The Injectable Estradiol and Progesterone Shortages of 2018

MTF Trans Hormonal Therapy

Rev. 6, by Beverly Cosgrove, 9-6-2018

UPDATE 9-9-2018: Perrigo states that there is a limited supply of the 40mg/ml generic available. Perrigo also forecasts that the 20mg/ml generic will become available this month, in September.

UPDATE 6-26: (1) Perrigo has declared, finally, an official shortage, but confirmed that they intend to CONTINUE production of EV in 20mg/ml and 40mg/ml strengths. Their announcement says “Perrigo has estradiol valerate 20 mg and 40 mg vials on back order and the company estimates a release date of August 2018.” (2) A new shortage of Estradiol Cypionate injection in the Los Angeles area has been reported by patients. (3) One patient in Sweden has reported a shortage of Polyestradiol Phosphate (Estradurin).


Once again, shortages of injectable estradiol have appeared. AMAB trans women who are entirely dependent on injected estradiol are finding that their usual prescription is entirely unavailable. And a sense of panic is…

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Democracy (& Governance) implemented by the Blockchain– what if??

Political system(Proof of Representation –DLT based tech for voting on policies):

* — Inspired by thoughts/comment on a tweet. ([original commenti](https://twitter.com/softwarmechanic/status/939001090044919810))

*– Verbatim: rmehta: Democracies hacked by lying, autocracies by murder, Any option?       softwaremechanic: We might have to come up with something like Proof of       Representation on top of the Distributed ledger tech(aka crypto currency). Be       assured, there’ll be new hacking methods invented after though.

How to Read:

* — This is partly sci-fi and partly realistic (Only in the very, very long-term).

* — Techies do read the Techie Section at the end.

### Core proposal:

* — A DLT/Crypto coin based policy making system

* — Create a few category of policies

* — A set of proof validation techniques.(For ex: crowd sourced face recognition for   identity).

* — Create a set of proof of xxx implementation for voting in policies

* — Map policy categories to proof validation techniques.
### Some examples:

* — Policies need to be categorized based on their (primary aka first-order) impact .For ex:(geographical for land impacts on say agriculture, natural resources etc. , economical for impacts on economy   like interest rates, inflation rates, real-estate prices, etc.. policies might be SEZs,   tax-policies etc.. )
* — For Geographical policies, proof of representation should depend on land ownership   proofs, and proof of living for the policy’s governing area
* — For economic policies, proof of status of living in that area should be used.
* — For social policies(law and order), it’ll be interesting, proof of living should be   used, but how to figure out proof of living in the community is a tricky question.
### Some cons:

* — Intersection of impacts is common for policies and people will constantly and   consistently try to mis-categorize policies for the sake of   influencing/dominating/take-over attack the voting on the blockchain.

* — For Geographical policies, can be dominated by biggest land owners and so will get some   dominance by them. Will raise echoes of say the Zamindar system.
* — Will probably[^1] take more time for decision-making than representative democracy.
* — Will probably be harder to convince people to adopt it as it’ll be called   discrimination.
### Some pros:

* — Less centralized than the current [representative democracy](https://en.wikipedia.org/wiki/Representative_democracy) (ELI5: Some chosen(generally by voting) people represent a bigger group of people and vote for them in bigger policies)
* — Less decentralized than the complete [participatory democracy](https://en.wikipedia.org/wiki/Participatory_democracy)(ELI5: Everybody votes for every policy)
* — More participation and interestingly, can be more participation at a segregated level.
* — Can help or work better in the globalized economy, by preventing mistakes done by a   central authority to prop-up their currency.

* — Can be extended to include compensation for the Govt. employees and subsidies. =

* — Has potential to reduce bribery, as there’ll be no way to not leave a trail

* — If implemented on a protocol, that implements an identity centric implementation as   opposed to anonymity focus, can be used as a public record without needing [RTIs](http://rti.gov.in/) and such.
### Techie Section: #### Bitcoin-specific:

* — A crypto currency is defined as a string of digital signatures.

* — Distributed Ledgers are basically a big long immutable hash map of strings that appends   a new string every transaction.

* — Verification is by majority consensus.

More generic:

* — A crypto currency is defined as a string of digital signatures.

* — Anyone can add a new string provided they satisfy some xxx condition and consensus.

* — The xxx condition is called proof in case of [bitcoin](https://fermatslibrary.com/s/bitcoin)   it is a complex computation that by design takes a long time, and (by putting   a cap of total mineable coins) is mostly costlier than the electricity it takes.

* — In the case of [Ethereum](https://ethereum.org) it is called proof of stake(or will be).

* — There are non-mineable coins too, which are implemented by a different type of   contract.

* — The contract(of proof of xxx) and the number of coins are defined during the [Initial Coin Offering(ICO)](https://www.investopedia.com/terms/i/initial-coin-offering-ico.asp) in a whitepaper.

* — One hackable issue is few people gaining majority of the coins and is called majority   attack

* — By definition during the initial problem few people have the majority and can screw   over the rest of the community.

* — Crowd sources trust issues.

Scifi-section:

* — The context was inspired by only DLT based currencies for everything including budget   allotment.

* — It will work well in a futuristic world of energy utopia.(there might be a way around,   but they’re all hard to bootstrap).

* — Can be built on top of [Ethereum](https://ethereum.org/).

Disclaimer, References & Footnotes:

* — Some parts/ideas were inspired by the blog [The Blockchain Man](https://www.ribbonfarm.com/2017/10/10/the-blockchain-man/)

* — Particularly light on the implementation details of the protocol, because it’s not   clear what’s best at the moment
* — Author is NOT a political  scientist. Primarily a technologist, with some orthogonal   degrees and self-learnt knowledge in a few other fields.
* — For the techies who know about the DLT area, you’d notice, some of the PO(X) terms can be   replaced by Proof of Stake, and it is correct. The only reason, the author uses a   different term is the Stakes are complicated and need to be categorized/grouped as such by policy.
[^1] — Probably, because technology, can speed up, if we have enough energy, which we may not.

Block Chain (or crypto currency) based government

## Political system(Proof of Representation –DLT based tech for voting on policies):
* — Inspired by thoughts/comment on a tweet.
([original commenti](https://twitter.com/softwarmechanic/status/939001090044919810))
*– Verbatim: rmehta: Democracies hacked by lying, autocracies by murder, Any option?
softwaremechanic: We might have to come up with something like Proof of
Representation on top of the Distributed ledger tech(aka crypto currency). Be
assured, there’ll be new hacking methods invented after though.
### How to Read:
* — This is partly sci-fi and partly realistic (Only in the very, very long-term, energy utopia(or atleast cheap energy)).
* — Techies do read the Techie Section at the end.

### Core proposal:
* — A DLT/Crypto coin based policy making system
* — Create a few category of policies
* — A set of proof validation techniques.(For ex: crowd sourced face recognition for
identity).
* — Create a set of proof of xxx implementation for voting in policies
* — Map policy categories to proof validation techniques.

### Some examples:
* — Policies need to be categorized based on their (primary aka first-order) impact .For ex:(geographical for land impacts on say agriculture, natural resources etc. , economical for impacts on economy
like interest rates, inflation rates, real-estate prices, etc.. policies might be SEZs,
tax-policies etc.. )

* — For Geographical policies, proof of representation should depend on land ownership
proofs, and proof of living for the policy’s governing area

* — For economic policies, proof of status of living in that area should be used.

* — For social policies(law and order), it’ll be interesting, proof of living should be
used, but how to figure out proof of living in the community is a tricky question.

### Some cons:
* — Intersection of impacts is common for policies and people will constantly and
consistently try to mis-categorize policies for the sake of
influencing/dominating/take-over attack the voting on the blockchain.
* — For Geographical policies, can be dominated by biggest land owners and so will get some
dominance by them. Will raise echoes of say the Zamindar system.

* — Will probably[^1] take more time for decision-making than representative democracy.

* — Will probably be harder to convince people to adopt it as it’ll be called
discrimination.

### Some pros:
* — Less centralized than the current [representative democracy](https://en.wikipedia.org/wiki/Representative_democracy) (ELI5: Some chosen(generally by voting) people represent a bigger group of people and vote for them in bigger policies)

* — Less decentralized than the complete [participatory democracy](https://en.wikipedia.org/wiki/Participatory_democracy)(ELI5: Everybody votes for every policy)

* — More participation and interestingly, can be more participation at a segregated level.

* — Can help or work better in the globalized economy, by preventing mistakes done by a
central authority to prop-up their currency.
* — Can be extended to include compensation for the Govt. employees and subsidies.
* — Has potential to reduce bribery, as there’ll be no way to not leave a trail
* — If implemented on a protocol, that implements an identity centric implementation as
opposed to anonymity focus, can be used as a public record without needing [RTIs](http://rti.gov.in/) and such.

### Techie Section:
#### Bitcoin-specific:
* — A crypto currency is defined as a string of digital signatures.
* — Distributed Ledgers are basically a big long immutable hash map of strings that appends
a new string every transaction.
* — Verification is by majority consensus.

#### More generic:
* — A crypto currency is defined as a string of digital signatures.
* — Anyone can add a new string provided they satisfy some xxx condition and consensus.
* — The xxx condition is called proof in case of [bitcoin](https://fermatslibrary.com/s/bitcoin)
it is a complex computation that by design takes a long time, and (by putting
a cap of total mineable coins) is mostly costlier than the electricity it takes.
* — In the case of [Ethereum](https://ethereum.org) it is called proof of stake(or will be).
* — There are non-mineable coins too, which are implemented by a different type of
contract.
* — The contract(of proof of xxx) and the number of coins are defined during the [Initial Coin Offering(ICO)](https://www.investopedia.com/terms/i/initial-coin-offering-ico.asp) in a whitepaper.
* — One hackable issue is few people gaining majority of the coins and is called majority
attack
* — By definition during the initial problem few people have the majority and can screw
over the rest of the community.
* — Crowd sources trust issues.

### Scifi-section:

* — The context was inspired by only DLT based currencies for everything including budget
allotment.
* — It will work well in a futuristic world of energy utopia.(there might be a way around,
but they’re all hard to bootstrap).
* — Can be built on top of [Ethereum](https://ethereum.org/).

### Disclaimer, References & Footnotes:
* — Some parts/ideas were inspired by the blog [The Blockchain Man](https://www.ribbonfarm.com/2017/10/10/the-blockchain-man/)
* — Particularly light on the implementation details of the protocol, because it’s not
clear what’s best at the moment

* — Author is NOT a political scientist. Primarily a technologist, with some orthogonal
degrees and self-learnt knowledge in a few other fields.

* — For the techies who know about the DLT area, you’d notice, some of the PO(X) terms can be
replaced by Proof of Stake, and it is correct. The only reason, the author uses a
different term is the Stakes are complicated and need to be categorized/grouped as such by policy.

[^1] — Probably, because technology, can speed up, if we have enough energy, which we may not.

Fungible Code monkey.

Something i wrote a loong looong time ago, inpsired by this scene

I’m not a fungible code monkey
I’m in another category
What you have with you
Is not some script kiddie
Nothing here is faked
I’ve done a mighty time with code,
A few things have been added
And one or two subtractions

I’m not a fungible code monkey
I won’t let you forget it

When you say “Just get it done”
You stab me all the way through
My tender,bleeding hacker heart

And if you happen to be ex-programmer
You could show a little heart and understanding
Instead of ordering and whining and pointing Judas fingers
Like a bunch of cowards in a battlefield
And if you think I’m such a freak
There’s no need to cut me down
And put me in my place
You just may want to look at yourself , oh so smug

I’m not a fungible code monkey
I don’t write foot-long scripts
Don’t pound a server keyboard
I don’t want your five cents
Before this song is over

‘Cause I’m not a fungible code monkey
So please don’t be so rude
I’ll break your fucking mind, sir
And then I’ll python while
I mend my hacker heart
Can’t you just “Lisp”
And “haskell” and “node” and “llvm”
To my tender, hacker heart

Experts, Journalism..rent-seeking vs risk-taking principle

Experts are a clas of people who have been exalted in our society, since the industrial revolution freed our time and attention from mundane chores and science got the credit for that. The point that has gone missing though is that the pioneers and catalysts of industrial revolution have been many, many.. Sure definitely there have been scientists(academicians) working in laboratories and discovering facts that led to the industrial revolution.

But there have also been entrepreneurs(think edison), tinkers(Think wright  brothers) etc.. who have made substantial contributions.

Before I take a stance in favour of either, disclaimer, I identify/fall closer to the tinkerer side of things than academia, and have old grudges with the standard schooling system(I have post-graduate degree, stopped short of going for a doctorate).

@nntaleb takes the stance that the academicians/scientists generally tend to take a very conservative approach to the risk management problem involved here and some of them tend to over-inflate their importance to real world decisions and applications.

I tend to lean towards him. I do think he has a very strong point when he says, these academicians(particularly from economics field) when they move into policy and regulation, make/create absurd rules and policies that create disasters like the 2009 CDS crisis which the general public end up paying the price for.

 

The counter argument or rather closely counter argument(as it’s not an exact opposite) is the mathematicians’ apology. The point made there being that, there’s a place for academicians with low risk, because that enables them to go hunting for rare, ambitious and moon-shot projects. The general public will call them black swan events, but i think NNT will disagree, that it’s not enough to just be rare.

Anyway, the risk-taker vs rent-seeker classification can be applied to behaviour and the beauty of it is that it works without scale invariance.

 

For ex: a tenured professor, will be rent-seeking behaviour with his professorship but can be risk-taking with his research projects(hopefully). but the same professor in his financial portfolio can have Govt. Bonds for rent-seeking needs and risk-taking trying to chase multi-bagger stocks.  It can even be applied to day-to-day activities for example rent-seeking/socio-political conflict avoidance* in lectures Vs mountain climbing or para jumping or in his adventurous leisure time(or just rash driving on university commute).

 

Different professions have different patterns of this kind of trade-offs and not only is it a static in time trade-off, it is also a temporally dynamic trade-off.

For ex: A day trader might  face a lot of upside/downside on a day-to-day basis, but it might be very conservative trading  strategy over the year or two. (I’m afraid i don’t know much about day-trading).

 

One of the main conflicts/dichotomy i see between the left and the right hinges on the same principle and the different strategies they take to manage the risk and how they offload the risk.  For ex: “Whenever we label something, we judge” (Paraphrasing fro memory, From Nomi marks) implying judgement is bad, because it stresses on the differences between each other.(based on context).  On the other hand, we have John Galt, who would proclaim “There are two sides to every issue: one side is right and the other is wrong, but the middle is always evil.”  These two seemingly irreconcilable ends have a meeting point.i.e: to say, there’s a false dichotomy. You’d find this theme repeated in many different philosophical stances and arguments.

I suggest the rent-seeking Vs risk-taking behaviour can resolve this conflict. For ex: when two people are in a transaction (say a used car, to use a cliche american ex), they both have personal risk -management strategies and risk capacities regarding that particular transaction(or rather the ideal rational man probably does, but all of us just have our biases and instincts/heuristics about our risks). Circling back to answer John Galt, sure in the outside world there’s always a true/false situtation, but each person can have their own confidence level or probability belief about thet outcome and might lean either way based on that. (Think of the yes/no language here as being dictated by a logistic function which is based on subjective beliefs about the probability before the pre-experiment (opening the schroedinger’s box if you will) )

To answer the Nomi Marks part of the point, True labeling ==> judging ==> stressing on the differences, but that doesn’t mean the differences lead to decisions that are harmful by default for the other. (Once again, in an ideal transhuman ) All that needs to be the point of judging is that to make the right decision one that doesn’t incentivise rent-seeking at the cost of offloading risk to the future generation or the other party in the transaction. Without labeling/judging that’s impossible and the character per se knows that. (If you follow the series, the character prefers the welfare of the cluster over any other humans and acts accordingly harming others when needed).

So why I’m writing about this ? This might seem aimless, but it’s not. This is a way of thinking that’s rather handy for any big decisions. And also exemplifies why decisions that are made in a highly time-constrained situation tend to have closer to chance level of positive outcomes.  In my personal case, the transgender diagnosis is not neccessarily dependent on a psychiatrist giving me a certificate. It also explains, why there are so many therapists/psychiatrists unwilling to diagnose someone with gender dysphoria. It’s just a simpler risk management strategy for them given the lack of numbers/minority of psych. disorders in the general population and also less work for them to research. Which of coures is the reason, “Informed Consent” is a thing.

At an individual level, it can also be a helping tool when thinking about transition, coming out(personally and professionally) etc.  This is one of the reasons there are other labels like “non-binary”, “genderfluid”, “genderqueer” etc. This is also one of the reasons, it is not a good idea for the gatekeeping to be hand-wavy. It’s better for the gate-keeping process/systems(laws involving trans discrimination, bathroom usage etc..)  to be more open and free than restrictive. But i digress, at the personal level , does physical, social transitioning important for anyone, if the risks and rewards are commensurate. (For ex; chronic/acute depression originating in dysphoria and potentially much happier social life etc..) (To digress again, this is one of the reason, some practitioners insist on not rushing transgender HRT treatment to teens, to make sure there’s progressive worsening of the dysphoria and/or depression resulting from it. **) .

I think that’s it for now,  i am out of word-fuel for now, so i’ll  leave with a comic that kinda triggered all this thoughts in hopes it can point to the various other situations the same principle can be applied.

 

* — Note this probably is not the same for all subjects and almost definitely is a different pattern between say journalism/literature vs physics/maths fields.

** — I am not here taking the sides on this one, I tend to lean on the may be puberty blockers (and social transition) till the persons/teens are sure of what they want side, but I don’t have a strong opinion, as i surely am not early-onset-dysphoric person. Context: I am 36, and only now beginning to accept that might be trans, currently on 2-months of DIY HRT and in the middle of gender therapy, but also in the middle of unrelated marital issues so long way to go.