Month: April 2022

Irina, her husband and 4-year-old son hid in the cellar of their house in Chernihiv, north of Kyiv, for three weeks as intense fighting, including a tank battle, raged around them.

“At first my son seemed to be coping okay,” she says. “But then with unrelenting stress, shelling and blasts, there was a deterioration — the boy started to become withdrawn. He became nervous. He started to stutter,” she says.

Their escape from Chernihiv wasn’t gentle either.

“We had to drive along a road, which we knew was mined. And we saw a lot of burned-out cars with people, families, scorched inside. We tried to ignore it all and just continue because we had our kid and just wanted to save him,” she says.

She doesn’t know what her son saw, what he took in from the carnage and how it is churning inside him. He was in his booster seat in the back of their car. She hopes he slept through a lot of the dangerous and terrifying journey from Chernihiv.

“I have not tried to raise anything with him about what he saw,” she added. She has heard that drawing is good therapy for traumatized children and has been encouraging him to do so.

So far, he has been drawing repeatedly the yellow and blue Ukrainian colors.

Many Ukrainian evacuees say they have noticed their children have changed and seemed to be displaying signs of trauma and stress, even those who did not witness at first hand horrifying scenes.  Some exhibit rage; others seem withdrawn. Some are bed-wetting.

“It won’t just be combatants, we will have to help after this war,” says the Reverend Mykola Kwich, a Greek-Catholic priest in western Ukraine. Kwich is a trained counselor and has helped rehabilitate soldiers suffering from post-traumatic stress disorder.

“Civilians who have gone through bombardments and shelling and have witnessed a lot will need help,” he said. “We are expecting to have to do a huge amount of psychological work. We will have to do this work because it will impact our society and lead to more problems.

“Wars are about destruction. In the same way towns and buildings get damaged during war, so with people inside. After war, you can’t be the same person. But there are methods and therapy we can use to help restore people’s mental health and assist them to pursue a normal life, if they are willing. Of course, you won’t return to being the person you were before,” he adds.

Refugee reception centers in central and Western Ukraine are trying to offer traumatized adults counseling and play therapy for kids. “We do have specialists and priests coming to visit the evacuees” says Valeriy Dyakiv, director of a reception facility sheltering about 300 evacuees in the central Ukrainian town of Vinnytsia.

“Prayers calm people a little bit,” he adds. “And for children there are different types of activities. We had a puppet show the other day, and for some kids it was a huge surprise because they were from small villages and they had never seen puppets before,” he says. The activities for the kids also involve drama and poetry readings.

 The center managed by Dyakiv has the benefit of having as an evacuee a well-known Ukrainian actress, Olena Prystup, who fled her hometown of Kharkiv, the beleaguered eastern Ukraine town. “My favorite role? Prystup ponders when asked. “Ophelia,” she then says.

That seems highly fitting what Prystup is trying to do now — to help traumatized children deal with their stress. William Shakespeare’s Ophelia, from the drama “Hamlet,” is a young Danish noblewoman and potential wife for Prince Hamlet, who, due to Hamlet’s actions, ends up falling into a state of madness that ultimately leads to her drowning herself.

“We have two groups of kids,” Prystup says. “The youngsters are learning some poems by heart and then reciting them at short performances. And the older ones, teenagers, are actually working on a play right now. I don’t know how it’s going to shape out. I hope it is going to be okay, and some of them are talented,” she adds.

Professional psychiatrists worry, though, that Ukraine doesn’t have the health care capacity to cope with what is likely to be needed when the war is over. Even before Russia’s invasion, Ukraine suffered a high prevalence of depression, alcoholism and suicide compared to some other European countries.

A report by the World Health Organization in 2020 noted that mental health disorders are the country’s second leading cause of disability and affect about 30 percent of the population. The WHO also noted that many Ukrainians distrust psychiatry because of the Soviet past when psychiatry was used as a tool of repression — dissidents were often accused of being “mentally ill” and incarcerated in hospitals during the Communist era.

It said in a report, “Challenges include a large institutionalized psychiatric system associated with human rights violations, alongside public stigma and low awareness of mental health. Social services for people with mental disorders are limited or absent in the community.”
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The future of abortion rights is in flux in the U.S. as the Supreme Court is expected to weigh in on the issue in June. Since September, Texas has banned abortions after six weeks.

Amy, a spoken-word poet, recently had an abortion. And it was no easy task. The divorced mother of a 3-year-old said she barely had time to think once she realized she was pregnant — because she is in Texas.

“If I would have had a little bit more time, lowered my blood pressure a little bit — maybe I would have made a different decision. We’ll never know,” she said.

In September, the state enacted the most restrictive abortion law in the U.S. Amy, who declined to give her last name, knew she had just days to make her decision, find a place to get an abortion, and then go through with it.

“I don’t even think I had gotten the results from the pregnancy test, and I was already googling where to get an abortion in Texas, just so that I could have the option,” she said.

Amy’s experience in Texas may soon become reality for more women in the U.S.

The Supreme Court is expected to decide on an abortion case in June that could spur a wave of abortion rights restrictions throughout the nation.

Worried abortion rights advocates point to life in Texas under the new law, where abortion is illegal after a fetal heartbeat is detected, which is around six weeks of being pregnant for most women.

The law also carries the ability to sue anyone who helps a woman get an abortion after six weeks.

The reality for most women is the deadline is even shorter. When Amy missed her period, two weeks after having sex, she was considered to be four-and-a-half to five weeks pregnant, since pregnancy is calculated from the first day of a woman’s last period. Amy had less than a week, but after multiple phone calls, she was able to get into a clinic.

“I didn’t even have time to assess my own thoughts, I felt the clock ticking,” she said.

For anti-abortion activists, this time constraint is a big step in the right direction.

“Our goal is to make a society such that no woman would even consider having an abortion because she feels there are no alternatives. We do have vast alternatives,” said Joe Pojman, founder of Texas Alliance for Life.

Instead of seeking an abortion, Pojman wants pregnant women to visit Texas’ nearly 200 crisis pregnancy centers, where he says they can find support.

Brittany Green-Benningfield, who heads the Pflugerville Pregnancy Resource Center, said such groups offer a variety of resources for pregnant women.

“So this is our baby boutique for our moms,” she said while offering a tour of the center. “This is where, when they come and take lessons with us, they get an opportunity to shop. Through classes, they earn points, and then they are able to take what they need. We have a licensed sonographer, and she provides ultrasounds for any of our clients that come in. We are giving our moms a first glimpse to see their baby.”

The centers also help women make doctor’s appointments and offer things like canned goods until the child is 2-and-a-half to 3 years old. Pojman said it’s all a big step in the right direction, but that much more work is needed.

“While the number of abortions has substantially decreased and women are seeking more agencies that provide alternatives to abortions, there are still tens of thousands of abortions in Texas going on,” he said.

In some ways, Amy was a best-case scenario for someone seeking an abortion in Texas. She knew the law, she knew she had to move quickly, and she had resources to get an abortion and possibly travel out of state, if necessary. That’s not the case for poorer women who are being harmed most by the law, say abortion rights advocates.

Sarah Wheat, a spokesperson for Planned Parenthood, said she sees the obstacles women can face.

“Once they find out and are informed that Texas law prevents them from accessing an abortion right here as they’re sitting already in our health center, it’s too much, the barriers are too great, whether that is that they don’t have access to reliable transportation or they can’t get time off of their job or they don’t have somebody to take care of their children. It is totally out of reach,” she said.

In each month between September and December, 1,400 Texas women went out of state for an abortion, according to the University of Texas. That’s more than 4,000 women. Many others who missed the deadline ordered abortion pills online, which come with risks when not taken under medical supervision.

Amy said this makes her worry.

“Women are going to get abortions,” she said. “They’ve done it for centuries, even when they were fully illegal, and that’s how women died from abortions. So if you take away this decision, you’re ultimately just taking away women’s lives.”
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The future of abortion rights is in flux in the U.S. as the Supreme Court is expected to weigh in on the issue in June. Since September, Texas has banned abortions after six weeks. For women seeking an abortion, many are in a race against time. Deana Mitchell has the story. 
Camera: Deana Mitchell Produced by: Deana Mitchell
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The Kremlin’s clampdown on news of the war in Ukraine has hackers and volunteers from around the world are sending messages directly to Russian citizens’ phones to keep them informed. Matt Dibble has the story.
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Cameroon is struggling to contain a cholera outbreak that has sickened 6,000 people with the bacteria and killed nearly 100 since February. Authorities have dispatched the ministers of health and water to affected areas and have begun quarantining cholera patients to prevent it from spreading.

Cameroon’s Public Health Ministry said the number of cholera patients received in hospitals was growing by the day.  

In the seaside city of Limbe in the past week alone, 200 of 300 patients were treated and discharged from the government hospital. 

Filbert Eko, the highest-ranking official in Cameroon’s Southwest region where Limbe is located, said the region was the worst hit by cholera, with more than 800 cases since February, forcing the the quarantining of patients to prevent the disease from spreading.

“The treatment center will be separated from the hospital and from the public. No outsider will be allowed to have access to the patients,” Eko said. “We don’t want contact between families and the patients. We are taking [efforts] upon ourselves, searching for resources to feed these patients free of charge.”

Cameroon’s Public Health Ministry says many of those sickened by cholera do not go to hospitals, seeking only traditional cures, and end up dying at home, though no official figures are given.  

Health officials are urging traditional healers to direct their cholera patients to the closest hospital. 

Linda Esso, director of epidemics and pandemics at Cameroon’s Public Health Ministry, said cholera has spread to more than 40% of major towns, including the capital, Yaounde, the economic capital, Douala, and western commercial towns like Buea, Limbe and Bafoussam.  Esso said scores of villages have reported cholera cases and the entire country is threatened by the outbreak. She said the public should be very careful and protect itselves because contaminated persons may be spreading the disease without knowing it.

Cameroon’s president, Paul Biya, dispatched the ministers of health and water this week to cholera-affected areas to assess the situation.  

The two ministers blamed a shortage of clean drinking water in towns and villages, brought on by the long dry season, for rising cholera infections. 

They said medical staff were increased in the areas and about 30 new public toilets have been constructed in Limbe, Buea, and Douala to improve public hygiene. The ministers called on the public to stop defecating in the open and in streams.  

Cameroon’s minister of water, Gaston Eloundou Essomba, said officials are also providing clean water to villages and towns hit by the outbreak. He said he has asked the Cameroon Water Distribution Company (CAMWATER) to make sure trucks transport water regularly and free of charge to towns and villages that lack piped water.  He said the water distribution company should immediately treat water in all community and family wells to ensure the public has quality drinking water.

Cameroon’s public health minister, Manaouda Malachie, says Douala’s New Bell Prison has become an epicenter of cholera.  

He said hygiene had been improved at the prison but would not say how many of the more than 6,000 inmates were infected or died from the bacteria.  

Cameroon suffers from frequent cholera outbreaks.  One of the worst, in 2011, infected more than 23,000 people and killed more than 800.
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Golden butterflies adorn the walls of the Netherland’s only euthanasia expertise center, put up in remembrance of thousands of patients who have chosen to die with dignity over the past two decades.

Situated in a leafy upmarket suburb of The Hague, the Euthanasia Expertise Center is the only one of its kind, giving information, assisting medical doctors and providing euthanasia as end-of-life care, which was legalized in a world first in the Netherlands on April 1, 2002.

Belgium soon followed later that year and Spain last year became the sixth country to adopt euthanasia — the act of intentionally ending a life to relieve a person’s suffering, for instance through a lethal injection given by a doctor.

The number of people seeking euthanasia is growing in the Netherlands, with some 7,666 last year, up by more than 10 percent from the year before, according to official figures.

The vast majority are aged 60 or over, suffering from cancer or other terminal illnesses.

“Twenty years ago, when the law was passed, it was known, but certainly not used as often as today,” said Sonja Kersten, director of the Euthanasia Expertise Center.

The reasons are many: an ageing Dutch population; the fact that euthanasia is no longer a taboo subject and society has opened up to the issue.

“Dying with dignity is a debate that’s growing within Dutch society, which is quite open to the subject,” Kersten said.

‘Existential question’

Euthanasia is only authorized in a few countries around the world.

In Belgium, which will mark two decades of euthanasia in May, some 40 French citizens also benefitted from the practice last year.

The decision to ask for euthanasia as end-of-life care remains a “difficult and existential question,” Kersten said.

“It’s neither a patient’s right, nor a doctor’s duty,” to have euthanasia, she added.

In the Netherlands, euthanasia can only be carried out under strict conditions set down in Dutch law.

Children aged up to 16 need the permission of their parents and guardians, while parents must be involved in the process for children aged 16 and 17. From 18, any Dutch citizen may ask for assisted death.

In all cases, the patient must have “unbearable suffering with no prospect of improvement” and must have requested to die in a way that is “voluntary, well considered and with full conviction”.

Other criteria apply as well, like the absence of a reasonable alternative to the patient’s situation.

Doctors, too, cannot be forced to perform euthanasia.

‘Die at home’

The Euthanasia Expertise Centre helps doctors through the process by sharing knowledge and providing guidance. At the same time, the center helps patients whose doctors refuse to help them.

The center, established in 2012, is a foundation but patient care is reimbursed by health insurers.

It first positioned itself as the “Levenseindekliniek,” Dutch for “End-of-life clinic,” offering on-site euthanasia.

But even before the start, it became apparent that most patients preferred to die at home, Kersten said.

Today, the center can call upon a network of about 140 doctors and nurses around the country, employed by the Euthanasia Expertise Center.

Most euthanasia requests, however, are handled by the patient’s own physician, with whom they already have a relationship of trust. Last year, this was true for 80 percent of euthanasia procedures performed in the country.

“There are however still doctors in the Netherlands who are opposed to euthanasia,” said Kersten, adding “they have every right.”

The center’s medical team itself provided euthanasia to nearly 900 people in 2020, out of nearly 3,000 requests, with figures on the rise.

About 20 percent had dementia or psychiatric disorders.

The Netherlands’ highest court ruled in 2020 that doctors can euthanize patients with severe dementia without the fear of prosecution.

It concerns patients with advanced dementia who are no longer mentally competent but who previously had a clear request for euthanasia.

The decision followed a landmark case, not related to the Expertise center, in which a doctor was acquitted of providing euthanasia on a woman in 2016 with severe Alzheimer’s disease, who earlier requested the procedure.
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When the end of the COVID-19 pandemic comes, it could create major disruptions for a cumbersome U.S. health care system made more generous, flexible and up-to-date technologically through a raft of temporary emergency measures.

Winding down those policies could begin as early as the summer. That could force an estimated 15 million Medicaid recipients to find new sources of coverage, require congressional action to preserve broad telehealth access for Medicare enrollees, and scramble special COVID-19 rules and payment policies for hospitals, doctors and insurers. There are also questions about how emergency use approvals for COVID-19 treatments will be handled.

The array of issues is tied to the coronavirus public health emergency first declared more than two years ago and periodically renewed since then. It’s set to end April 16 and the expectation is that the Biden administration will extend it through mid-July.

Some would like a longer off-ramp.

Transitions don’t bode well for the complex U.S. health care system, with its mix of private and government insurance and its labyrinth of policies and procedures. Health care chaos, if it breaks out, could create midterm election headaches for Democrats and Republicans alike.

“The flexibilities granted through the public health emergency have helped people stay covered and get access to care, so moving forward the key question is how to build on what has been a success and not lose ground,” said Juliette Cubanski, a Medicare expert with the nonpartisan Kaiser Family Foundation, who has been researching potential consequences of winding down the pandemic emergency.

Medicaid churn

Medicaid, the state-federal health insurance program for low-income people, is covering about 79 million people, a record partly due to the pandemic.

But the nonpartisan Urban Institute think tank estimates that about 15 million people could lose Medicaid when the public health emergency ends, at a rate of at least 1 million per month.

Congress increased federal Medicaid payments to states because of COVID-19, but it also required states to keep people on the rolls during the health emergency. In normal times states routinely disenroll Medicaid recipients whose incomes rise beyond certain levels, or for other life changes affecting eligibility. That process will switch on again when the emergency ends, and some states are eager to move forward.

Virtually all of those losing Medicaid are expected to be eligible for some other source of coverage, either through employers, the Affordable Care Act or — for kids — the Children’s Health Insurance Program.

But that’s not going to happen automatically, said Matthew Buettgens, lead researcher on the Urban Institute study. Cost and lack of awareness about options could get in the way.

People dropped from Medicaid may not realize they can pick up taxpayer-subsidized ACA coverage. Medicaid is usually free, so people offered workplace insurance could find the premiums too high.

“This is an unprecedented situation,” said Buettgens. “The uncertainty is real.”

The federal Centers for Medicare and Medicaid Services, or CMS, is advising states to take it slow and connect Medicaid recipients who are disenrolled with other potential coverage. The agency will keep an eye on states’ accuracy in making eligibility decisions. Biden officials want coverage shifts, not losses.

“We are focused on making sure we hold on to the gains in coverage we have made under the Biden-Harris administration,” said CMS Administrator Chiquita Brooks-LaSure. “We are at the strongest point in our history and we are going make sure that we hold on to the coverage gains.”

ACA coverage — or “Obamacare” — is an option for many who would lose Medicaid. But it will be less affordable if congressional Democrats fail to extend generous financial assistance called for in President Joe Biden’s social legislation. Democrats stalling the bill would face blame.

Republicans in mostly Southern states that have refused to expand Medicaid are also vulnerable. In those states, it can be very difficult for low-income adults to get coverage and more people could wind up uninsured.

State Medicaid officials don’t want to be the scapegoats. “Medicaid has done its job,” said Matt Salo, head of the National Association of Medicaid Directors. “We have looked out for physical, mental and behavioral health needs. As we come out of this emergency, we are supposed to right-size the program.”

Telehealth static

Millions of Americans discovered telehealth in 2020 when coronavirus shutdowns led to the suspension of routine medical consultations. In-person visits are again the norm, but telehealth has shown its usefulness and gained broader acceptance.

The end of the public health emergency would jeopardize telehealth access for millions enrolled in traditional Medicare. Restrictions predating COVID-19 limit telehealth mainly to rural residents, in part to mitigate health care fraud. Congress has given itself 151 days after the end of the public health emergency to come up with new rules.

“If there are no changes to the law after that, most Medicare beneficiaries will lose access to coverage for telehealth,” the Kaiser Foundation’s Cubanski said.

A major exception applies to enrollees in private Medicare Advantage plans, which generally do cover telehealth. However, nearly 6 in 10 Medicare enrollees are in the traditional fee-for-service program.

Tests, vaccines, treatments, payments & procedures

Widespread access to COVID-19 vaccines, tests and treatments rests on legal authority connected to the public health emergency.

One example is the Biden administration’s requirement for insurers to cover up to eight free at-home COVID-19 tests per month.

An area that’s particularly murky is what happens to tests, treatments and vaccines covered under emergency use authorization from the Food and Drug Administration.

Some experts say emergency use approvals last only through the duration of the public health emergency. Others say it’s not as simple as that, because a different federal emergency statute also applies to vaccines, tests and treatments. There’s no clear direction yet from health officials.

The FDA has granted full approval to Pfizer-BioNTech’s COVID-19 vaccine for those 16 and older and Moderna’s for those 18 and older, so their continued use would not be affected.

But hospitals could take a financial hit. Currently Medicare pays them 20% more for the care of COVID-19 patients. That’s only for the duration of the emergency.

And Medicare enrollees would have more hoops to jump through to be approved for rehab in a nursing home. A suspended Medicare rule requiring a prior three-day hospital stay would come back into effect.

Health and Human Services Secretary Xavier Becerra recently told The Associated Press that his department is committed to giving “ample notice” when it ends the public health emergency.

“We want to make sure we’re not putting in a detrimental position Americans who still need our help,” Becerra said. “The one that people are really worried about is Medicaid.”
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Laura Purdy is a U.S. doctor on Ukraine’s front lines. In her case, that’s a computer screen in Tennessee.

“Patients that I have talked to from some of the larger cities in Ukraine are fearful of leaving their homes because of air raid sirens or offshore attacks,” said Purdy, a surgeon who, until 2016, served in the U.S. Army’s units that provide health care to civilians worldwide. “They need/want to speak to a physician but are fearful to venture out to do so.”

Purdy now cares for patients in Kyiv and other cities under Russian attack through Starlink, an internet constellation of some 2,000 satellites operated by billionaire Elon Musk’s private firm SpaceX.

Russia invaded Ukraine on February 24, and as of March 30, 1,189 Ukrainians had been killed and 1,901 injured, according to the U.N. Human Rights Office.

U.S. doctors are stepping up to provide much-needed advice via telehealth, a practice honed during the pandemic, to the Ukranian soldiers, civilians and refugees injured in the fighting or attempting to manage chronic diseases amid the chaos.

Purdy is just one of the many physicians who have joined Aimee, a 10-year-old telehealth platform headquartered in Silicon Valley. Having built the telehealth systems for the International Space Station and SpaceX, Aimee is staffed by self-described “nerds who want to make a difference” and are now partnering with Ukraine’s Ministry of Health to provide Ukrainians with free telemedicine visits.

By using the Aimee app, Purdy said, patients can get advice and treatment recommendations from a U.S. physician while they remain in a safe location.

Milton Chen, founder and CEO of VSee, the telehealth company that launched Aimee, said a “couple thousand” physicians and a “couple hundred” translators have joined the platform to provide 24/7 telecare in Ukraine. The doctors provide care for battlefield trauma injuries as well as basics such as prenatal care, chronic disease management and mental health services.

“You could do a remote ultrasound; you could connect to a digital stethoscope to listen to someone’s heart and lung sound. All these medical signals will stream live to the physicians — so other than physically touching the patient — and the physician could get quite a bit of information on the patient,” he said via video.

Through telemedicine, Purdy treated a legally blind man who relies on his family for all his daily needs. Purdy helped him set up a free consultation with an ophthalmologist to interpret tests he underwent in Ukraine.

“This occurred in a city that was actively under attack, and we were able to provide advice and support to the patient while allowing him to stay safely sheltered in place,” she told VOA Mandarin.

The lack of medicine is one of the biggest hurdles for patients in Ukraine, said Purdy, who earned her medical degree at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

“The pharmacies have run out of medication, or they are closed. So, many times we find patients who we can give medical recommendations to, but they may not have access to the pharmaceuticals that they need to treat the condition they are experiencing,” she said.

And while remote doctors can’t solve challenges such as the lack of insulin for patients with diabetes, they can provide much-needed assistance. Dr. Mohamed Aburawi, founder and CEO of Speetar, a telehealth platform founded in 2017 to operate in Libya, told Forbes that “every day a conflict lasts, the situation worsens, and telehealth provides care, relief and stability to communities and people that need it most. Our own experience in protracted conflict highlights how telehealth maintains continuity of care for refugees, migrants and internally displaced populations.”

Telemedicine can also include teaching patients how to stop bleeding from wounds and injuries, a challenge for citizens in war zones, said Patricia Turner, executive director of the American College of Surgeons, which since 2015 has trained people without medical backgrounds through the Stop the Bleed initiative launched by the White House.

“When you bleed … you can actually die in as quickly as five minutes, so stopping the bleeding helps … save a life,” she told VOA Mandarin.

Two doctors who have family ties to Ukraine and work at Brigham and Women’s Hospital in Boston, Massachusetts, turned to telemedicine and developed a training video for Ukrainians.

Dr. Nelya Melnitchouk, a Ukraine native, came up with the idea for the video, and Dr. Eric Goralnick, who is of Ukrainian descent, helped organize the collaboration between the hospital and the Stop the Bleed initiative, according to The Boston Globe.

The training course can be finished in a few hours, Turner said, and can help health care workers and the public learn how to effectively stop bleeding.

“More than 100 people are being trained every other day,” she said. “We’re doing it via video so you can watch them on YouTube. We’re also doing them live remotely so that we can answer questions.”
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The U.K. will ban conversion therapy for gay or bisexual people in England and Wales, but not for transgender people, ITV reported Thursday.

Hours earlier, the government had confirmed an ITV report that it would drop a plan to introduce legislation to ban LGBT conversion therapy and would instead review how existing law could be utilized more effectively to prevent it.

That prompted an angry response from LGBT groups and some lawmakers.

“The Prime Minister has changed his mind off the back of the reaction to our report and he WILL now ban conversion therapy after all,” ITV political reporter Paul Brand tweeted.

“Senior Govt source absolutely assures me it’ll be in Queen’s Speech (of planned legislation). But only gay conversion therapy, not trans,” he said.

A Downing Street spokesperson declined to comment.

Prime Minister Boris Johnson’s government has come under increasing pressure on the issue after former leader Theresa May vowed in 2018 to eradicate a procedure that aims to change or suppress someone’s sexual orientation or gender identity.

In May last year, when the government set out its post-pandemic parliamentary agenda, it said measures would be brought forward to prevent these “abhorrent practices which can cause mental and physical harm,” starting with a consultation on how best to protect people and how to eliminate coercive practices.
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