When the ESRB rates a title, it means the game is content complete. That usually also indicates the developer is putting the final touches on the game ahead of release.
The game's M rating is very much justified given the product description. Graphic content includes 'realistic gunfire', 'cries of pain', 'blood splatter', 'characters impaled', as well as sexual material like 'posters of women in revealing outfits', 'dialogue alluding to sexuality' and so on.
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