Rachel Levine, physician general for the state of Pennsylvania, is interviewed following a press conference at a pharmacy near Harrisburg May 17. Levine is one of the few transgender public officials in the nation. (Bonnie Jo Mount/Washington Post)

The staid office where Rachel Levine works as the Keystone State’s top doctor is lined with family photos, including one perched high on a shelf that was taken on a vacation long ago, when her children were young and she was a broad-shouldered man named Richard.

Levine is the highest-ranking transgender official in Pennsylvania and one of only a handful serving in elected or appointed offices nationwide. For many Americans, the faces of the debate over transgender rights have belonged to celebrities — activist Caitlyn Jenner or actress Laverne Cox — rather than the lawmakers and state officials wrangling over the issue.

“I’m very grateful and I’m very honored to be one of those officials,” she said. “I take that responsibility very seriously.”

[‘Not about bathrooms’: Critics decry North Carolina law’s lesser-known elements]

Nationwide, there are only three elected transgender officials and a smattering of appointed officials on the state and local level. “It’s really bad. There’s hardly anybody. We don’t really have a plan to get more,” said Mara Keisling, executive director of the National Center for Transgender Equality.

Rachel Levine, physician general for the state of Pennsylvania, dines with her mother Lillian Levine, in Harrisburgon May 16. Levine is transgender and has a close relationship with her mother. (Bonnie Jo Mount/Washington Post)

Levine, 58, is one of the appointed state officials, and her foray into politics was more of a fluke than a concerted effort to work in government. In 2014, she was a top doctor at Penn State Milton S. Hershey Medical Center and served on the board of Equality Pennsylvania, a statewide gay rights group, when Gov.-elect Tom Wolf (D) asked her to co-chair his transition team for health matters.

Wolf later asked her to serve as physician general. After a few days of debate, she decided to do it, mostly because she thought she could “make a difference from a broader point of view, from a broader brush.”

Disturbing rhetoric

But first she had to get confirmed by the Pennsylvania Senate. Levine had been openly living as a transgender woman for a few years, and felt she could move past the issue simply by sitting down one-on-one with officials and talking about medicine and public health. Levine was unanimously confirmed.

“With very few exceptions my being transgender is not an issue,” she said.

At least one public figure has criticized Levine in the wake of a law passed in North Carolina mandating that people use the public bathroom that corresponds with the gender on their birth certificates. “Question: You’re in a public restroom and this person walks in. What do you do?” former congressman Allen West wrote last month on Twitter, attaching a photo of Levine and link to a blog post on his website about her.

Levine declined to comment on the West tweet, but she calls the recent flurry of anti-transgender rhetoric and legislation “disturbing,” including the North Carolina law. “It just fuels my desire to do my job and to advocate,” she said.

She favors chunky necklaces and Earl Grey tea and is in constant motion. She helps shape policy on issues including childhood lead testing, the Zika virus, immunizations, and HIV and AIDS. She oversees the state bureaus of epidemiology and laboratory sciences and chairs the board of patient safety. Her workdays routinely stretch beyond 12 hours.

A family photo in the office of Rachel Levine, Pennsylvania’s physician general, shows her and her family when she was a married man named Richard. Her children are now in college. She is divorced but said she remains good friends with her ex-wife. (Bonnie Jo Mount/Washington Post)

Levine has also worked to improve access to health care for gay, lesbian, bisexual and transgender people and often speaks about issues of diversity and access in health care, universities and other settings in the state and nationwide.

Her primary focus has been the opiate epidemic that has reached crisis levels here in Pennsylvania and nationwide. Nearly 2,500 people died of drug overdoses in Pennsylvania in 2014, and the numbers for 2015 are expected to be higher. It is, she said, the state’s most urgent health crisis.

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Levine signed an order allowing law enforcement officials to carry Naloxone, a drug that can reverse the effects of an opiate overdose. She also wrote what amounts to a statewide prescription allowing the drug to be dispensed to the public in pharmacies. She said the drug has saved nearly 1,000 lives in Pennsylvania.

On a drizzly Tuesday last month, Levine navigated her white Mercedes SUV through Harrisburg, with the radio playing one of her favorite artists, Joni Mitchell, and over the Susquehanna River to a pharmacy in neighboring Lemoyne, where she and Wolf hosted a news conference about the issue.

“Naloxone is a unique medication,” she said. “All it does is reverse the fatal effects of a drug overdose. It is a medication that can literally save someone’s life.”

“I compartmentalized it”

Levine moved to central Pennsylvania from Manhattan in the early 1990s: “I still think that was my most difficult transition,” she quipped.

She quickly found a home at Hershey Medical Center, where she rose through the ranks and was a facilitator for LGBT groups. Richard Levine had a full life: a wife, two children, a career at the top of his field. But there was a void inside of him — a feeling he learned to ignore decades before as a child and student at an all-boys school outside Boston.

“I compartmentalized it,” Levine said. “There was no other context to put it in. It’s not like there was an alternative. So I fit in.”

That meant playing linebacker on the football team, where Levine said she would tackle but didn’t like the idea of potentially hurting another player. She does remain a rabid New England Patriots fan and closely connected to the school she attended.

Levine went on to Harvard University and Tulane Medical School, getting married during her fourth year, and was the chief resident at Mount Sinai Medical Center in New York, where she also taught.

Her transition from Richard to Rachel was slow, deliberate and filled with research. She started seeing a therapist about 15 years ago. About eight years ago she started growing out her hair, which is now long and curly, and publicly announced herself as a transgender woman about five years ago. She initially told close family members, leaving her mother Lillian, who is now 91, for last. Family members weren’t sure how she would react.

[For a private woman, joining a public transgender battle changed her life]

“She said ‘I love you unconditionally and so I accept you,’ and I started to cry,” Rachel said during a recent dinner with her mother, who moved to Pennsylvania about seven years ago to be closer to Rachel and her children. The two dine out together multiple times a week and have a standing date for Sunday brunch.

“It is what it is. My children are my children. They’re my love,” said Lillian Levine, who only recently stopped practicing law. “I would say she’s a role model.”

Confidence “in who I am”

The former Richard Levine picked the name Rachel for no other reason that it seemed to fit; she kept her middle name and initials and her signature stayed basically the same. Lillian later told her that if she were born a girl, she and her husband planned to name their daughter Rachel.

“Moving from one gender to another, especially in your 50s, is a challenge,” Rachel Levine said. “But it was very rewarding.”

That meant taking a year and a half of voice lessons to sound more like a woman, though the Massachusetts native still drops her r’s. Levine does not discuss whether she took hormones or had surgery, calling it a private medical matter. She used to perform in musical theater — her last role was Dr. Scott in “Rocky Horror Picture Show.” She no longer sings.

“I have this very nice baritone,” she said. “I haven’t learned how to sing alto.”

Levine said her children, who are now in college, were very accepting of her transition. She and her wife divorced three years ago, and Levine lives with two dogs.

For now, her life consists mostly of work, save for time with her mother, playing with her dogs and walking for exercise.

Although she often speaks to LGBT groups, Levine said she wants to be known as the state’s physician general — who just happens to be a transgender woman.

“I’m very confident in who I am,” she said.