What Affirming Care Actually Does

This is the third post in the Pride 2026 Series.

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In April 2026, Nathan Lane sat down with Howard Stern and told a story he has carried for more than fifty years. He was twenty-one years old, about to leave for New York to become an actor, and he had decided he could not leave without being honest with his mother. He sat her down and told her he had been seeing a man, not the woman she had assumed. She looked at him and said, without anger, without vindictiveness, simply with the weight of a generation’s worth of certainty about what his life now meant: “I’d rather you were dead.”

He replied, instantly: “I knew you’d understand.”

The humor is the point. Not because the moment was funny—it wasn’t—but because Lane had already learned, at twenty-one, what queer people learn earlier than they should: that sometimes the only way to survive what is being said to you is to refuse to let it land without a response. The joke was a refusal. A small, quick, unmistakable act of self-preservation in the face of a sentence that told him his existence was worse than his absence.

Lane’s mother was not a monster. He has said so himself: she was a woman of her generation, without the framework to hold what he was telling her, doing the best she could with what she had. His brother asked if it might be a phase. His other brother said, simply, “I love you no matter what.” Three responses to the same information, in the same family, in the same hour. The full spectrum.

I have sat with versions of that hour many times in my clinical work and personal life. The details change. The spectrum does not.

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What affirming care does, at its most basic level, is this: it ensures that when a queer person walks into a clinical space, they do not have to perform the calculation Nathan Lane performed at twenty-one. They do not have to decide, before they can say what is wrong, whether the person across from them is the mother, the brother who wonders if it’s a phase, or the brother who doesn’t care. That calculation has a cost. It is not hypothetical or anecdotal. It is documented, replicated, and measurable.

Minority stress theory, first formally articulated by Ilan Meyer , maps the specific mechanisms by which discrimination becomes biology. The clinical environment, when it is not an affirming one, generates both the external stressors—discrimination, the use of wrong pronouns, visible discomfort—and the internal ones: the vigilance required to read a room before speaking, the calculation of what to disclose and to whom. A provider who uses the wrong pronoun after being corrected is generating a measurable stressor. The queer patient who decides, after that correction, not to mention the relationship that is actually the source of their distress, is experiencing one. Both have health consequences.

The research on what affirming environments prevent is not subtle. LGBTQ+ people who report high levels of provider-level stigma—being treated differently, being lectured, being met with visible discomfort—are significantly less likely to disclose relevant health information, significantly less likely to return for follow-up care, and significantly more likely to delay seeking care until a problem has become acute . The affirming clinical environment is not a political statement. It is the precondition for doing the job.

What that environment looks like in practice is neither complicated nor expensive: asking for and using correct pronouns, collecting and recording SOGIE data in the medical record, displaying visible signals of welcome—a Pride flag in the waiting room, a nondiscrimination statement on intake forms, staff training that goes beyond tolerance toward genuine cultural competence. These are not ideological acts. They are clinical ones. They are the equivalent of asking a patient whether they have stairs at home before you discharge them with a broken leg.

A note on terminology: federal agencies and research bodies use SOGI (Sexual Orientation and Gender Identity) as the standard measurement term. Affirming clinical practice more often uses SOGIE, which adds Expression as a distinct dimension—how a person presents their gender publicly—that matters in the clinical encounter even when it is not captured in population-level data. Both terms appear in what follows, each in its own context.

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The current federal environment is systematically dismantling the infrastructure that makes affirming care possible—not through any single dramatic act, but through the same procedural, incremental mechanism that has characterized the broader erasure documented in the first two posts in this series.

Consider the data. Since January 20, 2025, approximately 360 federal data collections have removed at least one SOGI measure , according to research from the Williams Institute at UCLA School of Law. The majority of removals targeted gender identity, but 60 data collections also removed sexual orientation measures—even though the executive order that prompted the removals did not require it. In February 2025, HRSA instructed community health centers to remove SOGI data from their 2024 annual data reports, effectively erasing a decade of demographic infrastructure from the federally qualified health centers that disproportionately serve the most vulnerable populations in the country. The Behavioral Risk Factor Surveillance System—the largest continuously conducted health survey in the world, with 400,000 participants annually—had its SOGI data removed. So did the Youth Risk Behavior Surveillance System, which had been our primary source for understanding what is happening to queer young people in American schools.

The Williams Institute’s lead author put it plainly: “Federal data on sexual orientation and gender identity are essential for understanding LGBTQ populations in the United States. These data allow us to identify disparities in health, economics, and exposure to violence among a group that’s been shown to be disproportionately at risk of these outcomes.” Without that data, we are not simply less informed. We are clinically blind. You cannot address a disparity you have stopped measuring. You cannot advocate for a population you can no longer count. A community that has been made statistically invisible has not had its health needs eliminated. It has had its health needs made officially irrelevant.

Then there is the 988 crisis line—the sharpest and most concrete example of what happens when specialized care is dismantled in the name of serving everyone equally.

When the 988 Suicide and Crisis Lifeline launched in 2022, it included a specialized option for LGBTQ+ youth: press 3, or text PRIDE, to be connected with a counselor specifically trained to support queer young people. The rationale was straightforward and evidence-based. LGBTQ+ youth are four times more likely to attempt suicide than their peers. The specialized subnetwork existed because the general line, staffed by counselors without specific training in the experiences of queer youth, was not reliably meeting that population’s needs. In three years of operation, the service fielded nearly 1.5 million contacts. In April 2025 alone, it handled 70,000 crisis interactions—an all-time high.

On July 17, 2025, SAMHSA officially terminated the program. The stated reason was that the allocated funding had been fully spent. The administration’s spokesperson described it as a service “where children are encouraged to embrace radical gender ideology.” SAMHSA’s official announcement notably referred only to “LGB+ youth”—omitting the T and the Q in the same administrative gesture that had been applied to the Stonewall monument website six months earlier.

The Trevor Project’s CEO called it clearly: “This administration has decided to say, loudly and clearly, that they believe some young people’s lives are not worth saving.” A study published in JAMA this April found that the 988 Lifeline’s launch was associated with an 11 percent reduction in youth suicide deaths—and identified the elimination of the LGBTQ+ specialized services as a significant emerging threat to sustaining those gains.

The argument that general services are sufficient—that “everyone” will be served equally by a line no longer staffed with counselors trained to understand the specific experiences of queer youth—is not a clinical argument. It is the argument that disappears people by insisting they were never there. It is, in the most precise sense, the same argument that removed Marsha P. Johnson from the Stonewall monument website: the one that says the specific does not matter, that the general is enough, that tailoring care to the people who need it most is a form of favoritism rather than a form of medicine.

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I want to be honest about what primary care behavioral health can and cannot do in this environment.

It can create the conditions Nathan Lane’s mother did not create—a space where a person does not have to perform the calculation before they can speak. It can collect and record SOGIE data locally, even when federal systems have stopped asking. It can train staff. It can display visible signals. It can ask the question that too many providers have stopped asking because they are afraid of the answer, or because they were never taught how to ask it: How are you doing with all of this? For a queer patient in 2026, that question—asked without flinching, in an environment that has signaled it is safe—is a clinical intervention.

What it cannot do is substitute for the infrastructure being dismantled. A warm, affirming primary care visit does not replace a specialized crisis line for a queer teenager at three in the morning. A behavioral health consultant who asks the right questions does not replace the SOGI data that would allow us to track what is happening to queer patients across health systems, over time, at a population level. Affirming care in the clinic is necessary and insufficient. It is what we can offer in the space where the federal government has stopped showing up. And it is not nothing.

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Nathan Lane came out publicly in 1999. He has said what prompted him: Matthew Shepard had been murdered the year before, and silence no longer felt like something he was willing to afford.

Shepard was twenty-one years old when Aaron McKinney and Russell Henderson lured him out of a bar in Laramie, Wyoming, drove him to a remote field, beat him with a pistol until he lost consciousness, tied him to a fence post, and left him there. He was found eighteen hours later by a passing cyclist who initially mistook his battered body for a scarecrow. He died four days later without regaining consciousness. His killers deployed a “gay panic” defense at trial—arguing that Shepard had made advances on them and they had simply reacted. The jury rejected it. McKinney and Henderson were each convicted of first-degree murder and sentenced to two consecutive life terms.

It is worth sitting with that age for a moment. Twenty-one. The same age Nathan Lane was when he sat his mother down and told her the truth and heard “I’d rather you were dead.” The same age at which countless queer people have their first honest conversation with the people who are supposed to love them unconditionally—and discover that the condition was always there, waiting.

The revisionism started almost immediately, and it has never fully stopped. The argument circulating in Laramie and beyond—that Shepard provoked his own murder by hitting on his attackers, that the violence was understandable if not quite justifiable, that the gay panic defense was closer to the truth than the jury believed—is not a fringe position. It is repeated in books, in church basements, at kitchen tables. The Matthew Shepard Foundation has called it plainly what it is: “based on untrustworthy sources, factual errors, rumors and innuendo rather than the actual evidence gathered by law enforcement and presented in a court of law.” The killers’ own attorneys made the same argument and lost. The verdict has not changed. The revisionism persists anyway, because the revisionism was never really about what happened in Laramie. It was about what it would mean if what happened in Laramie was simply a hate crime—if a young man was beaten to death for being gay, and that was the whole story, and there was no complexity to hide behind.

There is no complexity to hide behind.

The federal government, in the years since, has at least nominally acknowledged this. The Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act, signed by President Obama in 2009, expanded federal hate crime protections to include sexual orientation, gender identity, and disability. It bore Shepard’s name because his parents, Judy and Dennis, had spent eleven years demanding that a government that failed to protect their son at least commit to protecting others. It passed with bipartisan support, 281 to 146 in the House.

The current administration’s proposed FY2026 budget calls for cutting all grants authorized under the Matthew Shepard Act. The DOJ’s Community Relations Service—the agency responsible for mediating community tensions and responding to hate crimes—has had references to hate crimes based on sexual orientation and gender identity removed from its website. Its training video on working with transgender communities is gone. The DOJ’s own hate crimes page, which once described the Shepard-Byrd Act and its protections in detail, now exists only as an archived page marked: This is archived content from the U.S. Department of Justice website. The information here may be outdated.

Matthew Shepard has been dead for twenty-seven years. His name is on a federal law. The government that is supposed to enforce that law is defunding it, archiving it, and removing the training materials that taught federal agents how to apply it—procedurally, incrementally, in the same administrative register that has characterized every other erasure documented in this series.

He was twenty-one years old. Nathan Lane was twenty-one years old. The calculation they were both performing—whether it was safe to be who they were, in the room they were in, with the people in front of them—is the same calculation every queer person learns far earlier than anyone should.

What affirming care does is remove that calculation from the clinical encounter. It means asking about chosen names and pronouns before the patient has to correct you. It means recording SOGIE data in the chart even when federal systems have stopped asking for it. It means having the conversation about mental health and safety that a queer twenty-one-year-old may not be able to have anywhere else—not at home, not at church, not in the bar in Laramie. It means being, for the duration of a clinical encounter, the room where the calculation is not required.

That is not a political act. That is medicine.

And if you are not a provider—if you are a parent, a sibling, a friend, a person sitting in the pew next to someone you love—you already have everything you need to be the room where the calculation is not required. You do not need a degree or a training manual or a complete understanding of everything your person is carrying. Nathan Lane’s brother did not have any of those things. He had six words: I love you no matter what. That was sufficient. That has always been sufficient. It is what the mother could not give, and what the other brother hedged on, and what the clinical environment is designed to provide in their absence—but it is not, and should not be, the clinic’s alone to offer.

Be the brother. That is not a political act either. That is just love.

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If you or someone you know is in crisis, please call or text 988 to reach the Suicide and Crisis Lifeline, or contact the Trevor Project directly by texting START to 678-678 or calling 1-866-488-7386.

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If you are looking for ways to act, or for support for yourself or someone you love, these organizations are doing essential work: PFLAG supports families and loved ones of LGBTQ+ people with resources, community, and advocacy; the ACLU is tracking anti-LGBTQ legislation state by state; the Trevor Project provides free, confidential crisis support to LGBTQ+ young people twenty-four hours a day; GLAAD monitors and responds to anti-LGBTQ rhetoric in media and government; and the Human Rights Campaign works toward full legal equality for LGBTQ+ Americans.

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This post was drafted and revised by the author. Claude (Anthropic) was used to verify details and sources of current events, clarify and revise the structural arc of the series, assist with revision and editing, and generate ZotPress and WordPress shortcode syntax for citation rendering and post formatting. All positions, interpretations, and personal statements are the author’s own.

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