sou · H9B384 · 2021-10-29 00:00:00 — Utredningen bedömer att metod är acceptabel utifrån aspekten medicinska risker och ur ett integritetsskydds- perspektiv. Kapacitet vad gäller ärendemängd och handläggningstider Utredningen bedömer att metoden i sig inte begränsade Rätts- medicinalverkets möjlighet att inom rimlig tid handlägga de ärenden som inkom 2017. har ärendeinströmningen minskat väsentligt. En medicinsk åldersbedömning genomförs , vilket är en väsentlig del av den totala handläggningstiden i asylären- dena som har varit cirka . De långa hand- läggningstiderna orsakas delvis av faktorer som verket inte råder över. Utredningen ser det dock som angeläget att de ansvariga myndig- heterna löpande ser över vilka åtgärder som kan vidtas för att ytter- ligare korta handläggningstiderna. Metoder för medicinsk åldersbedömning i andra länder Utredningen har koncentrerat sin sammanställning kring vilka meto- der för medicinsk åldersbedömning som används i asylprocessen i andra europeiska länder. Sammanställningen visar på både likheter och skillnader. Metoder i olika länder skiljer sig åt inte bara med avseende på vilka kroppsdelar som undersöks och med vilka undersökningsmetoder, utan också i fråga om vilken typ av storhet som presenteras som re- sultat och hur resultatet tolkas. Inom ramen för asylprocessen i de undersökta länderna genom- förs medicinsk åldersbedömning om det råder tvivel om en asylsök- andes påstådda underårighet, överårighet eller ålder. Det grundläggande syftet med den medicinska åldersbedömningen torde därmed alltid vara att ta reda på om personen är under eller , men sättet att redovisa det varierar i olika länder. I vissa länder redovisas resul- tatet av undersökningen i form av en bedömning av den undersökta individens mest troliga ålder medan det i andra länder handlar om att, när så är möjligt, konstatera om en undersökt individ är under eller . Det är ovanligt att en sannolikhet för att individen är under eller redovisas. Den absoluta majoriteten av de länder som utredningen har fun- nit information om använder flera olika undersökningar inom ramen för den medicinska åldersbedömningen. De använder olika kombina- tioner av röntgenundersökning av hand och handled, röntgenunder- sökning av visdomständer, datortomografiundersökning av nyckel- benen och kropps- eller könsmognadsundersökning. Även olika referenspopulationer används för samma kroppsdel. De skäl som har framförts till varför en viss metod har valts gäller såväl tillförlitligheten i det vetenskapliga underlaget och metodens precision som hälsa och säkerhet för de personer som genomgår undersökningarna. Flera av de beskrivna länderna hänvisar till att metoden har valts för att den har bäst vetenskapligt stöd. Alla länder som använder medicinsk åldersbedömning använder minst en metod som inbegriper strålning. Datortomografiundersök- ning av nyckelbenen, som inbegriper en högre stråldos än röntgen- undersökning av hand och handled samt visdomständer, används dock som ett sista steg och endast vid behov. Vissa länder använder undersökning som kräver nakenhet och/eller undersökning av köns- organen trots att Europeiska stödkontoret för asylfrågor (EASO) rekommenderar att sådana moment inte bör användas under några omständigheter. Det kan vidare konstateras att det skiljer sig åt mellan länderna när det gäller hur resultaten av de olika undersökningarna vägs sam- man och hur osäkerheter i form av statistiska felmarginaler redovisas. Länderna inom EU använder olika metoder och drar kanske dessutom olika slutsatser utifrån liknande undersökningsresultat, som EU har ett i huvudsak gemensamt asylsystem. Utredningen anser där- för att det skulle vara befogat att ett gemensamt grepp kring forskning och utveckling gällande medicinsk åldersbedömning tas på EU-nivå. The Inquiry’s remit was to examine the method applied by () for age assessment in the asylum process, the current underlying scientific basis for the method and how the scientific basis and the statements of the Board have developed over time. In line with the Inquiry’s terms of ref- erence, its review is to incorporate aspects such as capacity in terms of the caseload, personal privacy, risks and how uncertainties are dealt with in the form of statistical of error. Regarding the examination of the current underlying scientific basis for the method, the Inquiry tasked the for Assessment and Assessment of () with examining what scientific support there is for assessing whether a person of the male or the female sex respectively is over the age of 18 using the method of age assessment applied in the asylum process in . The Inquiry’s remit also included describing how equivalent and alternative methods for age assessment with regard to the age threshold of 18 are applied in other countries and how age assessments are used in other countries. An interim report on certain specific aspects is to be submitted by 29 October 2021. The Inquiry was also tasked with ensuring that one or more re- search studies are carried out with the aim of expanding the under- lying scientific basis for the application of magnetic resonance imaging (MRI) of the growth zone in the distal femur in combination with X-ray examination of third molars to judge the probability of people of the female or male sex whose age is unknown being over or under 18 years of age. Once the research is complete, the Inquiry is to analyse the combined underlying scientific knowledge on the method in question and, where called for, propose the development of RMV’s statements based on this new data. The Inquiry is also to provide an account of the prevalence of foreigners who have undergone a medi- cal age assessment at RMV submitting and citing a different examination regarding the issue of age in permit cases. Under this remit, the final report is to be presented no later than 31 2024. The investigation presented in the interim report has been carried out by a full-time secretary under the leadership of the Government appointed chair of the inquiry, in close cooperation with a panel of experts. The examination of the method has been done through studies of scientific articles, evaluation of research, of reports and of debate articles and through contacts with scholars, debaters, and organisations. age assessment in general Under current law, a person seeking asylum in must render their identity probable, which includes making their age probable. Whether an asylum seeker is under or over 18 is significant to how the asylum case is handled and to the question of a permit. is also significant regarding the reception of the asylum seeker and the rules applied regarding repatriation. If the judges that an asylum seeker has not rendered it probable that he or she is under the age of 18 through written or oral evidence, and the is therefore considering making a decision that means that the per- son is judged to be an adult, the Agency is to offer the asylum seeker the opportunity to undergo a age assessment by RMV. The examination is voluntary but an asylum seeker who refuses to con- sent to assessment of age without an acceptable reason risks being assessed as being or older. Criteria for age assessment age assessment is founded on the link between chrono- logical age and biological maturation. Chronological age is the time in years, months and days that have passed since birth. Biological maturation is a measurement of how far a part of the body has reached in its maturation process. People’s different body parts undergo a maturation process before they are fully grown. The maturation pro- cess varies for different parts of the body. Some parts of the body reach full maturity relatively early while others reach full maturity in the late teenage years or in early adulthood. However, there are major individual variations in maturation processes and it is not possible to translate biological maturity to an exact chronological age. In age assessment, the starting point is an individual with an unknown chronological age. A picture of the maturity of the body parts is gained by examining one or more parts of the individual’s body, e.g. by X-ray or MRI. These images are then compared with reference material that describes the different chronological ages with which a certain stage of maturity is associated. The reference material describes what the correlation between stage of maturity and chronological age looks like in the population, or in what is termed the reference population, i.e. the group of people studied in the research. The correlation often has to be estimated using mathe- matical and statistical methods. Based on the correlations between stage of maturity and chronological age in the reference population, conclusions are accordingly drawn regarding the age of the individual who has undergone the examination. There are a few parts of the body and maturation processes used in age assessment when assessing ages close to the age threshold of 18. There is broad consensus that a method for age assessment should include examination of more than one of these. There is, however, no consensus on which combination of examinations produces the best assessment of either age or proba- bility in relation to the age threshold of 18, or how the results of more than one examination are to be weighed together. No current method of age assessment can precisely deter- mine a person’s age or always determine whether a person is under or over 18. The question of whether a person is under or over 18 is to determine the closer the person is to the age threshold of 18. RMV’s method In autumn , when approximately 35 000 unaccompanied child migrants sought asylum in , the did not commission any age assessments. Many of the asylum seekers in this group lacked reliable identity documents. In the light of this, in 2016, RMV was tasked by the Government with starting to implement age assessment within the framework of applications for permits, with great haste and based on current research and proven experience. RMV started conducting age assessments in 2017. RMV’s method for age assessment in the asylum process is based on a combined assessment of two examinations: firstly an assessment of dental maturity by means of an X-ray with ionising radiation of third molars and secondly an assessment of skeletal maturation through an MRI of the growth plate in the distal femur (in the interim report referred to as the knee). In the dental maturity assessment, two dentists, independently of each other, make an assessment of whether or not at least one third molar in the lower jaw has reached its final stage of development. In the knee maturity assessment, two radiologists, independently of each other, make an assessment of whether or not the growth zone in the distal femur has reached its final stage of development. RMV has chosen to divide the maturation of the knee and the third molars into only two stages in order to reduce the risk of in- correct assessment of the stage of development of the person in question. For every combination of the maturity of the two parts of the body, RMV has calculated a probability, for applicants of the male and female sex respectively, of a person with this combination being under 18 or 18 or over. No combination of degree of maturation is such that the probability of being a child or an adult is 100 percent. The person being over or under the age threshold can thus never entirely be stated by the method. The Inquiry’s assessment Examination of RMV’s method In a European perspective, RMV’s method is unique. It is the only method to include an MRI of the knee as part of the assessment. In other countries, examinations use different combinations of hand and wrist, teeth, collarbone and/or physical or sexual maturity. Additionally, in a European context it is relatively uncommon for the age assessment to result in a statement of the probability that a person is under or over 18. In most other countries, a state- ment is issued regarding a minimum age, a most probable age and/or whether the person has been found to be under or over 18. The Inquiry considers that, in the light of the fact that the ’s assessment of age in the first instance is based on assessing whether a person is underage or overage, it is more appropriate to report the result of the examination in the form of a probability in relation to the age threshold of 18 in the way that RMV does, instead, for example, of a most probable age or an age range. However, it is considerably more complicated to calculate a pro- bability in relation to the age threshold of 18 than a minimum age on the basis of reference material. Making the calculation based on examinations of several body parts involves additional complexity. The underlying scientific data and RMV’s probability model RMV’s probability model is based on different standpoints and assumptions. These are reached based on underlying scientific data which is more or less complete and clear cut for the different ele- ments. RMV has, for example, taken the view that data from different studies can be combined, that it is appropriate in the model to assume an even age distribution between the age of 15 and 21 and conditional independence of knee and dental development given age. The Inquiry can state that other assessors draw different con- clusions on these questions, based on a different evaluation of the underlying scientific data. For example, following the review con- ducted by SBU at the behest of the Inquiry, SBU has drawn the conclusion that the underlying scientific data for the knee method is insufficient. SBU bases its conclusion on the fact that the studies used different MRI methods and on the heterogeneity of the popu- lations between the studies. SBU also judges the underlying scientific data for the dental method to be insufficient, despite having found and reviewed 20 studies with a low risk of bias. SBU’s conclusion in this respect is based on the fact that different populations were studied in the studies, which, according to SBU means that the results of the different studies cannot be combined. Furthermore, SBU points out that the probability that a person is under or over 18 respectively given the maturity of one of the parts of the body cannot be calcu- lated unless the age distribution of those tested is known, which is not the case. This shows that there exist different ways to evaluate and draw conclusions from underlying scientific data which is more or less complete and clear cut. The fact that such different conclusions can be drawn about the elements that constitute RMV’s probability model shows, according to the Inquiry, that there are uncertainties in the model. Certain such uncertainties have been manifested over the period that the model has been in use. An additional knee study in 2017 led to new estimates and changed statements for women. A changed way of combining information from the knee and dental examinations led to changed statements in several categories in 2021. These changes have meant that the same examination result regarding several com- binations of maturity of knee and third molars has produced different statements over time. Precision and risk of inaccurate assessment Using RMV’s method to assess minority and majority involves a risk that a child will be inaccurately assessed as being an adult and that an adult will be inaccurately assessed as being a child. According to RMV’s own estimations, 10 percent of the boys aged 15–18 display maturation in parts of the body that produces a preponderance of probability that the individual is an adult, and thus risk being incorrectly assessed. The equivalent proportion of 17-year- old boys is estimated to be 20 percent. Of girls aged 15–18, 3 percent are judged to display such maturation. For 17-year-old girls, this pro- portion is estimated to be 6 percent. There is also a risk that a person who in fact is adult will receive a statement that gives a preponderance of probability that the person is under 18. RMV judges the risk to be 22 percent for men and 76 per- cent for women aged 18–21. According to the Inquiry’s assessment, however these estimated percentages are associated with uncertainty. RMV has also estimated the probability produced by the model of a person being a child given that they belong to one of the cate- gories associated with preponderance of probability of being an adult. This probability is estimated as being 11 percent for boys and 12 per- cent for girls. In the view of the Inquiry, if RMV was to use more stages of maturity than just two, more informative estimates of probability could be made in relation to the age 18 threshold. What risk of incorrectly assessing children and adults, respectively, that is acceptable, is a central question in age assessment and contains several considerations. There is, for example, often a trade- off to be made between the risk of incorrectly assessing children and the risk of incorrectly assessing adults, in the sense that a method with a low risk of incorrectly assessing children has a high risk of incorrectly assessing adults and vice versa. The Inquiry can state that RMV had, in its choice of method, to consider the fact that the Government had pointed out that it is important not to incorrectly assess children as adults nor adults as children. There are methods which are used in other countries that have a lower risk of incorrectly assessing children as adults than the method used by RMV, but at the same time these have a higher risk of in- correctly assessing adults as children. The Inquiry doesn’t consider itself tasked with giving its position on what level of risk of incorrect assessments of children and adults, respectively, that is acceptable. Based on that it is more serious to incorrectly assess a child as an adult than an adult as a child, it is, however, the Inquiry’s judgement that that a method for age assessment should have a lower risk of incorrectly assessing children as adults than vice versa. The application of the method in practice RMV’s age assessment method is based on an assessment of which stage of maturity the knee and the third molars have reached. This assessment is often crucial for whether the statement is that there is a preponderance of probability that the person is a child or adult. The fact that RMV in every single case uses two qualified assessors reduces the risk of incorrect assessments. It can, however, not be excluded that there are cases where both assessors, and not only one of them, make an assessment that is not in accordance with the one that should have been made in the research that the maturity scale is based on.. The Inquiry has not been able to determine how great a risk there is of such incorrect assessments. In cases where both assessors from RMV’s providers make different assessments of the maturity stage, the result is that the part of the body is assessed as immature. This means that in uncertain cases the risk is reduced that a child incorrectly is assessed as an adult, which is reasonable. A comprehensive account of assumptions and uncertainty is needed For uncertainties, risks, and consequences to be evaluated by the and the Migration Courts in particular, but also by politicians, researchers, and others who are interested, in the Inquiry’s opinion, firstly, an account is needed of the underlying scientific data on which RMV’s method is based, the model and the assumptions that have been used to estimate the probabilities in the different categories, the uncertainties and of error that exist and the extent to which the method can correctly classify children and adults. For further knowledge of how certain or uncertain the probability model is, secondly, its robustness should be tested by RMV, by adjusting the assumptions and standpoints made and reporting the impact this has on the probability estimates. RMV has reported some of the above, but a comprehensive and complete account of the desired kind does not exist today and should be produced by RMV. According to the Inquiry’s judgement, it had been motivated that such an account had been produced already when RMV reported the Government’s remit, i.e. before starting to use the method. RMV’s statements RMV has, since the actual method of age assessment was introduced in 2017, changed the form of the statements at a few occasions, due to the changed state of knowledge and the changed probability estimations. The statements currently contain firstly a main conclusion expressed in terms of “strongly indicates”, “indicates”, and “possibly indicates” and secondly an explanatory text describing the estimated probability with a number. The number is however associated with uncertainty that can be interpreted and valued in many ways. The Inquiry will come back to the question of the form of the statements in its final report. risks and personal privacy The Inquiry judges that the method used by RMV is acceptable based on the aspect of risks and from a privacy perspective. Capacity regarding caseload and processing times The Inquiry judges that the method in itself did not limit RMV’s opportunity to handle the cases that were filed in 2017 within a rea- sonable time. Since then the number of filed cases has substantially decreased. A age assessment is completed in approximately three months. That is a crucial part of the total processing time for asylum cases, which has been approximately seven months during the last years. The long processing times are partly caused by factors that RMV cannot control. In the view of the Inquiry it is however im- portant that the competent authorities continually review what mea- sures to take in order to further reduce the processing times. age assessment methods in other countries The Inquiry has concentrated its summary on the methods used for age assessment in the asylum process in other European countries. Both similarities and differences were found. Methods in different countries differ not only in terms of which parts of the body are examined and using which methods, but also in terms of the type of units in which the results are presented and how the result is interpreted. Within the asylum process in the countries studied age assessment is carried out if there is doubt about an asylum seeker’s claimed minority, majority, or age. The fundamental purpose of age assessment should thus always be to find out whether the person is under or over the age of 18, but the way this is reported varies in different countries. In some countries, the result of the assessment is reported in the form of an assessment of the most probable age of the individual examined while in other countries it involves stating, where possible, whether an examined individual is under or over 18. It is uncommon for a probability of whether an individual is under or over 18 to be reported. The vast majority of the countries about which the Inquiry has obtained information use several different examinations as part of the age assessment. They use different combinations of X- rays of hands and wrist, X-rays of third molars, computed tomo- graphy (CT) scans of collarbones and examination of physical or sexual maturity. Different reference populations are also used for the same part of the body. The reasons cited as to why a certain method has been chosen concern the reliability of the underlying scientific data, the precision of the method, and the health and safety of the people undergoing the examination. Several of the countries described refer to the method having been chosen because it has the best scientific support. All countries that use age assessment use at least one method that involves radiation. CT scans of the collarbone, which involves a higher dose of radiation than X-raying the hand and wrist and third molars, are, however, used as a final step and only where necessary.