definitions of what constitutes a disorder [7]. Until such research is done, we remain without evidence-based guidelines for testoster- one supplementation in women. Rosemary Basson, MD, FRCP(UK),* Allan Young, MD, PhD, FRCPsyche, FRCP(C), † Lori A. Brotto, PhD, ‡ Miriam Driscoll, MD, FRCP(C),* Shauna Correia, MD, FRCP(C)*, and Fernand Labrie, MD, PhD§ *Psychiatry, University of British Columbia, Vancouver, BC, Canada; † Psychological Medicine, King’s College, London, UK; ‡ Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; §Laval University Hospital, Research Center in Molecular Endocrinology, Oncology, and Human Genomics, Laval University, Laval, QC, Canada References 1 Wåhlin-Jacobsen S, Pedersen AT, Kristensen E, Læssøe NC, Lundqvist M, Cohen AS, Hougaard D, Giraldi A. Is there a correlation between androgens and sexual desire in women? J Sex Med 2015;12:358–73. 2 Basson R, Brotto LA, Petkau AJ, Labrie F. 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Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques DOI: 10.1111/jsm.12915 It was with great interest that we read the article by Dr. Horbach etal., Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques [1]. We congratulate the authors on this well-designed systematic review from 1995 to the present and the discussion that points out that efforts should be made to measure outcomes with validated questionnaires and scores for sexual function and quality of life. We have three questions regarding their conclusion and recommendations, in which they wrote that, for now, the penile skin inversion tech- nique is the most researched method, and surgical outcome and sexual function are generally acceptable to good. In the light of your review, do you think that it is possible to get very good to excellent outcomes after penile skin inversion technique? What do you think about the learning curve associated with this sur- gical technique? Do you have guidelines in your university hos- pital in order to optimize the surgeon’s learning curve of this procedure? In our own department, a center of expertise for sex reas- signment surgery in France, more than 200 patients have been successfully operated on. This technique, even for an experi- enced surgeon, requires a learning curve. Despite the numerous reports on vaginoplasty in the literature, to our knowledge, there is no report specifically addressing the learning curve for this operation. In 2010, Reynolds et al. stated that the benefit of simulation is that it shifts the steep and dangerous part of the learning curve away from patients [2]. In transsexual surgery, where both functional (urination and sex life) and aesthetic results are essential, there is no opportunity for simulation, and therefore a concept must be established to optimize the learning curve accordingly. Leclère et al. therefore developed a learning concept that involves four steps: (i) formal identification of the surgical steps in order to provide both measures of surgical process and measures of outcomes, (ii) training on cadavers with expert assistance [3], (iii) performing the surgery under the supervision of an expert, and (iv) performing the surgery alone. At our institution, we are currently at step 4 of the learning program and have seen a clear reduction in the risks to the patient associated with the learning curve. In other words, the surgeon can refine their technique to a greater degree in advance of their first case. In our opinion, the clinical outcomes, when published, will underline the benefits of this concept, the possibility of becoming good to excellent and not simply acceptable to good, and the possibility of introducing the same training model for other complex operations. There is currently much debate on the learning curve and the contribution of new technologies to optimize it and to reduce its consequences for patients [2]. At the same time, we are aware of the increasingly strict legislations related to the use of cadavers in medicine. Herein we would like to reemphasize the importance of maintaining anatomical dissections for two indications in building new concepts to facilitate the transition from bench to bedside [4,5] and in optimizing the learning curve for complex operations such as that presented here [3]. Conflict of Interest: The author(s) report no conflicts of interest. Franck Marie Leclère, MD, PhD,* † Vincent Casoli, MD, PhD,* † and Romain Weigert, MD* *Department of Plastic & Transsexual Surgery, Center of Expertise for Sex Reassignement Surgery, CHU—Centre François-Xavier-Michelet, Groupe Hospitalier Pellegrin, University of Bordeaux, Bordeaux, France; † Department of Anatomy, Centre François-Xavier-Michelet, Groupe Hospitalier Pellegrin, University of Bordeaux, Bordeaux, France Letters to the Editor 1655 J Sex Med 2015;12:1654–1656