Purpose: The purpose of this study was to examine the prevalence of anal intercourse and its associated risk behaviors in a sample of Midwestern, predominantly white rural adolescents. Most of the research on this activity has been local or regional studies, with urban East and West Coast racial and ethnic minority adolescents. Methods: A surveillance questionnaire based on the Youth Risk Behavior Survey was distributed in 2009 to 820 rural middle and high school students in grades 6-12, across 2 rural counties in a Midwestern state. The school districts were stratified by grade level and a stratified random sample of schools (n = 17) was used. Data were analyzed using Fisher's exact test and multiple logistic regression. Findings: A total of 778 (95%) students completed the survey. The rural adolescents were in grades 6-12, were primarily white (95%), and were evenly distributed by gender. Similar amounts of students had engaged in sexual intercourse (24%) and oral sex (23%). Seven percent reported engaging in anal sex (1.6% middle school, 10.9% high school). Multivariate logistic regression controlling for other risk behaviors found that 2 variables were associated with increased anal sexual activity: ever had sexual intercourse (adjusted odds ratios [AOR]= 14.5) and ever had oral sex (AOR = 6.0). Conclusions: Anal sexual activity is a component of some rural adolescents' sexual experiences. These findings have important implications for sex education programs targeted to rural schools, where the typical high school classroom may have some students engaging in anal sex.