The Gaokao, a mandatory postsecondary entrance examination for all Chinese students, is often associated with psychological stress among Chinese students in their final year of high school. This project was conducted in summer 2017 in urban Beijing and rural Xi’an, China. The purpose is to explore the perspectives of urban and rural secondary school graduates after they have completed the examination, using in-depth clinical interviews. The study draws on Self-Determination Theory and research on moral reasoning to examine several themes surrounding Chinese adolescents’ perceptions of the Gaokao, including general perceptions of the purpose of education, intrinsic and extrinsic motivation, sources of support and pressure during study for the Gaokao, and issues of fairness and social inequality. The major findings are that students from all backgrounds reported psychological conflict regarding their general views of the aims of education and the extrinsic pressure deriving from the high-stakes Gaokao examination. Inequality was seen as further exacerbated by family background, resources, and quality of teaching. Urban parents tended to provide more support, both academic and interpersonal. Rural students rated their mental health as significantly lower than urban students during their senior year of high school.