Clowns, a source of such enjoyment to so many children but of fear to some (coulrophobia is a fear of clowns), appear in many different cultures and play a variety of roles. Clowns have been with us at least since 2400 BC, when they could be found in ancient Egypt.1 In the 7th century BC in ancient Greece, professional clowns including female clowns acted as comic characters, parodying the serious actors in plays and mimes, sometimes pelting the spectators with nuts. Rustic buffoon characters in Classical Greek theatre were known as sklêropaiktês (from paizein, to play like a child). In Roman mime, similar clowns wore pointed hats and motley patchwork robes and were the butt of fellow actors' ridicule.1

In medieval times and on into the Renaissance period, a court jester, or fool, was an entertainer employed as a member of the household of a nobleman or monarch to entertain guests. In the late Middle Ages in Europe, some members of the companies of travelling entertainers started to imitate the antics of court jesters, such that clowning became an integral part of the show. In France, amateur festive societies, known as sociétés joyeuses, would perform short comic plays during festivals. One of the largest, founded in Paris by merchants, craftsmen and students, was called the Enfants sans Souci, which translates as children with no worries.

In the late 16th century in Italy, a professional travelling theatre emerged called the Commedia dell'arte (comedy of the profession), which included the Arlecchino or Harlequin, who wore a black domino mask and carried a bat which he frequently wielded to smack other characters' bottoms.

English clowns often performed with Shakespeare's theatre company. Shakespeare himself was fascinated by clowns and fools. He portrayed clowns as simple, uneducated rustics, whose ignorant comments would entertain the audience (e.g. Bottom in A Midsummer Night's Dream or Dogberry in Much Ado About Nothing). In contrast, Shakespeare saw the court fool or jester as the possessor of a caustic wit who employed satire to point out the foibles of humanity (e.g. Touchstone in As You Like It, Feste in Twelfth Night and the Fool in King Lear). The court jester was given a degree of licence to make fun of courtiers and even of royalty, but was whipped at the whim of his master if judged to have overstepped the mark.

The traditional clown's white face make-up probably started in the late 17th century, with the character of Pierrot, a French clown with a bald head who was a butt for Harlequin. The first melancholic clown was the French pantomime artist Jean-Gaspard Debureau and the first true circus clown was Englishman Joseph Grimaldi (‘Joey’) in the early 19th century.1 A colleague's children sometimes used to say they were ‘happy-saddish’, surely an apt emotional description of the melancholic clown.

Clowns scare some children, perhaps because of their underlying ambiguity. Their painted faces with fixed smiles lack emotion, even when they fall and seem to hurt themselves. There are parallels with disguise by wearing masks.2 Clowns are sometimes portrayed as sinister characters. In horror movies, some clowns commit evil acts and even murder children. The idea that we would use clowns in children's hospitals seems controversial to say the least. A 1908 Parisian journal depicting clowns in a London children's hospital says in French ‘to make the children laugh’, but the children look bewildered rather than amused (Fig. 1). In 1971, a young American physician, Hunter Doherty Adams (‘Patch’ Adams) founded a free community hospital called the Gesundheit! Institute (Gesundheit means ‘good health’ in German, but also used for ‘Bless you’ when someone sneezes). Patch Adams believed in compassion and humour. He wore a red nose on ward rounds and is widely acknowledged as the first clown doctor. Professional clown doctors started working in the US hospitals in 1986 (Fig. 2); there are now programmes of clown doctors in the USA, Canada, Europe, Israel, Australasia, South Africa, Asia and South America.3 Clown doctors in children's hospitals need to undergo training and to have police and working with children checks. We do not often hear of child patients being scared by clown doctors, but do we ask them?

Clowns in a London children's hospital on the front cover of the September 1908 edition of the Parisian newspaper Le Petit Journal.3

Clown doctor by Yaejnesh Srikrisna (from Operation Art).

While it seems intuitive that making children laugh might have health benefits, there is only a limited amount of supportive evidence. A systematic review of studies of clown doctors in children's hospitals found 13 randomised and 11 non-randomised studies, but many of the study designs were weak or open to bias.3 Children whose procedures were performed with clowns present, with or without the child's parents, reported less anxiety and had improved psychological adjustment.3 Three studies of children with chronic conditions found clowns reduced stress, fatigue, pain and distress.3 Infection control concerns during COVID-19 have caused clowns to use Zoom to chat to hospitalised children.4 Furthermore, a randomised Turkish study showed kindergarten children educated by clowns were better at washing their hands than those educated by teachers.5

Clowns have a long, intriguing but ambivalent history, dating back thousands of years, amusing us, scaring some and also exposing our human foibles. Circus clowns have been performing for more than two centuries. While clown doctors and nurses now attend many children's hospitals regularly, it should be possible to perform more high-quality studies to show what effect clowns have on children's health and well-being.

The author would like to thank Chris Elliot, Steve Isaacs, Henry Kilham, Anne Preisz and Mike South for their insightful comments that significantly improved this editorial.