It has been awhile since we have seen the Adult Only rating show up without the developers deeming self-deeming their game worthy of the ESRB rating.
That being said, Hatred is the second game to receive the Adult Only rating without having any nudity in the game. The developers went onto the forums for the game(which you have to sign up to see) and posted the following message
Although Hatred is fairly controversial, the game itself isn’t as violent as you would expect. (for those interested, you can take a look at the trailer here.) It’s the theme that seems to get under everyones skin. The theme, which has appeared in many movies, TV shows, and video games over the years is simple. A random man decides to go on a killing spree. He kills cops. civilians. everyone he sees. The difference? you are playing as this character.
What is it in society that decides once the developers claim it is a game about mass genocide, and once we are playing through the villains perspective it becomes wrong?
If we were stopping this villain, taking down his organization and/or killing him and civilians that got in the way, perhaps the game wouldn’t make peoples skin crawl as much.