American Indian adolescents have two to four times the rate of sexually transmitted diseases (STDs) compared to whites nationally, they shoulder twice the proportion of AIDS compared to their national counterparts, and they have a 25% higher level of teen births. Yet little is known about the contemporary expectations, pressures, and norms that influence American Indian youth or how those might be shaped by today's lived cultural experiences, which frustrates attempts to mitigate the apparent disparity in sexual health. This paper used data from focus groups, in-depth interviews, and surveys with American Indian adolescents and young male and female adults from a Northern Plains tribe to contextualize sexual risk (and avoidance). Placing the findings within an adapted indigenist stress-coping framework, we found that youth faced intense pressures for early sex, often associated with substance use. Condoms were not associated with stigma, yet few seemed to value their importance for disease prevention. Youth encountered few economic or social recriminations for a teen birth. As such, cultural influences are important to American Indian sexual health and could be a key part of prevention strategies.