Rachel Levine Becomes 1st Transgender 4-Star

The Assistant Secretary for Health has put on a uniform and become an instant Admiral.

WaPo (“Rachel Levine, openly transgender health official, to be sworn in as four-star admiral in Public Health Service“):

A senior Biden health appointee who made history when she became the nation’s highest-ranking openly transgender official is also set to become its first openly transgender four-star officer, the administration announced on Tuesday.

Rachel Levine, the U.S. assistant secretary for health, will be sworn in Tuesday as an admiral of the U.S. Public Health Service Commissioned Corps, a 6,000-person force that responds to health crises on behalf of the federal government, including administering coronavirus vaccines and delivering care after hurricanes. Levine is also the organization’s first-ever female four-star admiral.

In an interview, Levine stressed that her new position as an admiral was “not just symbolic,” and that she would take a leadership role in shaping the public health corps’ priorities. “I’m doing this because of my dedication to service … [and] with the utmost respect and honor for the uniform that I will be wearing,” Levine said, adding she would begin wearing the group’s blue uniform immediately.

The public health service is one of the nation’s eight uniformed services, although it is distinct from the six military services — including the Navy, Army and Air Force — by explicitly focusing on medical issues. The National Oceanic and Atmospheric Administration Commissioned Officer Corps, whose officers command vehicles that probe hurricanes and map the seafloor, is also a uniformed service.

The 63-year-old Levine, who was previously Pennsylvania’s health secretary and had not served in the commissioned corps, is now set to take a more prominent role in the service’s operations. She will be the sixth four-star admiral in the corps’ history, according to the Department of Health and Human Services.

Political appointees are regularly tapped for senior roles in the corps. Brett Giroir, Levine’s predecessor during the Trump administration, was sworn in as an admiral after his 2018 Senate confirmation. Vivek H. Murthy, the nation’s surgeon general, also serves as a vice admiral.

While the historic milestone is rightly the headline here—and sure to draw outrage in some circles—I must confess that what interests me here is the sheer weirdness of appointing a civilian as a four-star admiral. Traditionally, the head of the U.S. Public Health Service Commissioned Corps is the Surgeon General which, by statute, must be appointed from the uniformed ranks. Unlike the armed services, though, the Surgeon General doesn’t necessarily have to rise through the ranks.

The Surgeon General reports to the Assistant Secretary for Health, the position Levine holds. Occasionally—and there seems no obvious rationale for whether and when this happens—that person is also appointed as a four-star admiral.

None of the seven other uniformed services does this. In all the other cases, uniformed generals and admirals who have risen through the ranks report to civilians appointed by the President and confirmed by the Senate. Donning a uniform and four unearned stars doesn’t enhance Levine’s authority.

FILED UNDER: Gender Issues, Health, Military Affairs, , , ,
James Joyner
About James Joyner
James Joyner is Professor and Department Head of Security Studies at Marine Corps University's Command and Staff College. He's a former Army officer and Desert Storm veteran. Views expressed here are his own. Follow James on Twitter @DrJJoyner.


  1. Jay L Gischer says:

    I too, think it’s a bit odd that a civilian should become a 4-star. And yet, this isn’t the first time.

  2. Cheryl Rofer says:

    I think it’s silly that the Public Health Service has all the trappings of the military. But yeah, I sorta get the historical reasons.

  3. Gustopher says:

    The Surgeon General reports to the Assistant Secretary for Health, the position Levine holds. Occasionally—and there seems no obvious rationale for whether and when this happens—that person is also appointed as a four-star admiral.

    I wonder if this would even raise an eyebrow if she were the first left-handed four-star admiral Surgeon General.

    Not trying to accuse James of making a dishonest argument, just pointing out that this is exactly the thought process behind unequal enforcement — an entirely reasonable, well-meaning complaint that comes up against the minority more often because they stand out.

    (And, knowing James’ pedantry for military rank and matters, there’s a decent chance that the last time this happened, he also commented on the oddity of it)

  4. HarvardLaw92 says:

    Kudos to her for being confirmed into the role (for which she’s apparently well qualified), but I’ll agree with James here: Civilians should not be wearing uniforms and assuming commissioned ranks that they have not been commissioned into. She has no more business wearing a uniform than SECDEF does. It’s inappropriate.

  5. HarvardLaw92 says:


    I wonder if this would even raise an eyebrow if she were the first left-handed four-star admiral Surgeon General.

    No, because 1) She isn’t the Surgeon General, she’s a civilian appointee Assistant Secretary, and 2) She can’t be the Surgeon General, because by statute, that role must be filled by someone actually commissioned into the uniformed service. It’s appropriate for that individual to wear a uniform, because they are (and must be) a commissioned member of the uniformed service. Levine is not, and has never been.

  6. HarvardLaw92 says:

    This also brings another question into specific relief – Assistant Secretaries are slotted into the ES Level 4 paygrade. How is she being paid due to being ranked as a 4 star admiral? At the prevailing ES rate which should be applied to her position, or equivalent to her peers in the other uniformed services?

    The difference is substantial if it’s the latter, and would amount to a nearly $27,000 de facto pay raise which technically she should not be receiving.

  7. HarvardLaw92 says:

    @Jay L Gischer:

    5 out of 17 (including Levine) have been elevated this way, and it seems to be a recent phenomenon Prior to 1989, it had never happened. The others who wore uniforms while aerving in the office were either already commissioned members of the PHS who were temporarily elevated to ASH but retained their commissioned rank (i.e. they were not elevated to 4 star rank) and one individual who was had already been a commissioned 4 star in both the Navy and Coast Guard prior to assuming the office.

    It’s very irregular, to say the least.

  8. DrDaveT says:

    Setting aside all of the substantive issues that have been raised, this reminds me of one of the most fascinating projects I ever worked on. It involved trying to figure out how many veterans there are (or, rather, were at the time) and how they were distributed geographically and demographically*. A key part of that involved the question “what makes someone a ‘veteran’?” and the answer to that turns out to be delightfully quirky. You were a stewardess on a Pan-Am flight that was commandeered for troop transport in the Pacific Theater during WW2? Congratulations, you’re a veteran! You were a lighthouse keeper prior to the incorporation of the Coast and Geodetic Survey into NOAA in 1970? Congratulations, you’re a veteran. Etc.

    *If you think that should be easy, you’re right — but this is America. Between a national distaste for tracking individuals and catastrophic losses of historical records due to fire, flood, etc., the VA only knew about the people who were drawing checks.

  9. DrDaveT says:


    You were a stewardess on a Pan-Am flight that was commandeered for troop transport in the Pacific Theater during WW2? Congratulations, you’re a veteran! You were a lighthouse keeper prior to the incorporation of the Coast and Geodetic Survey into NOAA in 1970? Congratulations, you’re a veteran. Etc.

    Rats, no edit function. I was intending to finish with musings about whether Dr. Levine, upon leaving this position, would (like other commissioned officers of the PHS) be a veteran.

  10. dazedandconfused says:

    The tradition of public health heads being “officers” stems from a historical memory of great plagues. Should anything resembling the Bubonic plague break out the anticipated governmental response will effectively be a state of martial law and for medical experts to be calling the most of the shots. Originally there was much broader acceptance of the quaint notion of science being superior to people’s gut fee-fees.

  11. HarvardLaw92 says:


    Correct, but the traditional head of the uniformed PHS has always been the Surgeon General (which is a commissioned, uniformed position which is always, by law, a three star rank), who reported to the civilian Assistant Secretary of Health. Going off of the law, there is no provision for a four star admiral in the PHS. Somebody, somewhere, just decided it was OK and did it with no legislation.

    Much in the same way that the uniformed head of the Army is the Army Chief of Staff, who reports to the civilian Secretary of Defense.

    What they’re doing here is basically akin to just arbitrarily deciding to make an incoming SECDEF a 5 star general. It’s well out of bounds.

  12. HarvardLaw92 says:

    No edit function. That should read “reports to the civilian Secretary of the Army”, not SECDEF. Mea culpa.

  13. dazedandconfused says:


    I suspect dragging military rules into this dept is a mistake. It’s not within the DOD. The stars can mean completely different things from what they mean in the military services, even nothing at all. Moreover, it’s stated in the article the four stars have been awarded 6 times previously within the “corps”. Not breaking any new ground there.

  14. HarvardLaw92 says:


    It’s a uniformed, commissioned service that qualifies for full veteran benefits. The military comparison is honestly right on target.

  15. Richard Gardner says:

    Wow, in charge of the medical care at (non-military) Federal prisons to include immigrant detention centers seems at most to be a 2-star job (OK, plus tribal nations). Certainly not 4-star.

  16. dazedandconfused says:


    Despite the similarity of terms, IMO they live in something of their own private Idaho of commissions. HHS, not DOD. Takes an act of Congress to make them part of the DOD, but there’s some built in cross pollination in personnel. The wiki page shows the Assistant Sec as nominally ranking the Surgeon General in pay, an O-10 over an O-9. There is apparently nothing exceptional about having a “4 star” in the position.


  17. Just nutha ignint cracker says:

    I’m awestruck at how much discussion this is generating. Who actually gives a [censored] and why? So the nation had a event naming somebody an honorary Admiral (my take entirely). Last year, 4000-however-many universities and colleges awarded doctorates in pretend academic honors to people who have never darkened the doors of their institutions (and in many cases, probably not any others either) for giving inspiring bloviations to graduates. It’s all of a piece. The person needs an honor–we make one up. Easy peasy.

  18. HarvardLaw92 says:


    Precedence / courtesy, ie seating at functions, etc. The ASH is (or should be) paid as an ES4. The closest equivalent in military terms is an O8 with 18 years of service. It’s quite a bit less than an O10’s pay.

  19. rachel says:

    Man, it’s just so strange to me that a person can be a civilian at one moment and then become a high-ranking military officer the next, especially since she’s of an age when many people are ready to retire from work altogether.

    I mean, I guess it makes sense in a way, but I never heard of this tradition before.

  20. James Joyner says:

    @Just nutha ignint cracker: Having an earned doctorate, I don’t much mind the awarding of honorary “Doctor of Humane Letters” degrees to esteemed practitioners but hate it when we do it for those who simply donated a lot of money to the school. But this isn’t that: honorary doctors aren’t entitled to the title “Doctor” or to represent themselves as having earned doctorates. Here, Levin is literally wearing the uniform of a four-star admiral on a daily basis.

    @dazedandconfused: But, as @HarvardLaw92 notes above, the previous cases aren’t of people from outside the service. Levin has been a civilian her entire career and is now an instant admiral.

    @dazedandconfused: And, no, a four-star admiral is a four-star admiral. Aside from the five military services in the DoD, the Coast Guard, part of Homeland Security, is also an “armed service.” Those six plus the NOAA (Commerce) and the PHSCC (HHS) are the “uniformed services.” The rank structure of all eight are intentionally parallel. The Coast Guard, NOAA, and PHSCC all wear US Navy uniforms with minor insignia variations and use Navy ranks.

  21. John430 says:

    The Chinese preview a supersonic missile. We counter with a transgendered admiral! Cool move, Ex-Lax.

  22. HarvardLaw92 says:

    @James Joyner:

    I tried to tread delicately. As far as I can tell Dr. Levine is a talented and well-regarded physician with an excellent professional reputation. She absolutely deserves to have confirmed into the position.

    It’s not a situation where she shouldn’t be wearing a uniform so much as one of none of the five (including her) should ever have worn one. She’s unfortunately fallen into being part of / the latest example of a continuing bad trend that never should have happened in the first place.

  23. James Joyner says:

    @HarvardLaw92: I was unaware of this custom previously. This service is unique in that, as best I can tell at least, captain (O-6) seems to be the highest permanent rank with appointees as Surgeon General and, sometimes, Assistant Secretary holding temporary Vice Admiral and Admiral billets. But I gather the precious four-stars were permanent members of the commissioned service.

  24. dazedandconfused says:

    @James Joyner:
    But several of the previous have had no military service. Koh is a recent example. It appears some did not call themselves admirals, but it’s still O-10, with that designation as far as pay goes.

    That would be ridiculous in any of the other services, as you say, so I deem this dept. as living in something of their own world in regards to ranking.

  25. HarvardLaw92 says:

    @James Joyner: Likewise. It honestly never even occurred to me that someone would pull something like this off. I was shocked when I read this.

  26. James Joyner says:

    @dazedandconfused: @HarvardLaw92: It’s truly bizarre and something I was simply unaware of. The NOAA is also an unusual organization but it doesn’t have civilians directly commissioned as admirals.

  27. HarvardLaw92 says:


    That’s the point – pay / rank status for general/flag officers is tightly regulated by law. There are statutory limits on the total number of military flag officers, and finite statutory limits on the number of those flag officers which may be in a 4 star billet on active duty in each service. Moreover, every military officer serving at O-7 and above has to have been confirmed by the Senate into that status. There is a tight, structured legal framework which controls the whole situation.

    There is no provision in the law for a 4 star admiral at the PHS. None. It just doesn’t exist. What’s happening here is that somebody or somebodies (I’d really love to know who) just took it upon themselves – with no legislation, no Senate approval of the rank status, nothing – to just say *pouf* she’s a four star admiral. It’s extremely irregular.

    There IS, however, a statute – 5 U.S. 5315 – which explicitly denotes her appropriate, legal pay grade as being Executive Schedule IV. Which is why I asked above – how is she being paid? Did somebody / somebodies also take it upon themselves to grant her an unauthorized pay raise to go along with her unauthorized rank? There are a lot of questions here which need to be answered.

  28. HarvardLaw92 says:


    I double checked just now, and as I suspected, the Senate vote was explicitly to confirm her as an Assistant Secretary of Health and Human Services. Not a single word about her being commissioned into anything, at any rank. Technically speaking, she’s illegally wearing a uniform and using a title she’s not authorized for.

  29. dazedandconfused says:


    I’m drawing from the wiki page, which seems to show the Asst Sec of Health as an Admiral. Scroll down a bit for the chart.

    The position is titled Admiral, Surgeon General is Vice Admiral, etc. This is why I suggest they are living in their own special little world. Traditions get downright weird. Nowhere else that I can think of is any civilian appointed to such ranks. I agree with something though, some of the others who held that position who were civilians with no military experience decided not to don the uniform. Good call.