Stores will not carry Adult Only rated games. Just like many stores don't carry porn.
There are tons of AO rated games being made for the PC that you can download off the net. Just like how there are "unrated" DVD versions of movie releases, they're starting to pop up for some games (Indigo Prophecy, Playboy: The Game, and Leisure Suity Larry: Magnum Cum Laude).
Basically the only way a game will receive a AO rated is the same way a movie will receive a NC-17 rating: SEX!!!!!! Basically if penetration is shown or gentials are shown than the movie/game gets an AO/NC-17 rating but in the movie industry if it is artistically and tastefully done than it may get a R-rating (like the ending of Boogie Nights). Excessive violence like showing torture or abuse of children or animals will probably result in an AO/NC-17 rating also.
In Europe it's the opposite way, movies and games can usually get away with Sex but violence is a big no no. Germany bans anything that shows any Nazi things unless it's about World War 2. Gears of War and Manhunt wwer banned in Germany for too much violence. Indigo Prophecy received a 16+ with no censorship, the American version had to take out the sex parts to get an M rating.
Also religious themes can effect a rating for a game. Shin Megami Tensei 3: Nocture received an M rating in the US, a 12+ (same as a T rating) rating in Europe, and in Japan it received an "All Ages" (same as an E rating). Shin Megami wasn't really violent, there were a few naked people but they weren't sexualized, but anything that would probably disturb a child's mind, not really.Â
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