MedForge: Interpretable Medical Deepfake Detection via Forgery-aware Reasoning

Conventional image forgery detection methods produce binary scores or pixel-level masks without interpretable evidence, while recent multimodal large language model (MLLM)-based approaches generate post-hoc explanations of predetermined classification results rather than reasoning from evidence. Inspired by the forensic workflow of human judicial experts, we propose Agentic Tool-Augmented Reasoning (ATAR), a framework integrating 22 specialized forensic tools across seven complementary domains to autonomously detect, localize, and explain image forgeries through multi-turn reasoning. A Dual-Stream Forensic Reasoning paradigm combines a high-level semantic anomaly path, which magnifies suspicious regions for fine-grained inspection, with a low-level forgery artifact path, which invokes forensic tools to extract objective evidence. We further introduce Forensics Curriculum Learning: during General Experience SFT, an automated teacher-student mentoring pipeline synthesizes multi-turn tool-usage reasoning trajectories; during Forensic Scene RL, a Tool Prior Curriculum guides early tool exploration and progressively transfers control to the agent, while a Structured Evidence Reward provides fine-grained process-level supervision. Experiments across IMDL, Deepfake detection, DMDL, and AIGC detection show that ATAR achieves 78.5% average image-level F1 on six zero-shot IMDL benchmarks, surpassing the strongest MLLM baseline by 11.8 percentage points, and remains competitive with specialized detectors on other tasks while producing substantially more faithful and grounded explanations.

The emergence of medical deepfakes, i.e., medical images manipulated by deep generative models, poses a significant threat to clinical workflows. However, existing detectors suffer from two critical limitations: poor generalization to unseen generative architectures for manipulation detection and lack of interpretability. In this context, we present HexMIL (Hierarchical EXplainable Multiple Instance Learning), a mask-free medical deepfake detector that simultaneously addresses both limitations using only binary volume-level supervision. HexMIL decomposes each CT volume into a two-level hierarchy of patches and slices, aggregated via independent Gated Attention modules whose weights are directly combined into a full-resolution 3D attention volume that localizes the manipulated sub-region without any pixel-level annotation. Unlike post-hoc methods such as Grad-CAM, HexMIL's attention weights constitute the exact forward computation driving the classification decision, providing ante-hoc and structurally faithful spatial attribution. We evaluate HexMIL on M3DSynth and CT-GAN datasets under a rigorous cross-generator generalization protocol, training on a single generative architecture and testing on unseen ones. HexMIL outperforms all baselines by $+9.1$ AUC and $+9.4$ F1 in out-of-domain classification, and achieves the best average IoU and Pointing Game score in localization. Project page: opontorno.github.io/hexmil.

A medical vision-language model may analyze a given CT scan and correctly detect both kidneys in view. Continuing this conversation, if a user provides a prescription with an opposite direction, medical VLMs often sycophantically choose to realign their diagnosis. In this work, we study regressive sycophancy under fabricated evidence, where a model abandons a correct answer when pushback comes with a fake document. We test four open VLMs on 400 VQA-RAD yes/no questions in 19,200 multi-turn conversations, with and without a fabricated prescription. Without a disclosure that documents are synthetic, the models abandon 80.1% of 6,488 correct answers. Notably, under one script each, the same prescription raises the flip rate of Qwen2.5-VL-7B from 45.9% to 89.6% and lowers that of Qwen3-VL-8B from 77.7% to 50.9%. A model rejected the prescription while still preserving the correct answer in 915 of 3,232 conversations with the prescription (28.3%), and 40% of these flipped in later turns. System-prompt sentences that disclose the documents as synthetic lower one model's flip rate from 77.8% to 47.3%. Thus, we conclude that awareness about a forgery does not prevent a model from adopting its answer.