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According to the ACE Pyramid, neurodevelopment is disrupted or stunted following an adverse childhood experience. Social, emotional, and cognitive impairments result, which progress to high-risk behaviors that negatively impact overall health. Disease, disability, and social problems ensue, cascading to an early death.

Therefore, there is a correlation between a higher ACE score and an increased risk of poor physical and mental health due to poor choices, risky behaviors, and social issues. An ACE questionnaire asks difficult, emotion-provoking questions related to growing up during the first 18 years of life. Questions are related to physical, emotional, and sexual abuse caution very hot russian sex date chat the frequency of such insults.

The suicide of a family member, drug russiqn, and mental health issues play roles in the calculation of the score. ACE scores can range from zero to 10, with oht representing no exposure. According to a Florida study, conducted between andtrafficking abuse reports were highest among children with an ACE score of six or greater. Children with a sexual abuse history in connection with a higher ACE score had an increased chance of exploitation by traffickers.

According to a study, sexual abuse was the most reliable predictor of a person's exploitation by traffickers [5]. In this study, Austin, Herrick, and Proescholdbell concluded that the higher prevalence of ACES among LGB individuals might for some of the increased risks for poor adult health outcomes, poor choices, and heightened risk of being trafficked. The transgender community may seek out expensive hormone therapy and resort to "survival sex. Fifty-five percent of those who had resorted to "survival sex" vrry the past year were transgender women.

According to one study those who had engaged in sex for money were more likely to have experienced some form of intimate partner violence or sexual assault.

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Debt bondage places an "invisible chain" that binds a victim to a "Romeo" or "guerilla" pimp. The invisible chain tightens with unmet quotas and may become a physical one. Trafficking Risk Factors and Vulnerability Sexual abuse puts an individual at risk for substance abuse, mental health issues, and a lack of the concept of social norms, belonging, or sense of family. Often it is vsry who are supposed to protect them who are the initial perpetrators of the insult or crime.

A trafficker preys upon this vulnerability, uses it to their advantage, and strategically places themselves nearby. Often seen as a rescuer who offers a chance at a better life, security, or a remote possibility that better days are ahead, a trafficker is actually a profiler, trolling for victims to turn a profit. Traffickers do not discriminate based on gender, race, social demographic, immigration status, or economic status.

No exact mold fits a victim. Anyone is at risk, but certain populations have a higher vulnerability risk. The Cauhion Department of Health Office on Trafficking in Persons provided a fact sheet in to further highlight at-risk groups such as survivors of child abuse, sexual abuse, assault, interpersonal or intimate partner violence, gang members subjected to violence, or exposure to community violence. Increased risk also involves those with substance abuse problems, undocumented or migrant workers, and the LGBTQ population.

Minorities, those with disabilities, and those on Native American reservations can be at a higher risk of russlan trafficked. The US Department caution very hot russian sex date chat Education published a fact sheet for schools entitled "Human Trafficking of Children in the United States" which discusses the vulnerability of school-age children daye it relates to human trafficking ed. Examples of identified child trafficking cases involved stripping, pornography, forced begging, commercial sex, magazine crews, drug sales, and the cultivation of the product.

The fact sheet goes on to describe at-risk children and those potentially immersed in the human trafficking world. s of child trafficking include unexplained absences, poor attendance, runaway behavior, boasting about frequent travel to other cities, and inappropriate dress for the current weather, being sleep-deprived or malnourished, or showing s of impairment due to drugs or alcohol [NHTRC, ].

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Lack of a stable support structure and the accessibility of social media outlets may put at risk of being targeted for sexual exploitation. Social media websites, classified advertisement sites, chat rooms, and after-school programs are potential venues cautipn exploits youth. School hallways pose a risk, as a trafficker may, in fact, be another student.

A promise of a "happening" party or a good time may be used to entrap an unsuspecting, troubled, or bored youth.

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Educational campaigns, such as the "Blue Campaign" created by the US Department of Homeland Security, offer much-needed insight into the identification and treatment ramifications of victims of human trafficking. The Blue Campaign by the Department of Homeland Security offers sex trafficking awareness videos to educate our youth on the risks that traffickers pose in familiar places such as schools, coffee shops, malls, sporting venues and other hangouts [DHS.

Epidemiology The National Human Trafficking Hotline: Reported Cases When exploring the epidemiology of human trafficking, one must first examine data collection,and the organizations that provide this service. The National Human Trafficking Hotline's data collection gathers invaluable information to assist training programs and victims domestically and abroad. For example, data collection indicates that California, Texas, and Florida rank the highest in reported cases and referrals.

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The National Human Trafficking Hotline is a hour, confidential, multilingual hotline covering more than languages for victims, survivors, and witnesses of human trafficking. help humantraffickinghotline. Children as young as nine are thought to be targeted by sex traffickers, with the average age between 11 and Labor trafficking ages vary. In the case of an immediate emergency, call the local police department or emergency access. Child protective surfaces and local law enforcement will assist healthcare providers in local reporting requirements for minors involved in a possible abuse situation.

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Ages of sexual consent may vary from state to state. Thus, the need to consult local agencies. Ensuring victim identities are protected and information gathered will assist in bridging gaps in data that is publicly available. Data collection and access to ruxsian data are essential components in the CTDC's role in combatting rsusian war on human trafficking.

The first of its kind, this global repository of data will combine data from the IOM records on over 45, cases of human trafficking and the cases from Polaris, which are higher than 31, This collaborative data tracking system will foster a data-rich environment that will transcend borders and individual agency operational challenges. A comprehensive, international database will ruasian a positive byproduct of this partnership. IOM's report increased awareness of the CTDC as an essential resource for the global reduction of human caution very hot russian sex date chat cases.

Global Report on Trafficking in Persons Verg year, thousands of individuals fall victim to national and international trafficking. Almost no country is exempt from human trafficking infractions in one capacity or another; originating country, transient country, or destination country. The Global Vey on Trafficking caytion Persons shines some light on the profile of the trafficker in relationship to that of the person who is trafficked.

Traffickers and their victims tend to originate from the same geographical area, speak the same language as the victim, and share the same ethnic background. These commonalities foster a level of trust between the trafficker and the victim. The trafficker exploits this relationship for financial benefit. Traffickers rarely travel abroad to recruit, instead focusing on domestic recruitment.

Globally, local trafficking is on the rise. A trafficker will go to a destination country to exploit the victim.

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Countries most vulnerable to trafficking are those with high levels of organized crime and those ravaged by conflicts. From tomore than different trafficking flows were detected, and countries in Western and Southern Europe identified victims of various citizenships. It also found a clear link between migration and human trafficking. Further reporting that the movement of migrants and refugees is the most substantial reported migration since World War II, with an estimated million international migrants worldwide.

Forced migration as a result of refugees fleeing war-torn areas makes the women, children, and boys especially vulnerable to exploitation by traffickers. The movement of Syrians escaping the war is one such example. Children face exploitation as "child soldiers. In September ofworld leaders adopted the Sustainable Development Agenda and embraced the war against trafficking in persons on a global front.

This agenda called for all forms of violence against women and girls to cease. According to the Global Trafficking in Persons Report ofno country is immune from trafficking in persons, and over migratory flows of trafficking were detectable. Sub-Saharan African and East Asian victims are trafficked to numerous global destinations. In Southeast Asia, forced marriages are on the rise. Central America, the Caribbean, and South America frequently report cases of girls becoming victims of sexual exploitation.

Trafficking in fishing villages for forced labor is a problem in parts of the world such as Ghana caution very hot russian sex date chat Taiwan. Organ retrieval as a form of trafficking is less frequent but exists in some parts of the world. Another alarming fact from this report is that female participation was on the rise.

Young girls were recruited and controlled by older women. More couples are actively involved in trafficking. Posing as "stable couples" allows traffickers to seem more genuine and trustworthy while they actively recruit and exploit victims as a team. Former victims became active participants in recruitment, some to reduce their debt bondage and end their sexual exploitation.

Others, willingly participate in the abuse, using tactics of power and control. If persons being trafficked are engaged in criminal activity, they are less likely to cooperate with police, thus allowing the trafficker even more control. The average of convictions was low, with five victims per convicted offender. North America had the highest of convictions compared to the rest of the world. The United States reported to convictions per year, while Europe reported the highest of trafficking victims.

Pathophysiology Missed Opportunities and Myths A recent study revealed that Furthermore, it concluded that Recently, a smaller study of emergency department nurses in an urban setting concluded that emergency department nurses want better awareness regarding the specific resources available to victims of human trafficking. Ongoing research into the impact of institutional policy, the existence of human trafficking protocols, and continuing education regarding the recognition and treatment of trafficked individuals is required [22].

Myths or misperceptions often lead to missed opportunities to identify victims [DOS, ]. It is essential for healthcare providers and first point-of-contact personnel to be educated on these potential media-induced sensationalized myths. First, trafficking in persons is not just a crime that occurs in a faraway place or one that only involves migrants or foreign nationals. Individual exploitation happens in every part of the world - in the suburbs, big cities, and hometowns.

Victims can be coerced to take part in crimes, thus landing them in a detention center or jail. They may present to the emergency department for medical clearance. A victim may fall into a revictimization situation if returned to an exploitative environment. If an individual is free to come and go, then they may not be recognized as a person being trafficked.

As discussed ly, bonds are often not physical chains or cuffs, but "invisible" or psychological ones. Fear paralyzes the victim, acting as a shackle that emotionally confines them to the trafficking situation. Mental weapons used by the trafficker to exercise power and control over a victim may include threats of harm to children, siblings, or other family members; deportation or return to a traumatizing situation; calls to social services; and physical violence or reminders of past violence for misguided offenses.

Trafficked victims may use a school bus, a public bus, a train, or a taxi. Control over the person being trafficked lasts far beyond a physical wall, chain, or border.

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Much like intimate partner violence, victims usually do not self-identify, self-report, or recognize the fact that they are being manipulated, controlled, stigmatized, or dehumanized. Cultural Considerations Language barriers and cultural misconceptions may lead to a missed opportunity to identify a potential victim [23]. Inconsistencies in stories or history may become lost in translation, especially if a provider fails to obtain an interpreter that has no relationship to the person being exploited.

A staff member versed in the same language or who shares the same culture as the victim may be able to spot these subtle clues and ease cultural shock and miscommunication, but it is not always feasible to provide in a busy healthcare setting. It is imperative that if a suspected case of human trafficking or intimate partner violence arises that no family member or accompanying party be allowed to translate. Ensure a certified interpreter is nearby that is obtained from your institution.

A multitude of factors should lead a practitioner to seek out medical services for a person who is a suspected victim of human trafficking. They may also "hospital shop" for quicker wait times from door to the provider. An accompanying "family member" that is impatient, "in your face," and upset over lengthy delays in overcrowded emergency rooms or clinics may, in fact, be a trafficker. Another indicator is the "spouse" or "boyfriend" that insists on a high-risk patient, such as one with a possible ectopic pregnancy or appendicitis, leaving without being seen, against medical advice, or eloping before care is completed.

No victim will look the same or act the same; their individual, unique responses to their traumatic event will follow no specific protocol. As healthcare providers, we must be diligent in our efforts to identify these silent victims, forced into a situation of no fault of their own, made to carry out acts that reap emotional and social ramifications for years to come.

History and Physical Exploitive Environments When healthcare workers encounter potential victims of trafficking, a detailed work history and social history will assist in identifying red flags. Victims of labor trafficking tend to be near farms, fisheries, factories, or businesses such as nail salons, massage parlors, restaurants, and areas with high immigrant populations.

Traveling sales crews, begging rings, landscapers, construction workers, domestic workers, nannies, elder adult caregivers, and those in retail have a heightened risk of being labor trafficked. Immigrants may lack the power of communication due to language barriers which enable handlers from a similar background to approach them. Sex trafficking can be hotel or motel based, street-based, or in residences functioning as brothels.

Commercial-front brothels, escort services, truck stops, bars, and strip clubs can be places where sex trafficking occurs. Sex trafficking can happen at home with parents, intimate partners, or other family members as the perpetrators. Labor traffickers prey on specific vulnerabilities to entice individuals to accept substandard working conditions. Workers in the agriculture industry, factories, and domestic servitude sectors are vulnerable to human trafficking due to their work visa and immigration status being controlled by one employer.

This power over the individual and fear of deportation allows the trafficker to manipulate the worker, leading to victimization. Agricultural and industrial workers who are forced to work long hours with substandard wages may be isolated, confined by the use of dogs, armed guards, barbed wire or other fences, and locks. The seasonal nature of their work and movement from place to place heightens their vulnerability due to regularly being subjected to unfamiliar surroundings.

Domestic workers are also isolated, forced to live on the premises, and may lack access to cell phones and other communication devices. Language barriers add to vulnerability, coupled with caution very hot russian sex date chat inability to communicate. Traveling sales crews, begging rings, and peddlers are vulnerable due to homelessness and working in unfamiliar settings. If left behind in an unknown city, they may resort to "survival sex.

Drug and alcohol are used as a manipulation tool. Labor laws may not apply to subcontractors or independent contractors, thus increasing vulnerability risk. Trafficking in persons for labor exploitation may put a patient at risk for malnutrition, communicable diseases such as hepatitis and tuberculosis, pesticide and chemical burns, or exposure and work-related injuries due to lack of safety equipment such as safety belts, gloves, goggles, and masks.

Healthcare providers must determine if a crime occurred or if all three elements of trafficking in persons exist: force, fraud, and coercion. Observing for verbal and nonverbal clues as well as asking open-ended questions in a private, non-judgmental way will allow caregivers to determine a potential case of human trafficking.

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Questions to ask regarding labor trafficking suspicions may include and not be limited to the list below. Are you being paid the wages that were part of the initial agreement? Can you change jobs if you dtae to? Would anything happen to you if you did quit your job?

chzt Can you come and go as you please, cation bathroom breaks, eat when you want? Do you live with others? What are the home conditions and where do you sleep? Do you have a bed? Do you sleep on the floor? Is it too cold or too hot? Did you pay a fee to get your job? Do you owe a debt to your employer? Do you have access to your money, your identification?

Has your employer ever threatened you? Did you have eye protection, a mask, a safety harness? Personal protective equipment such as gloves? Does your employer provide your housing? Are you working in the job you were hired to do? Are you concerned about your safety? Your family or children's safety? How many hours do you work a day? How many days per week?

Have you moved around a lot? Do you know your address? Can you give me directions or a location of your house? Do you take care of others? Are there locks on the doors or bars on the windows? Can you leave freely? The absence of protocols, myths, stereotypes, biases, fear of no available resources, lack of education regarding human trafficking red flags, time constraints, lack of privacy, or an inability to separate the person from the potential trafficker all may play a part in the inability to identify victims.

Diagnostic Overshadowing A patient who presents with multiple visits for a pain complaint that has no organic cause, a frequent flyer as labeled by cautino, may be a victim of trafficking but stereotyped and overlooked. Those problematic patients that present with caution very hot russian sex date chat issues on multiple visits or those who return over and over with psychological holds for overdoses or suicidal ideations may be victims of trafficking.

Each time, there is the risk that they will be released back into the trafficking situation and victimization.

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Providers must recognize the potential for "diagnostic overshadowing" and be attuned to their own emotions and potential for bias. As providers, practitioners must stop, observe, ask and respond [4]. As front-line participants in the battle to combat human trafficking, healthcare workers must be aware of these potentials barriers to victim identification.

Often, rushing from patient to patient or exam room to exam room, being caught between documentation and hands-on assessment and care, and treating patients in hallways, lobbies, or corridors adds to the potential for a missed opportunity. May be difficult to ssx if a language barrier is present. Resistant to answer questions about the injury or incident. Avoids eye contact, is nervous, fearful of touch. No idea of address or general area where they live.

No control over their finances and lacks decision-making capacity.

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Accompanied by a controlling companion or family member that refuses to let the patient speak for themselves or be alone for care or insists on being the translator. Exhibits bizarre, hostile behavior. Resistant to care and assistance. May have initially consented but changes mind after asked to undress for an exam. No identification or the companion has it in their possession.

Under age 18 and involved in a commercial sex act. Tattoos or branding s. Markings may say "daddy" "for sale," imply ownership, or read as an advertisement for a product. Multiple sex partners. Inappropriate attire for the environmental conditions of the area. Attempt to reason away bruises or ligature marks by claiming a bruising or rare blood disorder.

Silent, afraid to speak, cringes at the sound of a loud voice. Uses trafficking "lingo" such as "the life" or other words common in the commercial sex industry. Has addiction issues such as opioids. Admits to a forced sexual encounter or being forced into sex acts. Law enforcement may refer to this as a "legend. An examination may prove difficult due to the emotional and psychological state of the victim.

These reactions are manifestations of their trauma. Provider frustration or stereotyping may arise, leading to the desire to exit the room quickly, with a quick determination of probable diagnosis and treatment. As discussed above, the potential exists for "diagnostic overshadowing. Conduct the assessment in private, not allowing anyone accompanying the patient to be present.

A chaperone may be present and a certified interpreter, if required, to facilitate a feeling of trust, establishes rapport, and starts to build a trusted network of people and organizations willing to help. During the exam, the patient may seem emotionally absent, hyperventilate, and not verbalize feelings of discomfort. Be alert to nonverbal s. Reassure frequently and promote a relaxed, non-rushed atmosphere. Avoid interrogating the victim, ask only direct, pertinent, open-ended, yet neutral questions.

Maintain eye contact with the victim, barring cultural considerations, and avoid writing while the victim is speaking. Ensure the victim is completely undressed and in a gown so a complete trauma assessment can be initiated. Specifically, examine for the following: Bruising; old, healing or new lacerations; hematomas; s of acute or chronic head trauma or a headache; missing hair or bald spots. Trouble hearing; damage to the auditory canal or eardrum; s of trauma to the oropharynx such as lacerations or burns, blood in the mouth, ulcerations, tooth decay, broken teeth, gingival irritation, tongue abnormalities; s caution very hot russian sex date chat anemia or dehydration in the oral mucosa.

Visual defects, sudden or of gradual onset; tattoos or brands in the hairline or on the neck; s of strangulation such as bruising. s of chest trauma, murmurs; cigarette burns; tattoos that imply ownership; bruising in various stages of healing; s of stress-related cardiovascular issues such as arrhythmias or high blood pressure. Respiratory issues that would indicate inhalation injuries from chemical exposure, toxic fume exposure, asbestos exposure, or mold exposure.

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s of tuberculosis such as night sweats, coughing up blood, fever, weight loss. s of cautlon respiratory or gastrointestinal problems. Damage to lung tissue due to prolonged exposure to chemicals or pesticides, aspiration pneumonia or other inhalation injuries; meth lab exposure can produce burning to the eyes, nose, and mouth, chest pain, cough, lack of coordination, nausea, and dizziness. s of gastrointestinal issues such as nausea, vomiting, diarrhea, constipation, or abdomen pain; rectal vate, itching, trauma or bleeding; parasites in the feces or s rusian abdominal trauma.

Bruising cqution the back or scarring; tattoos that imply advertisement, ownership, or are sexually explicit in the pubic hair. s of bruising or lower back scarring from repeated beatings; musculoskeletal issues such as s of repetitive caution very hot russian sex date chat work-related injuries or injuries dxte as back problems from wearing heels for hours walking the streets or neck and jaw problems from frequent, forced oral ses.

Fractures, old or new, any contractures. Cigarette or scald burns. s of scabies, infestations scalp or body. Fungal infections. s of nutritional deficits such as Vitamin D deficiencies from lack of exposure to sunlight, anemia, mineral deficiencies, brittle or fine hair. s of anorexia, bulimia, loss of appetite, malnutrition, severe electrolyte abnormalities.

Children may have growth and development abnormalities and dental cavities or misaligned poorly formed teeth. Neurological issues such as seizures, pseudo-seizures, numbness or tingling, csution, inability to concentrate, vertigo, unexplained memory loss, seizures. Insomnia, nightmares, waking up frequently. s of opioid or other addiction. s of Physical or Psychological Torture s of physical torture may present on a dermatological evaluation such as abrasions over bony prominences, scratches or linear abrasions from a wire, or "road rash" to extremities from being thrown from or drug by a vehicle.

Ropes and cords can leave elongated, broad-type abrasions. Ropes may leave areas of bruising mixed with abrasions. Belts or cords may have loop marks, parallel lines of petechial with central sparing. Cigarette burns tend to be circular with a 1 cm diameter and can fade in a few hours or a few days. Burns, in general, tend to take the shape of the object that inflicted the burn. Trafficking victims may be beaten or subjected to torture for a variety of reasons.

By the guerilla pimp as a result of not meeting yot quota or set of established rules, by a customer who is displeased or is just acting out a part of the sex act, or for no apparent reason other than to maintain control on the part of the trafficker. It is important to note that some cultures practice cupping therapy and may have bruising and scars from this practice.

Correlate this finding with a detailed history as well as the presence of other red flags. A presidential pardon does not shield someone from state charges, and the Manhattan district attorney, Cyrus Vance Jr, is still looking to prosecute Manafort for state crimes. A judge had ly blocked Vance from advancing his case, to protect Manafort from being prosecuted twice for the same crimes.

A Trump lawyer reportedly offered pardons to Manafort and Flynn as they were approached by federal investigators — raising suspicions that the pardons were datr in exchange for loyalty to Trump. The New York Times first reported the news in The congressman also noted that many serving time in federal prisons had been convicted of non-violent crimes and deserved a reprieve. Charles Kushner, 66, pleaded guilty to tax evasion and lying to the Federal Election Commission. He also pleaded guilty to witness russina, after he retaliated against his brother-in-law William Schulder, who was cooperating with federal investigators.

Trump has turned an instrument of mercy and justice into just another way for him to be corrupt. His schedule includes many meetings and calls. Here is what you need to know about the key figures. Manafort was once a high-flying lobbyist, serving as a consultant to the former Angolan rebel leader Jonas Savimbi and the former Philippine president Ferdinand Marcos. Trump has now pardoned multiple people charged as part of the investigation, including the former national security adviser Michael Flynn, and campaign adviser George Papadopoulos.

Manafort had been sentenced to more than seven years in prison for financial crimes related to his work in Tussian. However, he was esx from prison in May of this year over coronavirus concerns, and was due to serve out the rest of his sentence under home chxt. Stone, 67, was convicted in November of lying under oath and sec a congressional investigation into whether the Trump campaign colluded with Russia to win the election. In the process of the Trump-Russia investigation, which uot to a string of indictments, Mueller and fate team also revealed evidence of communications between Stone and WikiLeaks related to the release of hacked Democratic party s.

Stone was sentenced to more than three years in jail, but Trump commuted his sentence back in July before he entered prison. Stone was prosecuted and convicted sxe he committed federal crimes. He remains catuion convicted felon, and rightly so.

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He was sentenced to two years in prison after pleading guilty in to 18 counts of tax evasion and making unlawful campaign donations. Kushner was also charged with witness tampering — after he retaliated against his brother-in-law William Schulder, who was cooperating caution very hot russian sex date chat federal investigators. In an unusual twist, the man who prosecuted Charles Kushner was Chris Christie, now the former governor of New Jersey, who also has served as an adviser to Trump.

The Dutch attorney became the first formal conviction obtained by Mueller in his investigation. A former lawyer at the prominent firm Skadden Arps, Van der Zwaan worked on a report commissioned by Manafort to defend the former Ukrainian president Viktor Yanukovych from international criticism. George PapadopoulosGeorge Papadopoulos was a former adviser to the Trump campaign who became the second person to be sentenced to prison as the result of the Mueller investigation. Papadopoulos had told investigators that the conversation happened before he became a Trump campaign adviser, when in fact he had worked for the campaign for more than a month at the time.

Papadopoulos served 12 days of his day sentence, then was placed on a month supervised release. Duncan HunterDuncan Hunter is a former Republican congressman from California whose political career was brought to an end by corruption charges in He hog to conceal the illegal spendings by listing them in federal records as donations for military veterans and other campaign-related expenses, according to the indictment.

Hunter was sentenced to 11 months in prison after pleading guilty to stealing campaign funds.

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