The process began in Obama’s first year in office when he issued a June 2009 memo instructing agencies to extend some benefits enjoyed by the spouses of federal employees to same-sex couples. Over time, that directive eventually led to a decision by the Social Security Administration to significantly lower the threshold requirements for changing one’s gender on official government documents, a change that would determine how a person’s gender is recorded on passports, tax returns, marriage licenses and other forms.

Since June 2013, someone wishing to change their gender classification on their Social Security card has needed only provide a doctor’s note guaranteeing that “appropriate clinical treatment” was underway.

Before then, a person seeking to change their gender on had to undergo gender reassignment surgery, a hugely expensive and, many LGBT advocates and doctors say, unnecessary procedure for a transition to take place.

Suddenly, gender — once believed by many, including a rigid federal government, to be immutable from birth — could be changed on Social Security cards with a simple note from a medical professional overseeing such a transition, such as the one Elishe Wittes carried with him to the Social Security Administration last summer.