Female-to-male Transgender Patients Research Articles

Abstract 18991: Effect of Sex Steroids on Lipid Profile in Female to Male Transgender Patients: A Systematic Review and Meta-Analysis

Background The medical transition of transgender individuals involves the administration of exogenous sex steroids to induce desired changes in secondary sexual characteristics. In the case of female-to-male (FtM) transgender individuals, the use of testosterone therapy is common. The impact of testosterone on lipid metabolism and dyslipidemia in this specific population is not well understood. Our study combines all the previous studies to study the impact of sex steroids in FtM transgender population. Aim To assess the effects of sex steroids on lipid profile in FtM transgender patients. Methods: PubMed, Cochrane, and Embase were searched from inception till May 2023 for all randomized control trials (RCTs) and observational studies. Primary outcomes were changes in basal metabolic profile (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), triglyceride levels (TG), HDL, and LDL. All the baseline values before and after utilization of sex steroids were studied. A meta-cont module was used along with Inverse-variance method to calculate the pooled standard mean difference (SMD) for continuous outcomes with a probability value of p < 0.05 considered to be statistically significant. Results: A total of 21 studies with 1208 FtM transgender patients were included. Sex steroids resulted in statistically significant elevation in LDL-C (SMD 0.2850 [0.1169; 0.4531] p < 0.0009), TG (SMD 0.4312 [0.2522; 0.6101] p < 0.0001), TC (SMD 0.1754 [0.0536; 0.2972] p < 0.0048), and BMI (SMD: 0.2429 [0.0983; 0.3875] p < 0.0010) while HDL levels were significantly reduced from the baseline. However, no significant relationship between SBP and DBP was studied (Figure 1). Conclusion: In conclusion, sex steroids increase lipid levels in transgender patients, potentially contributing to dyslipidemia and cardiovascular risk.

Case Series of Ischemic Stroke occurring in Male- to- Female Transgender population on Gender - Affirming Hormonal Therapy and Review of the Literature (P2-5.022)

<h3>Objective:</h3> To stress the importance of individualized vascular risk assessment and shared decision-making to continue Gender-Affirming Hormonal therapy (GAHT) in the Male to Female (MTF) transgender population following ischemic stroke with review of the literature. <h3>Background:</h3> Transgender individuals have higher mental health burden and suicide rates. GAHT is the standard of care for transgender individuals suffering from symptoms of gender dysphoria. Estrogen therapy has been associated with increased stroke risk, but its specific contribution is poorly characterized and appears to be impacted by the route of administration. <h3>Design/Methods:</h3> We include three self-identified MTF transgender patients who had taken GAHT and treated for ischemic stroke inpatient or were seen for stroke follow-up. Data was gathered from chart review including demographics, vascular risk factors, type of GAHT, clinical course, and outcomes. <h3>Results:</h3> Two MTF transgender patients on GAHT were treated inpatient for an acute stroke and one was seen in follow up. At the time of infarct, one MTF transgender patient was on combination hormonal therapy, one patient was on combination hormonal therapy and spironolactone, and one patient was on estrogen hormonal therapy of unknown type. Traditional vascular risk factors were present in the patient population prior to ischemic stroke including: hypertension, hyperlipidemia, type 2 diabetes mellitus, morbid obesity, prior ischemic stroke, tobacco use disorder, alcohol use disorder. <h3>Conclusions:</h3> Each patient in our small series had traditional vascular risk factors in addition to GAHT use prior to ischemic infarct. Identifying and treating comorbid vascular risk factors in MTF transgender patients prior to and during GAHT is essential to decrease ischemic stroke risk. Additional studies are needed to determine the relative impact of GAHT on stroke risk. Given mental health burden of gender dysphoria symptoms, shared decision-making is necessary to determine risks and benefits of continuing GAHT after ischemic stroke in MTF transgender patients. <b>Disclosure:</b> Ms. Giovannini has nothing to disclose. An immediate family member of Dr. Ivan has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Journal of Cellular and Molecular Medicine. An immediate family member of Dr. Ivan has received intellectual property interests from a discovery or technology relating to health care. Dr. Karel has nothing to disclose.

The Role of Gender Dysphoria in the Development of an Eating Disorder

The Role of Gender Dysphoria in the Development of an Eating Disorder

Prostate Cancer in Male-to-Female Transgender Individuals: Histopathologic Findings and Association With Gender-affirming Hormonal Therapy.

Male-to-female (MtF) transgender individuals are at risk for prostate cancer, although guidelines for screening and management in this population are not well established. We describe a series of 9 MtF transgender patients who underwent prostate tissue sampling and highlight histopathologic features and challenges related to pathologic interpretation of prostate tissue in this patient population. Seven of 9 total patients were diagnosed with prostate cancer and all had elevated prostate-specific antigen at the time of diagnosis. Three of the 7 patients diagnosed with prostate cancer had received different types of hormone therapy for gender affirmation before the diagnosis of prostate cancer, and in all 3 of these patients, there was histologic evidence of hormone therapy effect in both benign prostate tissue and/or the adenocarcinoma. The 2 patients with benign prostate tissue underwent transurethral resection for lower urinary tract symptoms and were previously on hormone therapy for gender affirmation. Both of these specimens showed diffuse glandular atrophy and basal cell hyperplasia, indicative of hormone therapy effect on benign prostatic tissue. In the patients diagnosed with prostate cancer, a spectrum of grades was observed, ranging from Grade Group 1 to Grade Group 5. Four patients underwent radical prostatectomy, with 2 cases showing extraprostatic extension and Grade Group 5 prostatic adenocarcinoma, and 2 showing Grade Group 2 prostatic adenocarcinoma. Three of the 4 patients who underwent radical prostatectomy had received gender-affirming hormone therapy before surgery, and all 3 of these specimens showed hormone therapy effect in non-neoplastic prostate tissue and focal hormone therapy effect in prostatic adenocarcinoma. The presence of areas of viable carcinoma without hormone therapy effect enabled the assignment of a Gleason score and Grade Group in these 3 cases. Hormone therapy administered for gender identity affirmation induces histopathologic changes to both benign prostate tissue (nonkeratinizing squamous metaplasia, diffuse atrophy, basal cell hyperplasia, and stromal dominance with decreased numbers of glands) and prostatic adenocarcinoma (nuclear pyknosis, atrophy, cytoplasmic vacuolization, and architectural patterns that would qualify for Gleason 4 and 5 in the absence of hormone therapy effect) that have been traditionally seen in cis-male prostate cancer patients receiving hormone therapy. In the absence of hormone therapy, the morphology of prostatic adenocarcinoma in transgender patients shows classic morphologic features similar to those seen in cis-male patients not on hormone therapy. Prostate cancer with hormone therapy effect may not only be histologically quite subtle and may be overlooked if not suspected, but also should not be assigned a Gleason score because the Gleason score would substantially overstate its biologic potential. Therefore, similar to cis-male patients who have received androgen deprivation therapy for prostate cancer, transgender patients on hormone therapy for gender affirmation may be at risk for both underrecognition and over-grading of prostate cancer, particularly if the pathologist is not aware of the clinical history.

Transgender Mastectomy: Incidence of High-Risk Pathologic Findings and the Need for Postoperative Cancer Surveillance.

Chest masculinization surgeries are one of the most common gender-affirming procedures performed. There is a need for better understanding of the risk of breast cancer and postsurgical screening in female to male (FtM) individuals. This study aimed to evaluate the incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery. Medical records were reviewed from all FtM patients undergoing gender-affirming chest reconstructive surgery from January 2010 to February 2021 by 3 plastic surgeons at the University of Pittsburgh Medical Center. Relative risk of malignant progression was used to stratify pathologic data. Subsequent management of atypical, in situ, and invasive pathology were recorded. A total of 318 patients were included in this study; the average age at surgery was 24.6 ± 8.1 years. Eighty-six patients (27%) had a family history of breast and/or ovarian cancer. Overall, 21 patients (6.6%) had some increased risk of breast cancer: 17 (5.3%) had proliferative lesions, mean age 38.2 ± 12.4 years; 2 had atypical ductal hyperplasia, ages 33.4 and 38.3 years; and 2 had invasive ductal carcinoma, ages 35.4 and 40.6 years. In this study, we found that 6.6% of FtM transgender patients undergoing top surgery had an elevated risk of breast cancer, with 1.2% of patients having a greater than 2 times risk of breast cancer. These results highlight the importance of appropriate preoperative screening as well as pathological analysis of surgical specimens to help guide clinical care. The authors advocate for a thorough breast cancer risk assessment before surgery for all patients, as well as using pathologic findings to guide postoperative cancer screening and follow-up.

Efficacy of Sex Steroid Therapy Without Progestin or GnRH Agonist for Gonadal Suppression in Adult Transgender Patients.

Testosterone (T) or estradiol (E2) are administered to suppress gonadal function in female-to-male (FTM) and male-to-female (MTF) transgender patients. How often sex steroids cause adequate suppression without GnRH agonist (GnRHa) or progestin therapy has not been reported. (1) To determine how often T and E2 therapy alone can effectively suppress gonadal function in MTF and FTM transgender patients, and (2) to determine the frequency and range of serum E2 levels above the normal male range in FTM patients receiving T therapy. Retrospective cohort study. Outpatient reproductive endocrinology clinic at an academic medical center. A total of 65 FTM and 33 MTF patients were included who were > 18 years of age and not receiving progestin or GnRHa therapy. Female-to-male patients were receiving T through injections or gel. Male-to-female patients were receiving oral or subcutaneous E2. In FTM patients the indicator of ovary suppression was amenorrhea. In MTF patients, the indicator of testes suppression was T levels <50 ng/dL. Median serum total T level for FTM patients was 712 ng/dL (range, 370-1164 ng/dL). On T therapy alone, 90.8% of patients achieved amenorrhea and 49.2% of patients had serum E2 levels above the normal range for women. For MTF patients, the median serum E2 level was 129.2 pg/mL (range, 75-197 pg/mL). On E2 therapy alone, 84.8% of MTF patients had adequate suppression of testicular function. Testosterone and E2 therapy are usually effective without progestin or GnRHa therapy to suppress gonadal function in transgender patients. Progestin and/or GnRHa therapy should only be initiated in those patients who do not have adequate gonadal suppression on optimized doses of T or E2 alone.

Cytomorphologic findings of cervical Pap smears from female-to-male transgender patients on testosterone therapy.

The cervical cancer screening recommendation for transgender female-to-male (FTM) patients is the same as that for cisgender females. A lack of literature on testosterone-induced changes in cervical cytology in these patients may result in interpretation errors, especially without a proper clinical history. The aim of this study was to delineate the Papanicolaou (Pap) test findings in this patient population. A pathology laboratory information system was used to obtain a cohort of FTM transgender patients on testosterone therapy (2009-2019). A cohort of age-matched, atrophic, control cisgender female patients (postpartum or menopausal) was selected. A retrospective review of the cytomorphologic findings on cervical Pap smears, pertinent follow-up, and human papillomavirus (HPV) test results was performed. Fourteen transgender patients (age range, 21-64years; mean age, 42.5years) receiving testosterone therapy with 17 Pap smears were identified. One of the 5 available HPV tests was positive for HPV, and 4 were negative. A Pap smear review revealed the following: negative for intraepithelial lesion (NILM; 82.4%), unsatisfactory (5.9%), atypical squamous cells of undetermined significance (ASCUS; 5.9%), and low-grade squamous intraepithelial lesion (5.9%). The Pap smears of the atrophic cisgender cohort (102 patients) revealed the following: NILM (92.5%), unsatisfactory (0.9%), ASCUS (5.6%), and high-grade squamous intraepithelial lesion (0.9%). The difference between the rates of epithelial cell abnormality in the 2 cohorts was not statistically significant. Although atrophy was noted in both groups, cytomorphologic findings of transitional cell metaplasia (TCM; 88.2%) and "small cells" (82.4%) were characteristic of the testosterone-treated transgender cohort. Histologic correlates of TCM and small cells were noted in hysterectomy specimens from 6 patients. Small cells and TCM are common cytomorphologic findings in Pap smears of testosterone-treated transgender (FTM) patients. On the basis of histologic follow-up, small cells most likely represent atrophic parabasal cells of cervical-vaginal epithelium.

Effect of Cross-Sex Hormone Therapy on Venous Thromboembolism Risk in Male-to-Female Gender-Affirming Surgery.

Individuals with gender dysphoria often seek medical interventions, such as hormone treatment and surgery, to live as their identified gender. Cross-sex hormone therapy typically consists of various estrogen formulations which confer varying risks of venous thromboembolism (VTE). Currently, there is no standard practice by surgeons regarding the preoperative gender-affirming surgery (GAS) hormone regimen of male-to-female (MTF) patients to minimize thromboembolic postoperative complications. The aim of this review is to examine the current literature on VTE occurring in MTF transgender patients on cross-sex hormone therapy (CSHT) when undergoing various gender-affirming surgeries-facial feminization surgery (FFS), top surgery (TS), and bottom surgery (BS)-to understand how evidence-based recommendations regarding perioperative hormone regimens can be established to improve clinical outcomes. Within the past 25 years, 7 published studies have examined the incidence of VTE in MTF patients undergoing GAS procedures. Two of these articles examined MTF patients undergoing FFS, 1 article reported a patient who had undergone BS and FFS during the same hospitalization, and the remaining 4 articles investigated VTE risk in BS. Our review supports that plastic surgeons who perform GAS are divided on their preferred CSHT protocols, with some requiring patients to suspend their CSHT weeks before surgery and others allowing patients to continue CSHT through the day of surgery. Three of the 7 studies detailed a CSHT perioperative regimen which instructed patients to suspend CSHT sometime before surgery; 1 study tapered CSHT to lower levels before surgery; the remaining 3 studies did not specify a CSHT perioperative regimen. This review highlights the paucity of data failing to support that continuing CSHT through GAS elevates VTE risk. We conclude that in the absence of definitive VTE risk factors (e.g., smoking, clotting disorders, or malignancy), surgeons may engage MTF patients in joint decision-making process to determine the most optimal perioperative CSHT management plan on a case-by-case basis. Future studies are warranted to evaluate VTE risk based on patient age, type of surgery, operating time, prophylactic measures, follow-up time, and CSHT perioperative regimens.

Female-to-Male Gender-Confirming Drainless Mastectomy May Be Safe in Obese Males.

Gender dysphoria is a medical condition associated with suicidality. Transgender men who have undergone female-to-male (FTM) chest reconstruction report higher quality of life and reduced gender dysphoria. It has been reported that transgender men are at higher risk of obesity. The objective of this study was to compare perioperative outcomes and complications between different classes of obesity in FTM transgender patients who underwent chest masculoplasty. A retrospective review of 145 consecutive patients who underwent mastectomy with free nipple graft was conducted. Postoperative outcomes and complications were collected. Patients were divided into nonobese (body mass index [BMI] <30 kg/m2), obese (BMI 30-39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), and super obese (BMI >50 kg/m2) groups. Sixty-six of the 145 patients were not obese, 52 were obese, 22 were morbidly obese, and 5 were super obese. There was a statistically significant increase in amount of breast tissue resected between each of the 4 groups (866.8 g vs 1672.4 g vs 3157.1 g vs 4827.6 g; P ≤ 0.0005) as BMI increased, respectively. There was a significant difference in operative time between the nonobese and obese groups (128.7 vs 134.6 vs 150.5 vs 171 minutes; P = 0.026). A significant increase in postoperative infections was observed between the morbidly obese, super obese, and the nonobese group (P = 0.048). Chest wall reconstruction in FTM and nonbinary transgender people is important in relieving gender dysphoria. Postoperative complications were not significantly increased in obese patients (30-39.9 kg/m2). Delaying surgery for weight loss may not be necessary unless patients are morbidly obese.

Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes.

Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (=N) ultimately filled out both parts of the questionnaire sets: 1day before the first stage (T0) and 6months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p<0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p<0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale. Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Serum Testosterone Concentrations Remain Stable Between Injections in Patients Receiving Subcutaneous Testosterone.

Purpose:Intramuscular (IM) testosterone is the most common modality for testosterone therapy of both male hypogonadism and female-to-male (FTM) gender transition. However, IM injections can be painful and often are not self-administered by the patient. The objective of this study was to further characterize subcutaneous (SC) administration of testosterone as an effective and safe alternative to IM injections by evaluating the pharmacodynamics of serum total and free testosterone concentrations between weekly testosterone injections.Methods:Eleven FTM transgender patients already receiving weekly SC testosterone cypionate with documented therapeutic levels prior to enrollment had free and total serum testosterone levels measured at eight different time points during a 1-week dosing interval.Results:Mean levels of total and free testosterone were stable and remained well within the normal range between injections. Overall mean ± standard deviation levels for the seven samples taken between injections were 627 ± 206 ng/dL (range, 205 to 1410) for total testosterone and 146 ± 51 pg/mL (range, 38 to 348) for free testosterone. No adverse effects were encountered.Conclusions:The results of this study support use of SC testosterone to achieve therapeutic and stable serum testosterone levels for the purpose of gender transition. It is anticipated that these results can be extended to hypogonadal men. This route may be preferred over IM testosterone because it is relatively painless and easy to self-inject thus allowing for the convenience and economy of patient self-administration.

Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes

Several therapy options exist for male-to-female (MTF) transgenders desiring sex reassignment. Surgery includes numerous different procedures. Of those, vaginoplasty is predominant and aims at providing attractive esthetics and fully functional genitals. This study aimed to present the surgical results of our modified combined vaginoplasty technique in a consecutive patient cohort. We included 40 MTF transgender patients who underwent a two-stage sex reassignment surgery (SRS) in an observational prospective study between September 2012 and January 2014. Demographic characteristics, medical and surgical history, operative details, and outcomes after surgery were documented. Postoperatively, 23 patients received a pelvic examination following the standardized protocol. Measured vaginal depth was 11.77-14.99cm depending on the size of the dilator used (25-40mm). Vaginal, clitoral, and labial sensitivities were intact and favorable in all examined patients. Nineteen women (47.5%) opted for breast augmentations to achieve a feminine cosmesis, making it the most common nongenital operation. Complications were mostly minor and temporary. Severe adverse events, such as wound infections (n=3), colon injuries (3), short (1) or narrow (1) vaginas, or partial clitoral necroses (1), were rare and immediately addressed by the surgical team. No vaginal construction was lost, and no secondary reconstructive approaches were required. Satisfactory physical results and favorable low rates of complications endorse our combined technique for MTF SRS. These findings, however, need to be confirmed by other research groups as well. Therefore, in our opinion, MTF SRS remains an evolving area of development, whose research is aiming to establish a state-of-the-art surgical technique.

Masculine Chest-Wall Contouring in FtM Transgender: a Personal Approach.

Chest-wall contouring surgery is one of the first steps in sexual reassignment in female-to-male (FtM) transsexuals that contributes to strengthening of the self-image and facilitates living in the new gender role. The main goal is to masculinize the chest by removing the female contour. Chest contour, scar placement, scar shape, scar length, nipple-areola position, nipple size and the areola size are the key points. Between July 2013 and June 2016, 25 FtM transgender patients underwent surgical procedures to create a masculine chest-wall contour. In our study, we just considered 16 patients who have undergone chest surgery with the double incision method. The patients' survey revealed a high satisfaction rate with the aesthetic result. In our group, no complications occurred, and two patients have undergone supplementary surgery for axillary dog-ear revision and nipple reconstruction. The authors propose a new technical approach and indications for FtM transgender patients' surgery. A longer scar that emphasizes the pectoralis muscle, a smaller nipple and a resized and refaced areola are the key points of our technique to give a masculine appearance to the chest. The scars are permanent, but most of them will fade and the patients are enthusiastic with their new "male" chest appearance. The high level of satisfaction, the great aesthetic result and the low rate of complications suggest to us the use of this technique in medium- and large-size breasts. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of Sexual Orientation Identity on Medical Morbidities in Male-to-Female Transgender Patients.

We aim to describe the relationship between sexual orientation identity and medical morbidities in a large sample of male-to-female (MTF) transgender patients. We reviewed medical records of patients presenting for MTF sex reassignment surgery (SRS) by a single, high-volume surgeon from 2011 to 2015. Sexual attraction to men (heterosexual), women (lesbian), or both (bisexual) was asked of each patient. We examined 16 medical morbidities for this analysis. During the study period, 330 MTF transgender patients presented for SRS. The average age at the time of surgery was 38.9 (range 18-76). One hundred and one patients (32%) reported being heterosexual, 110 patients (34%) reported being lesbian, and 108 patients (34%) reported being bisexual. Lesbian patients presented for SRS at older ages (mean = 43 years old) compared with heterosexual patients (mean = 36 years old) and bisexual patients (mean = 37), P < 0.01. No differences were found in the majority of coexisting medical morbidities by sexual orientation identity. Lesbian patients had greater odds of having a history of depression, age-adjusted odds ratio (aOR) = 2.36, 95% confidence interval (CI) 1.26-4.40, compared with heterosexual patients. Lesbian patients had higher odds of being married or partnered, aOR = 2.31, 95% CI (1.27-4.19), compared with heterosexual patients. Heterosexual patients had higher odds of having human immunodeficiency virus (HIV), aOR = 9.07, 95% CI (1.08-76.5) compared with lesbian patients. Sexual orientation identity in MTF transgender patients is variable. The majority of medical morbidities are not associated with sexual orientation identity. Although HIV and depression are common morbidities among MTF patients seeking SRS, the prevalence of these morbidities differs by sexual orientation identity, but these findings need replication. Counseling and future research initiatives in transgender care should incorporate sexual orientation identity and associated risk behavior.

Fertility preservation in transgender patients

ABSTRACTFertility preservation is an important consideration for transgender people prior to initiating cross-sex hormones or undergoing sex reassignment surgery. We performed a retrospective chart review identifying all transgender patients referred for fertility preservation at one university-affiliated fertility clinic from November 2011 to March 2014. Eleven male-to-female (MtF) transgender patients and 3 female-to-male (FtM) transgender patients were seen for sperm banking or fertility preservation consultation. FtM transgender patients were referred for fertility preservation at a later age and after being on a longer duration of cross-sex hormone therapy than MtF transgender patients. Nine of eleven MtF patients cryopreserved sperm resulting in 1 pregnancy following IVF-ICSI. None of the FtM patients underwent any cryopreservation techniques. This study highlights the need to increase awareness on the effects of age on fertility for FtM patients, and to improve awareness of and access to fertility preservation technologies for all transgender people early on in their transition.

Modified Preparation of the Neurovascular Bundle in Male to Female Transgender Patients

Introduction: The main objective of gender reassignment surgery (GRS) in male to female (MtF) transgender people is to create a functional and aesthetic vagino-clitoral complex. Here we report on a modified preparation of the neurovascular bundle (NVB). Materials and Methods: Between May 2011 and September 2014, 96 consecutive MtF transgender patients underwent GRS at our department. Sensitivity of the neoclitoris was assessed afterwards. Results were compared with a historical cohort from our department (2004-2010, n = 119) in which perioperative treatment was the same except for the preparation of the NVB. Results: In 92 (95.8%) and 78 (81.2%) patients information on neoclitoral sensitivity was available and in 79 (82.3%) and 69 (71.9%) sensitivity was tested semiquantatively after first and second stage procedure respectively. A semiquantitative grading system correlated significantly with intermedium-term ability to achieve orgasms (p = 0.036). The modification led to a reduction in operation time by an average of 61 min. With the modified technique, we had a higher rate of postoperative local hematoma but with no need for further intervention. Conclusions: Preparation is safe and time saving both preserving the neoclitoral sensitivity and promoting a preferably feminine aspect of the mons pubis. Semiquantitative testing of sensitivity correlates with the intermedium-term capability of achieving orgasms.