Standards
Of Care For Gender Identity Disorders - Sixth Version (February 2001) -
Part Three
***
| VII.
Requirements for Hormone Therapy for Adults |
***
Reasons
for Hormone Therapy -
***
Cross-sex hormonal treatments
play an important role in the anatomical and psychological gender transition
process for properly selected adults with gender identity disorders. Hormones
are often medically necessary for successful living in the new gender.
They improve the quality of life and limit psychiatric co-morbidity, which
often accompanies lack of treatment. When physicians administer androgens
to biologic females and estrogens, progesterone, and testosterone-blocking
agents to biologic males, patients feel and appear more like members of
their preferred gender. |
***
Eligibility
Criteria -
***
The administration of hormones
is not to be lightly undertaken because of their medical and social risks.
Three criteria exist: |
***
1.
Age 18 years;
2. Demonstrable knowledge of what hormones medically can and cannot do
and their social benefits and risks;
3. Either: |
***
a.
A documented real-life experience of at least three months prior to the
administration of hormones; or
b. A period of psychotherapy of a duration specified by the mental health
professional after the initial
||||evaluation
(usually a minimum of three months). |
***
|
In selected circumstances, it can be acceptable to provide hormones to
patients who have not fulfilled criterion 3 - for example, to facilitate
the provision of monitored therapy using hormones of known quality, as
an alternative to black-market or unsupervised hormone use. |
***
Readiness
Criteria -
***
Three criteria exist: |
***
1.
The patient has had further consolidation of gender identity during the
real-life experience or psychotherapy;
2. The patient has made some progress in mastering other identified problems
leading to improving or continuing stable
||||mental health
(this implies satisfactory control of problems such as sociopathy, substance
abuse, psychosis and
||||suicidality;
3. The patient is likely to take hormones in a responsible manner. |
***
Can
Hormones Be Given To Those Who Do Not Want Surgery or a Real-life Experience?
-
***
Yes, but after diagnosis and
psychotherapy with a qualified mental health professional following minimal
standards listed above. Hormone therapy can provide significant comfort
to gender patients who do not wish to cross live or undergo surgery, or
who are unable to do so. In some patients, hormone therapy alone may provide
sufficient symptomatic relief to obviate the need for cross living or surgery. |
***
Hormone
Therapy and Medical Care for Incarcerated Persons -
***
Persons who are receiving treatment
for gender identity disorders should continue to receive appropriate treatment
following these Standards of Care after incarceration. For example, those
who are receiving psychotherapy and/or cross-sex hormonal treatments should
be allowed to continue this medically necessary treatment to prevent or
limit emotional lability, undesired regression of hormonally-induced physical
effects and the sense of desperation that may lead to depression, anxiety
and suicidality. Prisoners who are subject to rapid withdrawal of cross-
sex hormones are particularly at risk for psychiatric symptoms and self-
injurious behaviors. Medical monitoring of hormonal treatment as described
in these Standards should also be provided. Housing for transgendered prisoners
should take into account their transition status and their personal safety. |
***
| VIII.
Effects of Hormone Therapy in Adults |
***
|
The maximum physical effects of hormones may not be evident until two years
of continuous treatment. Heredity limits the tissue response to hormones
and this cannot be overcome by increasing dosage. The degree of effects
actually attained varies from patient to patient. |
***
Desired
Effects of Hormones -
***
Biologic males treated with estrogens
can realistically expect treatment to result in: breast growth, some redistribution
of body fat to approximate a female body habitus, decreased upper body
strength, softening of skin, decrease in body hair, slowing or stopping
the loss of scalp hair, decreased fertility and testicular size, and less
frequent, less firm erections. Most of these changes are reversible, although
breast enlargement will not completely reverse after discontinuation of
treatment.
***
Biologic females treated with
testosterone can expect the following permanent changes: a deepening of
the voice, clitoral enlargement, mild breast atrophy, increased facial
and body hair and male pattern baldness. Reversible changes include increased
upper body strength, weight gain, increased social and sexual interest
and arousability, and decreased hip fat. |
***
Potential
Negative Medical Side Effects -
***
Patients with medical problems
or otherwise at risk for cardiovascular disease may be more likely to experience
serious or fatal consequences of cross-sex hormonal treatments. For example,
cigarette smoking, obesity, advanced age, heart disease, hypertension,
clotting abnormalities, malignancy, and some endocrine abnormalities may
increase side effects and risks for hormonal treatment. Therefore, some
patients may not be able to tolerate cross-sex hormones. However, hormones
can provide health benefits as well as risks. Risk-benefit ratios should
be considered collaboratively by the patient and prescribing physician.
***
Side effects in biologic males
treated with estrogens and progestins may include increased propensity
to blood clotting (venous thrombosis with a risk of fatal pulmonary embolism),
development of benign pituitary prolactinomas, infertility, weight gain,
emotional lability, liver disease, gallstone formation, somnolence, hypertension,
and diabetes mellitus.
***
Side effects in biologic females
treated with testosterone may include infertility, acne, emotional lability,
increases in sexual desire, shift of lipid profiles to male patterns which
increase the risk of cardiovascular disease, and the potential to develop
benign and malignant liver tumors and hepatic dysfunction. |
***
The
Prescribing Physician's Responsibilities -
***
Hormones are to be prescribed
by a physician, and should not be administered without adequate psychological
and medical assessment before and during treatment. Patients who do not
understand the eligibility and readiness requirements and who are unaware
of the SOC should be informed of them. This may be a good indication for
a referral to a mental health professional experienced with gender identity
disorders.
***
The physician providing hormonal
treatment and medical monitoring need not be a specialist in endocrinology,
but should become well-versed in the relevant medical and psychological
aspects of treating persons with gender identity disorders.
***
After a thorough medical history,
physical examination, and laboratory examination, the physician should
again review the likely effects and side effects of hormone treatment,
including the potential for serious, life- threatening consequences. The
patient must have the capacity to appreciate the risks and benefits of
treatment, have his/her questions answered, and agree to medical monitoring
of treatment. The medical record must contain a written informed consent
document reflecting a discussion of the risks and benefits of hormone therapy.
***
Physicians have a wide latitude
in what hormone preparations they may prescribe and what routes of administration
they may select for individual patients. Viable options include oral, injectable,
and transdermal delivery systems. The use of transdermal estrogen patches
should be considered for males over 40 years of age or those with clotting
abnormalities or a history of venous thrombosis. Transdermal testosterone
is useful in females who do not want to take injections. In the absence
of any other medical, surgical, or psychiatric conditions, basic medical
monitoring should include: serial physical examinations relevant to treatment
effects and side effects, vital sign measurements before and during treatment,
weight measurements, and laboratory assessment. Gender patients, whether
on hormones or not, should be screened for pelvic malignancies as are other
persons.
***
For those receiving estrogens,
the minimum laboratory assessment should consist of a pretreatment free
testosterone level, fasting glucose, liver function tests, and complete
blood count with reassessment at 6 and 12 months and annually thereafter.
A pretreatment prolactin level should be obtained and repeated at 1, 2,
and 3 years. If hyperprolactemia does not occur during this time, no further
measurements are necessary. Biologic males undergoing estrogen treatment
should be monitored for breast cancer and encouraged to engage in routine
self-examination. As they age, they should be monitored for prostatic cancer.
***
For those receiving androgens,
the minimum laboratory assessment should consist of pretreatment liver
function tests and complete blood count with reassessment at 6 months,
12 months, and yearly thereafter. Yearly palpation of the liver should
be considered. Females who have undergone mastectomies and who have a family
history of breast cancer should be monitored for this disease.
***
Physicians may provide their
patients with a brief written statement indicating that the person is under
medical supervision, which includes cross- sex hormone therapy. During
the early phases of hormone treatment, the patient may be encouraged to
carry this statement at all times to help prevent difficulties with the
police and other authorities. |
***
Reductions
in Hormone Doses After Gonadectomy -
***
Estrogen doses in post-orchiectomy
patients can often be reduced by 1/3 to 1/2 and still maintain feminization.
Reductions in testosterone doses post-oophorectomy should be considered,
taking into account the risks of osteoporosis. Lifelong maintenance treatment
is usually required in all gender patients. |
***
The
Misuse of Hormones -
***
Some individuals obtain hormones
without prescription from friends, family members, and pharmacies in other
countries. Medically unmonitored hormone use can expose the person to greater
medical risk. Persons taking medically monitored hormones have been known
to take additional doses of illicitly obtained hormones without their physician's
knowledge. Mental health professionals and prescribing physicians should
make an effort to encourage compliance with recommended dosages, in order
to limit morbidity. It is ethical for physicians to discontinue treatment
of patients who do not comply with prescribed treatment regimens. |
***
Other
Potential Benefits of Hormones -
***
Hormonal treatment, when medically
tolerated, should precede any genital surgical interventions. Satisfaction
with the hormone's effects consolidates the person's identity as a member
of the preferred sex and gender and further adds to the conviction to proceed.
Dissatisfaction with hormonal effects may signal ambivalence about proceeding
to surgical interventions. In biologic males, hormones alone often generate
adequate breast development, precluding the need for augmentation mammaplasty.
Some patients who receive hormonal treatment will not desire genital or
other surgical interventions. |
***
The
Use of Antiandrogens and Sequential Therapy -
***
Antiandrogens can be used as
adjunctive treatments in biologic males receiving estrogens, though they
are not always necessary to achieve feminization. In some patients, antiandrogens
may more profoundly suppress the production of testosterone, enabling a
lower dose of estrogen to be used when adverse estrogen side effects are
anticipated.
***
Feminization does not require
sequential therapy. Attempts to mimic the menstrual cycle by prescribing
interrupted estrogen therapy or substituting progesterone for estrogen
during part of the month are not necessary to achieve feminization. |
***
Informed
Consent -
***
Hormonal treatment should be
provided only to those who are legally able to provide informed consent.
This includes persons who have been declared by a court to be emancipated
minors and incarcerated persons who are considered competent to participate
in their medical decisions. For adolescents, informed consent needs to
include the minor patient's assent and the written informed consent of
a parent or legal guardian. |
***
Reproductive
Options -
***
Informed consent implies that
the patient understands that hormone administration limits fertility and
that the removal of sexual organs prevents the capacity to reproduce. Cases
are known of persons who have received hormone therapy and sex reassignment
surgery who later regretted their inability to parent genetically related
children. The mental health professional recommending hormone therapy,
and the physician prescribing such therapy, should discuss reproductive
options with the patient prior to starting hormone therapy. Biologic males,
especially those who have not already reproduced, should be informed about
sperm preservation options, and encouraged to consider banking sperm prior
to hormone therapy. Biologic females do not presently have readily available
options for gamete preservation, other than cryopreservation of fertilized
embryos. However, they should be informed about reproductive issues, including
this option. As other options become available, these should be presented. |
***
| IX.
The Real-Life Experience |
***
|
The act of fully adopting a new or evolving gender role or gender presentation
in everyday life is known as the real-life experience. The real- life experience
is essential to the transition to the gender role that is congruent with
the patient's gender identity. Since changing one's gender presentation
has immediate profound personal and social consequences, the decision to
do so should be preceded by an awareness of what the familial, vocational,
interpersonal, educational, economic, and legal consequences are likely
to be. Professionals have a responsibility to discuss these predictable
consequences with their patients. Change of gender role and presentation
can be an important factor in employment discrimination, divorce, marital
problems, and the restriction or loss of visitation rights with children.
These represent external reality issues that must be confronted for success
in the new gender presentation. These consequences may be quite different
from what the patient imagined prior to undertaking the real-life experiences.
However, not all changes are negative. |
***
Parameters
of the Real-Life Experience -
***
When clinicians assess the quality
of a person's real-life experience in the desired gender, the following
abilities are reviewed: |
***
1.
To maintain full or part-time employment;
2. To function as a student;
3. To function in community-based volunteer activity;
4. To undertake some combination of items 1-3;
5. To acquire a (legal) gender-identity-appropriate first name;
6. To provide documentation that persons other than the therapist know
that the patient functions in the desired gender
||||role. |
***
Real-Life
Experience versus Real-Life Test -
***
Although professionals may recommend
living in the desired gender, the decision as to when and how to begin
the real-life experience remains the person's responsibility. Some begin
the real-life experience and decide that this often imagined life direction
is not in their best interest. Professionals sometimes construe the real-life
experience as the real-life test of the ultimate diagnosis. If patients
prosper in the preferred gender, they are confirmed as "transsexual," but
if they decided against continuing, they "must not have been." This reasoning
is a confusion of the forces that enable successful adaptation with the
presence of a gender identity disorder. The real-life experience tests
the person's resolve, the capacity to function in the preferred gender,
and the adequacy of social, economic, and psychological supports. It assists
both the patient and the mental health professional in their judgments
about how to proceed. Diagnosis, although always open for reconsideration,
precedes a recommendation for patients to embark on the real-life experience.
When the patient is successful in the real- life experience, both the mental
health professional and the patient gain confidence about undertaking further
steps. |
***
Removal
of Beard and other Unwanted Hair for the Male to Female Patient -
***
Beard density is not significantly
slowed by cross-sex hormone administration. Facial hair removal via electrolysis
is a generally safe, time- consuming process that often facilitates the
real-life experience for biologic males. Side effects include discomfort
during and immediately after the procedure and less frequently hypo- or
hyper-pigmentation, scarring, and folliculitis. Formal medical approval
for hair removal is not necessary; electrolysis may be begun whenever the
patient deems it prudent. It is usually recommended prior to commencing
the real-life experience, because the beard must grow out to visible lengths
to be removed. Many patients will require two years of regular treatments
to effectively eradicate their facial hair. Hair removal by laser is a
new alternative approach, but experience with it is limited. |
***
***
Sex
Reassignment is Effective and Medically Indicated in Severe GID -
***
In persons diagnosed with transsexualism
or profound GID, sex reassignment surgery, along with hormone therapy and
real-life experience, is a treatment that has proven to be effective. Such
a therapeutic regimen, when prescribed or recommended by qualified practitioners,
is medically indicated and medically necessary. Sex reassignment is not
"experimental," "investigational," "elective," "cosmetic," or optional
in any meaningful sense. It constitutes very effective and appropriate
treatment for transsexualism or profound GID. |
***
How
to Deal with Ethical Questions Concerning Sex Reassignment Surgery -
***
Many persons, including some
medical professionals, object on ethical grounds to surgery for GID. In
ordinary surgical practice, pathological tissues are removed in order to
restore disturbed functions, or alterations are made to body features to
improve the patient's self image. Among those who object to sex reassignment
surgery, these conditions are not thought to present when surgery is performed
for persons with gender identity disorders. It is important that professionals
dealing with patients with gender identity disorders feel comfortable about
altering anatomically normal structures. In order to understand how surgery
can alleviate the psychological discomfort of patients diagnosed with gender
identity disorders, professionals need to listen to these patients discuss
their life histories, and dilemmas. The resistance against performing surgery
on the ethical basis of "above all do no harm" should be respected, discussed,
and met with the opportunity to learn from patients themselves about the
psychological distress of having profound gender identity disorder.
***
It is unethical to deny availability
or eligibility for sex reassignment surgeries or hormone therapy solely
on the basis of blood seropositivity for blood-borne infections such as
HIV, or hepatitis B or C, etc. |
***
The
Surgeon's Relationship with the Physician Prescribing Hormones and the
Mental Health Professional -
***
The surgeon is not merely a technician
hired to perform a procedure. The surgeon is part of the team of clinicians
participating in a long-term treatment process. The patient often feels
an immense positive regard for the surgeon, which ideally will enable long-term
follow-up care. Because of his or her responsibility to the patient, the
surgeon must understand the diagnosis that has led to the recommendation
for genital surgery. Surgeons should have a chance to speak at length with
their patients to satisfy themselves that the patient is likely to benefit
from the procedures. Ideally, the surgeon should have a close working relationship
with the other professionals who have been actively involved in the patient's
psychological and medical care. This is best accomplished by belonging
to an interdisciplinary team of professionals who specialize in gender
identity disorders. Such gender teams do not exist everywhere, however.
At the very least, the surgeon needs to be assured that the mental health
professional and physician prescribing hormones are reputable professionals
with specialized experience with gender identity disorders. This is often
reflected in the quality of the documentation letters. Since fictitious
and falsified letters have occasionally been presented, surgeons should
personally communicate with at least one of the mental health professionals
to verify the authenticity of their letters.
***
Prior to performing any surgical
procedures, the surgeon should have all medical conditions appropriately
monitored and the effects of the hormonal treatment upon the liver and
other organ systems investigated. This can be done alone or in conjunction
with medical colleagues. Since pre-existing conditions may complicate genital
reconstructive surgeries, surgeons must also be competent in urological
diagnosis. The medical record should contain written informed consent for
the particular surgery to be performed. |
***
***
Breast augmentation and removal are common operations, easily obtainable
by the general public for a variety of indications. Reasons for these operations
range from cosmetic indications to cancer. Although breast appearance is
definitely important as a secondary sex characteristic, breast size or
presence are not involved in the legal definitions of sex and gender and
are not important for reproduction. The performance of breast operations
should be considered with the same reservations as beginning hormonal therapy.
Both produce relatively irreversible changes to the body.
***
The approach for male-to-female
patients is different than for female-to-male patients. For female-to-male
patients, a mastectomy procedure is usually the first surgery performed
for success in gender presentation as a man; and for some patients it is
the only surgery undertaken. When the amount of breast tissue removed requires
skin removal, a scar will result and the patient should be so informed.
Female-to-male patients might may have surgery at the same time they begin
hormones. For male-to-female patients, augmentation mammoplasty may be
performed if the physician prescribing hormones and the surgeon have documented
that breast enlargement after undergoing hormone treatment for 18 months
is not sufficient for comfort in the social gender role. |
***
***
Eligibility
Criteria -
***
These minimum eligibility criteria
for various genital surgeries equally apply to biologic males and females
seeking genital surgery. They are: |
***
1.
Legal age of majority in the patient's nation;
2. Usually 12 months of continuous hormonal therapy for those without a
medical contraindication (see below, "Can
||||Surgery Be
Performed Without Hormones and the Real-life Experience");
3. 12 months of successful continuous full time real-life experience. Periods
of returning to the original gender may
||||indicate
ambivalence about proceeding and generally should not be used to fulfill
this criterion;
4. If required by the mental health professional, regular responsible participation
in psychotherapy throughout the real-life
||||experience
at a frequency determined jointly by the patient and the mental health
professional. Psychotherapy per se
||||is not an
absolute eligibility criterion for surgery;
5. Demonstrable knowledge of the cost, required lengths of hospitalizations,
likely complications, and post surgical
||||rehabilitation
requirements of various surgical approaches;
6. Awareness of different competent surgeons. |
***
Readiness
Criteria -
***
The readiness criteria include: |
***
1.
Demonstrable progress in consolidating one's gender identity;
2. Demonstrable progress in dealing with work, family, and interpersonal
issues resulting in a significantly better state of
||||mental health
(this implies satisfactory control of problems such as sociopathy, substance
abuse, psychosis, suicidality,
||||for instance). |
***
Can
Surgery Be Provided Without Hormones and the Real-Life Experience?
-
***
Individuals cannot receive genital
surgery without meeting the eligibility criteria. Genital surgery is a
treatment for a diagnosed gender identity disorder, and should undertaken
only after careful evaluation. Genital surgery is not a right that must
be granted upon request. The SOC provide for an individual approach for
every patient; but this does not mean that the general guidelines, which
specify treatment consisting of diagnostic evaluation, possible psychotherapy,
hormones, and real-life experience, can be ignored. However, if a person
has lived convincingly as a member of the preferred gender for a long period
of time and is assessed to be a psychologically healthy after a requisite
period of psychotherapy, there is no inherent reason that he or she must
take hormones prior to genital surgery. |
***
Conditions
under which Surgery May Occur -
***
Genital surgical treatments for
persons with a diagnosis of gender identity disorder are not merely another
set of elective procedures. Typical elective procedures only involve a
private mutually consenting contract between a patient and a surgeon. Genital
surgeries for individuals diagnosed as having GID are to be undertaken
only after a comprehensive evaluation by a qualified mental health professional.
Genital surgery may be performed once written documentation that a comprehensive
evaluation has occurred and that the person has met the eligibility and
readiness criteria. By following this procedure, the mental health professional,
the surgeon and the patient share responsibility of the decision to make
irreversible changes to the body. |
***
Requirements
for the Surgeon Performing Genital Reconstruction -
***
The surgeon should be a urologist,
gynecologist, plastic surgeon or general surgeon, and Board-Certified as
such by a nationally known and reputable association. The surgeon should
have specialized competence in genital reconstructive techniques as indicated
by documented supervised training with a more experienced surgeon. Even
experienced surgeons in this field must be willing to have their therapeutic
skills reviewed by their peers. Surgeons should attend professional meetings
where new techniques are presented.
***
Ideally, the surgeon should be
knowledgeable about more than one of the surgical techniques for genital
reconstruction so that he or she, in consultation with the patient, will
be able to choose the ideal technique for the individual patient. When
surgeons are skilled in a single technique, they should so inform their
patients and refer those who do not want or are unsuitable for this procedure
to another surgeon. |
***
Genital
Surgery for the Male-to-Female Patient -
***
Genital surgical procedures may
include orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labiaplasty.
These procedures require skilled surgery and postoperative care. Techniques
include penile skin inversion, pedicled rectosigmoid transplant, or free
skin graft to line the neovagina. Sexual sensation is an important objective
in vaginoplasty, along with creation of a functional vagina and acceptable
cosmesis. |
***
Other
Surgery for the Male-to-Female Patient -
***
Other surgeries that may be performed
to assist feminization include reduction thyroid chondroplasty, suction-assisted
lipoplasty of the waist, rhinoplasty, facial bone reduction, face-lift,
and blepharoplasty. These do not require letters of recommendation from
mental health professionals.
***
There are concerns about the
safety and effectiveness of voice modification surgery and more follow-up
research should be done prior to widespread use of this procedure. In order
to protect their vocal cords, patients who elect this procedure should
do so after all other surgeries requiring general anesthesia with intubation
are completed. |
***
Genital
Surgery for the Female-to-Male Patient -
***
Genital surgical procedures may
include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty,
scrotoplasty, urethroplasty, placement of testicular prostheses, and phalloplasty.
Current operative techniques for phalloplasty are varied. The choice of
techniques may be restricted by anatomical or surgical considerations.
If the objectives of phalloplasty are a neophallus of good appearance,
standing micturition, sexual sensation, and/or coital ability, the patient
should be clearly informed that there are several separate stages of surgery
and frequent technical difficulties which may require additional operations.
Even metoidioplasty, which in theory is a one-stage procedure for construction
of a microphallus, often requires more than one surgery. The plethora of
techniques for penis construction indicates that further technical development
is necessary. |
***
Other
Surgery for the Female-to-Male Patient -
***
Other surgeries that may be performed
to assist masculinization include liposuction to reduce fat in hips, thighs
and buttocks. |
| XIII.
Post-Transition Follow-up |
Long-term postoperative follow-up is encouraged in that it is one of the
factors associated with a good psychosocial outcome. Follow-up is important
to the patient's subsequent anatomic and medical health and to the surgeon's
knowledge about the benefits and limitations of surgery.
***
Long-term follow-up with the
surgeon is recommended in all patients to ensure an optimal surgical outcome.
Surgeons who operate on patients who are coming from long distances should
include personal follow-up in their care plan and attempt to ensure affordable,
local, long-term aftercare in the patient's geographic region. Postoperative
patients may also sometimes exclude themselves from follow-up with the
physician prescribing hormones, not recognizing that these physicians are
best able to prevent, diagnose and treat possible long term medical conditions
that are unique to hormonally and surgically treated patients. Postoperative
patients should undergo regular medical screening according to recommended
guidelines for their age. The need for follow-up extends to the mental
health professional, who having spent a longer period of time with the
patient than any other professional, is in an excellent position to assist
in any post-operative adjustment difficulties. |
***
|
|
|
Notes
On The Standards Of Care
***
The
Standards of Care are provided on this site for informational purposes
only -
***
The Standards of Care are intended
for use as guidelines, designed to promote the health and welfare of persons
with gender identity disorders, and exist for the protection of both the
patient and the theraputic provider of such treatment. As such, they are
not cast in stone but rather open to interpretation on a case by case basis
between the patient and the treatment professional involved, both should
be aware of these guidelines and the treatment standards they are designed
to maintain. |
***
| The
Standards of Care are created and maintained by - |
***
The
Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA)
1300 South Second Street, Suite 180
Minneapolis, MN 55454 USA
(612) 625-1500
http://www.hbigda.org/ |
***
These
standards are updated and revised as new scientific information becomes
available -
***
The current edition of the Standards of Care presented here was released
in 2001, and is the sixth version since the original 1979 document.
Previous revisions were in 1980, 1981, 1990, and 1998. See archives
for versions previously presented on this site. |
***
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Contributions
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