WASHINGTON — Nearly two months into the Biden administration, in the thick of the worst public health crisis in a century, the Department of Health and Human Services remains largely leaderless, with President Joe Biden’s nominees to run the sprawling agency under concerted attack from Republicans over abortion and gender politics.

Twenty-three of 31 top leadership posts at the department — including the secretary of health and human services, the commissioner of the Food and Drug Administration and the assistant secretary for preparedness and response, all critical to fighting the coronavirus pandemic — are held by career officials in acting capacities.

Biden has yet to nominate an FDA commissioner or a head of preparedness and response, but other vacancies exist in part because Biden’s top health nominees have been stymied on Capitol Hill, including Xavier Becerra, Biden’s nominee for health secretary, and Rachel Levine, the nominee for assistant secretary for health, as Republicans target them in an effort to revive the culture wars.

Conservatives and some Catholic leaders have branded Becerra, the California attorney general, an unqualified “liberal extremist,” citing his support for abortion rights.

And Levine, the first openly transgender person nominated to a position that requires Senate approval, was the subject of a tirade by Sen. Rand Paul, R-Ky., who likened sex reassignment surgery to “genital mutilation” and demanded to know whether she supports such procedures for minors.

On Wednesday, both Becerra and Levine took a step closer toward confirmation. The Senate voted 50-49 to break off debate and move to Becerra’s confirmation vote, with a crucial Republican, Sen. Susan Collins of Maine, siding with Democrats. At the same time, the Senate health committee voted to send Levine’s nomination to the full Senate, with Collins and another Republican, Sen. Lisa Murkowski of Alaska, voting in favor. But even as their nominations have moved forward, conservatives across the country have escalated their attacks against the two and have renewed their push to limit protections for transgender people.

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Last week, Mississippi’s governor, Tate Reeves, a Republican, signed legislation to ban transgender athletes from competing on girls’ or women’s sports teams, the first of more than 20 states considering restrictions on athletics or gender-based health care for transgender minors this year.

During the Trump administration, social conservatives in posts at the Department of Health and Human Services spearheaded a governmentwide push to roll back transgender and abortion rights as well as government-mandated access to birth control. Now out of government, some of those officials have joined the attacks on Biden’s nominees.

Roger Severino, a champion of social conservative causes who ran the Department of Health and Human Services’s civil rights office under former President Donald Trump and led the fight against transgender protections, called Levine a “divisive pick that goes contrary to President Biden’s promise of unity.”

Democrats are incredulous.

“We’re in the middle of a pandemic,” complained Sen. Chris Coons, D-Del. and a close ally of Biden’s. “To have all these other major Cabinet positions — secretary of education, secretary of transportation, secretary of Treasury — and not have the secretary of HHS strongly suggests to me that there is more politics than legitimate concern about making progress.”

A Senate floor vote on Becerra’s confirmation is expected to come Thursday. If he secures 51 votes, officials expect more jobs to be filled soon.

But floor votes have not yet been scheduled for Levine or for Dr. Vivek Murthy, Biden’s pick for surgeon general, whose nomination was also approved by the Senate health panel Wednesday. In the meantime, the department is being run by career officials.

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Former health officials in both Republican and Democratic administrations said that was not ideal. “Career employees take their cues from the top,” said Bill Pierce, the department’s assistant secretary for public affairs under former President George W. Bush. “You can move along without that for a while, but you can’t do it forever.”

Nicole Lurie, the assistant secretary for preparedness and response in the Obama administration, said permanent leadership has become especially important after Trump, who waged an assault against civil servants, many of whom lost trust that their bosses would back them up — and have become fearful of making decisions.

“There are a lot of people who might have trusted their instincts before, but that trust has been eroded,” Lurie said. “They need to be sure that they are doing the right thing and that if they step out and do something now that is perceived as risky that nobody is going to cut their neck off for it.”

Levine, a pediatrician and former secretary of health in Pennsylvania, has found herself targeted by Severino, who said he met with Levine early in his tenure at the department. At the time, he was considering whether to amend an anti-discrimination rule in the Affordable Care Act that the Obama administration had interpreted as protecting transgender people; the Trump administration ultimately cut back those protections.

While he said they engaged in a “very respectful dialogue and a good exchange,” he challenged Levine about whether she would favor hormone blockers or sex reassignment surgery for minors — topics that Paul raised during Levine’s confirmation hearing.

“You’re willing to let a minor take things that prevent their puberty, and you think they get that back?” Paul, who is an ophthalmologist, said angrily at one point. “You give a woman testosterone enough that she grows a beard; you think she’s going to go back looking like a woman when you stop the testosterone?”

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Levine replied, “Transgender medicine is a very complex and nuanced field with robust research and standards of care.”

Detractors have seized on a 2017 speech that Levine gave describing hormone therapy as a standard of care for transgender youth, and also on a Twitter post she made in January 2020 about a study showing that transgender youth with access to puberty-blocking drugs are at decreased risk of suicide.

After the hearing, Sen. Chuck Schumer, D-N.Y. and the majority leader, denounced Republicans for “their attacks on trans people,” which he called, “just mean, mean and show a complete lack of understanding, a complete lack of empathy.” In a statement Wednesday, Sen. Bob Casey, D-Pa., said Paul’s “questioning was transphobic and a source of pain for many Americans, particularly transgender youth.”

But Severino and his fellow conservatives say Levine is being evasive. The Conservative Action Project, a coalition of conservative leaders, issued a public letter Tuesday calling on the Senate to reject Levine’s nomination. It complains that she did not answer Paul’s questions and questions her handling of the coronavirus pandemic, including Pennsylvania’s decision to designate abortion as an essential health care service.

Opposition to Becerra centers on abortion and birth control. Republicans have seized on a suit he brought against the Trump administration to block it from expanding religious exemptions for employers that did not want to provide contraceptive coverage through their insurance plans. The Little Sisters of the Poor, a Catholic organization, later joined the suit.

Republicans, led by Sen. Tom Cotton of Arkansas, have accused Becerra of suing a group of nuns. “Becerra did sue nuns. He repeatedly harassed the Little Sisters of the Poor,” Cotton wrote on Twitter last month. “That’s why he should be rejected by the Senate.”

Becerra, in his own defense, has said, “I never sued a nun — any nuns.” The fact-checking website PolitiFact rated the statement “half true,” noting that the lawsuit did involve an issue on which the Little Sisters had long been a litigant and that Becerra continued to press the case after a court allowed them to intervene as a defendant.

The pushback against Becerra appeared to catch the Biden administration off guard. When the Senate Finance Committee took up his nomination, it deadlocked, which forced Schumer to invoke a special maneuver known as a discharge petition to bring it to the floor for this week’s vote.