Background: To assess the need for cultural tailoring of an effective sexual health middle school curriculum, "It's Your Game: Keep It Real" (IYG), prior to implementation in Puerto Rican (PR) middle schools. Methods: Seventy-three seventh-grade bilingual students participated in IYG curriculum activities (both group-based and computer-based) in two 2-hour testing sessions in spring 2008. Rating scales of acceptability, understandability, credibility, ease of use, and motivational appeal and qualitative feedback via open-ended responses and group process provided insight into needed surface and deep structure cultural tailoring. Results: Students rated IYG highly on cultural tailoring and motivational parameters and were highly engaged by the lesson content. School personnel rated IYG as a feasible strategy for use in PR middle schools. While surface cultural elements (eg, characters, attire, body language) were identified as important foci for adaptation, content related to deeper cultural elements such as core behaviors, risky situations, attitudes, and specific skills were considered as relevant to PR youth as to their US counterparts. Conclusion: Effective human immunodeficiency virus, sexually transmitted disease, and pregnancy skills training prevention programs such as IYG that are developed for minority US youth may offer a feasible option for international implementation when extensive cultural adaptation is not a viable option. (Contains 1 figure and 2 tables.)