The Emperor's new clothes

Patji Alnæs-Katjavivi
Overelege, fødeavdelingen, OUS-Ullevål
Conflict of interest:  No

Thank you for pointing out the flaws inherent in the Norwegian Directorate of Immigration’s (UDI) employment of biological age assessment for asylum seeking minors. I have three criticisms of the practice in question. 

Firstly, the inherent flaw in relying upon a test where, so far, no biological marker succeeds in discerning an individual's chronological age as being above 0r below eighteen years. Prior to criticism from the Norwegian Medical Association in 2018, the same methodology was employed: age categorisation of X-rayed wrist (categorisation by Greulich & Pyle) and X-rayed dentition (now only using Demirijan categorisation) (1). Professor Tim Cole (professor of medical statistics, UCL, UK) has previously argued as to why the use of Greulich & Pyle stage 19 (mature wrist) gives a false low probability of the male minor in question being under 18 years of age. Using data from Tanner & Whitehouse (TW3), Professor Cole demonstrates that “this (method) increases the probability of (the minor) being under 18 from 22% to 61%. Put in words, it states that the majority of boys with a mature X-ray were under 18 when they became mature” (2). Tanner & Whitehouse has been shown to demonstrate a younger bone age when compared to Greulich & Pyle, and is perhaps more accurate (3). Why is there no mention of its incorporation into UDI’s BioAlder method? Given that UDI is fully aware that BioAlder’s predictions contain a margin of error, it can only follow that a given proportion of the minors predicted to be 18 years of age will have their age rounded down below 18 years. If 100% of those predicted by BioAlder to be 18 years of age, remain 18 years, then this would suggest that UDI is knowingly demonstrating a bias for adjusting predicted age above the 18-year threshold. Such data should be publicly available in the audits of good governance UDI, an important State institution, is expected to perform.

Secondly, the basis of consent appears unchanged by UDI despite criticism by the Norwegian Medical Association. It is a physician’s duty to provide informed consent prior to exposure to medical investigations and treatments. The fallibility of BioAlder that UDI themselves state in their published regulations, is not demonstrated in UDI’s latest information to the guardians and lawyers of minors (4). As of today, refusing BioAlder’s predictions is deleterious to the minor’s asylum application. Thus, the consent given today still risks being uninformed and under implicit duress from the State.

Thirdly, I question the ethical basis for continuing to use BioAlder 1.0 considering it’s admitted fallibility, combined with resultant predictions (of age being above 18 years) being wrongly interpreted as fact by the Norwegian courts. 

1.    Aarseth S, Tønsaker S. K. While we await a new method of determining the age of young asylum seekers. Tidsskr Nor Legeforen 2018; 138. doi: 10.4045/tidsskr.17.0960
2.    Cole TJ. People smugglers, statistics and bone age. Royal Statistical Society 2012; Volume 9, Issue 3, pages 8-12.
3.    Shah N, Khadilkar V, Lohiya N et al. Comparison of Bone Age Assessments ... in Healthy Indian Children. Indian J Endocrinol Metab. 2021 May-Jun; 25(3): 240–246.
4.   UDI Regelverk. UDI 2020-007 Enslige mindreårige asylsøkere og aldersvurdering. Lest 22.8.2022.  

Published: 18.08.2022
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