Peak Entertainment, a provider of online gambling services, submitted its product to the ESRB for an AO rating to demonstrate its commitment to discouraging underage gambling. Playboy Screensaver: The Women of Playboy Realistic blood and gore, strong sexual contentĮrotic Heat Vol. In light of these regulatory challenges, most AO-games have been released for personal computers, and nearly all erotic game publishers forgo the rating process entirely and sell on unregulated marketplaces.

Most retailers refuse to stock them, and the popular video game live streaming service Twitch forbids streaming them. Steam permits them, but hides them by default. All three major video game console manufacturers ( Nintendo, Microsoft, and Sony ) prohibit AO-rated games from being published on their platforms. Self-imposed restrictions by publishers and distributors limit the availability of AO-rated games, thus the rating has been described as a 'kiss of death' by journalists, and is considered essentially a ban. Grand Theft Auto: San Andreas (2004) was temporarily re-rated from M ('Mature') to AO after a sexually-explicit minigame was found hidden in the game, but the M rating was reinstated after Rockstar Games patched out the content. The only game to receive the rating for reasons other than pornographic content or extreme violence is Peak Entertainment Casinos (2003), which allows players to gamble using real money. A fourth game, The Punisher (2005), was also given the AO rating solely due to excessive, brutal violence, but like Manhunt 2, was censored before its release to meet a Mature rating.

Three games have been given the rating solely due to extreme levels of violence: the canceled Thrill Kill (1998), the initial cut of Manhunt 2 (2007), and Hatred (2015). The majority of AO-rated games are adult video games, typically those with pornographic or strong sexual content. AO is the highest rating in the ESRB system, and indicates the game's content is suitable only for players aged 18 years and over.

The Entertainment Software Rating Board (ESRB), the video game content rating board for North America, has issued an ' Adults Only' ( AO) rating for 26 released video games.

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