The purpose of this study on university handling of Campus Sexual Assault (CSA) was to understand the experiences of Title IX Coordinators as key administrators in this work. CSA continues to be a pervasive problem, and the dialogue on campuses and externally is highly contentious. Guidance from the federal government, combined with a recent surge in lawsuits against universities, have created a precarious legal context for CSA that is exceedingly difficult for universities to manage. How institutions handle the array of moving parts with CSA is largely absent from the current literature. This study interviewed university Title IX Coordinators, who are responsible for overseeing the institutional response to CSA and therefore are uniquely positioned to offer insight into how universities are handling the problem and the internal and external factors that are playing a role. Sixteen interviews were conducted of Title IX Coordinators responsible for overseeing student CSA matters at NCAA Division I institutions. The research questions guiding this study included: (a) how do Title IX Coordinators handle and carry out their responsibilities related to CSA; what shapes the ways in which Title IX Coordinators handle their responsibilities related to CSA, and (b) how does university culture influence Title IX Coordinators’ work related to CSA? The theory that emerged from the data indicates that Title IX Coordinators have an array of complexities to navigate in their CSA work, stemming from an interplay of both internal and external pressures and factors, that can lead to a range of outcomes that are most often negative. Using grounded theory methodological procedures, a theory and visual model were generated to explain the interactions among the following components: Title IX Coordinator values and priorities; processes involved in CSA work; university culture and structure; collaboration with and management of university partners; the legal landscape and external context; and case outcomes and Title IX Coordinator impact. The theory has implications for policy, for Title IX Coordinators and universities, and for future research.