Objective We examined the relationship between American Indian men's attitudes toward pregnancy prevention, STI/HIV prevention, and sexual risk behavior. Attention was given to: (1) attitudes and intentions to use condoms and sexual risk behavior; (2) STI/HIV prevention characteristics and sexual risk behavior; (3) attitudes toward abstinence and monogamy and sexual risk behavior; and (4) decision‐making in relationships and sexual risk behavior. Study Design Our sample included 120 heterosexual American Indian men aged 18 to 24 living on a reservation. Data were collected during in‐depth interviews. A community‐based participatory research framework was used to ensure the relevancy and acceptability of the study given the sensitivity of the topic. Principal Findings Results demonstrated that attitudinal factors were associated with sexual risk behavior, particularly inconsistent condom use. Attitudes associated with consistent condom use suggested greater levels of positive dispositions toward prevention and intention to use condoms. Consistent condom use was associated with more cautious attitudes toward sex with multiple sex partners. Study results suggested that American Indian men who reported sex with multiple partners exhibited a set of attitudes and beliefs toward pregnancy prevention and STI/HIV prevention that corresponded with a disposition resulting from their behaviors, in that engaging in sexual risk behavior elevated their levels of risk perception. Conclusions Our findings suggest that heterosexual American Indian men living in rural environments need sexual and reproductive health programs and clinical services that address differing attitudes toward condom use within the context of multiple sex partners and sexual risk behavior.