Denouncing Medical Practices That Imperil Unaccompanied Youth

Unaccompanied children flee violence, persecution and poverty from around the globe and seek safety in the United States. The vast majority are teenagers, often arriving with few possessions–a small backpack, phone numbers written on slips of paper sewn into the seams of their clothes. Few have identity documents or birth certificates; some arrive empty handed. Within 72 hours of apprehension, US Customs and Border Protection must transfer unaccompanied minors to the care and custody of the Office of Refugee Resettlement (ORR). At any point in federal custody, unaccompanied children can be subject to controversial medical exams to redetermine their age. Age redetermination leads to their immediate transfer to adult detention and a loss of the few legal protections afforded to minors.

Scientifically, radiographs and dental scans aim to measure the magnitude of the difference between chronological age and skeletal age. Methods of age reassessments in federal custody include radiographs of the clavicle or wrist or dental scans.[1] Each method remains highly problematic and scientifically dubious when applied to a global population of migrant youth. Take, for example, radiographs of the left wrist measure bone density associated with osteoporosis; yet consider that greater bone density also occurs amid malnutrition and stunting[2]—a polemic affecting many of the tens of thousands of Central American children[3] in federal custody each year. In fact, wrist and clavicle radiographs are compared to a standard atlas of bone development, an atlas normed on a sample of Caucasian youths in the 1930s.^[4] Experts concur that the bone atlas does not account for ethnic, geographic, or socioeconomic variation in pediatric populations.^[5]

Both dental and bone radiographs do not provide a finite number but a range to be interpreted.[6] Indeed, the margin of error is up  to 6 years.^[7] In policy, the federal government should consider the lower threshold in the range as the child’s age, also weighing corroborating evidence such as a child’s testimony, available documents, and parental input. However, in our national study on conditions in ORR detention, attorneys and staff alike report that in practice federal authorities singularly rely on the upward age range.^[8] For example, if dental exams indicate that a child is between 17 and 18.6 years old, ORR will presume the child is 18.6. These assessments pervert medical research by claiming “scientific certainty” where none exists and enlisting medical “evidence” that harms unaccompanied children.

ORR has experienced an exponential growth in the number of children in its custody—130,000 in fiscal year 2022 alone. Yet, there is limited supervision and oversight of its practices, including age redeterminations. It remains unclear who solicits, conducts, and interprets the radiographs and if these physicians, dentists, or radiologists know how these reports are used. This raises ethical concerns for providers, and likewise for children for whom neither assent nor parental consent are secured and whose attorney is not informed in advance. A dentist we interviewed reported that ORR officials explained the purpose of the exam only when pressed. She ultimately declined to conduct the exam because it exposed a child to radiographs absent a medical need, and because she was uncomfortable with how the report might be misinterpreted. A pediatrician reported that he conducts age assessments for ORR, interpreting clavicle and wrist radiographs despite having no specialized training to conduct these evaluations.

The undue weight assigned to dubious medical evidence in the age redetermination process violates US law. The use of radiographs was enshrined in the 2008 Trafficking Victims Protection Reauthorization Act to prevent fears of older migrants trying to pass as children. The legislative history suggests that the utility of radiographs was of significant concern and led to language that limits age redeterminations to the “non-exclusive use of radiographs.” In fact, ORR policy prohibits the use of dental exams as the sole determinant of age, stating exams “may be used to determine age, but only in conjunction with other evidence.”^[9] Yet, practitioners we interviewed repeatedly report that radiographs are dispositive.

Age redetermination occurs across ORR facilities but with very limited transparency. According to the 170 facility staff, attorneys, advocates and health professionals in our study, the reasons for age redetermination are typically because a minor “does not look like a child” or engages in behavioral disruptions while in custody. The requests, respondents contend, are deeply racialized, disproportionately affecting West African youth. Most age redetermination requests occur while a child is detained yet can be reassessed at any point while in federal custody. For instance, an attorney shared, one minor’s age was reassessed after nearly 2 years in federal foster care.

Age redetermination is deeply consequential for unaccompanied children. If reclassified as 18 years old, youth are transferred to adult detention. Most are thrust into large-scale facilities which the Office of the Inspector General found to have often unsafe and unsanitary conditions and where immigrants are subject to harassment and punitive policies.^[10] Most face imminent deportation, having lost the few, but important, child-specific legal benefits. For example, immigration law safeguards for unaccompanied children include eligibility for Special Immigrant Juvenile visa designated for abused, abandoned, and neglected children. Age redetermination abruptly terminates eligibility for this protection. The questionable medical evidence likewise can be used against a young person in immigration proceedings, calling into question their credibility in claims for other legal protections. In short, the misuse of medical evidence impairs an unaccompanied child’s ability to seek safety in the United States.

The mental health impacts of transfer to adult custody cannot be overstated. Decades of research underscores that confinement in large-scale institutions results in high rates of post-traumatic stress disorder, anxiety, depression and suicidal ideation.[11] These symptoms do not disappear upon release. Even brief detention, experts concur, can cause psychological trauma and induce long-term mental health risks.^[12]

Age redetermination of unaccompanied youth has been denounced by well-regarded European professional organizations, such as the European Academy of Pediatrics, the British Royal College of Pediatrics and Child Health[13], and the French Academy of Medicine.[14] Yet, the American medical community has remained conspicuously silent. The medical and public health communities in the United States have an opportunity to impact the perversion of medical evidence in children’s immigration cases by uniformly denouncing the federal government’s use of skeletal and dental radiographs to re-determine age. Productive interventions include the American Academy of Pediatrics and Pediatric Dentistry offering public policy statements on the use of radiographs in age redeterminations and the American Medical Association developing an advisory opinion on the use of radiographs in migrant children’s cases. Attorneys and advocates can leverage these statements to ensure the Office of Refugee Resettlement enlists scientifically-rigorous research to inform its policies and practices. Further, the American Public Health Association should engage government officials in developing medically sound, de–racialized practices for age assessments for all children, regardless of where they were born. The failure to act contributes to the ongoing use of medical science to inflict legalized violence against migrant children.