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Are gender interventions helpful? First do no harm!: David Zitner for Inside Policy

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From the Macdonald Laurier Institute

By David Zitner

Canadian public health bodies are lagging far behind peer nations in calling for evidenced-based approach to gender-affirming care.

Public health bodies in Europe and the United States are sounding the alarm, calling for serious research into the safety and benefits of youth gender transition interventions. On August 12, the American Society of Plastic Surgeons became the first major US medical association to challenge the consensus of medical groups over “gender-affirming care” for minors.

Meanwhile, systematic reviews of evidence conducted by public health authorities in Finland, Sweden, and the United Kingdom concluded that the risk/benefit ratio of youth gender transition ranges from unknown to unfavourable.

According to a US study, each stage of gender affirming treatment – social affirmation, pubertal blockade, administration of cross-sex hormones, and sex reassignment surgery – poses harms and risks that are not fully disclosed to minors and families.

Regulators in Europe and the UK have already reacted accordingly, with more emphasis on psychosocial support over medical interventions.

Canadian regulators, on the other hand, have been mum on the need for evidence-based treatment and they have not even insisted that proponents of aggressive treatments track the long-term physical and mental health outcomes of gender-affirming interventions.

Doctors and parents trying to support children with gender issues are faced with important, sometimes conflicting, moral and ethical dilemmas as they try to help distressed children while avoiding harm.

For most established treatments across the various areas of medicine, researchers have studied the chances and types of benefits and harms, the research is accessible, and patients can choose based on their own values and subjective assessment the anticipated benefits and risks. It is entirely different for those who consider gender-affirming interventions.

Parents acting as agents for children with gender identity issues are in a particularly desperate situation because of the absence of reliable research identifying those children who will someday detransition. Too many parents will likely feel deeply aggrieved when they realize that what might have been a passing fancy of childhood or adolescence produced permanent, irreversible harms.

In pursuing gender-affirming care, doctors and parents simply cannot avoid harm because the evidence is insufficient to identify those who might benefit from aggressive therapies and those who will be harmed.

Unfortunately, this absence of reliable scientific research does not prevent people, including Canadian regulators, from expressing strong opinions in favour of aggressive gender interventions.

Some adolescents experience gender fluidity and uncertainty as they grow. From time to time, a person might change how they feel, expressing their identity one way and subsequently another. Such persons might dress and accept the identity compatible with their genetic identity (male or female) at one period of their life, and at other times identify with or express an identity incompatible with their genetics. Like other emotional preferences, they can change over time.

British Medical Journal article commenting on the Cass Review emphasized that anyone who genuinely cares for children should recognize that “gender medicine is built on shaky foundations.” Citing numerous articles in peer-reviewed pediatric journals, it concludes: “The evidence base for interventions in gender medicine is threadbare, whichever research question you wish to consider — from social transition to hormone treatment. Of more than one hundred studies examining the role of puberty blockers and hormone treatment for gender transition only two were of passable quality…. Intervention studies — particularly of drug and surgical interventions — should be designed to evaluate relevant outcomes with adequate follow-up.”

Despite the opinion of some professional gender-modification advocates, evidence of benefit is scant. On the other hand, the risk of aggressive gender-transition interventions include changes to fertility, bone, and cardiovascular health, and growth. It simply must be said that tampering with a young person’s hormone levels and appearance leads to dramatic, and often permanent, harmful biologic changes.

Canada’s peers are waking up to the dangers of gender-affirming care for minors and the threadbare evidence on which it has progressed thus far. Where is Canada?

Canadian public health bodies and regulators should follow other international bodies and insist on evidence-based care following the systematic study of the benefits and harms of aggressive gender interventions. Until that study is complete, we must insist that doctors remember their obligation to “do no harm.”


David Zitner is a senior fellow at the Macdonald-Laurier Institute. He has participated at every level of Canadian health care including clinical practice, research, administration, governance and patient and professional education.

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illegal immigration

A blanket amnesty for illegal migrants would be a disaster for Canada: David L. Thomas for Inside Policy

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From the Macdonald Laurier Institute

By David L. Thomas

The prospect of a general amnesty for illegals in Canada will be the final straw. How can there be any shred of integrity left in our immigration system if we reward those who broke the rules?

The Liberal government’s proposal to grant a pathway to citizenship to “undocumented” people who are in Canada illegally is a risky strategy and likely to backfire. It will be seen as an open invitation to billions of people around the world to come here, break our immigration laws, and eventually be rewarded for it.

In my years as an immigration lawyer, I met countless people who dreamed of one day possessing a Canadian passport. Holding one would unlock a world of opportunity in Canada. But it also has another attractive feature: Canadian passport-holders can travel visa-free to 188 countries. When I began my legal career, we used to say there were only about 20 “good passports” in the world – passports that allowed unrestricted travel abroad and a good standard of living in the home country. Given general rises in prosperity and geopolitical progress (think the fall of the Berlin Wall), I would argue the number of “good passports” has risen to about 45.

Of course, that means there are still around 155 “not-so-good passports” issued by other countries, where the majority of the world’s population happens to reside. Given that only a few countries actively promote immigration (Canada leads in this respect, followed closely by Australia and New Zealand) it is easy to see why Canadian citizenship is in such high demand.

Some activists argue there should be no borders – that “no one is illegal.” They are grossly underestimating the demand. If a border-free world popped into existence tomorrow, many estimated 250 million people would immediately choose to relocate. Some have put that number as high as 750 million. I believe these estimates are outdated and perhaps naïve. Surely the number today would be in the billions.

A recent survey suggested that 69 million Chinese would like to move to Canada, if they could. The same survey showed 137 million Chinese are considering moving to the US (Canada would be their second choice). Another survey indicated that almost 75 percent of Indians are seeking to emigrate, and 35 percent are actively working towards it (India has a population of 1.4 billion). A Gallup World Poll in 2017 showed a growing worldwide trend in the desire to relocate to a new country. In Sub-Saharan Africa, with a population of 1.24 billion, 33 percent indicated a wish to emigrate. In Nigeria alone, 48 percent indicated a desire to emigrate permanently (the population of Nigeria is 229 million).

Prior to 2017, Canada – surrounded by three oceans and neighbouring the United States – had reasonable control of its borders. Illegal border crossings were not that common. Some might recall in 1999 when four rusty ships washed ashore on western Vancouver Island, having transported 599 illegal migrants from Fujian, China. The federal government responded quickly – deporting 330 migrants and granting three dozen refugee status. As for the rest, well, they just disappeared.

Even though more than two hundred migrants slipped through the cracks during that 1999 event, that seems like a tremendous success compared to the open invitation Prime Minister Justin Trudeau made to the world in an infamous January 2017 tweet. In response to the inauguration of President Donald Trump and his promise to clamp down on illegal immigration, Trudeau posted on Twitter: “To those fleeing persecution, terror & war, Canadians will welcome you, regardless of your faith. Diversity is our strength #WelcomeToCanada.”

Many undocumented migrants in America saw this as an open invitation to simply walk across our border. By the end of 2018, more than 50,000 people had crossed into Canada illegally, most of them through Roxham Road in Quebec, at the border with upstate New York.

In 2019, a CBC reporter made these observations about the Roxham Road crossing:

But the majority of those who come here to Plattsburgh, N.Y., by bus, train or plane have spent little time in the U.S., arriving on tourist visas with the intent of treading the footpath to Canada. When CBC News visited the crossing recently, in one day we met families and single travellers from Pakistan, Turkey, Yemen, Lebanon, Nigeria, Sri Lanka, Eritrea, as well as a Palestinian family from the occupied territories. Some arrived with what appeared to be fresh baggage tags from overseas flights into New York. Others had made their way north from Mexico, South and Central America.

In 2017, Haitians who had overstayed their 2010 earthquake disaster-related visas in the United States formed the largest group of migrants illegally entering Canada. Trump had specially targeted this group, although, in the end, his administration made few deportations. By 2018, however, nearly 75 percent of illegal migrants at Roxham Road had freshly arrived from Nigeria. They had obtained valid US visitor visas in Nigeria, but it was widely believed to be part of a scheme in which the visa recipients understood they had to immediately leave the US by walking into Canada.

Trudeau could have easily stopped this charade at any time by amending the Safe Third County Agreement with the US (which he eventually did in 2023). But at the time, he instead dispatched then Immigration Minister Ahmed Hussen to Nigeria to try to persuade US officials to stop issuing so many dubious visas.

Even though authorities have since closed Roxham Road and similar illegal crossing points, Canadians are still feeling the repercussions of this open-border policy – and will be for years. There are still about 7,300 refugee claimants being housed in 36 hotels, mostly in southern Ontario, who on average each cost Canadian taxpayers about $208 per day. The total price tag for Trudeau’s 2017 tweet is already in the billions of dollars and ongoing.

Without question, surely some of the 113,000 people who walked into Canada since 2017 are legitimate UN Convention-definition refugees. Equally clear is that many are economic migrants, and others are just queue-jumpers looking for an easy way in. Moreover, if you were an undocumented person in the US with criminal charges outstanding, a swift exit into Canada across Roxham Road would seem extremely attractive. You could arrive without identification and make up a new identity. Why not? We have no idea how many criminals or terrorists may have walked in.

In the 2000s, when I was still actively practicing immigration law, there were many Mexican citizens working illegally in Vancouver. It was the same in Toronto. Some years earlier, the Liberal government had dropped the visitor visa requirement for Mexican citizens. It resulted in a flood of people over-staying their lawful period of admission as well as a deluge of Mexican refugee claims made within Canada. In 2009, Prime Minister Stephen Harper put an end to the madness and required Mexican citizens to apply for visitor visas.

Canada has established, objective standards in place for determining which countries should be exempt from our visitor visa requirement. In 2016, Trudeau hosted Mexican President Enrique Nieto in Ottawa. Nieto urged Trudeau to remove the visitor visa requirement for Mexican citizens. Trudeau ignored the objective standards and promised Nieto he would do so. (This resulted in immediate protests from Bulgaria and Romania, who also didn’t meet our standards. To avoid controversy, Trudeau removed their visa requirements as well.)

Unfortunately, removing the visitor visa requirement for Mexicans turned out to (again) be an unmitigated disaster. For instance, in 2023, there were more than 25,000 inland refugee claims from Mexico alone. Fast forward to 2024, and Trudeau had no choice but to reverse his decision – since February of this year, most Mexicans are required to apply for a visitor visa.

Canada also has a poor record for removing failed refugee claimants as well as non-Canadians who have committed crimes in Canada. Most people who have been issued deportation letters since 2016 are still in Canada. Moreover, if Donald Trump is elected this fall, he has promised a massive deportation effort to deal with illegal immigrants in the US, many of whom may be tempted to illegally escape into Canada.

Marc Miller, the current immigration minister, estimates there are between 300,000 and 600,000 people living illegally in Canada –- but even he’s not sure. Unlike many other countries, Canada does not track the departure of non-Canadians. Therefore, it is quite easy for someone whose visitor visa, study permit, or work permit has expired to simply remain in Canada. No one will be knocking on their door because they just aren’t on the radar.

We could begin tracking departures as other countries do, or we could start seriously enforcing our deportation orders. However, this seems to be too much effort. The federal government is apparently attracted to a much easier solution: just let them stay.

Lobby groups like the Migrant Rights Network (MRN) are pressuring the government to offer an amnesty for all “undocumented” migrants in Canada, and to grant permanent status to their family members upon arrival in the future. At a recent press conference calling for amnesty, the MRN estimated that between 20,000 and 500,000 people without immigration status are currently living in Canada.

Since 2017, the City of Toronto has celebrated “Undocumented Residents Day” and this year the City hosted a forum where activists spoke up to encourage the federal government to grant permanent residence to people living in Canada without authorization. Some of the speakers blamed “white supremacy” for shortcomings in our legal immigration system. However, the majority of legal immigrants to Canada have been non-white in every year since 1971.

Shortly after the 2021 federal election, Trudeau issued a mandate letter for his new Immigration Minister, Sean Fraser, that ordered him to explore an amnesty solution. More recently, Minister Miller commented, “There is no doubt that we have made a conscious decision to be an open country.” In May, Trudeau told reporters, “People who aren’t here regularly need to be supported and taken care of. There needs to be either a pathway towards regularization and citizenship, which I know the (immigration) minister is working on.” These recent comments by Trudeau and Miller suggest the Liberals are seriously considering an announcement of an amnesty in the near future.

Until recently, most Canadians were in favour of Canada’s immigration system. The reality today is that most Canadians feel that our immigration levels are too high, with the highest anti-immigration sentiment in decades. Even 42 percent of recent immigrants feel the numbers are excessive. Recently, the Bank of Canada also sounded the alarm, blaming record levels of immigration for driving up the cost of housing.

It is reckless, and possibly, dangerous for the federal government to ignore these warnings. Without broad public support, Canada’s immigration system is doomed. It also risks heightened levels of racism and xenophobia once the broad support is gone.

The prospect of a general amnesty for illegals in Canada will be the final straw. How can there be any shred of integrity left in our immigration system if we reward those who broke the rules? I spoke recently to a retired government immigration program manager who concurs: “An amnesty is pure madness,” he said, “and crushing in its unfairness to all those who have played by the rules.”

What message would a general amnesty send to legal migrants to our country? Why would others go through normal channels to come here? Would an amnesty now undermine future deportation orders? Why would failed refugee claimants or convicted criminals depart Canada? If Canada grants amnesty once, surely Canada will do it again, once the number of illegals bloats again.

If there is any doubt about that, consider the current illegal immigration crisis gripping the United States. In 1986, President Ronald Reagan signed a sweeping immigration reform bill into law. Sold as a crackdown on illegal immigration, it called for tighter security at the Mexican border, with employers facing strict penalties for hiring undocumented workers. As part of the bill, the US government offered amnesty with a path to permanent status to about 3 million undocumented migrants. Supposedly a one-time amnesty, it was to be followed up with strict border controls and other measures to make sure the number of illegals never grew to such a large number again.

Reagan’s amnesty plan was anything but a panacea. Rather, it acted as an invitation to billions of would-be migrants to come to America and break its immigration laws. Although it’s impossible to know the exact number, some estimate the number of illegals in the US today to be around 22 million. Canada is on the cusp of making the very same mistake.


David L. Thomas is a lawyer and mediator in British Columbia and a senior fellow with the Macdonald-Laurier Institute. From 20142021, he served as the chairperson of the Canadian Human Rights Tribunal in Ottawa.

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As war looms in Lebanon, will Canada be forced once again to evacuate “citizens of convenience?”: J.L. Granatstein for Inside Policy

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From the Macdonald Laurier Institute

By J.L. Granatstein for Inside Policy

It is too late to interfere with the pending evacuation from Lebanon, but we must consider what rights citizens living abroad in perpetuity can have.

Canada is preparing to evacuate Canadian citizens from Lebanon in case the ongoing conflict between Israel and Hezbollah, the well-armed, Iranian-backed terrorist organization, escalates into a full-blown war. Most of Lebanon’s southern border towns have been evacuated as have the kibbutzim and villages of Israel’s north. There are estimates that as many as 75,000 Canadian citizens may be living in or visiting Lebanon.

There is a precedent for an evacuation of Canadians from Lebanon. In 2006, Hezbollah and Israel engaged in a 34-day war that killed some 1,300 Lebanese and 165 Israelis and displaced 1.5 million residents of the two countries. The war ended after Lebanon, Israel, and Hezbollah accepted United Nations Security Council resolution 1701, which called for, among other things, an immediate ceasefire, and the withdrawal of all combatants from southern Lebanon.

There were as many as 50,000 Canadians in Lebanon at the time and Canada moved to get as many of its citizens it could reach – and who wanted to be evacuated – out to Cyprus or Turkey and on to Canada. Some 14,000 were evacuated by air or by sea at a cost that was later reported to be $94 million.

Almost no one asked in 2006 what were the obligations of the Canadian government to citizens living abroad. Many of these citizens had lived in Lebanon for decades, their only link to Canada being their passport. Consider Rasha Solti, who wrote in the Globe and Mail on July 22, 2006: “I hold a Canadian passport, I was born in Toronto when my parents were students there. I have never gone back. I left at age 2.” Solti’s passport was her escape route to Canada if she ever needed it. Did Canada owe her and others like her anything? And while there are no hard numbers, as many as 7,000 of the evacuees reportedly returned to Lebanon after the cessation of fighting.

Obviously, the government has some responsibility to assist Canadians caught up in a conflict. But what about citizens of convenience – those who renew their Canadian passports every five or ten years without visiting, let alone living, in Canada? What duty does Canada have to help Canadian passport holders who have not resided in or paid taxes to Canada for decades – if ever?

The Standing Senate Committee on Foreign Affairs and International Trade studied the 2006 evacuation and its report in May 2007 touched on this issue. A Department of Foreign Affairs official responsible for consular affairs told the Committee that “Until further notice, within the framework of the consular service, a Canadian is a Canadian; the rule is very clear. However, you are right, the debate has been launched and the discussion will take place.”

Well, no real public discussion took place. There were, however, conversations within the federal government, and the nation’s Citizenship Act has been amended several times since 2006. But there are still no residency requirements to remain a citizen. Should there be?

An amendment in 2009 instituted the “first generation limitation” that restricted the scope of those eligible for Canadian citizenship for the future. Citizenship by descent would henceforth be limited to one generation born outside Canada. This law was subsequently deemed unconstitutional by the Ontario Superior Court in December 2023, and the government now has a bill before Parliament that will grant citizenship to eligible foreign nationals whose parent(s) have a substantial connection to Canada and are impacted by the first generation limitation.

In other words – unless the courts subsequently define “a substantial connection” very narrowly – Canadian citizenship can be passed on for generations to those living abroad.

This summer Ottawa is again preparing to evacuate Canadians from Lebanon. The government has bolstered its embassy staff in Beirut and deployed Canadian Armed Forces personnel to Cyprus where they are working with allied nations to coordinate evacuation planning. Prime Minister Justin Trudeau, Global Affairs Canada, and the Canadian Embassy in Beirut have all urged Canadians to leave at once. It’s unknown how many people have taken this advice, but clearly Canada is preparing for a major evacuation if the fighting escalates.

Is it not long past time for Canada to consider what rights are appropriate for those who choose to live abroad? Many permanent residents living outside Canada, as in Lebanon, hold dual citizenship. Should they require genuine ties in or to our country to retain their citizenship and their passports?

Before 1977, Canadians who acquired another nation’s citizenship, except by marriage, lost their Canadian status. Until 1973, Canada required those who wanted its citizenship to renounce their former allegiance. A 1993 parliamentary committee questioned the meaning of loyalty when people held dual citizenship, and it suggested that this devalued the meaning of Canadian citizenship. The committee, in fact, recommended that a Canadian who voluntarily acquired another citizenship should cease to be a Canadian. What the courts might to say to efforts to implement such measures today is unknown.

Still, the Foreign Affairs official in 2006 was correct: A Canadian is a Canadian. But perhaps there is another way to limit the use of our passports as a public convenience. In the United States, all Americans, no matter where they live or how many passports they carry, must file an income tax return as a fundamental continuing obligation of citizenship. Essentially, the US says that those who want to enjoy the benefits of citizenship must help to pay the costs of running the government, and those who don’t want to pay must renounce their American citizenship. This applies to Americans living in Canada.

Washington’s regulation is both reasonable and right. Holding a US passport carries certain obligations. We need to find ways to impose similar obligations on Canadian passport holders living abroad.

In Yann Martel’s famous phrase, Canada is the greatest hotel on earth. He meant that as praise, but to many it has come to imply that they can enjoy the benefits of this country without sharing in the duties and obligations of citizenship. In other words, you can check in, enjoy the facilities, and then check out without paying the bill.

It is too late to interfere with the pending evacuation from Lebanon. But now it is time to consider what rights citizens living abroad in perpetuity can have. It’s time to fully examine whether dual (or triple or multiple) passport holders can remain Canadian citizens. Time at last for a hard look at what Canadian citizenship means in the 21st century.


J.L. Granatstein taught Canadian history for 30 years and was director and CEO of the Canadian War Museum. He sits on the Macdonald-Laurier Institute’s Research Advisory Board.

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