Complex post-traumatic stress disorder

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https://en.wikipedia.org/wiki/Complex_post-traumatic_stress_disorder 

 

Complex post-traumatic stress disorder
Other names	Formerly: Enduring personality change after catastrophic experience (EPCACE)
Potential causes of complex post-traumatic stress disorder
Specialty	Psychiatry, clinical psychology
Symptoms	Hyperarousal, emotional over-stress, intrusive thoughts, emotional dysregulation, hypervigilance, negative self-beliefs, interpersonal difficulties, attention difficulties, anxiety, depression, somatization, dissociation
Duration	> 1 month
Causes	Prolonged (or repetitive) exposure to a traumatic event or traumatic events
Differential diagnosis	Post-traumatic stress disorder, borderline personality disorder, grief

Complex post-traumatic stress disorder (CPTSD, cPTSD, or hyphenated C-PTSD) is a stress-related mental disorder generally occurring in response to complex traumas^[1] (i.e., commonly prolonged (or repetitive) exposure to a traumatic event (or traumatic events), from which one sees little or no chance to escape).

In the ICD-11 classification, C-PTSD is a category of post-traumatic stress disorder (PTSD) with three additional clusters of significant symptoms: emotional dysregulation, negative self-beliefs (e.g., shame, guilt, failure for wrong reasons), and interpersonal difficulties. C-PTSD's symptoms include prolonged feelings of terror, worthlessness, helplessness, distortions in identity or sense of self, and hypervigilance. Although early descriptions of C-PTSD specified the type of trauma (i.e., prolonged, repetitive), in the ICD-11 there is no requirement of a specific trauma type.

Classifications

The World Health Organization (WHO)'s International Statistical Classification of Diseases has included C-PTSD since its eleventh revision that was published in 2018 and came into effect in 2022 (ICD-11). The previous edition (ICD-10) proposed a diagnosis of Enduring Personality Change after Catastrophic Event (EPCACE), which was an ancestor of C-PTSD. Healthdirect Australia (HDA) and the British National Health Service (NHS) have also acknowledged C-PTSD as mental disorder. The American Psychiatric Association (APA) has not included C-PTSD in the Diagnostic and Statistical Manual of Mental Disorders. The related disorder, Disorders of Extreme Stress – not otherwise specified (DESNOS) was studied for inclusion in the DSM-IV, but not ultimately included. Instead, the symptoms of PTSD were expanded in the DSM-IV and then DSM-5 to better capture the range of symptoms that can follow from all types of trauma.

Signs and symptoms

Children and adolescents

The diagnosis of PTSD was originally given to adults who had suffered because of a trauma (e.g., during a war, rape). However, the situation for many children is quite different. Children can suffer chronic trauma such as maltreatment, family violence, school bullying, dysfunction, or a disruption in attachment to their primary caregiver. In many cases, it is the child's caregiver who causes the trauma. The diagnosis of PTSD does not take into account how the developmental stages of children may affect their symptoms and how trauma can affect a child's development.

The term developmental trauma disorder (DTD) has been proposed as the childhood equivalent of C-PTSD. This developmental form of trauma places children at risk for developing psychiatric and medical disorders. Bessel van der Kolk explains DTD as numerous encounters with interpersonal trauma such as physical assault, sexual assault, violence or death. It can also be brought on by subjective events such as abandonment, betrayal, defeat or shame.

Repeated traumatization during childhood leads to symptoms that differ from those described for PTSD. Cook and others describe symptoms and behavioral characteristics in seven domains:

• Attachment – problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and responding to others' emotional states
• Biomedical symptoms – sensory-motor developmental dysfunction, sensory-integration difficulties; increased medical problems or even somatization
• Affect or emotional regulation – poor affect regulation, difficulty identifying and expressing emotions and internal states, and difficulties communicating needs, wants, and wishes
• Elements of dissociation – amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events
• Behavioral control – problems with impulse control, aggression, pathological self-soothing, and sleep problems
• Cognition – difficulty regulating attention; problems with a variety of executive functions such as planning, judgment, initiation, use of materials, and self-monitoring; difficulty processing new information; difficulty focusing and completing tasks; poor object constancy; problems with cause-effect thinking; and language developmental problems such as a gap between receptive and expressive communication abilities.
• Self-concept – fragmented and/or disconnected autobiographical narrative, disturbed body image, low self-esteem, excessive shame, and negative internal working models of self.

Adults

Adults with C-PTSD have sometimes experienced prolonged interpersonal traumatization beginning in childhood, rather than, or as well as, in adulthood. These early injuries interrupt the development of a robust sense of self and of others. Because physical and emotional pain or neglect was often inflicted by attachment figures such as caregivers or other siblings, these individuals may develop a sense that they are fundamentally flawed and that others cannot be relied upon.

Earlier descriptions of CPTSD suggested six clusters of symptoms:

• Alterations in regulation of affect and impulses
• Alterations in attention or consciousness
• Alterations in self-perception
• Alterations in relations with others
• Somatization
• Alterations in systems of meaning

Experiences in these areas may include:

• Changes in emotional regulation, including experiences such as persistent dysphoria, chronic suicidal preoccupation, self-injury, explosive or extremely inhibited anger (may alternate), and compulsive or extremely inhibited sexuality (may alternate).
• Variations in consciousness, such as amnesia or improved recall for traumatic events, episodes of dissociation, depersonalization/derealization, and reliving experiences (either in the form of intrusive PTSD symptoms or in ruminative preoccupation).
• Changes in self-perception, such as a sense of helplessness or paralysis of initiative, shame, guilt and self-blame, a sense of defilement or stigma, and a sense of being completely different from other human beings (may include a sense of specialness, utter aloneness, a belief that no other person can understand, or a feeling of nonhuman identity).
• Varied changes in perception of the perpetrators, such as a preoccupation with the relationship with a perpetrator (including a preoccupation with revenge), an unrealistic attribution of total power to a perpetrator (though the individual's assessment may be more realistic than the clinician's), idealization or paradoxical gratitude, a sense of a special or supernatural relationship with a perpetrator, and acceptance of a perpetrator's belief system or rationalizations.
• Alterations in relations with others, such as isolation and withdrawal, disruption in intimate relationships, a repeated search for a rescuer (may alternate with isolation and withdrawal), persistent distrust, and repeated failures of self-protection.
• Changes in systems of meaning, such as a loss of sustaining faith and a sense of hopelessness and despair.

Diagnosis

C-PTSD was considered for inclusion in the DSM-IV but was excluded from the 1994 publication. It was also excluded from the DSM-5, which lists post-traumatic stress disorder. The ICD-11 has included C-PTSD since its initial publication in 2018 and a validated self-report measure exists for assessing the ICD-11 C-PTSD, which is the International Trauma Questionnaire (ITQ).

Differential diagnosis

Post-traumatic stress disorder

Main article: Post-traumatic stress disorder

In the ICD-11, there are two paired diagnoses, PTSD and CPTSD. A person can only be diagnosed with one or the other. A diagnosis of PTSD is made if a person has experienced a trauma and also experiences 1) re-experiencing the event in the form of intrusive memories, nightmares, or flashbacks, 2) avoidance of memories of the event or of people, places, and situations that remind them of it, and 3) perceptions of heightened current threat (e.g., hypervigilance, enhanced startle reaction). These symptoms must cause impairment in important areas of functioning.

In contrast, a diagnosis of CPTSD is made if the person meets all of the above criteria in addition to 1) difficulties in regulating emotions, 2) changes in beliefs about oneself such as feeling worthless with significant shame, and 3) difficulties in maintaining close relationships with important people. Again, these symptoms must cause significant impairment to be considered CPTSD.

In the DSM-5, many of the symptoms of complex PTSD are now captured in the symptoms of PTSD, which are much broader than the PTSD symptoms in the ICD-11. Moreover, the DSM-5 also includes a dissociative symptom subtype.

Earlier descriptions of CPTSD were broader but may no longer apply clinically; for instance, CPTSD was described to include captivity, psychological fragmentation, the loss of a sense of safety, trust, and self-worth, as well as the tendency to be revictimized. Most importantly, there is a loss of a coherent sense of self: this loss, and the ensuing symptom profile, most pointedly differentiates C-PTSD from PTSD. C-PTSD has also been characterized by attachment disorder, particularly the pervasive insecure, or disorganized-type attachment. Thus, a differentiation between the diagnostic category of C-PTSD and that of PTSD has been suggested.

Continuous traumatic stress disorder (CTSD), which was introduced into the trauma literature by Gill Straker in 1987, differs from C-PTSD. It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services. It has also been used to describe ongoing relationship trauma frequently experienced by people leaving relationships which involved intimate partner violence.

Traumatic grief

Main articles: Grief and Grief counseling

Traumatic grief or complicated mourning are conditions where trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in a death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.

For C-PTSD to manifest traumatic grief, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.

Borderline personality disorder

Main articles: Attachment theory and Borderline personality disorder

C-PTSD may share some symptoms with both PTSD and borderline personality disorder (BPD). However, there is enough evidence to also differentiate C-PTSD from borderline personality disorder.

It may help to understand the intersection of attachment theory with C-PTSD and BPD if one reads the following opinion of Bessel A. van der Kolk together with an understanding drawn from a description of BPD:

Uncontrollable disruptions or distortions of attachment bonds precede the development of post-traumatic stress syndromes. People seek increased attachment in the face of danger. Adults, as well as children, may develop strong emotional ties with people who intermittently harass, beat, and, threaten them. The persistence of these attachment bonds leads to confusion of pain and love. Trauma can be repeated on behavioural, emotional, physiologic, and neuroendocrinologic levels. Repetition on these different levels causes a large variety of individual and social suffering.

25% of those diagnosed with BPD have no known history of childhood neglect or abuse and individuals are six times as likely to develop BPD if they have a relative who was diagnosed as such compared to those who do not. One conclusion is that there is a genetic predisposition to BPD unrelated to trauma. Researchers conducting a longitudinal investigation of identical twins found that "genetic factors play a major role in individual differences of borderline personality disorder features in Western society." A 2014 study published in the European Journal of Psychotraumatology was able to compare and contrast C-PTSD, PTSD, and borderline personality disorder and found that it could distinguish between individual cases of each and when it was co-morbid, arguing for a case of separate diagnoses for each.

In Trauma and Recovery, Herman expresses the additional concern that patients with C-PTSD frequently risk being misunderstood as inherently 'dependent', 'masochistic', or 'self-defeating', comparing this attitude to the historical misdiagnosis of female hysteria. However, those who develop C-PTSD do so as a result of the intensity of the traumatic bond — in which someone becomes tightly biochemically bound to someone who abuses them and the responses they learned to survive, navigate and deal with the abuse they suffered then become automatic responses, embedded in their personality over the years of trauma — a normal reaction to an abnormal situation.

Treatment

While standard evidence-based treatments may be effective for treating post-traumatic stress disorder, treating complex PTSD often involves addressing interpersonal relational difficulties and a different set of symptoms which make it more challenging to treat.

Children

The utility of PTSD-derived psychotherapies for assisting children with C-PTSD is uncertain. This area of diagnosis and treatment calls for caution in use of the category C-PTSD. Julian Ford and Bessel van der Kolk have suggested that C-PTSD may not be as useful a category for diagnosis and treatment of children as a proposed category of developmental trauma disorder (DTD). According to Courtois and Ford, for DTD to be diagnosed it requires a

history of exposure to early life developmentally adverse interpersonal trauma such as sexual abuse, physical abuse, violence, traumatic losses or other significant disruption or betrayal of the child's relationships with primary caregivers, which has been postulated as an etiological basis for complex traumatic stress disorders. Diagnosis, treatment planning and outcome are always relational.

A number of practical, therapeutic and ethical principles for assessment and intervention have been developed and explored in the field:

• Identifying and addressing threats to the child's or family's safety and stability are the first priority.
• A relational bridge must be developed to engage, retain and maximize the benefit for the child and caregiver.
• Diagnosis, treatment planning and outcome monitoring are always relational (and) strengths based.
• All phases of treatment should aim to enhance self-regulation competencies.
• Determining with whom, when and how to address traumatic memories.
• Preventing and managing relational discontinuities and psychosocial crises.

Adults

Trauma recovery model

Judith Lewis Herman, in her book, Trauma and Recovery, proposed a complex trauma recovery model that occurs in three stages:

1. Establishing safety
2. Remembrance and mourning for what was lost
3. Reconnecting with community and more broadly, society

Herman believes recovery can only occur within a healing relationship and only if the survivor is empowered by that relationship. This healing relationship need not be romantic or sexual in the colloquial sense of "relationship", however, and can also include relationships with friends, co-workers, one's relatives or children, and the therapeutic relationship. However, the first stage of establishing safety must always include a thorough evaluation of the surroundings, which might include abusive relationships. This stage might involve the need for major life changes for some patients.

Securing a safe environment requires strategic attention to the patient's economic and social ecosystem. The patient must become aware of her own resources for practical and emotional support as well as the realistic dangers and vulnerabilities in her social situation. Many patients are unable to move forward in their recovery because of their present involvement in unsafe or oppressive relationships. In order to gain their autonomy and their peace of mind, survivors may have to make difficult and painful life choices. Battered women may lose their homes, their friends, and their livelihood. Survivors of childhood abuse may lose their families. Political refugees may lose their homes and their homeland. The social obstacles to recovery are not generally recognized, but they must be identified and adequately addressed in order for recovery to proceed.

It has been suggested that treatment for complex PTSD should differ from treatment for PTSD by focusing on problems that cause more functional impairment than the PTSD symptoms. These problems include emotional dysregulation, dissociation, and interpersonal problems. Six suggested core components of complex trauma treatment include:

• Safety
• Self-regulation
• Self-reflective information processing
• Traumatic experiences integration
• Relational engagement
• Positive affect enhancement

The above components can be conceptualized as a model with three phases. Not every case will be the same, but the first phase will emphasize the acquisition and strengthening of adequate coping strategies as well as addressing safety issues and concerns. The next phase would focus on decreasing avoidance of traumatic stimuli and applying coping skills learned in phase one. The care provider may also begin challenging assumptions about the trauma and introducing alternative narratives about the trauma. The final phase would consist of solidifying what has previously been learned and transferring these strategies to future stressful events.

Neuroscientific and trauma informed interventions

In practice, the forms of treatment and intervention varies from individual to individual since there is a wide spectrum of childhood experiences of developmental trauma and symptomatology and not all survivors respond positively, uniformly, to the same treatment. Therefore, treatment is generally tailored to the individual. Recent neuroscientific research has shed some light on the impact that severe childhood abuse and neglect (trauma) has on a child's developing brain, specifically as it relates to the development in brain structures, function and connectivity among children from infancy to adulthood. This understanding of the neurophysiological underpinning of complex trauma phenomena is what currently is referred to in the field of traumatology as 'trauma informed' which has become the rationale which has influenced the development of new treatments specifically targeting those with childhood developmental trauma. Martin Teicher, a Harvard psychiatrist and researcher, has suggested that the development of specific complex trauma related symptomatology (and in fact the development of many adult onset psychopathologies) may be connected to gender differences and at what stage of childhood development trauma, abuse or neglect occurred. For example, it is well established that the development of dissociative identity disorder among women is often associated with early childhood sexual abuse.

Use of evidence-based PTSD treatment

Cognitive behavioral therapy, prolonged exposure therapy and dialectical behavioral therapy are well established forms of evidence-based intervention. These treatments are approved and endorsed by the American Psychiatric Association, the American Psychological Association and the Veteran's Administration. There is a question as to whether these PTSD treatments can also treat CPTSD. Given that the ICD-11 CPTSD diagnosis is relatively young, it will be years before this is adequately studied. However, some preliminary studies have examined whether PTSD treatments work equally well in those with PTSD or CPTSD. Two different studies of phase-based PTSD treatment found that both standard PTSD treatment and phased treatment worked equally well whether participants had a diagnosis of PTSD or CPTSD (per the ITQ). Another study of an existing European intensive trauma treatment combining Prolonged Exposure and EMDR found that people with PTSD and CPTSD had comparable decreases in PTSD and CPTSD (though they had more severe PTSD at baseline).

One of the current challenges faced by many survivors of complex trauma (or developmental trauma disorder) is support for treatment since many of the current therapies are relatively expensive and not all forms of therapy or intervention are reimbursed by insurance companies who use evidence-based practice as a criterion for reimbursement.

Treatment challenges

It is widely acknowledged by those who work in the trauma field that there is no one single, standard, 'one size fits all' treatment for complex PTSD. There is also no clear consensus regarding the best treatment among the greater mental health professional community which included clinical psychologists, social workers, licensed therapists (MFTs) and psychiatrists. Although most trauma neuroscientifically informed practitioners understand the importance of utilizing a combination of both 'top down' and 'bottom up' interventions as well as including somatic interventions (sensorimotor psychotherapy or somatic experiencing or yoga) for the purposes of processing and integrating trauma memories.

Allistair and Hull echo the sentiment of many other trauma neuroscience researchers (including Bessel van der Kolk and Bruce D. Perry) who argue:

Complex presentations are often excluded from studies because they do not fit neatly into the simple nosological categorisations required for research power. This means that the most severe disorders are not studied adequately and patients most affected by early trauma are often not recognised by services. Both historically and currently, at the individual as well as the societal level, "dissociation from the acknowledgement of the severe impact of childhood abuse on the developing brain leads to inadequate provision of services. Assimilation into treatment models of the emerging affective neuroscience of adverse experience could help to redress the balance by shifting the focus from top-down regulation to bottom-up, body-based processing."

Complex post-traumatic stress disorder is a long term mental health condition which often requires treatment by highly skilled mental health professionals who specialize in trauma informed modalities designed to process and integrate childhood trauma memories for the purposes of mitigating symptoms and improving the survivor's quality of life. Delaying therapy for people with complex PTSD, whether intentionally or not, can exacerbate the condition.

Recommended treatment modalities and interventions

There is no one treatment which has been designed specifically for use with the adult complex PTSD population (with the exception of component based psychotherapy) there are many therapeutic interventions used by mental health professionals to treat PTSD. As of February 2017, the American Psychological Association PTSD Guideline Development Panel (GDP) strongly recommends the following for the treatment of PTSD:

1. Cognitive behavioral therapy (CBT) and trauma-focused CBT
2. Cognitive processing therapy (CPT)
3. Cognitive therapy (CT)
4. Prolonged exposure therapy (PE)

The American Psychological Association also conditionally recommends

1. Brief eclectic psychotherapy (BEP)
2. Eye movement desensitization and reprocessing (EMDR)
3. Narrative exposure therapy (NET)

While these treatments have been recommended, there is still a lack of research on the best and most efficacious treatments for complex PTSD. Psychological therapies such as cognitive behavioural therapy, eye movement desensitisation and reprocessing therapy are effective in treating C-PTSD symptoms like PTSD, depression and anxiety. For example, in a 2016, meta-analysis, four out of eight EMDR studies resulted in statistical significance, indicating the potential effectiveness of EMDR in treating certain conditions. Additionally, subjects from two of the studies continued to benefit from the treatment months later. Seven of the studies that employed psychometric tests showed that EMDR led to a reduction in depression symptoms compared to those in the placebo group. Mindfulness and relaxation is effective for PTSD symptoms, emotion regulation and interpersonal problems for people whose complex trauma is related to sexual abuse.

Many commonly used treatments are considered complementary or alternative since there still is a lack of research to classify these approaches as evidence based. Some of these additional interventions and modalities include:

• biofeedback
• dyadic resourcing (used with EMDR)
• emotionally focused therapy
• equine-assisted therapy
• expressive arts therapy
• internal family systems therapy
• dialectical behavior therapy (DBT)
• family systems therapy
• group therapy
• neurofeedback
• psychodynamic therapy
• sensorimotor psychotherapy
• somatic experiencing
• yoga, specifically trauma-sensitive yoga

History

Judith Lewis Herman of Harvard University was the first psychiatrist and scholar to conceptualise complex post-traumatic stress disorder (C-PTSD) as a (new) mental health condition in 1992, within her book Trauma & Recovery and an accompanying article. In 1988, Herman suggested that a new diagnosis of complex post-traumatic stress disorder (C-PTSD) was needed to describe the symptoms and psychological and emotional effects of long-term trauma. Over the years, the definition of CPTSD has shifted (including a proposal for DESNOS in DSM-IV and a diagnosis of EPCACE in ICD-10), with a different definition in the ICD-11 than per Dr. Herman's initial conceptualization. The ICD-11 definition of CPTSD overlaps more with DSM-5 PTSD than earlier definitions of PTSD.

Criticism of disorder and diagnosis

Though acceptance of the idea of complex PTSD has increased with mental health professionals, the research required for the proper validation of a new disorder was considered insufficient to include CPTSD as a separate disorder in the DSM-IV and DSM-5. The disorder was proposed under the name DES-NOS (Disorder of Extreme Stress Not Otherwise Specified) for inclusion in the DSM-IV but was rejected by members of the Diagnostic and Statistical Manual of Mental Disorders (DSM) committee of the American Psychiatric Association for lack of sufficient diagnostic validity research. Chief among the stated limitations was a study which showed that 95% of individuals who could be diagnosed with the proposed DES-NOS were also diagnosable with PTSD, raising questions about the added usefulness of an additional disorder.

Following the failure of DES-NOS to gain formal recognition in the DSM-IV, the concept was re-packaged for children and adolescents and given a new name, developmental trauma disorder. Supporters of DTD appealed to the developers of the DSM-5 to recognize DTD as a new disorder. Just as the developers of DSM-IV refused to included DES-NOS, the developers of DSM-5 refused to include DTD due to a perceived lack of sufficient research.

One of the main justifications offered for this proposed disorder has been that the current system of diagnosing PTSD plus comorbid disorders does not capture the wide array of symptoms in one diagnosis. Because individuals who suffered repeated and prolonged traumas often show PTSD plus other concurrent psychiatric disorders, some researchers have argued that a single broad disorder such as C-PTSD provides a better and more parsimonious diagnosis than the current system of PTSD plus concurrent disorders. Conversely, an article published in BioMed Central has posited there is no evidence that being labeled with a single disorder leads to better treatment than being labeled with PTSD plus concurrent disorders.

Complex PTSD embraces a wider range of symptoms relative to PTSD, specifically emphasizing problems of emotional regulation, negative self-concept, and interpersonal problems. Diagnosing complex PTSD can imply that this wider range of symptoms is caused by traumatic experiences, rather than acknowledging any pre-existing experiences of trauma which could lead to a higher risk of experiencing future traumas. It also asserts that this wider range of symptoms and higher risk of traumatization are related by hidden confounder variables and there is no causal relationship between symptoms and trauma experiences. In the diagnosis of PTSD, the definition of the stressor event is limited to life-threatening or sexually violent events, with the implication that these are typically sudden and unexpected events. Complex PTSD vastly widened the definition of potential stressor events by calling them adverse events, and deliberating dropping reference to life-threatening, so that experiences can be included such as neglect, emotional abuse, or living in a war zone without having specifically experienced life-threatening events. By broadening the stressor criterion, an article published by the Child and Youth Care Forum claims this has led to confusing differences between competing definitions of complex PTSD, undercutting the clear operationalization of symptoms seen as one of the successes of the DSM.

Multiracial people

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Multiracial_people

The term multiracial people refers to people who are mixed with two or more races and the term multi-ethnic people refers to people who are of more than one ethnicities. A variety of terms have been used both historically and presently for multiracial people in a variety of contexts, including multiethnic, polyethnic, occasionally bi-ethnic, biracial, mixed-race, Métis, Muwallad, Melezi, Coloured, Dougla, half-caste, ʻafakasi, mulatto, mestizo, mutt, Melungeon, quadroon, octoroon, griffe, sacatra, sambo/zambo, Eurasian, hapa, hāfu, Garifuna, pardo, and Gurans. A number of these once-acceptable terms are now considered offensive, in addition to those that were initially coined for pejorative use.

Individuals of multiracial backgrounds make up a significant portion of the population in many parts of the world. In North America, studies have found that the multiracial population is continuing to grow. In many countries of Latin America, mestizos make up the majority of the population and in some others also mulattoes. In the Caribbean, multiracial people officially make up the majority of the population in the Dominican Republic (73%), Aruba (68%), and Cuba (51%).

Definitions

In terms of race

See also: Race (human categorization)

While defining race is controversial, race remains a commonly used term for classification, often related to visible physical characteristics or known community. Insofar as race is defined differently in different cultures, perceptions of mixed race are subjective.

According to American sociologist Troy Duster and ethicist Pilar Ossorio:

Some percentage of people who look native European will possess genetic markers indicating that a significant majority of their recent ancestors were African. Some percentage of people who look African or native African will possess genetic markers indicating the majority of their recent ancestors were European.

In the United States:

Many state and local agencies comply with the U.S. Office of Management and Budget (OMB) 1997 revised standards for the collection, tabulation, and presentation of federal data on race and ethnicity. The revised OMB standards identify a minimum of five racial categories: European American; African American; Native American and Alaska Native; Asian; and Native Hawaiian and Other Pacific Islander. Perhaps the most significant change for Census 2000 was that respondents were given the option to mark one or more races on the questionnaire to indicate their racial identity. Census 2000 race data are shown for people who reported a race either alone or in combination with one or more other races.

Related terms

In the English-speaking world, many terms for mixed-race people exist, some of which are pejorative or are no longer used. Mulato, zambo and mestizo are used in Spanish, mulato, caboclo, cafuzo, ainoko (from Japanese) and mestiço in Portuguese, and mulâtre and métis in French. These terms are also in certain contexts used in the English-speaking world. In Canada, the Métis are a recognized ethnic group of mixed European and Indigenous American descent, who have status in the law similar to that of First Nations.

Terms such as mulatto for people of partially African descent and mestizo for people of partially Native American descent are still used by English-speaking people of the Western Hemisphere but mostly to refer to the past or to the demography of Latin America and its diasporic population. Half-breed is a historic term for people of partial Native American ancestry; it is now considered pejorative and discouraged from use. Mestee, once widely used, is now used mostly for members of historically mixed-race groups, such as Louisiana Creoles, Melungeons, Redbones, Brass Ankles and Mayles.

In South Africa and much of English-speaking southern Africa, the term Coloured was used to describe both mixed-race persons of African and European descent, and those Asians not of African descent.

In Latin America, populations became triracial after the introduction of African slavery. A panoply of terms developed during the Spanish and Portuguese colonial periods, including terms such as zambo for persons of Native American and native African descent. Charts and diagrams intended to explain the classifications were common. The well-known Casta paintings in Mexico and, to some extent, Peru, were illustrations of the different classifications.

At one time, Latin American census categories have used such classifications. In Brazilian censuses since the Imperial times, for example, most persons of mixed heritage, except Asian Brazilians with some European descent (or any other to the extent it is not clearly perceptible) and vice versa, tend to be thrown into the single category of "pardo". But racial boundaries in Brazil are related less to ancestry than to phenotype. A westernized Amerindian with copper-colored skin may also be classified as a "pardo", a caboclo in this case, despite not being mixed race. A European-looking person, even with one or more native African or Indigenous ancestors, is not classified as "pardo" but as "branco", a white Brazilian. The same applies to "negros", Afro-Brazilians whose European or Native American ancestors are not visible in their appearance. According to genetic research, most Brazilians of all racial groups (except Asian-Brazilians and natives) are, to some extent, mixed-race.

In the English language, the terms miscegenation and amalgamation were used for unions between whites, blacks, and other ethnic groups. The term 'miscegenation' initially replaced 'amalgamation' due to the latter's association with slavery in the 1800s, while 'miscegenation' is today often considered offensive and controversial. The terms mixed-race, biracial or multiracial are becoming generally accepted. In other languages, terms for miscegenation are not necessarily considered offensive.

In terms of ethnicity

The terms "multi-ethnic people" or "ethnically mixed people" refer to people who are of more than one ethnicity.

Regions with significant mixed-race populations

Africa

In East Africa, specifically Uganda, Kenya and Tanzania (including portions of the East African Community), people of mixed race are called half-castes (in English) or chotara (singular, in Swahili), wachotara (plural in Swahili).

North Africa

Further information: Afro-Arab

North Africa has numerous mixed-race communities, reflecting a history of both extensive Mediterranean trade around the region and later colonization and migration by African groups. Among these are the Haratin, oasis-dwellers of Saharan southern Morocco, Algeria, and Mauritania. They are believed to be an ethnicity composed of Sub-Saharan African and Berber ancestry. They constitute a socially and ethnically distinct group within the Maghreb.

For centuries, Arab slave traders sold sub-Saharan Africans as slaves in cumulatively large numbers throughout the Persian Gulf, Anatolia, Central Asia and the Arab world. Communities descended from these slaves and local peoples can be found throughout these regions. Barbary pirates were known to attack European and British ships and take Europeans into slavery as well. So many were taken, that the memoirs of survivors are considered a literary genre known as captivity narratives. When English and other European colonists were taken captive by Native Americans, they had models for recounting their trials.

Cape Verde, in west Africa, has one of the most mixed-race populations (around 75% of the population) on the planet.

South Africa

Extended Coloured family from South Africa.

Main article: Coloureds

In South Africa, the Prohibition of Mixed Marriages Act of 1949 prohibited marriage between Native Europeans (people of European descent) and non-Whites (being classified as African, Asian and Coloured). But this followed centuries of interaction and unions resulting in mixed-race children. This law was repealed in 1985.

Mixed-race South Africans are commonly referred to as Coloureds. According to the 2016 South African Census, they are the second-largest ethnic group (8.8%), behind Native Africans, or Native African Bantu peoples, who constitute (80.8%) of the current population. European South Africans make up 8.1%.

Madagascar

Main article: Malagasy peoples

Madagascar was settled between the first and ninth centuries AD by two groups: Austronesian peoples who arrived on outrigger canoes from across the Indian Ocean, and Bantu peoples who crossed the Mozambique Channel from mainland Africa. These two groups intermixed, forming the modern Malagasy people; later migrants from Arabia, Somalia, and India added to the genetic mixture.

Virtually all Malagasy people are of some degree of mixed descent; however, the amount of mixture varies greatly between regions of Madagascar, despite all Malagasy people sharing a common language and similar cultural elements. The Malagasy of the central highlands of Madagascar have predominantly Austronesian ancestry, the Malagasy of the west coast and the south of the island have predominantly Bantu ancestry, and Malagasy of the island's east coast are of roughly equal degrees Bantu and Austronesian ancestry. The average Malagasy person's genetic makeup includes a roughly equal blend of Southeast Asian and East African genes.

Asia

India

See also: Genetics and archaeogenetics of South Asia

Ancient India

The people of the Indian subcontinent have a diverse genetic pool, being composed of South Asian hunter-gatherers, Neolithic Iranians, and Western Steppe Herders. This makes up the genome of modern-day Indians and varies from caste and region.

Modern India

Henry Louis Vivian Derozio, a radical thinker and educator, was of Indian and European background. Prior to colonization, the peoples of India had a long history of trade and other interaction with other peoples. More recently a Eurasian mix developed during the Colonial period, beginning with the French, Dutch, Portuguese and other European traders and merchants, including British. Such interaction continued during the British Rule in India, although it lessened as British families settled in the country. The estimated population of Anglo-Indians, the term for these Eurasians, is 600,000 worldwide, with the majority living in India and the UK.

Article 366(2) of the Indian Constitution defines Anglo-Indian as:

(2) an Anglo-Indian means a person whose father or any of whose other male progenitors in the male line is or was of European descent but who is domiciled within the territory of India and is or was born within such territory of parents habitually resident therein and not established there for temporary purposes only;

Myanmar (Burma)

Myanmar (formerly Burma) was a British colony from 1826 until 1948. Other European nationals were active in the country before the British arrived. Intermarriage and relationships took place among such settlers and merchants with the local Burmese population, and subsequently between British colonists and the Burmese. The local Eurasian population is known as the Anglo-Burmese. This group dominated colonial society and through the early years of independence. After Burma gained independence in 1948, many Anglo-Burmese left the country; the diaspora resides primarily in Australia, New Zealand and the UK. An estimated 52,000 Anglo-Burmese live in Burma.

Philippines

See also: Filipino mestizo

Mestizos as illustrated in the Carta Hydrographica y Chorographica de las Yslas Filipinas, 1734.

The Philippines was a Spanish colony for almost four centuries, or 333 years. The United States took it over after the Spanish-American War, ruling for 46 years. Many Filipinos are mixed Spanish Filipino, and according to Fedor Jagor, one-third of Luzon which holds half the Philippine population, has Spanish or Latin-American admxiture. And it also has Philippine-American descent.

After the defeat of Spain during the Spanish–American War in 1898, the Philippines and other remaining Spanish colonies were ceded to the United States in the Treaty of Paris. The Philippines was under U.S. sovereignty until 1946, though occupied by Japan during World War II. In 1946, in the Treaty of Manila, the U.S. recognized the Republic of the Philippines as an independent nation. Even after 1946, the U.S. maintained a strong military presence in the Philippines, with as many as 21 U.S. military bases and 100,000 U.S. military personnel stationed there as defense in Asia and during the Vietnam War.

After the bases closed in 1992, American troops left, often abandoning partners and their Amerasian children. The Pearl S. Buck International foundation estimates there are 52,000 Amerasians in the Philippines, with 5,000 in the Clark area of Angeles City. An academic research paper presented in the U.S. (in 2012) by an Angeles, Pampanga, Philippines Amerasian college research study unit suggests that the number could be a lot more, possibly reaching 250,000. This is also partially due to the fact that almost all Amerasians intermarried with other Amerasians and Filipino natives. The newer Amerasians from the United States would add to the already older settlement of peoples from other countries in the Americas that happened when the Philippines was under Spanish rule, as the Philippines once received immigrants from Spanish occupied Panama, Peru, and Mexico.

In the United States, intermarriage between Filipinos and other ethnicities is common. They have the highest number of interracial marriages among Asian immigrant groups, as documented in California. Some 21.8% of Philippine-Americans are of mixed ancestry.

Indonesia

Main articles: Indo people and Mardijker

Singapore and Malaysia

According to government statistics, the population of Singapore as of September 2007 was 4.68 million. Mixed-race people, including Chindians and Eurasians, formed 2.4%.

In Singapore and Malaysia, the majority of inter-ethnic marriages are between Chinese and Indians. The offspring of such marriages are informally known as "Chindian". The Malaysian government classifies them only by their father's ethnicity. As the majority of these intermarriages usually involve an Indian groom and Chinese bride, the majority of Chindians in Malaysia are usually classified as "Indian" by the government. As for the Malays, who are predominantly Muslim, legal restrictions in Malaysia make it uncommon for them to intermarry with either the Indians, who are predominantly Hindu, or the Chinese, who are predominantly Buddhist and Taoist. But Indian Muslims and Arabs in Singapore and Malaysia often take local Malay wives, because of their common Islamic faith.

The Chitty people, in Singapore and the Malacca state of Malaysia, are Tamils with considerable Malay ancestry. The early Tamil settlers took local wives, as they had not brought their own women at that time.

In the East Malaysian states of Sabah and Sarawak, intermarriage has been common between Chinese and native tribespeople, such as the Murut and Dusun in Sabah, and the Iban and Bisaya in Sarawak. A mixture of cultures has resulted in both states. The offspring of these marriages are called "Sino-(name of tribe)", e.g. Sino-Dusun. Normally, children are strongly affected by the father's ethnicity and culture, being raised in his culture. These Sino-natives usually become fluent in both Malay and English. A smaller number are able to speak Chinese dialects and Mandarin, especially those who have received education in vernacular Chinese schools.

Sri Lanka

Due to its strategic location in the Indian Ocean, the island of Sri Lanka has been a confluence for settlers from various parts of the world. There are several mixed-race ethnicities in the island. The most notable mixed-race group is the Sri Lankan Moors, who trace their ancestry to Arab traders who settled on the island and intermarried with local women. Today, the Sri Lankan Moors live primarily in urban communities. They preserve Arab-Islamic cultural heritage while adopting many Southern Asian customs.

The Burghers are a Eurasian ethnic group. They are descendants through paternal lines of European colonists from the 16th to 20th centuries (mostly Portuguese, Dutch, German and British) and with maternal ancestry among local women. Other European minorities in such admixtures include Swedish, Norwegian, French and Irish.

The Sri Lanka Kaffirs are an ethnic group partially descended from 16th-century Portuguese traders and their enslaved Africans. The Kaffirs spoke a distinctive creole based on Portuguese, the Sri Lanka Kaffir language, which is now extinct. Their cultural heritage includes the dance styles Kaffringna and Manja, as well as the Portuguese Sinhalese, Creole, Afro-Sinhalese varieties.

Vietnam

See also: Bụi đời

Under terms of the Geneva Accords of 1954, departing French troops took thousands of Vietnamese wives and children with them after the First Indochina War. Some Eurasians stayed in Vietnam, after independence from French rule.

Japan

See also: GI Baby

China

Main article: Hùnxuě'ér

West Asia

Further information: Afro-Arab, Afro-Iranians, and Afro Turks

Ottoman slave traders sold slaves in cumulatively large numbers over the centuries throughout the Persian Gulf, Anatolia, Central Asia and the Arab world and communities descended from these slaves can be found throughout these regions.

Europe

Romani people are of mixed South Asian, Middle Eastern and European ancestry. They settled in Europe hundreds of years ago.

United Kingdom

Main article: Mixed (United Kingdom ethnicity category)

In 1991 an analysis of the census showed that 50% of Mixed Caribbean men born in the UK have native British partners, and the 2011 BBC documentary Mixed Britannia noted that 1 in 10 British children are growing up in mixed households.

In 2000, The Sunday Times reported that "Britain has the highest rate of interracial relationships in the world" and certainly the UK has the highest rate in the European Union. The 2001 census showed the population of England to be 1.4% mixed-race, compared with 2.7% in Canada and 1.4% in the U.S. (estimate from 2002), although this U.S. figure did not include mixed-race people who had a parent with African Ancestry. Both the US and UK have fewer people identifying as mixed race, however, than Canada.

In the United Kingdom, many mixed-race people have Caribbean, African or Asian heritage. For example, supermodel Naomi Campbell has Jamaican, African and Asian roots. Some, like seven time Formula One World Champion Lewis Hamilton, are referred to or describe themselves as 'mixed'.

The 2001 UK Census included a section entitled 'Mixed', to which 1.4% (1.6% by 2005 estimates) of people responded, which was split further into White and Black Caribbean, White and Asian, White and Native African and Other Mixed. In the 2011 census, 2.2% chose 'Mixed' for the question on ethnicity.

North America

Canada

See also: Métis in Canada

Canadian actor and musician Keanu Reeves is of English, Native Hawaiian, Irish, Portuguese and Chinese descent.

Canada Census Multiple Visible Minority 1996 – 2016

Mixed-race Canadians in 2006 officially totaled 1.5% of the population, up from 1.2% in 2001. The official mixed-race population grew by 25% since the previous census. Of these, the most frequent combinations were multiple visible minorities (for example, people of mixed black and South Asian heritage form the majority, specifically in Toronto), followed closely by white-black, white-Chinese, white-Arab and many other smaller mixes.

During the time of slavery in the United States, a very large but unknown number of African slaves escaped to Canada, where slavery was made illegal in 1834, via the Underground Railroad. Many of these people married in with European Canadian and Native Canadian populations, although their precise numbers and the numbers of their descendants are not known.

Another 1.2% of Canadians officially are Métis (descendants of a historical population who were partially Aboriginal—also called "Indian" or "Native"—and European, particularly English, Scottish, Irish and French ethnic groups). Although the term "Métis" stems from the Latin verb miscēre, "to mix", the Métis people are a distinct ethnic group within Canada.

United States

Main article: Multiracial Americans

Further information: Black Indians in the United States, Melungeons, Métis in the United States, and Children of the Plantation

US Census reporting of Two or Mixed Races 2010 – 2019

In the United States, the 2000 census was the first in the history of the country to offer respondents the option of identifying themselves as belonging to more than one race. This mixed-race option was considered a necessary adaptation to the demographic and cultural changes that the United States has been experiencing.

Mixed-race Americans officially numbered 6.1 million in 2006, or 2.0% of the population. There is considerable evidence that an accurate number would be much higher. Prior to the mid-20th century, many people hid their mixed-race heritage. The development of binary thinking about race meant that African Americans, a high proportion of whom have also had European ancestry, were classified as black. Some are now reclaiming additional ancestries. Many Americans today are multi-racial without knowing it. According to the Census Bureau, as of 2002, 75% of all African Americans had mixed ancestries, usually European and Native American.

In 2010, the number of Americans who checked both "black" and "white" on their census forms was 134 percent higher than it had been a decade earlier. In 2012, those choosing 'Two or more races' on the census was 2.4% of the total.

According to James P. Allen and Eugene Turner, by some calculations in the 2000 Census, the mixed-race population that is part white is as follows:

• White/Native American and Alaskan Native: 7,015,017
• White/African American: 737,492
• White/Asian: 727,197 and
• White/Native Hawaiian and other Pacific Islander: 125,628.

The stigma of a mixed-race heritage, associated with racial discrimination among numerous racial groups, has decreased significantly in the United States. People of mixed-race heritage can identify themselves now in the U.S. Census by any combination of races, whereas before Americans were required to select from only one category. For example, in 2010, they were offered choices of one or more racial categories from the following list:

European African American Indian or Alaska Native Asian Indian

Chinese Filipino Japanese Korean Vietnamese

Native Hawaiian Guamanian or Chamorro Samoan

Other Asian [specify] Other Pacific Islander [specify] Some Other Race [specify]

Barack Obama, the first mixed-race President of the United States

The US has a growing mixed-race identity movement, reflective of a desire by people to claim their full identities. Interracial marriage, most notably between whites and blacks, was historically deemed immoral and illegal in most states in the 18th, 19th and first half of the 20th century because of its long association of blacks with the slave caste. California and the Western United States had similar laws to prohibit European-Asian marriages, which was associated with discrimination against Chinese and Japanese on the West Coast. Many states eventually repealed such laws and a 1967 decision by the US Supreme Court (Loving v. Virginia) overturned all remaining US anti-miscegenation laws.

The United States is one of the most racially diverse countries in the world. Americans are mostly mixed ethnic descendants of various immigrant nationalities culturally distinct in their former countries. Assimilation and integration took place, unevenly at different periods of history, depending on the American region. The "Americanization" of foreign ethnic groups and the inter-racial diversity of millions of Americans has been a fundamental part of its history, especially on frontiers where different groups of people came together.

On January 20, 2009, Barack Obama was sworn in as America's first mixed-race president, as he is the son of a European American mother of mostly English descent and a Luo father from Kenya. He acknowledges both parents. His official White House biography describes him as African American. In Hawai'i, the U.S. state in which he was born, he would be called "hapa", which is the Hawaiian word for "mixed race".

Oceania

See also: Euronesian

Willie Apiata, the only recipient of Victoria Cross for New Zealand, is the son of European and Māori New Zealanders.

New Zealand

Ethnic intermarriage has historically been viewed with tolerance in New Zealand, which according to a 2006 study, Māori have on average roughly 43% European ancestry, and rates are rising. However, the notion of being "mixed-race" has always been uncommon. An informal one-drop rule is often used for Māori. Most Māori believe any degree of Māori ancestry being considered enough to identify as Māori.

Fiji

Fiji has long been a multi-ethnic country, with a vast majority of people being mixed race even if they do not self-identify in that manner. The indigenous Fijians are of mixed Melanesian and Polynesian ancestry, resulting from years of migration of islanders from various places mixing with each other. Fiji Islanders from the Lau group have intermarried with Tongans and other Polynesians over the years. The overwhelming majority of the rest of the indigenous Fijians, though, can be genetically traced to having mixed Polynesian/Melanesian ancestry.

The Indo-Fijian population is also a hodge-podge of South Asian immigrants (called Girmits in Fiji), who came as indentured labourers beginning in 1879. While a few of these labourers managed to bring wives, many of them either took or were given wives once they arrived in Fiji. The Girmits, who are classified as simply "Indians" to this day, came from many parts of the Indian subcontinent of present-day India, Pakistan and to a lesser degree Bangladesh and Myanmar. It is easy to recognize the Indian mixtures present in Fiji and see obvious traces of Southern and Northern Indians and other groups who have been categorised together. More of this phenomenon would have likely happened if the religious groups represented (primarily Hindu, Muslim and Sikh) had not resisted to some degree marriage between religious groups, which tended to be from more similar parts of the Indian subcontinent.

Over the years, particularly in the sugar cane-growing regions of Western Viti Levu and parts of Vanua Levu, Indo-Fijians and Indigenous Fijians have mixed. Others have Chinese/Fijian ancestry, Indo-Fijian/Samoan or Rotuman ancestry and European/Fijian ancestry (often called "part Fijians"). The latter are often descendants of shipwrecked sailors and settlers who came during the colonial period. Migration from a dozen or more different Pacific countries (Tuvalu, Solomon Islands, Vanuatu, Samoa and Wallis and Futuna being the most prevalent) have added to the various ethnicities and intermarriages.

Latin America and the Caribbean

Main articles: Race and ethnicity in Latin America and Casta

See also: Mestizo, Pardo, Zambo, Mulatto, and Dougla people

Bob Marley's mother is of African descent and his father is of European ancestry.

Sean Paul's mother is of English and Chinese Jamaican descent; his paternal grandmother was Afro-Caribbean and his paternal grandfather was a Sephardic Jew from Portugal.

The term “Mulatto” historically referred to individuals of mixed African and European ancestry. In the Caribbean, such individuals were often recognized as socially distinct from their parents, leading to the development of specific social classifications. These classifications were part of a broader colonial caste system designed to manage the complex racial and social hierarchies in colonial societies.

"Mestizo" is the common word for mixed-race people in Latin America, especially people with Native American and Spanish or other European ancestry. Mestizos make up a large portion of Latin Americans, comprising a majority in many countries.

In Latin America, racial mixture was officially acknowledged from colonial times. There was official nomenclature for every conceivable mixture present in the various countries. Initially, this classification was used as a type of caste system, where rights and privileges were accorded depending on one's official racial classification. Official caste distinctions were abolished in many countries of the Spanish-speaking Americas as they became independent of Spain. Several terms have remained in common usage.

Race and racial mixture have played a significant role in the politics of many Latin American countries. In most countries, for example Mexico, Puerto Rico, Dominican Republic and Panama, a majority of the population can be described as biracial or mixed race (depending on the country). In Mexico, over 80% of the population is mestizo in some degree or another.

The Mexican philosopher and educator José Vasconcelos authored an essay on the subject, "La Raza Cósmica", celebrating racial mixture. Venezuelan ex-president Hugo Chávez, of Spanish, indigenous and African ancestry, made positive references to the mixed-race ancestry of most Latin Americans from time to time.

Trinidad, Guyana, and Suriname

Main article: Dougla people

Author David Chariandy, born to an Indo-Trinidadian father and Afro-Trinidadian mother.

Global artist Nicki Minaj, born to an Dougla-Trinidadian (Afro and Indo mixed) father and Afro-Trinidadian mother.

Colonialism throughout the Caribbean has created diverse populations on many islands and countries, including people of mixed-racial identities. A highly notable blend is the mixture of Afro-Caribbean people descended from enslaved Africans, and Indo-Caribbean settlers, descendants of East Indian indentured laborers. Trinidad, Guyana, and Suriname have the highest mixed populations of such individuals, often regarded as dougla’s. In addition to this, prominent mixtures may include Mulatto, Mestizo, Zambo, Panyol, Pardo, Anglo-Indian, and Chindian.

Brazil

Main articles: Pardo Brazilians and Mixed-race Brazilian

Proportion of Mixed Brazilians in each department in 2022.

Adriana Lima is of Portuguese, Afro-Brazilian, Native Brazilian, Swiss and West Indian descent, which classifies her as a Pardo Brazilian.

According to the 2022 official census, 45.34% of Brazilians identified themselves as Pardo. This option is normally chosen by people who consider themselves mixed race. The Mixed Race Day (Dia do Mestiço), on 27 June, is official event in the states of Amazonas, Roraima, and Paraíba and a holiday in two cities. Other than pardo, people who are mixed race also have other names to refer to themselves such as moreno, caboclo, mestiço and mulatto. Those terms are not considered offensive and focus more on skin color than ethnicity (they are seen as comparable to other human characteristics, such as being short or tall).

Most Brazilians of mixed race are usually tri-racial, with Amerindian, European, and African origins. Other common mixed-race groups are between European and African (mulatto) and Amerindian and European (caboclo or mameluco). But there are also African and Amerindian (cafuzo) and East Asian (mostly Japanese) and European/other (ainoko or more recently, hāfu). These groups are found throughout the country to varying degrees.

Since mixed-race relations in Brazilian society have occurred for many generations, some people find it difficult to trace their own ethnic ancestry. Today a majority of mixed-race Brazilians do not really know their ethnic ancestry, but they are aware that their ancestors were probably Portuguese, African and Amerindian. Additionally, a very large number of Italians (Brazil has the largest Italian population outside Italy), Japanese (the largest Japanese population outside Japan), Lebanese (the largest Lebanese population outside Lebanon), Germans, Poles, Russians and others contributed to Brazil's racial makeup. A high percentage of Brazilians is also of Jewish descent, perhaps hundreds of thousands, mostly found in the northeast of the country who cannot be sure of their ancestry as they descend from the so-called "Crypto-Jews" (Jews who practiced Judaism in secret but outwardly pretended to be Catholics), also called Marranos or New Christians, often considered Portuguese. According to some sources, one third of families arrived from Portugal during colonization were of Jewish origin.