Background images used in the game were collected through an open call for background photos, from public-domain image collections, and by a dedicated photographer on the development team. Most of the art, sound, and animation assets used in the game are original and were created for the game by a dedicated team of artists on the development forums. The group took the name Four Leaf Studios (based on 4chan's four-leaf clover logo). From January 2007, the sketch was discussed extensively on the 4chan image board, and a development group was assembled from users of 4chan and other internet communities, who are of various nationalities not necessarily Japanese. The concept originated in a sketch created in December 2000 by Japanese doujinshi artist Raita Honjou (credited in Thanks as RAITA). Each of these paths chronicle Hisao's deepening and eventually romantic relationship (or lack thereof) with one of the five main female characters these may variously end well, badly, or neutrally. Depending on the choices made by the player, the story branches into multiple forks. The decisions made initiate possible events or dialogue within the story. The gameplay of Katawa Shoujo is choice-based, in which the player reads through text and occasionally has the chance to respond to prompts with a variety of preset responses. Over the course of the narrative, Hisao has the opportunity to come to grips with his condition and adjust to his new life. After a lengthy hospitalization, he is forced to transfer to a school specialized in providing education and healthcare for students with disabilities. The player takes the role of Hisao Nakai, an ordinary boy whose life changes dramatically after a heart attack caused by his long-dormant cardiac arrhythmia.

The majority of the story takes place at the boarding school Yamaku High School for disabled students, located in an unnamed city somewhere in modern, northern Japan. The game is licensed under the Creative Commons CC-BY-NC-ND. The game uses a traditional text and sprite-based visual novel model with an ADV-style text box running on the Ren'Py visual novel engine. 'Cripple Girls', translated 'Disability Girls') is a bishōjo-style visual novel by Four Leaf Studios that tells the story of a young man and five young women living with varying disabilities. Katawa Shoujo ( Japanese: かたわ少女, Hepburn: Katawa Shōjo, lit.

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