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In 2021, the country had one state with a ban on gender-affirming care for youth on the books — Arkansas. In March of the same year, Dr. Rachel Levine won confirmation by the Senate to lead the U.S. Public Health Service Commissioned Corps as the assistant secretary for health. She holds the rank of admiral.

Levine is the highest ranking, out transgender person ever to serve in the federal government.

In the nearly four years that she's been at the Department of Health and Human Services, there has been an explosion in anti-trans legislation. Twenty-five more states followed Arkansas in banning gender-affirming care for youth. Other laws focus on bathroom use in schools and public buildings, or bar transgender kids from participating in sports aligned with their gender identity.

In the closing days of the presidential campaign, Republicans used Levine's image in the "Kamala is for they/them" ads that — some pundits argue — helped Republicans win the presidency and both houses of Congress.

All this time, Levine has, pretty quietly, been working away at HHS in Washington, D.C. She sat down with NPR for an exit interview in late December.  She has a friendly, low-key personality and a pragmatic sensibility. She loves Joni Mitchell, and she brings her lunch from home — today; it's a turkey wrap.

She's a pediatrician with a specialty in adolescent medicine who was a public health official in Pennsylvania before being nominated to serve in the Biden administration. She wears the blue, wool dress uniform of the 

, which is the branch of the uniformed services that she leads.

Levine was excited about a new campaign promoting childhood vaccines called "

." Dipping childhood vaccination rates are one of the challenges she's tried to address in her role. She's aware that the incoming Trump administration is poised to put anti-vaccine activists in charge at HHS.

Can this effort last more than a few weeks? "It's impossible for me to say what happens after the inauguration," she says. "This campaign has been planned for more than a year; it's coming out now."

An eyewitness to the benefits of vaccines

She appears undaunted. Vaccines are incredible, she continues, and explains how she's seen that firsthand.

"I started my pediatric residency program at Mount Sinai Hospital in New York City in 1983," she says. That was before the HiB vaccine came out, which protects against a bacteria called 

. "We used to see so many children with very serious bacterial infections due to this bacteria — pneumonia, meningitis, sepsis. And after the vaccines came out and had been given for a number of years, we really no longer see those infections.

"Of course, pediatricians that are training now have never seen it — but I saw it," she says. "It's an example of a vaccine that we don't talk about much, but we have virtually eradicated that serious infection in children that I took care of in the hospital because of that vaccine. And that's just one example of many."

This is the meat-and-potatoes of her job — enthusiastically and clearly explaining why public health measures are important. She speaks proudly of the efforts of her office on climate change, on the HIV epidemic and on "food is medicine" initiatives. Policies will surely change under Trump appointees, but she believes public health work will continue. "We have amazing civil servants here," she says.

In her role, Levine has traveled the country, visiting local health departments and organizations. She speaks about a migrant farm worker she met in Orlando, Fla., and an arctic island she traveled to in Alaska. As she traveled, she likely was the first out transgender person many people she encountered had ever met.

‘I'm a resilient person and I'm fine’

She doesn't usually share a lot about her transgender identity. She was born in 1957 and attended an all-male prep school outside of Boston, which was "obviously, a very interesting experience," she says. "Remember, this is the early '70s — I obviously had feelings about my gender, but what were you going to say and who would you tell?"

She came out as transgender decades later. "I think, for anyone, having a secret is not a healthy thing to do," she says. "I think that transitioning and coming out and being my true authentic self has been liberating to me. It's been an amazing experience."

Levine has been a target in right-wing media, sometimes just for being trans, but also for supporting gender-affirming care.

She shrugs off the fact that her image was used in the anti-trans advertisements that dominated the final weeks of the presidential campaign. "It was very challenging, but I'm a resilient person and I'm fine."

 that "there is no argument among medical professionals [...] about the value and importance of gender-affirming care." Since then some high-profile medical professionals have called for caution in this medical field, including British pediatrician Hilary Cass. Those physicians are often cited by lawmakers seeking to ban this care. Cass was mentioned recently during Supreme Court arguments about whether such bans are constitutional.

"There is still widespread agreement about the medical utility of transgender medicine and transgender medicine for young people," Levine maintains. "There is always ongoing research to study any of our medical protocols, and that would include transgender medicine. We should always have robust discussion and analysis of our treatment protocols, and they need to be based on data."

She says those standards of care should then be applied carefully to individual patients. "That's how we do pediatrics and that's how it should be done," she says.

That is separate from what's happening with the proliferation of anti-trans state laws, she says. "This is really a politically and ideologically motivated effort developed by a think tank in Washington in order to attack the LGBTQI+ community, starting with the trans community," she says. "And unfortunately, it has been very successful."

She says she chooses to be optimistic that things will get better for trans people in the U.S.

Levine will resign on Inauguration Day. She says she's going to move back to central Pennsylvania, take a vacation, and plan her next steps.

Selena Simmons-Duffin

Author

Dr. Rachel Levine is the highest ranking, out transgender person ever to serve in the federal government. Her tenure at HHS ran concurrent with an explosion in state legislation targeting transgender people. 

Dr. Rachel Levine focused on her job at HHS. Still, anti-trans politics followed her

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