Background: This study examined the prevalence of oral sexual activity in rural Midwestern adolescents. We also examined the correlates of a series of risk behaviors with oral sexual activity. Methods: A questionnaire based on the Youth Risk Behavior Surveillance System was distributed to 2121 rural middle and high school students in grades 6-12 across 5 rural counties in a Midwestern state. The schools within districts were stratified by grade level and a stratified random sample of schools was used (n = 49). Results: A total of 2000 (94%) students completed the survey. The rural adolescents were: male (51%), White (85%), with an average age of 14.7 years (SD = 1.9). Overall, one-fourth (26%) of the students had engaged in sexual intercourse (8% of middle school and 39% of high school students). Slightly more than one-fourth of the students (29%) had engaged in oral sex (9% of middle school and 44% of high school students). Logistic regression was used to calculate adjusted odds ratios and found 3 risk behaviors were statistically significantly associated with oral sexual behavior: ever having had sexual intercourse (16.6 times more likely to engage in oral sex), having drunk alcohol in the past 30 days (2.2 times more likely), and having smoked 1 or more cigarettes in the past 30 days (2.0 times more likely). Conclusions: Oral sexual activity is an established component of many rural adolescents' sexual experiences. These findings have important implications for sex education programs targeted to rural adolescent youths. (Contains 4 tables.)