Adjustment of wording of the clinical significance criterion for the Paraphilias
In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), the criteria sets for the Paraphilias included a clinical significance criterion (i.e., "the person has acted on these urges, or is markedly distressed by them") in recognition of the fact that the mere presence of paraphilic sexual urges or fantasies do not necessarily warrant a diagnosis of a paraphilia in an individual. During the preparation of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the wording of this criterion was adjusted (i.e.,”the fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning") as part of the effort to adopt uniform wording for the clinical significance criterion across the disorders.
An unforeseen side effect of this rewording was that it led to confusion regarding the DSM-IV definition of Pedophilia. Specifically, the replacement of the DSM-III-R phrase “acts on these urges” with the phrase “causes clinically significant…impairment” was misconstrued to represent a fundamental change in the definition of Pedophilia. Some readers misunderstood this new wording as greatly restricting the number of individuals who would be diagnosed with Pedophilia by requiring that they be distressed by their behavior in order to qualify for the diagnosis. This was clearly never intended, since it is well recognized that many (if not most) individuals with Pedophilia are not distressed by their pedophilic urges, fantasies, and behaviors. In fact, rather than restricting the diagnosis of Pedophilia to fewer individuals, the original purpose of the change was to potentially broaden the diagnosis to include individuals whose pedophilic urges interfered with functioning in a variety of ways (e.g., causing impairment in occupational functioning because of a preoccupation with pedophilic thoughts and images at work). There was never any intention to no longer include individuals who acted on their urges.
To remove any possible ambiguity regarding whether acting out pedophilic urges with others is sufficient for a diagnosis of Pedophilia, the original DSM-III-R wording has been reinstated. Furthermore, the original DSM-III-R wording has been reinstated for other paraphilias that inevitably harm their victims (i.e., voyeurism, exhibitionism, and frotteurism). Because some cases of Sexual Sadism may not involve harm to a victim (e.g., inflicting humiliation on a consenting partner), the wording for sexual sadism involves a hybrid of the DSM-III-R and DSM-IV wording (i.e., “the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty”).