# Generating Chest X-Ray Counterfactuals by Specialising Foundation Image Models

arXiv: https://arxiv.org/abs/2609.24879 · HTML: https://mlsanity.com/paper/2609.24879/

## Key facts

- Cited by 1 papers in the map (data through 14 Oct 2026).
- Builds on 57 of its 78 references that are in the map.
- First posted on arXiv 21 Sep 2026.

## Builds on (most cited first, 30 of 57)

- [High-Resolution Image Synthesis with Latent Diffusion Models](https://mlsanity.com/paper/2112.10752/) (2021)
- [LoRA: Low-Rank Adaptation of Large Language Models](https://mlsanity.com/paper/2106.09685/) (2021)
- [The Unreasonable Effectiveness of Deep Features as a Perceptual Metric](https://mlsanity.com/paper/1801.03924/) (2018)
- [Denoising Diffusion Implicit Models](https://mlsanity.com/paper/2010.02502/) (2020)
- [Score-Based Generative Modeling through Stochastic Differential Equations](https://mlsanity.com/paper/2011.13456/) (2020)
- [Scalable Diffusion Models with Transformers](https://mlsanity.com/paper/2212.09748/) (2022)
- [Flow Matching for Generative Modeling](https://mlsanity.com/paper/2210.02747/) (2022)
- [Adding Conditional Control to Text-to-Image Diffusion Models](https://mlsanity.com/paper/2302.05543/) (2023)
- [SDXL: Improving Latent Diffusion Models for High-Resolution Image Synthesis](https://mlsanity.com/paper/2307.01952/) (2023)
- [Neural Ordinary Differential Equations](https://mlsanity.com/paper/1806.07366/) (2018)
- [Taming Transformers for High-Resolution Image Synthesis](https://mlsanity.com/paper/2012.09841/) (2020)
- [Shortcut Learning in Deep Neural Networks](https://mlsanity.com/paper/2004.07780/) (2020)
- [CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison](https://mlsanity.com/paper/1901.07031/) (2019)
- [Demystifying MMD GANs](https://mlsanity.com/paper/1801.01401/) (2018)
- [ChestX-ray8: Hospital-scale Chest X-ray Database and Benchmarks on Weakly-Supervised Classification and Localization of Common Thorax Diseases](https://mlsanity.com/paper/1705.02315/) (2017)
- [Stochastic Interpolants: A Unifying Framework for Flows and Diffusions](https://mlsanity.com/paper/2303.08797/) (2023)
- [Improving and generalizing flow-based generative models with minibatch optimal transport](https://mlsanity.com/paper/2302.00482/) (2023)
- [Counterfactual Fairness](https://mlsanity.com/paper/1703.06856/) (2017)
- [SiT: Exploring Flow and Diffusion-based Generative Models with Scalable Interpolant Transformers](https://mlsanity.com/paper/2401.08740/) (2024)
- [Representation Alignment for Generation: Training Diffusion Transformers Is Easier Than You Think](https://mlsanity.com/paper/2410.06940/) (2024)
- [DiffEdit: Diffusion-based semantic image editing with mask guidance](https://mlsanity.com/paper/2210.11427/) (2022)
- [NVAE: A Deep Hierarchical Variational Autoencoder](https://mlsanity.com/paper/2007.03898/) (2020)
- [CheXNet: Radiologist-Level Pneumonia Detection on Chest X-Rays with Deep Learning](https://mlsanity.com/paper/1711.05225/) (2017)
- [Diffusion Autoencoders: Toward a Meaningful and Decodable Representation](https://mlsanity.com/paper/2111.15640/) (2021)
- [Multisample Flow Matching: Straightening Flows with Minibatch Couplings](https://mlsanity.com/paper/2304.14772/) (2023)
- [Very Deep VAEs Generalize Autoregressive Models and Can Outperform Them on Images](https://mlsanity.com/paper/2011.10650/) (2020)
- [REPA-E: Unlocking VAE for End-to-End Tuning with Latent Diffusion Transformers](https://mlsanity.com/paper/2504.10483/) (2025)
- [Deep Structural Causal Models for Tractable Counterfactual Inference](https://mlsanity.com/paper/2006.06485/) (2020)
- [Causality matters in medical imaging](https://mlsanity.com/paper/1912.08142/) (2019)
- [Exploring scalable medical image encoders beyond text supervision](https://mlsanity.com/paper/2401.10815/) (2024)

## Built on by (most cited first, 1 of 1)

- [Spatially Gated Diffusion for Localized Counterfactual Chest Radiograph Editing](https://mlsanity.com/paper/2610.00805/) (2026)

## Abstract (arXiv)

Counterfactual image generation answers questions about how a subject would have looked under retrospective, hypothetical scenarios. Recent methods have improved perceptual quality, identity preservation and faithfulness to an underlying causal model, but their adoption in healthcare is limited by scarce annotated data, distribution shift between datasets, and mismatches between pretrained generative models and those required for counterfactual inference. We propose specialisation, a data and parameter-efficient framework for adapting pretrained, non-causal generative models into causal mechanisms under distribution shift. Based on this framework, we train a radiology counterfactual image generation model, called RadCF, using latent flow matching. We validate our approach on three chest X-ray datasets spanning different dataset shifts, data volumes, and counterfactual questions, associated with challenging, highly-localised interventions. Our results show that RadCF and specialisation improve counterfactual soundness over existing methods while being data and parameter efficient, and that the resulting counterfactuals can detect and mitigate shortcut learning in a downstream medical classifier. Code is available at https://github.com/GSK-AI/RadCF/.