Why Shadows Of The Damned Earned Its "M" Rating From The ESRB

Since its a Grasshopper Manufacture title game done in the style of grindhouse cinema, Shadows of the Damned was destined to be a "M" rated game from the day Suda51 started planning it. What points struck a cord with the ESRB?

This is a third-person shooter in which players assume the role of Garcia Hotspur, a demon hunter who must retrieve his kidnapped girlfriend from Hell. Players use a former demon that can transform into various weapons (e.g., pistols, torches, shotguns, machine guns) to kill demonic creatures in underworld cities. Combat is highlighted by loud cries of pain, realistic gunfire, and large explosions. The violence is often accompanied by blood effects: large blood splashes occur when enemies are hit, and some demons explode into bloody gibs when killed; cutscenes also depict the decapitation of boss creatures, resulting in fountain-like sprays of blood. In one level, players can view a handful of strip club–themed billboards (e.g., ‘Strippers,’ ‘Sex Parade’). In another sequence, a giant female character gyrates while cupping her exposed breasts; moaning sounds can be heard in the background. The words ‘f**k,’ ‘sh*t,’ and ‘d*ck’ can be heard in the dialogue.

No mention of all the dick jokes? I suppose the machinegun being called a "boner" and other bits of toilet humor aren’t as significant as how Paula’s decapitated head starts screaming at Garcia. On second thought it looks like the ESRB missed that too.