infinite expectations, but bureaucracy is meant to be slow and hard to change…She’s doing everything she can, but that won’t be enough,” he said, before adding that he found solace in simply seeing a trans person live to old age. “The most exciting thing was that she had grey hair.”
On my last day with Levine, as we crossed a bridge over the Mississippi River, I asked her if she ever got frustrated with incrementalism. “Sure,” she replied. “It’s a big country.”
“Sometimes you can develop programs that will help a bunch of people,” she continued, “That’s the goal of public service and public health—but it doesn’t change the importance of helping one person. I think that is one of the most valuable things you can do.”