It's not simulated in films.
I remember being rather shocked when I read about that. How ghastly! @Cannibal Club: no, some actors really will do it for real for movies. Not pretend, not "it looks like they do it but they don't really."
I voted "somewhere in the middle." For the most part, you don't need gore, six, and genitals to make a game interesting. In fact, I think it takes quite a bit of talent to come up with a compelling story and NOT have the characters diddle around, shoot each other up with guns, and cuss each other like sailors. I get the feeling a lot of the six, drugs, gore, and nudity is just thrown in there.
Honestly, I'm just so sick and tired of gore, explosions, and people exchanging bodily fluids. None of the six really has anything to do with the story. It isn't the sort of action that advances an overarching plot, you know?