Organizations: Institute of Data Science, Faculty of Science and Engineering, Maastricht University, Maastricht, The Netherlands · Department of Advanced Computing Sciences, Faculty of Science and Engineering, Maastricht University, Maastricht, The Netherlands · VITO, Belgium
Abstract
Per-subgroup fairness audits of medical image classifiers face a sample-size problem: minority subgroups in held-out test sets have so few samples that the resulting confidence intervals on per-subgroup performance are wider than the bias the audit is meant to detect. We argue that a demographically-conditioned synthetic generator can do both: mitigate bias on the training side and detect bias on the evaluation side. Working on COVID-19 chest CT classification with an end-to-end fine-tuned Stable Diffusion 2.1 generator, we make two findings. For bias mitigation (training), a demographically-balanced synthetic cohort is most useful as a pretraining prior, not as joint augmentation: with the same fixed data, sequential pretraining followed by fine-tuning substantially outperforms joint augmentation, and the resulting classifier surpasses the full-real baseline at \sim$$100\times real-data efficiency. For bias detection (evaluation), across five synthetic minority cohorts and five classifier seeds, the synthetic estimator reproduces the subgroup ranking of a well-powered real oracle (Spearman ρ=1.00 on MCC and Recall) and gives the more reliable per-cell estimate where the small real test set runs out of samples. The synthetic cohort is therefore most useful in exactly the cells that fairness audits care about, as both a fix for and a measure of subgroup bias.
Medical imaging is central to modern diagnostics, and artificial intelligence (AI) systems are increasingly used to support image-based analysis by improving efficiency, accuracy, and access to care. However, inequities in healthcare access and differential disease prevalence create severe demographic imbalances in clinical image data. Such imbalances are compounded by the fact that diseases can manifest with distinct features across demographic groups, rendering certain phenotypic presentations naturally rare. AI models trained on such imbalanced data risk perpetuating diagnostic bias and widening healthcare disparities. Here we introduce FairGen, a fairness-aware diffusion framework that synthesizes demographically balanced medical images while preserving pathology-relevant visual features. By embedding physician-aligned preferences into the generation process, FairGen improves subgroup coverage during synthesis and downstream classification. Applied to dermatology, radiology, and neuroimaging benchmark tasks, FairGen achieves fairness improvements of 95.9% for skin images, 80.0% for chest radiography, and 35.2% for brain MRI, while maintaining competitive diagnostic accuracy relative to models trained on original clinical data. Clinician-facing expert review and external validation on independent cohorts further support that these gains extend beyond standard fidelity metrics and are not confined to the original in-distribution datasets.
Class imbalance is a persistent challenge in visual recognition, particularly in safety-critical domains where collecting positive examples is expensive and rare events are inherently underrepresented. We propose a lightweight synthetic data augmentation pipeline that fine-tunes a LoRA adapter on as few as 20-50 real images of a rare class and uses a pretrained diffusion model to generate synthetic samples for training. We systematically vary the synthetic-to-real ratio and evaluate the approach across two structurally different domains: chest X-ray pathology classification (NIH ChestX-ray14) and industrial surface crack detection (Magnetic Tile Defect dataset). All evaluations are performed on held-out sets of real images only. Across both domains, synthetic augmentation consistently improves rare-class recall and F1 compared to training with real data alone. Performance improves with moderate synthetic augmentation and shows diminishing returns as the synthetic ratio increases. These results suggest that LoRA-adapted diffusion models provide a simple and scalable mechanism for augmenting rare classes, enabling effective learning in data-scarce scenarios across heterogeneous visual domains.
Daniil Dushenev, Nazariy Karpov, Daniil Zinovjev +2
Generative models are increasingly used to augment medical imaging datasets for fairer AI, yet a key assumption often goes unexamined: that generators produce equally high-quality images across demographic groups. Models trained on imbalanced data inherit these imbalances, degrading synthesis for rare subgroups and struggling with intersections absent from training: the imbalanced generator problem. Remedies such as loss reweighting operate at the optimization level and provide limited benefit when training signal is scarce or absent. We propose CompDiff, a hierarchical compositional diffusion framework that addresses this at the representation level. A dedicated Hierarchical Conditioner Network (HCN) decomposes demographic conditioning into single-attribute, pairwise, and composed representations, producing a demographic token concatenated with CLIP embeddings as cross-attention context. This structured factorization encourages parameter sharing across subgroups and supports compositional generalization to rare or unseen intersections. On chest X-rays (MIMIC-CXR) and fundus images (FairGenMed), CompDiff compares favorably against standard fine-tuning and FairDiffusion across image quality (FID 64.3 vs. 75.1), subgroup equity (ES-FID), and zero-shot intersectional generalization (up to 21% FID improvement on held-out intersections). Downstream classifiers trained on CompDiff data show improved AUROC and reduced demographic bias, suggesting that the architectural design of demographic conditioning is an important and underexplored factor in fair medical image generation. Code: https://github.com/mahmoudibrahim98/CompDiff.