sexually aroused by both, though a sexual preference for one over the other in this case may also exist. If the attraction is a sexual preference for prepubescent children, such offenders are considered pedophiles in the same vein as exclusive offenders. Neither the DSM nor the ICD-11 diagnostic criteria require actual sexual activity with a prepubescent youth. The diagnosis can therefore be made based on the presence of fantasies or sexual urges even if they have never been acted upon. On the other hand, a person who acts upon these urges yet experiences no distress about their fantasies or urges can also qualify for the diagnosis. Acting on sexual urges is not limited to overt sex acts for purposes of this diagnosis, and can sometimes include indecent exposure, voyeuristic or frotteuristic behaviors. The ICD-11 also considers planning or seeking to engage in these behaviors, as well as the use of child pornography, to be evidence of the diagnosis. However the DSM-5-TR, in a change from the prior edition, excludes the use of child pornography alone as meeting the criteria for "acting on sexual urges." This change is controversial due to being made for legal reasons rather than scientific. According to forensic psychologist Michael C. Seto, who was part of the DSM-5-TR workgroup, the removal of child pornography use alone was to avoid diagnosing criminal defendants convicted of child pornography offenses, but no in-person offenses, with pedophilic disorder, as this could potentially lead to such defendants being committed to mental institutions under sexually violent predator laws. Seto, who has published several research studies on pedophilia and its relationship with child pornography, objected to this reasoning by the APA, as it would only apply to a tiny minority of commitments, as well as deny help-seeking pedophiles access to clinical care due to not having an official diagnosis for insurance purposes. In practice, the patient's behaviors need to be considered in-context with an element of clinical judgment before a diagnosis is made. Likewise, when the patient is in late adolescence, the age difference is not specified in hard numbers and instead requires careful consideration of the situation. Debate regarding criteria There was discussion on the DSM-IV-TR being overinclusive and underinclusive. Its criterion A concerns sexual fantasies or sexual urges regarding prepubescent children, and its criterion B concerns acting on those urges or the urges causing marked distress or interpersonal difficulty. Several researchers discussed