'Malignant' twist ending explained: Medical fact or fiction

Madison (Annabelle Wallis) can't get horrifying murders out of her head in "Malignant."

Sept. 10, 2021 4:53 PM PT

Please note: This article examines the real-life basis of the genuinely surprising central plot twist of “Malignant.” It is therefore full of spoilers. If you have not seen the film, check out this review instead and stop reading now! What are you doing? Stop!

The new horror film “Malignant” concerns a woman, Madison, having nightmarish visions of murders that turn out to be really happening. Does Madison have some sort of bond with the monstrous killer, whom we learn is called “Gabriel”?

The short answer is ... and we remind you, don’t read this if you haven’t seen the film, because you really do need to see it to believe it ...

Yes. Yes, she does, because the killer turns out to be part of her — what a doctor in the film describes in an authoritative accent as “an extreme version of a teratoma: A tumor consisting of hair, teeth, muscles, bones. And more specifically in this case, it’s a parasitic twin. When two embryos don’t separate in the womb like they should, one twin is dominant while the other is underdeveloped. It’s not considered conjoined because the underdeveloped twin is dependent on the body of the other. Like a parasite, Gabriel feeds off Emily.” (Madison’s birth name is revealed to be Emily.)

Whatever memories Madison had about this when she was younger have long since been repressed, following the operation to “remove” Gabriel and her adoption by a kindly couple with no knowledge of Gabriel’s existence. (Whenever she refers to him, they believe she’s talking about an imaginary friend. And eventually, she does too.)

But killer Gabriel is the unknowing Madison-slash-Emily’s tumor-slash-twin. He was essentially reactivated by Madison’s abusive husband, who also becomes his first victim.

It’s a cool twist, and pulled off by director James Wan and screenwriter Akela Cooper with enough panache to almost make up for the rest of the film’s overly familiar elements. But is it remotely realistic? Or pure horror genre fantasy?

According to the National Cancer Institute, a teratoma is “a type of germ cell tumor that may contain several different types of tissue, such as hair, muscle, and bone ... Teratomas usually occur in the ovaries in women, the testicles in men, and the tailbone in children. They may also occur in the central nervous system (brain or spinal cord), chest, or abdomen. Teratomas may be benign (not cancer) or malignant (cancer).”

The National Institutes of Health, in an article describing the “rare case” of a teratoma in an 8-year-old girl (they usually don’t occur until reproductive age), cited “one case of [a] 20-month-old infant who had a complaint of urinary retention.”

However, a 2008 article in the Journal of Neurosurgery: Pediatrics (via the National Library of Medicine) studied “the cases of 14 children with intracranial [within the skull] teratomas. The mean age at diagnosis was 10.5 years (range 2 days-18 years).” Sure, they’re more common in the tailbone, but having a deformed killer emerge from the protagonist’s butt might have had a different effect than the makers of “Malignant” intended.

But ... a Hindawi article described the effects of tumors located in the skull thus: “Common presenting symptoms of intracranial teratomas may include signs of raised intracranial pressure, visual disturbance, polydipsia [extreme thirst], and polyuria [excessive production of urine].”

A woman sitting at a desk speaks into a telephone

So teratomas of the brain do exist, and in children. But that “Malignant” doctor’s adjective “extreme” is doing a lot of work.

One could call Emily’s visions “visual disturbances,” but she isn’t shown to be particularly parched or frequently dashing for the toilet. One supposes it’s way less scary to have her saying, “He’s here ... I gotta pee!”

Rather, her symptoms include a freaky, skinless face that pops out of the back of her head and takes control of her/their body to enact gory revenge killings. Oh, and as childhood Emily says to doctors, “Gabriel makes me strong” — in the film, that means that when Emily is having a Gabriel episode, she demonstrates the strength of perhaps two people. That’s definitely not on the official list of symptoms for intracranial teratomas. Ditto Gabriel’s undefined electrical powers that make lights flicker and allow him to communicate via radio waves.

The story also conflates elements of teratomas and parasitic twins (when one twin stops developing in the womb but relies physically on the developed twin, as Gabriel does with Emily), which really don’t have anything to do with each other. Healthline says “In some cases, the dominant twin looks like a normally developed baby with extra limbs or unrecognizable protrusions.” When Gabriel pops all the way out, that accounts for some otherwise unrecognizable protrusions, all right.

A woman looks up as a girl looks up at her

When we see Emily as an adult, only the bits of Gabriel that are essential to Emily’s survival remain attached to her brain. But surprise, surprise, he has been growing back this whole time, trapped in her surgically repaired skull.

Thus, the script’s most clever conceit: The idea that Gabriel is “only in Emily’s head.”

And there, folks, is the scientific/medical basis for that bonkers twist in “Malignant.” It’s certainly set up for a sequel, which would deserve to be called, simply, “Malignant II.”

Let’s talk about that crazy twist in ‘Malignant’ — is it real or pure fiction?

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