This year has been excruciating for many Americans who have been battered by Covid, extreme weather disasters and political discord, but for one individual 2021 will be remembered for having propelled her into national prominence. Rachel Levine has shattered not one but two major glass ceilings this year. In March, she became the first openly transgender person to win confirmation in the US Senate after Joe Biden nominated her as assistant secretary of health. Then in October she was sworn in as the first openly transgender four-star officer as an admiral and head of the US Public Health Service Commissioned Corps. At that exalted rank she gets to wear the blue uniform of the corps, which though non-military is one of eight uniformed services. It’s been a heady 12 months, having been plucked from relative obscurity as health secretary for Pennsylvania on to the national stage. Levine’s meteoric rise is all the more impressive given how few openly trans federal officials there are in American public life. In an interview, Levine told the Guardian that she was touched not only by the honour and privilege of her new roles, but also by the “profound responsibility that I take very seriously”. She added that she would be looking to make an impact “both in terms of my advocacy through the LGBTQ+ community and also through the policy changes we can make across health and human services and the administration”. As the new head of the 6,000-strong commissioned corps, tasked with leading the federal government’s response to a multitude of health crises, Levine now finds herself in the thick of several raging disputes. Most poignantly for her, as the highest-profile trans official in the country, she is at the centre of the debate around appropriate treatments for individuals considering gender transition, especially adolescents. A graduate of Harvard and Tulane Medical School, she was trained as a pediatrician and specialised in adolescent medicine at Penn State. As such she has both personal and professional skin in the game. Levine said her starting point when thinking about trans youth was how at risk they are. “Transgender youth are very vulnerable,” she said. “They are vulnerable to being bullied, to discrimination and harassment.” Sensitive and supportive medical care has overwhelmingly positive outcomes, she said. “There is so much evidence that trans youth, when they are supported by their family and community and receive the standards of care treatment, they have excellent physical and mental health outcomes.” By contrast, “trans youth who are not accepted, do not have support from family or community, do not have access to the standard of care treatment, have big mental health issues. So we need to empower transgender youth, we need to nurture them, not discriminate against them.” In May, the Department of Health and Human Services (HHS) announced through its civil rights office that section 1557 of the Affordable Care Act, which bans discrimination on grounds of sex, would henceforth include sexual orientation and gender identity. The decision, which is being challenged by religious groups, requires health providers in receipt of federal funds to offer gender transition treatment. Levine said a priority for next year would be to roll out that rule change across the nation. “We are going to work to promulgate and distribute that for health insurance throughout the US,” she said. Much of the toxicity around the trans debate, Levine believes, is whipped up by partisan posturing. “A lot of this is political. There are those who are using these issues as wedge issues in the upcoming election.” She has personal experience of being targeted by such hostility. Rand Paul, the Republican senator from Kentucky, was rebuked during Levine’s confirmation hearing for his “harmful misrepresentation” of transgender surgery as a form of genital mutilation. Jim Banks, a Republican congress member from Indiana, was temporarily suspended from Twitter in October for willfully misgendering Levine. In a tweet, he said: “The title of first female four-star officer gets taken by a man”. In addition to such politically laden hatred, Levine thinks that fear plays a large role in driving much of the transphobic agenda. “People fear what they don’t understand and have experience of. I’m hoping that my appointment, and my being open and out and working for the nation’s public health, will lead to less fear and more acceptance. That’s my goal.” How does she cope with the virulent personal attacks? She said that as a pediatrician, treating sick children, she learned how to compartmentalize. “I sublimate that. I take those challenges and I throw them into my work, and it motivates me even more.” The transgender debate is just a small part of Levine’s daily workload. There is no shortage of health crises piling up on her desk, not least the gathering storm of Omicron and the resultant battle to get millions of Americans boosted. Within the fight against Covid, Levine said she was especially ardent about addressing the health inequities that have been exposed by the pandemic. “Covid-19 like nothing else has shown the depth and breadth of health disparities in the United States, particularly among individuals of colour,” she said. She is also passionate about directing the resources of the Public Health Service Commissioned Corps towards dealing with the health consequences of the climate crisis. As the crisis deepens, she said, the US is likely to be affected by the spread of vector-borne diseases such as those carried by mosquitoes. Already vulnerable communities are being assailed by extreme weather conditions. Life-threatening heatwaves have been found to disproportionately affect communities of colour. Levine highlighted the plight of many agricultural workers. “Farmworkers shouldn’t have to risk their health, even risk dying, due to extreme heat just to put food on their family’s table,” she said. “Minimum-wage workers shouldn’t have to decide between cooling their homes with electricity or paying for medication. Families across the country shouldn’t have to worry about safe drinking water.” Levine said that as the dangers of the climate crisis gather pace, the role of federal government was to help vulnerable communities build resilience. “The health equity lens is critical,” she said, “as we look at climate change and fight for environmental justice.”