Regulating children’s and adolescents’ access to video games appeared on the agenda of media lawmakers from the 1990s on. Approaches in western democracies have largely followed the approach of industry self-regulation, resulting in a diverse set of different types of self-regulation systems. This study applies a comparative perspective on the actual rating practices, asking how far regulation systems differ systematically and how far these differences might lead to different rating decisions. The study analyzes both the set-up of three major western regulation systems (the German USK, the pan-European PEGI and the US ESRB) and the actual rating decisions in each of the three systems relying on secondary data at the aggregate level, individual rating decisions for 182 top-selling titles and a list of favorite video games of 744 adolescents in the US and Germany. Findings illustrate that each system has a distinct focus, according to which it regulates different video game use more strongly than the other systems.