In 2000 a study began to examine the health needs and help seeking behaviour of young people in New South Wales, and their service provision. More than 650 high school students took part in focus groups in 2001-2002, with 56 focus groups in urban areas, 22 in rural areas, and 3 in regional areas. This current article examines the results for rural and urban and gender differences, with a particular emphasis on structural disadvantage. Rural and urban teenagers had several concerns in common, including alcohol and drugs, bullying, and sexual health, but rural teenagers also expressed concern over suicide and teenage pregnancy. Rural teenagers also faced more disadvantage with health care access, including limited choice of providers, cost, and confidentiality, and were more likely to raise concerns about the effect of limited educational, employment and recreational opportunities on risk taking behaviour. Gender differences were evident for mental health issues in both areas, with boys less willing to seek help for stress or depression. The article finds that structural disadvantage adversely impacts upon rural adolescents health outcomes and health access, and suggests service improvements.