Although the majority of lesbians reside in urban areas, lesbian couples significantly outnumber partnered gay men in rural communities and are an important part of the rural demographic landscape. However, being present does not mean lesbians are fully embraced within rural culture. Rural culture is often associated with traditional gender roles, conservatism, patriarchy, fundamental religiosity, hetero-normative family structures, and conformity—all of which can have significant effects upon mental and social wellbeing. Furthermore, rural residents frequently report negative perceptions of lesbian, gay, bisexual, and transgender (LGBT) people. These aspects of rural living can create challenges and vulnerabilities for lesbians who make their home there, creating unique considerations for mental health providers practicing in rural areas. The current article is a comprehensive review of the existing literature regarding the mental health of rural lesbians, summarizing current findings of the literature, highlighting areas of additional research need, and providing recommendations for mental health practitioners.