Diagnostic dilemmas of child sexual abuse

Globally, an estimated 12-13% of children experience sexual abuse, with prevalence rates of approximately 18% among girls and 8% among boys. Clinicians evaluating pediatric patients who present with anogenital complaints or lesions face considerable diagnostic challenges. The purpose of this narrative review is to outline the most frequently encountered conditions that can mimic child sexual abuse (CSA), thereby raising clinical awareness and helping to minimize both false-positive and false-negative diagnoses. We conducted a semi-systematic literature search in PubMed covering the period from 2000 to 2025, using the search terms "child sexual abuse," "differential diagnosis," "mimics," and "mimickers," supplemented by the German interdisciplinary guideline on child abuse and neglect. Notably, the vast majority of children who have been sexually abused present without detectable physical abnormalities. Conversely, an erroneous diagnosis of abuse-or the failure to identify a treatable underlying condition-can carry severe consequences. Many practitioners in primary care lack sufficient training to distinguish the wide range of dermatologic and systemic disorders that may affect the anogenital region. Precise recognition, careful documentation, and scientifically grounded interpretation of physical findings are critical to ensue child protection. Optimal medical care for suspected CSA victims requires that clinicians possess expertise in pediatric and adolescent gynecology and forensic medicine, recognize the constraints inherent to physical examination findings, and consistently employ up-to-date classification frameworks and clinical guidelines. Heightened awareness of CSA mimickers is essential both to prevent unfounded allegations and to ensure timely, appropriate management of genuine abuse.