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."
Earlier this month, the city apologized to a transgender couple when they were asked to show their birth certificates when getting married because the clerk claimed their appearance didn't match their photo IDs. State laws do not require couples to show birth certificates when getting married.
Lewis cites a recent study by National Center for Transgender Equality (NCTE) that shows 80 percent of women and 95 percent of men do not undergo sex reassignment surgery because of the cost, which can be tens of thousands of dollars.
The report, released in February, paints a bleak picture of life as a transgender person in the United States. The survey, "Injustice at Every Turn," says discrimination is pervasive.
Most respondents said they lived in extreme poverty, and many reported attempting suicide. They revealed harassment in education, employment, housing and health care, as well as in the government and prison systems.
"We have an unemployment rate twice the national average and four times the national average of people who live on less than $10,000 a year," said Mara Keisling, NCTE's executive director. "Part of the problem is people are less employable because they don't have IDs that match who they are?It's tied together in a cycle."
One of the litigants, Sam Berkley, who is a student, has had a double mastectomy, but not genital surgery, partly because of cost. "I don't have $20,000 to $100,000 at the moment," he said.
Berkley also said he didn't want to subject himself to an invasive procedure to create a phallus. "It doesn't make me a man."
"I think that transgendered people should have access to updated and accurate documents," Berkley, 30. "To have a document that says I am female and I am not completely legitimized by the city where I pay taxes, doesn't make any sense. It sets me up to be a second class citizen and for discrimination."
Another litigant, Patricia Harrison, 58, has been fully transitioned since 2000 with all appropriate legal documents.
She faced a challenge when she moved from New York to New Jersey and had to transfer her driver's license. One of the requirements was to show a birth certificate or a passport. She didn't have the latter.
When she presented her male birth certificate to the New Jersey DMV, they turned her away. "I had to go back to the doctor again and get another letter even though I had gone through that process for New York State," said Harrison.
"All I did was cross the Hudson and I had to prove who I am all over again," she said. "It was like going to a foreign country. It wasn't right."
She, too has not had surgery. "My doctor and therapist agree that it has reached the point where I present myself as a female and am comfortable with the way I am," said Harrison. "It's not like I am 22 and sexually active. It's major surgery with a lot of potential complications."
As for Prinzivalli, for years she "hid" as a woman trapped in a man's body until she was inspired by reading the story of Christine Jorgensen, an American soldier who had sex reassignment surgery in Denmark in 1952.
Prinzivalli had give up plans to transition to a woman when her psychiatrist was not supportive. She married for 20 years and had four children, but eventually came out fully in 2000 with devastating consequences.
"I lost my spouse, my family and my home and the last straw was my job," she said. "That was the last day I did anything male."
Prinzivalli changed her name and all her documents. She sought counseling and underwent 400 hours of electrolysis and hormone replacement therapy. After three years she knew, "I wasn't going back."
The final effort was to amend her birth certificate and she had a letter from her endocrinologist saying she had medically transitioned.
But the Bureau of Vital Records didn't recognize her common-law name change and required a judicial name change, but Prinzivalli needed to provide a copy of her New York birth certificate. "It was circular reasoning," she said.
The 50 states have a collection of different laws on how transgender Americans can change their birth certificates.
Three states -- Idaho, Ohio and Tennessee -- ban any change to the birth certificate at all. Some require a court order, some, like New York, require proof of a surgical procedure.
In Washington state, which advocates say is a model, birth certificate changes require a doctor, under penalty of perjury, to validate the gender transition.
"Why would anyone who has not transitioned even think of doing this?" asked NCTE's Keisling. "You have a right to do this. It doesn't make sense. What possible fraud is there?"