the main character has a hole in their apartment wall that they can use to spy on their female neighbor. she is later taken by a serial killer who has been tracking her for the purposes of a ritual.
a mysterious kid is spotted multiple times in the game in stressful environments. he seems confused and lost but not totally scared. in one scene, he is verbally abused by an adult. a major part of the story involves a baby being abandoned in an apartment building after being born because his parents don't want him. one level is set in an orphanage that you learn abuses and indoctrinates children into a violent cult. another level is in a water tower-like prison used by the cult to lock up kids. it's implied the prison warden physically and sexually abuses the kids.
a pet store is massacred (not shown) and you can hear sounds of various animals shrieking. you can also kill the zombie dogs in the game. later, there is a frightening monkey-like enemy you fight.
there are tentacle-like worm creatures that sprout from the ground in some areas. some levels have a huge worm-like thing woven through them, but it is more thematically relevant to interpret it as a giant umbilical cord.
nothing closeup, but there are some bug-like creatures in the game that you can kill or be pestered by: slugs, leeches, buzzing bat-like creatures that can be mistaken for a large flying insect, etc.
when you pin a ghost with a sword of obedience (an item used to incapacitate ghosts so they stop chasing you), the ghost will make a horrible gurgling sound as long as you're close enough to hear or until you remove the sword.
No. If you’re here because of the whole “Silent Hill 4 foreskin theory”, please understand that there is no deliberate reference to circumcision and that all of that was ramblings. There is no explicit genital mutilation in this game whatsoever, nor is it ever implied.
A character is nearly beaten to death--the player sees the aftermath--and left badly injured. This may not fit individual definitions of torture, but given how prolonged and severe it is, I think it qualifies.
one enemy has two sleeping baby heads on it, which you can kill. the enemy represents twin children who were murdered by a serial killer, but the murder is not shown, only mentioned.
ghosts are a common and particularly frightening enemy type in the game. supernatural hauntings and spirits play a major role in what makes this game scary.
throughout most of the game, you need to crawl through small holes in the wall to get from level to level. you can skip most of the hole-crawling sequences, but you still have to approach and interact with the holes to travel through them. there are also first-person segments in the character's very small apartment building.
you never see an actual childbirth, but pregnancy, motherhood, and childbirth are themes/motifs of the game, since it's about a serial killer trying to summon a mother figure through a cult ritual.