Yauk gyar mann yin (Be a Man!): Masculinity and betel quid chewing among men in Mandalay, Myanmar

Abstract

Betel quid chewing is associated with various oral cancers and other health concerns, including reproductive health issues. Nevertheless, the practice is widespread in Myanmar, especially among men. This qualitative study elucidates the gendered aspects of betel quid chewing by examining how it links with masculine ideology among male betel quid chewers in Mandalay, Myanmar. Data were collected through in-depth interviews, focus group discussions, key informant interviews and participant observation. The thematic content analysis was guided by Connell’s concept of hegemonic masculinity and Butler’s notion of gender performativity. The findings indicated that young Mandalay men were drawn to betel quid chewing by the value they gave to satisfying their curiosity, power competition, risk-taking, and a display of manliness. Thus, the practice of betel quid chewing, as defined by our participants, was perceived as manly, trendy, stylish, and sexually attractive. For adult men, betel quid chewing was a social lubricant that assisted them in talking with clients and co-workers, thus enhancing their economic opportunities with other men. It also helped working-class men to work harder. Betel quid chewing harm reduction programs therefore need to be mindful of masculinity issues as well as the economic aspects of betel quid chewing.

Introduction

Betel quid chewing is deeply rooted in Burmese traditional culture; for example, offering betel quid (kun-yar in Burmese) to guests has been considered an important element of hospitality (Kyaing et al. 2005). Originally, betel quid contained pieces of areca nut, slaked lime, and betel leaf. More recently, tobacco in various forms has become a common ingredient of betel quid. The majority of experienced betel quid chewers in Myanmar add tobacco to their quids, and chewing betel quid containing tobacco is the most common way to consume smokeless tobacco in the country; less popular forms include chewing tobacco leaf and drinking of tobacco water (Kyaing, Sein, Sein, Than Htike, Tun, Shein 2012).

Health consequences and prevalence of betel quid chewing

WHO/IARC (2004) have documented that chewing betel quid, with or without tobacco, is associated with the development of cancer and precancerous lesions of the oral cavity, because the areca nut itself is carcinogenic, and added tobacco is another source of cancer risk. One study indicated that those who chewed betel quid with tobacco had a 10-fold risk of developing cancer inside the cheek, compared to non-chewers (Way et al. 1984 as quoted in Reichart and Way 2006). Oral cavity cancer is relatively common in Myanmar (Moore et al. 2008) and the number of cases recorded among men at Yangon and Mandalay General Hospitals (where most cancer patients in Myanmar are referred to) has significantly risen (Oo et al. 2011).

Betel quid chewing has also been found to be linked to reproductive health issues, such as reduction of birth weight and length, and an altered birth sex ratio (Yang et al. 2008). Arecoline, an important component of the armen males (Kuo et al. 2014).

Chewing betel quid with tobacco is steadily becoming more popular in Myanmar, while the proportion of smokers is dropping (MoH 2009). A community-based cross-sectional survey among 275 18–24 year-old young men in 2012 indicated that 94.1% of tobacco users used smokeless tobacco; 65.4% of tobacco users both smoked and used smokeless tobacco (Linn et al. 2013).

In Myanmar, betel quid chewing is more common among men than among women: A 2007 sentinel prevalence survey indicated that among those over the age of 15 years, 31.8% of men and 12.1% of women used smokeless tobacco, mostly through betel quid chewing (MoH 2009). This higher prevalence (along with the higher prevalence of smoking) probably contributes to the higher prevalence of certain cancers among men in Myanmar (Oo et al. 2011). For example, the male-female ratio among oral squamous cell carcinoma patients in a Myanmar cancer registry dataset was 3.6:1 (Oo et al. 2011).

Although betel quid chewing is now clearly established as a health risk, previous studies have not clearly established why betel quid chewing is particularly common among Burmese men.

Gender identity and men’s health-related practices

Gender has been defined as the socially constructed identity through which people define themselves as masculine or feminine through repetitive bodily performances (Butler 1999). Previous studies have demonstrated that men engage in health-risk behaviours in their everyday social interactions to prove their normative masculinity, avoid social ridicule and to enjoy the societal power that comes with masculine gender expression. Many men in various contexts drink alcohol and/or smoke tobacco or marijuana because they wish to appear masculine (de Visser and Smith 2007; Haines et al. 2009; Odimegwu, Pallikdavath, and Adedini 2013). High-risk sexual practices (Bowleg et al. 2011; Odimegwu, Pallikdavath, and Adedini 2013), various other risk-taking behaviours (Muñoz-Laboy et al. 2012), delayed reporting of illness symptoms, late use of healthcare facilities (Maclean, Sweeting, and Hunt 2010; Odimegwu, Pallikdavath, and Adedini 2013), and unhealthy food consumption patterns (Gough 2007) have also been linked to socially constructed notions of masculinity among men in various cultures. On the other hand, Robertson (2003) has described how young boys often engage in sports not for health or for fun, but because sports are a way to compete for power and authority with other boys through attaining a hegemonic masculine identity. Thus, gender (as distinct from sex) is an important social determinant of health (Courtenay 2000).

Although masculinity has been identified as an important influence on health-related behaviour, little was previously known about how betel quid chewing is associated with the enactment of masculinity in Myanmar. However, in Taiwanese culture, betel quid chewing among young men has been described as “a way of projecting an aura of toughness, strength and macho image” (Williams et al. 2002, 150). Some research on smokeless tobacco consumed in other forms than betel quid has likewise linked its use to enactments of masculinity. In Ohio Appalachian culture, chewing tobacco is a way for men to exhibit their manliness, especially in front of women, who hardly ever engage in this practice and are disapproved of if they do it (Nemeth et al. 2012).

In Myanmar, the study of betel quid consumption has mainly been carried out as a part of research on smokeless tobacco use. Previous studies have focused primarily on the socio-demographic characteristics of respondents, types of tobacco used, tobacco-related expenditures, as well as knowledge, attitudes, and practices with regard to tobacco use (Kyaing et al. 2005; Linn et al. 2013). An earlier review of smokeless tobacco use in Myanmar only covered the prevalence, sociocultural backgrounds of users, and the types of smokeless tobacco used (Kyaing et al. 2005). These previous studies do not reveal why men in particular chew betel quid in Myanmar, and what meanings they ascribe to this practice. The fact that the practice is rooted in Burmese tradition (Kyaing et al. 2005) does not explain why it is now becoming increasingly popular among men in particular.

To help close this gap in the research literature and to guide future gender-sensitive behaviour modification approaches for reducing betel quid use, this paper describes men’s betel quid chewing in relation to masculine gender ideology in the context of Mandalay, the second largest city in Myanmar.

Methodology

This qualitative study on betel quid chewing among men was conducted in July–December 2013 in Chan Aye Tha Zan Township in Mandalay City, Myanmar.

Fieldwork was started with participant observation by the first author among betel quid chewers in and around one famous tea shop and at several betel quid stalls, to inform the recruitment of research participants and understand the social contexts of betel quid chewing. The first author also visited exclusively male spaces (e.g., tea shops, betel quid stalls and jade or car trading markets) to observe how men socialised and the role betel quid chewing played. She followed some participants to their workplaces and observed them in construction sites, taxi stands, and cargo loading spots to see how betel quid chewing featured in their daily working lives. Observations were recorded as field notes.

Initial key informants (one betel quid vendor and one university lecturer) were purposively recruited on the basis of their wide connections among betel quid chewers and of their knowledge on the social context of betel quid chewing. The researcher then interviewed the key informants and requested them to identify and recruit regular male betel quid chewers as participants for further two focus group discussions (FGDs, with 5 participants each) and 10 in-depth interviews (IDIs). The FGD and IDI participants had to match these selection criteria: (1) male and under the age of 40 years; (2) chewing betel quid for at least three days a week for a minimum of 18 months; and (3) presently living or working in Mandalay City. Five of the IDIs were conducted with men in lower-skilled occupations (age range 18–25 years), and another five among lower-middle class men (age range 26–35 years). These two different groups were selected to gain information from two groups of men that may be particularly likely to use betel quid.

The IDIs and FGDs were guided by a semi-structured question schedule. Each IDI and FGD lasted about 2–3 hours. All discussions were audio recorded and some photos were taken with the participants’ permission. The context of the IDIs and FGDs was observed while they were being conducted. Every participant was interviewed twice to capture any information not stated during the first round.

Field notes and the key informant interview, IDI and FGD transcripts comprised the raw data. Using a combination of research methods and theoretical triangulation served to validate these data. Thematic content analysis was then used to identify major themes in the data.

Ethical issues

The study was reviewed and approved by the Institutional Review Board (IRB) at Mahidol University, Thailand. For confidentiality, pseudonyms were given to all participants. Before starting interviews and discussions, participants were reassured about the research, its confidentiality, and their right to withdraw from the research. All the participants were recruited voluntarily with informed verbal consent. In accordance with the culture, all the participants were provided a present valued at around 5 USD instead of being given money as an incentive.

Findings

Betel quid chewing contexts and practices

Initiation to betel quid chewing

According to the findings of this ethnographic study, one third of the participants had first encountered betel quid through their family member(s) during their childhood. They were either offered it by a family member (e.g., father or grandmother) or became interested in it by themselves and decided to try it out, which was not difficult because it was readily available at home, and they were sometimes asked to go buy some for other family members. Exposure at this age (6–13 years), however, did not usually make a person a habitual user.

Rather, the workplace was the main social context where most participants began to develop a regular betel quid chewing habit. Peers were also a major influence, particularly for those who started chewing betel quid as students. The availability of different types of betel quid made it very easy and tempting for some participants to chew it.

Chewing took place within a social network–when unsupervised, during leisure time and as a group activity. Beginners might only chew 1–2 quids for the sake of experimenting with continuous chewing and spitting, without much noticeable effect. This direct participation allowed beginners to obtain knowledge on what betel quid actually was and to acquire a deeper understanding of why others were chewing it. Students would chew when they were together on their way to school in the morning, between classes, during lunchtime, and after school when hanging out together. Workers would chew secretly during work hours, when they bought betel quid for senior colleagues, or after work when going around with peers.

The type of betel quid chewed depended on with whom one chewed. Most started with betel quid without tobacco. Participants would tend to chew 1–2 times a day or perhaps a bit more, depending on the number of get-togethers with friends or other opportunities they had for chewing. A typical pack of betel quid contains 3–4 quids and costs only one hundred kyat (approximately $0.1 US). Since chewing was infrequent and the amount used was not large, usually one person would purchase 1–2 packs and share them. Thus, the cost of chewing for the beginner was not substantial.

Becoming a habitual chewer

Our results suggest that poor economic conditions and/or a poor family environment facilitate the habituation of betel quid chewing for most participants.

Most habitual chewers chewed betel quid with dried tobacco, while some chewed with more than one type of tobacco and other ingredients as well. The type and the amount of tobacco added to the quid varied on the basis of individual preference. Once a person became a regular betel quid chewer, he could chew it the whole day from dawn to evening, whether he was alone or with others. Commonly, the numbers of quids chewed daily increased over time, ranging from 12 (0.3 USD) for the regular chewer to 120 (3 USD) for the heavy chewer. Thus, the money spent on betel quid could be substantial, especially for low-wage workers.

In the process of betel quid chewing, every participant had encountered dizziness, particularly at their first exposure. Although this effect was more severe than that from any other substance they had previously used, no-one had stopped chewing because of these effects. Eventually, the health consequences and environmental pollution resulting from unregulated spitting of betel juice changed the opinion of some chewers, from previously viewing it as acceptable traditional practice, to considering it a disgusting habit. Chewers worried about being perceived negatively by non-chewers, some of whom thought that betel quid chewing looked ugly; this worry caused some to try giving up their habit.

The following case study vividly illustrates the context of men’s betel quid chewing and the practice as part of their daily life:

Ko Tun, a 24-year-old motorcycle taxi driver, first experienced betel quid chewing when he was young and stayed with his grandmother, who chewed betel quid. But this occasional chewing ceased when he returned to his home, where no betel quid was available. When he was 20 years old, economic hardship and poor family conditions pushed him to seek a better income in Mandalay. He stayed at his uncle’s home, where his cousin was a betel quid chewer. The repeated exposure and the perceived stylishness of his cousin’s practice reintroduced him to chewing betel quid. Later, his betel quid chewing habit made him feel out of step when he worked in a company with no other betel quid chewers. This environmental context again stopped him from chewing.

Being a man in Mandalay

Yauk gyar mann yin (Be a man!) is a slogan commonly heard among young men during our fieldwork in Mandalay. From our informants’ view, it is uttered to encourage and challenge oneself to do something daring, particularly when competing with someone. Therefore, men in our study tend to think of themselves as brave, responsible, and wise to fit into the socially constructed idea of masculinity. Ever since their childhood, men are exposed to expectations as to how men should behave. Under patriarchy, men are expected to be leaders and protectors of their families, communities and their nation, so they are also supposed to be physically strong and resilient, able to work hard, decisive, and intelligent. They are expected to be open-minded, with their own ideas and decision-making power, and able to survive under any conditions. They are expected to know how to live, communicate, and be sociable as well as practical, faithful and trustworthy. Men with these characteristics are perceived as ‘real men’. Therefore, the expectation is that real men respond to and even welcome challenges. Hence, responsibility, curiosity, and risk-taking are valued among men in Mandalay as elements of manliness.

Responsibility

Our findings reflect that men in Mandalay are expected to be ‘responsible’ in many ways. Masculinity ideology has led them to perceive themselves as hearty, tough and stout:

Yauk gyar mann yin (Be a man!), loat ye yin kan ye yamae (be able to take responsibility), refers to the notion that one must be able to accept the consequences of what he has done. Men must be tha` tishiyamae (brave). (Ko Zaw, grade 10, 21 years, jade broker)

Most young men and boys in this context view that being a man means the welfare of the family is under their responsibility and so is responding to problems in society at large. Men in our study reported that they take on difficult, physical domestic work to take care of their families and to contribute economically to their welfare, inspired by their own parents’ care and devotion to the family. Hence, men are respected as the backbones and decision-makers of their families. Many participants reported having contributed to their family’s financial resources, and some even had needed to interrupt their studies and start working to help out during a family financial crisis:

My family’s business was failing when I was in grade 8. In my family, only my father worked. I felt sorry and I could not stay away when I saw my mom cry and suffer from poverty. I had a sister, but since I was the son, I had to stand up and help solve the problem. So I stopped my studies and started to earn money. (Ko Ni, grade 10, 20 years, jade broker)

Curiosity

Results from our FGDs and IDIs suggest that curiosity and an outgoing personality are viewed as key characteristics of a ‘real man.’ This curiosity and extroverted character is part and parcel of what it means to be a competent, knowledge-seeking male in Mandalay:

We have the concept that men should experience everything we can. This makes it impossible for us to stop being curious. (Ko Too, grade 10, 31 years, tattoo designer)

Curiosity is also linked with the value given to independence – not believing what one is told, but learning from one’s own experiences:

I was thinking why many people chewed betel quid even though it was not good, damaged teeth and was also ugly. So I tried to chew it to know what it was! And I became addicted to it. We could not control our curious minds. We would try it without concern for its consequences. I believe that in our age, those who become betel quid chewers, it is mainly because of curiosity. (Ko Sai, university student, 20 years, cycle taxi driver)

Most participants shared this view that they had become betel quid chewers because of their strong curiosity. Curious young men, when exposed to betel quid chewing, tend to try it out despite any constraints that may exist. Another young man, who worked as a jade broker, explained how being born as a man was a precious opportunity for experiencing everything:

It was difficult to be born as a man, so a man should not pass up any chance to experience something. (Ko Ni, grade 10, 20 years, jade broker)

Risk taking

From our findings, we observed that risk taking is also a common characteristic of young men in Mandalay. The value given to risk taking leads them to dare to do almost anything without fear, whether right or wrong. Often, a risk might be taken to mimic what someone else is doing, without considering the consequences. Taking risks demonstrates to others and themselves that they have what it takes to overcome a particular difficulty. This characteristic motivates them to challenge their parents’ and the communities’ perceptions, for example with regard to a particular habit or behaviour that is currently viewed as bad or inappropriate. Young men often feel proud for daring to do what is against the rules, believing it helps to make them a hero, and hence a real man:

I thought that society would perceive me as a brave man if I did things that other people disliked. I believed that I was a ‘hero’ if I could do what adult men did, such as drinking, smoking and chewing betel quid. (Ko Too, grade 10, 31 years, tattoo designer)

Symbolic meaning of betel quid chewing

Maturity and power competition

In the eyes of their parents, young men in Mandalay are often considered to lack the proper knowledge to make wise decisions and likely to be engaged in making mistakes. This perception restricts young men’s freedom. However, as explained above, breaking the rules fits these men’s concept of ideal manhood, so the more they are controlled, the more they like to go against the rules. Some young men, particularly those living under strict family control, are easily ‘intoxicated’ by new interests due to their lack of previous experience.

Despite being overall a culturally accepted practice in Mandalay, many there now view betel quid chewing negatively, out of concern for its health impact or the public nuisance caused by unregulated spitting. Chewing betel quid therefore provides an easy opportunity for young men to demonstrate an irreverent, ‘tough guy’ attitude and thus indicate to those around them that they have grown up and are free from familial control:

Young men tend to over-emphasise their masculine maturity [‘I have grown up’] by doing what adult men are doing. Similarly, by taking up betel quid chewing, what adult men do, they think they have grown up. (Ko Chit, graduate, 33 years, photographer)

All participants had heard about the negative consequences of betel quid chewing and almost all had had negative experiences when they chewed betel quid. At their first exposure, they experienced severe dizziness, and some continued to encounter it during later chewing events. However, what they called their ma khan chin zeik (indomitable spirit) endlessly pushed them to compete with others and not be outdone, and so led them to continue with betel quid chewing despite its negative physical effects:

I heard that chewing betel quid was not good. I also experienced ill effects when I first tried it. Although I suffered from dizziness, I did not give up because I thought, ‘other people can chew, why not me.’ (Ko Theik, grade 7, 22 years, car mechanic worker)

This quotation explicitly demonstrates how young men tend to imitate what others are doing, especially if they regard the action as stylish among their own group. More importantly, it reveals their concern that they will be perceived weaker than other men if they are outdone by the negative effects of betel quid.

Sub-group identity, unity and sociability

Young men who chew betel quid do so to present themselves as independent, defiant, masculine men. However, they also want to show they are strong and powerful by doing things as a group. They demonstrate this free, careless attitude by skipping classes, drinking toddy palm alcohol, and whiling away the time playing games on the Internet. As a result, they draw attention to themselves, which also serves as a warning to others not to cross them. Chewing betel quid makes these men feel they are manly; it is a way of exercising power and of presenting a subtle challenge to other young men:

Young men like to gather in groups as a gang. They have similar behaviours, by chewing betel quid, smoking cigarettes, dressing the same way, having the same hairstyle, and always appearing in their group in order to show their power and intimidate others. (Ko Naing, graduate, 34 years, swimming trainer)

Young men in Mandalay gather in the evening after work or during their leisure time, normally at a betel shop, and hang out, perhaps riding around on motorbikes to enjoy the feeling of the wind. They sit outside the fence of Mandalay’s palace or gather at a friend’s house. They talk about their experiences and explore their feelings. Sometimes, they sing songs and play guitar in front of a girl’s residence and assist each other in courting a potential girlfriend. By doing so, they strengthen their sense of brotherhood with the company of the betel quid, an essential component that gives them confidence and unity whatever they do and wherever they go. Being part of a group with others who share the same habits and values puts them in a shared world with shared topics. They chat, interact, and look after each other. However, in such groups, a young man who does not chew betel quid would feel like an outsider. So, some young men became betel quid chewers simply to be part of the group and not be excluded or appear inferior to others:

I began chewing because all my friends were betel quid chewers. I felt there was a power imbalance between us since I was the only non-chewer. (Ko Htwe, grade 10, 23 years, gas station attendant)

For adult men, betel quid is a social food. It is shared with whomever they meet. It is an introductory offering to establish friendship and facilitate intimacy. Betel quid is shared with friends to extend business networking and is normally present wherever adult men engage in social activities. Betel quid is chewed at business meetings and after drinking, thus serving as a social lubricant in men’s social contexts:

For example, if you introduce a man to me, we will feel that we do not have much to talk about since we do not know each other. But if a betel quid is shared, it breaks the ‘stranger barrier’ between us. (Ko Too, grade 10, 31 years, tattoo designer)

Trendy, stylish, attractive, and confident: Betel quid chewing and sexuality

As young boys, most participants had admired adult men who chewed betel quid and had red, betel-stained lips, considering them handsome. To them, chewing betel quid and spitting out betel juice during conversation was daring and eye-catching. Some would forcefully and noisily spit betel juice to a certain distance. This act was seen as ‘brave’ and as a display of an irreverent attitude, being oblivious to the negative aesthetic effects it had on the immediate environment. Perceiving betel quid chewing as stylish, and considering those who chewed betel quid as great, brave, manly, and attractive, young men began to imitate what they saw. Subsequently they would perform this act to attract the attention of the opposite sex:

We displayed our ‘style’ in front of girls and others at school. We intentionally spat betel juice and added a quid into the mouth because we felt that talking while chewing betel quid, laughing, and spitting in front of others was the ‘style’ and that by doing so we could get attention, particularly from the girls. (Ko Naing, graduate, 34 years, swimming trainer)

Though our participants valued being ‘cool,’ in control, and confident, they sometimes felt shy and excited, particularly when walking by a group of girls alone. They felt ‘sheepish’ and were worried the girls would tease them. Chewing a quid of betel helped to solve this problem – it gave them confidence and made them more comfortable, as if they had a companion beside them:

You know, I felt quite ma lon ma le` [sheepish] to pass by a group of girls alone. But if I was chewing a betel quid, I felt calm and confident. I could even walk by swaggering to get their attention. (Ko Wai, non-graduate university student, 28 years, photo frame developer)

Betel quid as an energiser for working-class men

In Mandalay, men are regarded as strong and unyielding. Thus, difficult, hard, and heavy tasks are normally reserved for men, who also welcome and accept such tasks as theirs. In their mind, they are supposed to be capable, and it is expected there is nothing they cannot do. They are expected to be able to work no matter how hard the work is or how troublesome the conditions are. Mandalay men take pride in successfully carrying out a difficult task without cheating or taking advantage of others. Their desire to be ‘true men’ motivates them to work hard, achieve their goals and never give up. Yet, in reality, it is also a struggle for them to constantly prove their manliness. Betel quid acts as an energiser that affords them strength, keeps them under control, and allows them to move forward without feeling exhausted. Our findings suggest that while the participants chew betel quid all the time, they chew even more when they have to work hard. Therefore, none of the participants could refrain from chewing betel quid particularly when they were working. Labourers rely heavily on betel quid to get through the day. This allows them to preserve their manly façade by bolstering their stamina as they perform hard labour:

It was tiring working in a fertiliser retail shop because the fertiliser bags were heavy and there were only two people to load many fertiliser bags in a day. I would chew more betel quid if I had to work very hard. Chewing betel quid gave me more energy so I could work without getting tired. (Ko Tun, grade 7, 24 years, cycle taxi driver)

Discussion

Our findings indicate that some men in Mandalay are first exposed to betel quid chewing in childhood. Most only develop a chewing habit in teenage, as a way of proving their maturity and manliness to themselves and others. Betel quid chewing is perceived as manly because it is considered a bad habit; doing something that others disapprove of helps to communicate an irreverent, independent mind set thought to signal both masculinity and maturity. Being able to tolerate its side effects is also considered a sign of manliness. Chewing is used to communicate one’s power to other men and one’s sexual attractiveness to women. Betel quid chewing links with three elements of idealised masculinity – it symbolises risk-taking, satisfaction of curiosity, and it also helps working-class men to work hard and bear the responsibility that falls on them as men.

As children grow up, they are exposed to societal expectations regarding gender (Maclean et al. 2010), and most boys are socialised to embody hegemonic masculinity (Connell and Messerschmidt 2005) and a ‘take it like a man’ ethos (Addis and Mahalik 2003). This socialisation that plants the stereotype of masculinity in the minds of boys and men occurs in almost all aspects of a man’s life, such as family, peers, schools, churches, public health programs and media (Odimegwu, Pallikdavath, and Adedini 2013; Gacoin 2010).

Our findings indicate that being responsible is an essential element of what is considered being a real man. Similarly, men living with HIV studied by Dageid, Govender and Gordon (2012) cited the need for men to be responsible as their key motivation for disclosing their HIV positive status to their families. On the other hand, risk-taking is also promoted, celebrated, and perceived as a natural behaviour for young men (Young and White 2000). Young men use their bodies as agents of gendered social practice when they engage in risk-taking (Kimmel and Messner 1998). Our findings indicated curiosity as a further celebrated aspect of masculinity.

Masculinity is constructed through various practices, including substance use. For example, for many adolescents, smoking is associated with masculinity and is a way to express their toughness and risk-taking character (Nichter et al. 2006). Similarly, drinking for young men in the UK allows them to exhibit their masculinity (de Visser and Smith 2007). Findings from our study suggest that betel quid chewing is a way for young men to perform their masculinity in Mandalay; Williams et al. (2002) have suggested that betel quid chewing also plays such a role among men in Taiwan.

Power relationships based on hegemonic masculinity both reflect and determine social relationships among men. Backing down from a challenge would lower a man to the status of being ‘less than a man.’ This in turn leads to a hierarchy of masculinities and the construction of an idealised version of dominant or hegemonic masculinity (Connell 2005). Furthermore, Courtenay (2003) illustrates the social risk associated with masculinity by stating that men feet stigmatised or marginalised if they fall short of achieving an idealised masculinity. If they fail to act, it means that they are not masculine (Connell 2005). Our findings indicate that in Mandalay, betel quid chewing is one challenge that men either take or suffer the consequences of being considered not quite a man. The health risks and side effects of betel quid chewing only serve to make it more valuable as a symbol of manly courage and perseverance.

Membership in a male peer group is also socially necessary to prove one’s masculinity (Maclean et al. 2010). Young men stereotype themselves and mimic others in order to be accepted by a male group. Chewing betel quid together serves for young men in Mandalay the same function as does marijuana smoking for young Canadian men in British Columbia: enhancing social bonds (Haines et al. 2009). On the other hand, our findings also indicate that those men who do not chew may not feel they belong to their group, or have less power than other members.

Both femininity and masculinity are based on how women and men measure up to the socially constructed expectations for their respective gender (Haines et al. 2009). Butler has argued that gender is rooted in performativity. In this view, gender as an identity is a product of actions performed repetitively, rather than vice versa. This identity is reinforced by the norms that already exist within a society (Butler 1999). In other words, being born as male is insufficient for being a man. It is essential that young men do certain things to reaffirm their gender identity. And, indeed, they are socialised to do so as they are growing up. When an older man does his gender performance by chewing betel quid, younger men imitate this behaviour to reiterate their manhood and to internalise their masculinity. If gender is all about individuals’ performances (Butler 1999), grinding of the hard areca nut with one’s teeth, spitting out betel juice, and the show of having the quid inside one’s mouth, are all acts that enable young men to perform their masculinity into being. Like smoking marijuana represents a display of masculinity for men (Haines et al. 2009), young men chewing betel quid communicate that they are as tough and hard as the areca nut itself (Williams et al. 2002). Therefore, gender is neither about what people are born with nor about the social imposition of a label on a gender-neutral body; rather, it is based on one’s performance. It is self-made; gender is always a doing (Butler 1999). That is also how young men in Mandalay, through betel quid chewing, establish their gender as men.

Traditional notions of masculinity dictate that real manhood is achieved by being the primary provider and authority in a household (Macia, Maharaj, and Gresh 2011). The norms of male dominance and female subornation, basically represented in the realm of sexual authority, also apply to other contexts (Tong 1989). The issue is one of power, hierarchy, and attractiveness. The social construction of heterosexuality produces a different set of requirements for the male body than for the female body. This discourse about men and women grants power to men on the basis that whatever men do ‘looks good.’ MacKinnon (1982) argues that sexuality is the locus of male power. In the domain of heterosexuality, men have been allowed to express their sexuality whenever they want to, unlike women. They express their sexuality through their physical manifestation and performances with the assumption that their bodies are vehicles for their pleasure (Holland et al. 2003). Similarly, young men in Mandalay chew betel quid as a challenge to themselves, which in turn makes them feel brave and hence appear more sexy and attractive to others.

Hardon, Idrus, and Hymans (2013) use the term ‘chemical sexuality’ in describing how Indonesian men and women manage their bodies, moods, and sexuality by using energy-enhancing substances and chemical products regardless of their side effects. Both genders use unauthorised chemical substances to attain and maintain their sexuality. Warner, Weber, and Albanes (1999) state that girls use marijuana to impress boys whereas young men in British Columbia and Canada think that marijuana use makes them look cool (Haines et al. 2009). Likewise, young men in Mandalay perform their sexuality through betel quid chewing, demonstrating a case of a ‘chemical sexuality.’ Hanging out and chewing betel quid in a group, having betel-stained lips, and spitting betel juice are all stylised performances that young men in Mandalay engage in to express their sexuality and to attract women’s attention.

Conclusion

This study demonstrates that for today’s young men in Mandalay, betel quid chewing is a means to construct and demonstrate their maturity and masculinity to themselves and others; it is thus an element of a hegemonic-masculinity ideology.

However, the psychosocial and physical consequences of betel quid chewing alarmed the participants themselves and made them consider quitting the practice as well as dissuading non-chewers from taking up the practice. Emphasising the physical and psychosocial embarrassment associated with betel quid chewing will lead to a better outcome, especially if these perceived constraints are highlighted in gender-sensitive behaviour change programmes for betel quid chewers. For instance, a young man who wants to quit betel quid chewing could be held up as a role model for the younger generation. For multiple approaches in behavioural change intervention programs, further studies should focus on factors other than masculinity, such as age and social class.

Limitations of the study

This study was conducted exclusively among a small sample of male betel quid chewers, although there are some female betel quid chewers in Mandalay. Our focus on men only limits the study’s potential for clarifying differences in betel quid chewing between men and women, and in how masculinity is viewed by men and women. Moreover, the first author, who conducted all data collection, was a female physician; given that the social contexts studied were dominated by working-class men, there could have been gender and class barriers despite the first author’s continuous efforts to act in a lively and natural manner to engage the participants. Lastly, although the participants were fully briefed about the procedures of the study, unfamiliarity with this type of research and the embodiment of the lack of freedom of speech, resulting from living for years under a political system in which people are not encouraged to speak out, may have prevented the participants’ full involvement and participation in this study.