Association of Adverse Childhood Experiences with Depression in Latino Migrants Residing in Tijuana, Mexico

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Pedro Kremer, MD, MPH¹; Monica Ulibarri, PhD²; Natalie Ferraiolo, MD³;
Miguel Pinedo, PhD⁴; Adriana Carolina Vargas-Ojeda, MD, PhD⁵;
Jose Luis Burgos, MD, MPH⁶; Victoria D Ojeda, PhD, MPH⁶

Perm J 2019;23:18-031 [Full Citation]

https://doi.org/10.7812/TPP/18-031

E-pub: 12/07/2018

ABSTRACT

Context: Physical, sexual, and emotional abuse in childhood—adverse childhood experiences (ACEs)—are associated with poor mental and physical health.
Objective: To determine the prevalence of ACEs and their relationship to depression among Latino migrants in Mexico, which has not been previously examined.
Methods: A total of 110 Latinos aged 18 years and older residing in Tijuana, Mexico, completed interviewer-administered questionnaires, including the ACE scale (range = 0 to 10 items), at baseline in 2015. We studied the prevalence of ACEs (score on the ACE scale) and the presence of depressive symptoms (Patient Health Questionnaire-9). Multivariate logistic regression models were used to estimate the association between the ACE score and depressive symptoms.
Results: Overall, 82% of participants were men, and 82% reported being deported from the US. At least 1 ACE was reported by 64% of participants, and 33% reported 3 or more ACEs. Those who reported ever being incarcerated were significantly more likely to have 3 or more ACEs compared with no ACEs (56% vs 28%; p = 0.039). Symptoms of mild, moderate, or severe depression were identified in 14% of participants. In multivariate analyses, for each additional ACE item reported, participants were significantly more likely to meet criteria for depressive symptoms (adjusted odds ratio = 1.42; 95% confidence interval = 1.13-1.78; p = 0.002).
Conclusion: Among Latino migrants residing in the US-Mexico border region, ACEs were pervasive and associated with depression symptoms. Programs and policies targeting migrants in this region should consider addressing both ACEs and depression.

INTRODUCTION

Exposure to repeated or multiple emotional trauma is linked to mental and physical health conditions, including anxiety disorders, major depression, and heart disease; traumatic events occurring during childhood can be particularly harmful.^1-3 Adverse childhood experiences (ACEs) are defined as traumatic experiences that occur before age 18 years. Exposure to traumatic events can be assessed via the 10-item US Centers for Disease Control and Prevention-Kaiser Permanente ACE scale; it was validated in more than 17,000 US adults. The scale probes for experiences of abuse, neglect, and household dysfunction. Such ACEs have been proposed to disrupt neurodevelopment and increase the likelihood of mental health disorders.^4-8 

Although ACEs have been examined in American populations, including US-based Latinos, the largest study of the association between traumatic childhood events and depression in later stages of life was conducted in a mostly white, middle- and upper-class, and educated population affiliated with a large health maintenance organization.⁹ The ACE scale has subsequently been fielded in diverse populations.^10-12 The current study assesses the prevalence and relationship between ACEs and depression symptoms in a sample of Latino migrants residing in Tijuana, Mexico, a major migrant- and deportee-receiving community. This study provides insight into factors that may affect Latino migrants’ mental health.

In both the US and Mexico, childhood abuse and neglect are concerning social and public health issues. In the US, approximately 3.2 million children reported abuse or neglect in 2014.¹³ Childhood abuse, a dimension of the ACE scale, has been associated with subsequent development of mental health problems, including posttraumatic stress disorder, borderline personality disorder, dissociative symptoms, and depression.^14-17 In Mexico, 62% of boys and girls have experienced abuse at some point in their lives, and the prevalence has increased by 50% between 2013 and 2015.¹⁸ Neglect (27%) and physical abuse (23.7%) are the most prevalent forms of childhood abuse in Mexico.^18-20 A 2008 study examining ACEs among 178 pregnant women in Mexico City, Mexico, reported that 60% experienced at least 1 ACE; 45% of women reported physical abuse, and 47% reported problematic parental alcohol consumption.²¹ The prevalence of ACEs in a Mexican internal migrant or Mexico-US transnational migrant population is unknown, as are implications for resilience after these traumatic events.

Depression is also pervasive, and the Centers for Disease Control and Prevention estimates that it affects 7.6% of persons age 12 years or older in the US.²² In Mexico the reported prevalence of depression ranges between 12% and 20%,²³ but other studies showed higher rates (20%-59%) in US-Mexico border populations.^24,25 This study complements prior literature by examining the experiences of a largely male migrant population.

Given the relationships between mental illness and physical health, it is important to further elucidate potential contributors to poor mental health in adulthood. Such data can support the development or implementation of interventions to prevent or to treat mental illness across the life course. This study aims to 1) assess the prevalence of ACEs among Latino migrants in Tijuana and 2) assess the relationship between ACEs and current depression symptoms in this population.

METHODS

Study Setting, Design, and Participants

This study examined baseline questionnaire data collected from 110 adults aged 18 years and older participating in a tattoo removal study. The study site was a free clinic situated in the Zona Norte (Tijuana’s red-light district). Clinic patients included very poor, homeless, and uninsured individuals as well as injection drug users. The clinic advertised the tattoo removal study widely via posters inside consultation rooms and in windows facing the community, so that any individual aged 18 years and older was eligible to be screened for participation. The sample for this study is composed of community members and the clinic’s patients, although we are unable to differentiate the number of persons that comprise these 2 groups. The clinic’s patients are primarily migrants (ie, migrants to the US, migrants within Mexico, or international migrants from other countries, such as Central America).

The parent study involved the screening of 147 participants, of which 22 were excluded for the following reasons: Breastfeeding (n = 1), color tattoos (n = 14; these persons were excluded because the laser was not designed to remove non-black tattoos), positive HIV test or HIV test refusal (n = 4), and short-term plans to relocate away from Tijuana (n = 3). These individuals did not undergo baseline interviews. Among the remaining 125 participants, 15 were excluded because of the absence of data corresponding to the ACEs scale. Thus, the final sample was composed of 110 individuals.

Trained bilingual interviewers administered questionnaires to the participants in a private room using Qualtrics cloud-based questionnaire software (Qualtrics, Provo, UT). The study protocol was approved by the human subjects protection programs at the University of California San Diego, the Universidad Autónoma de Baja California, Tijuana; and the free clinic where the study was implemented.

Measures

The baseline (Spanish or English) questionnaire (lasting approximately 45 minutes) addressed the following topics: 1) demographics (eg, age, sex, marital status, homeless status, self-rated economic status, employment status, and possession of a Mexican Federal Voter Identification [ID] card—Mexico’s main government identification); 2) US migration and incarceration history, either in Mexico or the US; 3) drug use (lifetime); 4) lifetime self-reported health diagnoses of chronic conditions by a clinician; and 5) self-rated health status. In the next paragraph, we provide additional details for these variables.

The Mexican Voter ID Card was included in this analysis because it is a required document for accessing federally funded health and social programs in Mexico; possession of this ID was ascertained via a yes/no question. Homeless status was a dummy variable created from the question “Where did you sleep most of the nights during the last 6 months?” and homelessness was registered for every participant who answered affirmatively to at least 1 of the following options: A church, a drug dealer’s house, a shelter, the streets, by the river, an abandoned building, or a park. Self-rated economic status was ascertained by the question “How do you define your current economic situation?”; response categories were collapsed, and we focused on “poor” and “ very poor” categories (vs good/very good/refuse to answer). Persons who reported no to the question: “Do you currently have a job?” were defined as unemployed. Lifetime drug use was ascertained as positive for participants who selected any drug from a list of illegal drugs (marijuana, cocaine, crack, PCP [phencyclidine], methamphetamines, heroin, etc). For the question “Have you ever received, from a doctor or a nurse, a diagnosis of … HIV, diabetes, or cancer?,” persons who responded affirmatively to any of these conditions were classified as having a chronic health condition. Variables included in this analysis were selected on the basis of their association with depression risk, according to extant literature.

Primary Variables

Our primary independent variable was the ACE scale, which ranges from 0 to 10 items and includes 3 subcategories: Abuse (3 items), neglect (2 items), and household dysfunction (5 items; Table 1).^1,7 The dependent variable was the score on the Patient Health Questionnaire-9 (PHQ-9), which has been validated in national US samples, including Latinos, to detect mild depression (5 to 9 points), moderate depression (10 to 14 points), moderately severe depression (15 to 19 points), and severe depression (20 to 27 points).^26,27 We dichotomized the data as follows: 0 referred to no or minimal depression (ie, PHQ-9 score: ≤ 4 points), and 1 referred to mild/moderate/severe depression (ie, PHQ-9 ≥ 5 points).

Statistical Analysis

We conducted descriptive analyses to characterize the study population using c² or analysis of variance tests for categorical and continuous variables respectively, to compare differences across groups. We examined the proportion of participants reporting each ACE scale item (Table 1). Next, we examined the unadjusted association between our independent variables and number of ACEs, as defined by the number of items reported (ie, 0 ACEs, 1-2 ACEs, ≥ 3 ACEs; Table 2) as well as all independent variables and PHQ-9 scores (Table 3). We estimated a binary logistic regression model to examine the association between the ACE scale (range = 0 to 10 items) with mild/moderate/severe depression (vs no/minimal depression; Table 4). We also estimated the association between the 3 ACE subcategories and depression (Table 5). Regression models were adjusted for demographics, health status, and economic indicators.

RESULTS

ACE Prevalence and Participant Characteristics

Table 1 provides each ACE item and the proportion of participants that reported each item before their 18th birthday. Overall, household substance abuse (33.6%) and emotional abuse (31.8%) were the most commonly reported ACEs, whereas household mental illness was the least commonly reported item (12.7%). In the abuse category, emotional abuse was most commonly reported (31.8%); in household dysfunction, substance abuse was most prevalent (33.6%); and in the neglect category, emotional neglect was most commonly reported (23.6%). Table 1 also shows the prevalence of depression (ie, ≥ 5 points on the PHQ-9 scale) for each ACE item; it ranged from 20% and 30%, with the exception of household mental illness (36%). Overall, 14% of participants (15 of 110 participants) met criteria for mild, moderate, or severe depression. Additional analyses found that only 10 individuals (9%) met criteria for moderate or severe depression (data not shown); given the small sample, we focused on mild/moderate/severe depression as a combined group.

Table 2 shows participants’ characteristics, including stratified by the number of ACEs reported (ie, 0 ACEs; 1-2 ACEs; ≥ 3 ACEs). Slightly more than one-third of participants (36.4%) reported never experiencing ACEs, although most did experience ACEs: 30.9% of participants reported experiencing 1 or 2 ACEs, and 3 or more ACEs were reported by 32.7% of participants. Regarding their demographic and social characteristics, participants were predominantly male (82%) and, on average, were 41 years old; 96% of participants were Mexico-born (data not shown). One-third of participants lacked the Mexican Voter ID card, 65% reported being homeless at the time of the interview, 30% were married or in a civil union, 82% had been deported from the US, and 43% had ever been incarcerated. Additionally, 85% had ever migrated to the US (data not shown). Overall, 60% rated their economic status as poor/very poor. Nearly half of participants reported injecting drugs in the prior 6 months (46%), and 80% mentioned past use of illegal drugs, excluding marijuana. Also, 44% reported having ever been diagnosed with cancer, diabetes, or HIV, and 17% had ever experienced forced sex. About 1 in 4 participants rated their health as fair/poor (23%).

Regarding the relationship between participants’ demographic and social characteristics and ACEs, we observed that individuals reporting 3 or more ACEs were more likely to have been incarcerated (56% vs 47% among those reporting 1-2 ACEs and 28% among those reporting 0 ACEs; p = 0.039). Those reporting 3 or more ACEs also were more likely to have ever experienced forced sex (31% vs 15% for reports of 1-2 ACEs and 5% among those reporting 0 ACEs; p = 0.012).

Factors Independently Associated with Depression

Table 4 presents results from a multivariate logistic regression model examining the relationship between ACEs and mild, moderate, or severe depression symptoms (ie, PHQ-9 ≥ 5 points), while controlling for demographic, health, and economic covariates. Results indicate that ACEs are positively associated with mild, moderate, or severe depression, such that the likelihood of depression was significantly increased by 42% for each additional point on the ACE scale (adjusted odds ratio [AOR] = 1.42; 95% confidence interval: 1.13-1.78; p = 0.002). Other variables were not statistically significant in their association with depression symptoms.

Table 5 presents data on the relationship between the 3 ACE subcategories and depressive symptoms; all were statistically significant. In Model 1, which included adjustments for age and sex, the AORs ranged from 1.75 for persons reporting items in the household dysfunction category to 2.15 for persons reporting items pertaining to neglect. These AORs were further elevated in Model 2, which was further adjusted for cohabiting partner status, homelessness, chronic diseases, self-rated health status, employment, and self-reported economic status. This model provided even higher and more homogeneous AORs, ranging between 2.29 and 2.42 for the 3 ACE subcategories.

DISCUSSION

This study examined the association between ACEs and depression symptoms in a sample composed primarily of male Latino migrants residing in Tijuana, a metropolis that is a major migrant sending, receiving, and transit community. To our knowledge, this is the first study examining the association between ACEs and depression in a vulnerable sample in the US-Mexico border region. Our results are comparable to those obtained in a recently published meta-analysis that included 184 studies, in which maltreated children were 2.66 (95% confidence interval: 2.38-2.98) to 3.73 (95% confidence interval: 2.88-4.83) times more likely to experience depression in adulthood.⁴

Our participants reported a higher prevalence of ACEs than has been reported in US-based populations.^1,9 Childhood stressors appear to increase the likelihood of depression in adulthood, and their effect may be compounded by the experience of additional adversity in adulthood. An investigation conducted in newly recruited US soldiers showed that those who experienced episodic emotional maltreatment during childhood were 50% more likely to develop a major depressive disorder shortly after a stressful event.²⁸ Our study participants experienced multiple stressors (eg, deportation, homelessness, incarceration) that could have contributed to current depressive symptoms among those who were already vulnerable because of prior ACEs.

Study limitations include the following. It is difficult to establish causality between ACEs and depression, especially among adults, given that their responses may be affected by recall or social desirability biases. To address generalizability of our findings, it is worth mentioning that our sample has some characteristics (eg, primarily male, high volume of deportees) that preclude further generalizations to the broader population, even in Tijuana. Future studies should include a greater number of participants, especially migrant women, as well as other communities within Tijuana to reduce the possibility of selection bias. Similar studies should be conducted in diverse geographic areas to understand the scope of ACEs across Mexico and Latin America. Additionally, we were unable to corroborate physical health status; this should also be examined in future studies via the use of biomarkers and medical assessments. Because of the stigma associated with experiencing sexual abuse, some degree of underreporting of ACEs is to be expected among men, more so than among women.^29-31 Finally, controlling for variables that could be mediators in the association between ACEs and depression (eg, homelessness, chronic diseases) could result in underestimation of the total effect of the traumatic events. Despite these limitations, the findings are robust and consistent with previously published research.

Conclusion

Our study findings have potential implications for future research and practice. Our analysis expands the existing body of evidence addressing the association between ACEs and adulthood depression. Furthermore, our findings may contribute to the understanding that males, migrants, and deportees living in border regions not only face the challenges of their current circumstances but also past adversity. Resilience in adulthood can be supported by promoting access to mental health services, especially among individuals who are the most socially and economically disenfranchised. Health systems should support the routine use of ACEs as a mental health screening tool; this should be accompanied by training clinicians to implement the ACE scale during clinical encounters. Lastly, social support networks for migrants, including migrant-led services, could be promoted to foster and support the recovery process.^32,33 

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

We acknowledge funding from the following sources: The University of California GloCal Fellowship and the AIDS International Training Research Program funded by the Fogarty International Center of the National Institutes of Health under Award Number R25TW009343 and D43TW008633 (Drs Ojeda, Pinedo, Ferraiolo), and the National Institute of Mental Health grant #K01MH095680 (Dr Burgos). Dr Kremer was supported by a Research Fellowship from the University of California, San Diego Office of Graduate Studies and Dr Ojeda and Dr Burgos were supported by a Faculty Fellowship by the University of California, San Diego Center for
US-Mexican Studies.

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Kremer P, Ulibarri M, Ferraiolo N, et al. Association of adverse childhood experiences with depression in Latino migrants residing in Tijuana, Mexico. Perm J 2019;23:18-031. DOI: https://doi.org/10.7812/TPP/18-031

Author Affiliations

¹ University of California, San Diego School of Medicine, La Jolla
² California School of Professional Psychology, Alliant International University, San Diego
³ Scripps Mercy Family Medicine Residency, Chula Vista, CA
⁴ Department of Kinesiology and Health Education, College of Education, University of Texas, Austin
⁵ Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana, Mexico
⁶ Department of Medicine at the University of California, San Diego School of Medicine, La Jolla

Corresponding Author

Victoria D Ojeda, PhD, MPH ()

References

1. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Prev Med 2003 Sep;37(3):
268-77. DOI: https://doi.org/10.1016/S0091-7435(03)00123-3.
 2. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009 Nov;37(5):389-96. DOI: https://doi.org/10.1016/j.amepre.2009.06.021.
 3. Almeida OP, Draper B, Pirkis J, et al. Anxiety, depression, and comorbid anxiety and depression: Risk factors and outcome over two years. Int Psychogeriatr 2012 Oct;24(10):1622-32. DOI: https://doi.org/10.1017/S104161021200107X.
 4. Nelson J, Klumparendt A, Doebler P, Ehring T. Childhood maltreatment and characteristics of adult depression: Meta-analysis. Br J Psychiatry 2017 Feb;210(2):96-104. DOI: https://doi.org/10.1192/bjp.bp.115.180752.
 5. Sundström A, Rönnlund M, Adolfsson R, Nilsson LG. Stressful life events are not associated with the development of dementia. Int Psychogeriatr 2014 Jan;26(1):147-54. DOI: https://doi.org/10.1017/S1041610213001804.
 6. Shaw MT, Pawlak NO, Frontario A, Sherman K, Krupp LB, Charvet LE. Adverse childhood experiences are linked to age of onset and reading recognition in multiple sclerosis. Front Neurol 2017 Jun 2;8:242. DOI: https://doi.org/10.3389/fneur.2017.00242.
 7. Felitti VJ. Adverse childhood experiences and adult health. Acad Pediatr 2009 May-Jun;9(3):131-2. DOI: https://doi.org/10.1016/j.acap.2009.03.001.
 8. Slavich GM, Irwin MR. From stress to inflammation and major depressive disorder: A social signal transduction theory of depression. Psychol Bull 2014 May;140(3):774-815. DOI: https://doi.org/10.1037/a0035302.
 9. Chapman DP, Whitfield CL, Felitti VJ, Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affect Disord 2004 Oct;82(2):217-5. DOI: https://doi.org/10.1016/j.jad.2003.12.013.
 10. Font SA, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl 2016 Jan;51:390-9. DOI: https://doi.org/10.1016/j.chiabu.2015.05.013.
 11. Cronholm PF, Forke CM, Wade R, et al. Adverse childhood experiences: Expanding the concept of adversity. Am J Prev Med 2015 Sep;49(3):354-61. DOI: https://doi.org/10.1016/j.amepre.2015.02.001.
 12. Thompson R, Flaherty EG, English DJ, et al. Trajectories of adverse childhood experiences and self-reported health at age 18. Acad Pediatr 2015 Sep-Oct;15(5):503-9. DOI: https://doi.org/10.1016/j.acap.2014.09.010.
 13. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2014 [Internet]. Washington, DC: US Department of Health and Human Services; 2016 [cited 2018 Sep 27]. Available from: www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment.
 14. Sansone RA, Wiederman MW, Sansone LA. Adult somatic preoccupation and its relationship to childhood trauma. Violence Vict 2001 Feb;16(1):39-47.
 15. Chu JA, Frey LM, Ganzel BL, Matthews JA. Memories of childhood abuse: Dissociation, amnesia, and corroboration. Am J Psychiatry 1999 May;156(5):749-55. DOI: https://doi.org/10.1176/appi.ajp.157.8.1346.
 16. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. Am J Psychiatry 1989 Apr;146(4):490-5. DOI: https://doi.org/10.1176/ajp.146.4.490.
 17. Widom CS. Posttraumatic stress disorder in abused and neglected children grown up. Am J Psychiatry 1999 Aug;156(8):1223-9. DOI: https://doi.org/10.1176/ajp.156.8.1223.
 18. Fundacíon en Pantalla Contra la Violencia Infantil (FUPAVI). Diagnóstico Situación de la Infancia en México Maltrato Infantil. Urgencia Nacional [Internet] [Web site in Spanish]. Mexico City, Mexico: Fundacíon en Pantalla Contra la Violencia Infantil; 2015 [cited 2018 June 19]. Available from: www.fundacionenpantalla.org/attachments/article/6/ESTADISTICAS_Y_ANALISIS_SITUACIÓN_INFANCIA_EN_MEXICO_2015.pdf.
 19. Red por los Derechos de la Infancia en México, Ensayo temático: La infancia cuenta en México 2010 [Internet] [article in Spanish]. México: Redim; 2010 [cited 2018 Sep 27]. Available from: www.derechosinfancia.org.mx/ensayoicm2010.pdf.
 20. México: 6 de cada 10 niños sufren maltrato infantil [Internet]. [Article in Spanish]. Jersey City, NJ: Forbes; 2013 Jun 4 [cited 2018 Jul 5]. Available from: www.forbes.com.mx/violencia-infantil-la-otra-cara-de-mexico/.
 21. Gonzalez-Pacheco I, Lartigue T, Vazquez G. Estudio de casos y controles en un grupo de mujeres embarazadas con experiencias adversas en la infancia y/o adolescencia e infecciones de transmisión sexual. [Article in Spanish]. Salud Mental 2008;31(4):261-70.
 22. Behavioral risk factor surveillance system [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2018 [cited 2018 June 19]. Available from: www.cdc.gov/brfss/.
 23. Depresión y suicidio en Mexico [Internet] [Web site in Spanish]. Mexico City, Mexico: Secretaria de Salud de Mexico; 2014 [cited 2018 Jul 5]. Available from: www.spps.gob.mx/avisos/869-depresion-y-suicidio-mexico.html.
 24. Bojórquez I, Mejía S, Aguilera RM, Cerecero D, Albicker S. Problemas de salud mental en migrantes de retorno en situación de calle en Tijuana, Baja California. [Article in Spanish]. Coyuntura Demográfica 2014;6:91-7.
 25. Dawes SE, Suarez P, Vaida F, et al; the HNRC group. Demographic influences and suggested cut-scores for the Beck Depression Inventory in a non-clinical Spanish speaking population from the US-Mexico border region. Int J Cult Ment Health 2010;3(1):34-42. DOI: https://doi.org/10.1080/17542860903533640.
 26. Martin A, Rief W, Klaiberg A, Braehler E. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry 2006 Jan-Feb;28(1):71-7. DOI: https://doi.org/10.1016/j.genhosppsych.2005.07.003.
 27. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001 Sep;16(9):606-13. DOI: https://doi.org/10.1046/j.1525-1497.2001.016009606.x.
 28. Bandoli G, Campbell-Sills L, Kessler RC, et al. Childhood adversity, adult stress, and the risk of major depression or generalized anxiety disorder in US soldiers: A test of the stress sensitization hypothesis. Psychol Med 2017 Oct;47(13):2379-92. DOI: https://doi.org/10.1017/S0033291717001064.
 29. Hodge S, Canter D. Victims and perpetrators of male sexual assault. J Interpers Violence 1998;13(2):222-39. DOI: https://doi.org/10.1177/088626098013002004.
 30. Walker J, Archer J, Davies M. Effects of rape on men: A descriptive analysis. Arch Sex Behav 2005 Feb;34(1):69-80. DOI: https://doi.org/10.1007/s10508-005-1001-0.
 31. Scarce M. Male on male rape: The hidden toll of stigma and shame. New York, NY: Basic Books; 1997.
 32. Ostrow L, Leaf PJ. Improving capacity to monitor and support sustainability of mental health peer-run organizations. Psychiatr Serv 2014 Feb 1;65(2):239-41. DOI: https://doi.org/10.1176/appi.ps.201300187.
 33. Red Voz Pro Salud Mental [Internet] [Web site in Spanish]. Mexico City, Mexico: VozPro Salud Mental; c2016 [cited 2018 Jan 26]. Available from: www.vozprosaludmental.org.mx/index.php/quienes-somos#ciudades.  

Keywords: ACE, ACE study, adverse childhood experiences, depression, males, Mexico, migrants