Most studies of risky sexual behaviors of men who have sex with men (MSM) have been conducted in cities. Few have documented risky sexual behavior of rural men despite increases in rural HIV. Fewer have addressed stigma and risk. This study explored the effects of stigma on sexual risk behavior among rural MSM. We hypothesized that stigma emanating from families, health care providers, and the communities of rural MSM would indirectly affect their sexual risk behavior through their mental health status, specifically self-esteem and internalized homophobia. A convenience sample of 414 rural MSM obtained through political, health service, and social organizations completed an anonymous self-administered questionnaire. Over half of the men reported high-risk sexual behavior. Sensation seeking directly affected levels of sexual risk while the effects of stigma on sexual risk behavior were mediated by mental health variables. Stigma related to respondents' low self-esteem, and low internalized homophobia increased risk behavior.