Joann Prinzivalli's New York City birth certificate still reads: Paul Joseph Prinzivalli Jr., male, even though she transitioned to a woman more than a decade ago.
"At the age of 4, when I first realized the difference between boys and girls, I knew I belonged with the girls," said Prinzivalli, 57, a title insurance lawyer. "I hated getting my hair cut. I didn't know the differences in genitalia, but I knew in the 1950s that girls had long hair and wore dresses and boys had short hair and pants."
She attempted a transition from man to woman in the 1970s, fully prepared to have genital surgery, but her psychiatrist rejected her request.
Prinzivalli, now 57, eventually changed her name and has legal documents -- a driver's license and a Social Security card -- but her birth certificate doesn't match.
She wants to take the final step to secure her identity, but the New York City Health Department has demanded she have sex reassignment surgery -- on her genitals.
Thirty years ago, she was healthy enough, but today Prinzivalli is morbidly obese and has type 2 diabetes, high cholesterol and a blood disorder that would make surgery dangerous.
She is one of three transgender New Yorkers who are challenging the city in a lawsuit, saying that requiring surgery amounts to discrimination.
The lawsuit was filed by the Transgender Legal Defense and Education Fund (TLDEF) in the state Supreme Court, arguing that many transgender people cannot afford the surgical procedures. They say a doctor's verification that they have fully transitioned is enough.
"It is an issue of fairness and equality, but also an issue of having the right thing on my records and on paper," said Prinzivalli. "I am not asking them for a change, I am asking for a correction. The way I look at it, I was born this way."
The federal government allows transgender Americans to change their gender marker on their passports and Social Security accounts with a doctor's certification that the person has had appropriate clinical treatment.
"When transgender people are forced to present an ID that does not match, they are laughed at and turned away at the DMV or applying for a job," said Noah Lewis, the TLDEF lawyer who is defending the New Yorkers. "The cost is prohibitive for some people and insurance often denies those claims. Some people feel that surgery is not necessary or appropriate for them."
"This should be a decision between them and their doctor," he said.
The New York City Health Department requires written proof, "satisfactory to the department that the applicant has undergone convertive surgery," which it defines as genital surgery.
"We are very sympathetic to the petitioners' concerns and recognize that this is a complex issue," wrote Gabriel Taussig, chief of the New York City Health Department's administrative law division, in a statement. "The health department must be satisfied that an applicant has completely and permanently transitioned to the acquired gender prior to the issuance of a new birth certificate."