Dental Age Assessment: What is it, and what does it have to do with the University of Iceland?

Translator: Julie Summers

Last school year, there was a great deal of discussion surrounding the University of Iceland's role in performing so-called dental age assessments. The media brought attention to medical age assessment of asylum seekers, protesters covered university buildings in graffiti, and first-year medical students addressed the controversy in a video made for their annual banquet. But what exactly are the assessments in question, and what do they have to do with the University of Iceland?

Medical age assessment of young asylum seekers

According to the United Nations High Commissioner for Refugees, there are approximately 68.5 million refugees worldwide, 85% of whom live in developing countries. Some of the remaining 15% have made it to Europe and applied for asylum and residence permits.

Unaccompanied minors are both more likely to have their cases heard and more likely to be granted residence permits than older asylum seekers. The United Nations Convention on the Rights of the Child states, "In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration."

Most European countries, with the exception of Germany and Sweden, have been reluctant to accept refugees and have taken harsh measures to protect their borders, whether through systematic abuse and high rates of refusal or with barbed-wire fences and force. Authorities in many countries have turned to physical assessments to determine the age of unaccompanied minors claiming to be younger than 18. Notified that the authorities have reason to doubt the validity of their claims, these individuals are asked to undergo physical exams, for instance to assess the development of their genitals, hands, kneecaps, and teeth. Jumping on the bandwagon, Icelandic authorities too have subjected young asylum seekers to X-ray evaluation of their wisdom teeth to determine whether the individuals in question are older or younger than 18 years of age. Such examinations are known as dental age assessments.

Criticism of dental age assessments – unreliable and unethical

Various humanitarian aid organizations, such as UNICEF, the Council of Europe, and the Red Cross, have criticized the practice of medical age assessment, including dental age analysis. Such organizations advocate for a more holistic means of assessing the age of young asylum seekers, grounded first and foremost in the professional opinion of child psychologists and pediatricians and taking into account the children's environmental and cultural circumstances. Lawyers with the Red Cross who advocate for asylum seekers here in Iceland say that the Directorate of Immigration bases its age assessments solely on the results of dental analysis.

It's not just humanitarian aid organizations that have criticized dental age assessment; the practice is also considered highly controversial by the professional community, both due to lack of scientific precision and the question of ethics. The German Medical Association, British Dental Association, and Doctors of the World are among the organizations that have declared medical age assessments of young asylum seekers to be unreliable and unethical.

Doctors of the World also points out that medical professionals adhere to a standard of ethics which includes an agreement not to subject individuals to potentially harmful examinations or procedures without good reason. As ionizing radiation is widely acknowledge to pose a potential risk, standard practice is that diagnostic studies exposing patients to radiation should only be done when a doctor has deemed them medically necessary. Why should asylum seekers be treated any differently?

Regarding the unreliability of these physical assessments, even the University of Iceland specialists who have performed such studies admit that the margin of error for dental age assessment is plus or minus 1.4 years. In May 2018, experts from Uppsala University and the University of Gothenburg in Sweden released a report detailing their findings regarding medical age assessment. From 2014-2015, 10-30% of medical age assessment results based on dental analysis and kneecap development were inaccurate and the individuals' age was assessed too high.

As the Directorate of Immigration bases its age determinations almost entirely on the results of dental analysis, such studies clearly have a significant effect on the processing of asylum cases and the fate of young asylum seekers here in Iceland. If the individual is judged to be older than 18, they lose all rights afforded to children. There was once a case here in which a minor was incorrectly judged to be over the age of 18; the child's age was eventually confirmed upon presentation of identification that Icelandic authorities deemed acceptable. Media outlet Stundin's reporting of this incident is what first drew attention to the University of Iceland's role in the controversy.

University of Iceland – involvement and benefits

Dental assessment of young asylum seekers in Iceland is performed in university facilities by specialists who are employed by the university. The results of these studies are printed on university letterhead and stamped by the Faculty of Odontology.

These assessments were performed at the university from 2014 through the end of 2017. After several individuals petitioned the school's Science Ethics Committee to look into the matter, it was determined that the committee could not investigate as there had been no formal agreement between the university and the Directorate of Immigration regarding the assessments. By October 2017, the Directorate of Immigration had paid up to 3 million ISK for services rendered despite the lack of any formal agreement. That means that for four years, the university was paid to perform controversial assessments with absolutely no rules, regulations, or oversight. School officials have still failed to acknowledge whether these 3 million ISK went directly to the specialists who performed the assessments, to the Faculty of Odontology, or to the university. It remains unclear who, if anyone, ultimately bore responsibility for the studies performed under the auspices of the university's department of dentistry.

It would seem that after school officials were made aware of these studies and informed of the criticism of various highly respected medical and humanitarian aid organizations, they might have considered the matter carefully before making any further decisions. It would seem only natural to consider the interdisciplinary expertise of university employees on the subject before making a decision about the next step. But that was not the case, and in fact university officials began drafting a formal agreement to continue the assessments. The rector, when asked whether the university had appointed a group of specialists to the task or sought the opinion of experts, answered no, adding, "when we have a draft of the proposal, the Science Ethics Committee and Equality Committee will be asked to look it over. After that, we will make a decision about the future."

It is certainly possible to make the case that dental age assessment of asylum seekers is in direct conflict with the university's scientific ethics requirements, first and foremost the requirement for informed consent. Article 2.4.1 defines informed consent as meaning that "participants shall make decisions independent of outside pressure or coercion." A form that the Directorate of Immigration asks asylum seekers to sign before undergoing dental age assessment states:

"The applicant is not obligated to submit to age assessment, but if the applicant refuses to undergo age assessment procedures and fails to provide a convincing reason for his refusal, the applicant's trustworthiness may be called into question and the applicant may be assumed to be an adult."

In other words, if an asylum seeker refuses to submit to dental analysis, the Directorate of Immigration assumes the individual to be an adult and proceeds with the case under that assumption. The applicant loses all the rights that minors are afforded by Icelandic and international laws and conventions, even though their age was never actually assessed. This is clearly a serious situation. The rector's insistence that asylum seekers are able to make a free choice regarding dental analysis is curious and demonstrates a tremendous lack of understanding regarding the plight of young asylum seekers, who make up a particularly vulnerable group.

For or against society's most vulnerable?

The issue of dental age assessment came to my attention when my friend, a refugee from Afghanistan, was denied a residence permit based on the results of dental analysis. When he was notified that he would be deported, he went on a hunger strike. He told me he didn't care whether he died here or in Afghanistan. He spent 41 days on a hunger strike and was close to death when the Directorate of Immigration, having received a number of letters from doctors and psychologists, reversed its decision.

In Iceland, asylum seekers are the members of society most likely to engage in hunger strikes, usually a weapon of choice for the incarcerated. The fact that asylum seekers feel they have no other choice but to starve themselves and risk their lives says something about their place in society and the limited freedoms they enjoy. Hopefully university authorities, with the Health Sciences Department and the Faculty of Odontology leading the way, will take this reality into account before stating definitively that asylum seekers submit to physical assessments uncoerced, and before the university decides to turn the lives of young refugees into a business venture.

The University of Iceland Student Council feels strongly that the university should not perform medical age assessments on behalf of the Directorate of Immigration. In taking this stance, the Student Council joins others in an attempt to uphold the university's scientific and ethical integrity. I strongly urge other members of the university community, both individual students and student organizations, to do the same, and to let school authorities know that we want to be part of a university community that stands with society's most vulnerable, not against them.

*For more information and resources, you can contact the author by email: eho5@hi.s