You Know Who's Bizarrely Good For People's Health? Clowns.

Over the past three decades, clowns have worked their way into the fabric of hospitals around the world. Through the judicious (and compared to the garish circus clowns from your nightmares, restrained) use of humor, songs, and play, these specialized medical clowns try to break the rhythm and tone of clinical settings. Historically many doctors welcomed their presence because they seemed innocuous at worst, but a proven boon for stress and morale at best. Recently, though, some medical professionals have started to take hospital clowns much more seriously thanks to emerging research that seems to indicate the humor they provide is consistently more than just a fleeting distraction.

Clowning reliably reduces stress and encourages the release of endorphins in patients, helping the immune system, blood pressure, and other biological systems. This lowered stress helps to improve patient-doctor communication, decreases the need for painkillers or sedatives in some procedures, and generally reduces hospital stays while improving perceptions of visits.

Although most studies have focused on children, some research indicates clowning has similar effects on adults: One odd study conducted in Israel in 2011 found that women entertained by a clown while undergoing IVF fertility treatments had about a quarter times higher chance of getting pregnant than those who were not so entertained. Another in Canada suggested clowns could help seniors with dementia with their mood and communication skills, as well as giving them a sense of autonomy.

Clownish characters have likely been a part of medicine as long as it's been a distinct field of human expertise and experience, breaking the flow of stressful situations to help doctors and patients manage illness and recovery. At least one early 20th century medical journal contains a sketch of a French nurse in a pediatric hospital done up as a clown, and Dr. Hunter "Patch" Adams famously brought humor and a degree of clown shtick into his medical practice in the 1970s.

But modern, quasi-systematized "hospital clowning" first emerged, experts tell me, in 1986 in the United States and Canada. Unlike volunteer clowns who show up every now and then and do standard performances for kids, hospital clowns usually get special training to navigate medical settings and either try to become as frequent a presence as possible at the hospital—or take staff positions in them.

Most hospital clowns wear a red nose, subdued make-up, and riff on hospital staff uniforms or a white doctor's coat and use props inspired by medical devices, satirizing what's ordinarily daunting. Unlike doctors, some of who use humor and maybe clown props at times but are constricted by a degree of routine and duty, clowns offer a constant source of engaged levity and have the ability to put patients entirely in control of a light and bizarre parallel hospital experience. And for decades they've tended to coalesce into foundations or communities, helping to organize and spread the practice of hospital clowning far and wide.

"[We] learn to watch body language, watch eye contact, find out: Should I engage or should I not engage?," explains Kathy Keaton, also known as Piccolo the Clown, who has worked as a hospital humorist and therapeutic clown at the San Angelo Community Medical Center in San Angelo, Texas, for 14 years. "Is it the right time or is it not? Everyone in a hospital has their own story."

There's no single way to train as a hospital clown, although most seek out or receive a continual education in medical protocol and patient engagement on top of their performance chops. Some roam hospitals on their own or in duos making judgment calls about who to engage and how, while others coordinate with staff to visit select patients based on their profiles and needs. Some participate directly in patient therapies or procedures alongside staff, hoping and often succeeding in lightening their moods and shifting attention away from their stress.

But, Keaton says, when she started clowning on military base hospitals 40 years ago, she didn't quite understand why her humor had an impact or how to improve its delivery. When in the late '90s she joined the Association for Applied and Therapeutic Humor, an organization formed in 1987 to advance the general value of humor in almost any interpersonal field, there still weren't many hard studies of humor's effects on medicine and human health, much less on clowning. "Before we used to say that humor was good medicine," she says. "But we didn't have any proof."

Then scholars started the clowns. While there'd been earlier anthropological studies and amateur works on hospital clowning, according to Paulien Trapman of the European Federation of Hospital Clown Organizations (EFHCO), the first quantifiable medical study of hospital clowning's effects came out in 2005. It's since been followed by at least 40 other medical studies that the EFHCO is aware of. Israel became a hub for this research, spurred on by an especially ambitious hospital clowning organization: Dream Doctors, founded in 2002, which now has 111 full-time clowns on staff at 29 hospitals in Israel and which promote research to help establish their craft as a recognized paramedical profession. "A network of academic researchers specifically [focusing] on hospital clowning [has] emerged" of late too, adds Trapman. So we can expect even more studies on the benefits of the practice.

Many of the positive effects seem to be the result of laughter and decreased stress in general, not some magical clown power. But hospital clowns are uniquely placed to disrupt medical experiences, reliably providing a supply of humor that other hospital workers might not be able to offer as frequently or effectively. And while many who hear of hospital clowns worry about coulrophobia, the fear of clowns, spoiling these effects with stress reactions, another Israeli study from last year suggests that this phobia is actually fairly rare. Clowns have in the past told me that it seems to stem from the exaggerated stage makeup used in the circus to help people see from the back row, mixed with negative depictions of clowns in horror and other pop culture.

A child between the ages of two and three might be afraid at first, says Keaton. "But they're afraid of the Easter Bunny, Santa Claus, and people in hats." They just need positive exposure. According to the EFHCO, this research has been invaluable in helping medical clowning groups make their cases to donors and hospitals. It's sparked interest in other fields, like psychiatry, where new bridges are being built between humor, clowns, and practice. It's created a great basis for improving or building clowning training programs; in addition to Israel's Haifa program the EFHCO knows of official courses in Austria and France. And it's helped convince officials to treat medical clowning as a vital profession, not just a lark and volunteerism. More and more hospitals are regularly integrating clowns into procedures or hiring them as full-time staffers. One Argentine province even requires by law that every public hospital have on one staff.

Yet while research has opened new doors for hospital clowning abroad, according to Keaton "it's still very difficult in the United States for clowns to be accepted into the medical community." In her experience, American medical officials can have strong stereotypes based on silly circus or amateur clowns, cultural norms about phobias, or bad experiences with untrained volunteers. Many aren't that familiar with research on clowning's benefits, or don't see it as vital enough to merit any expenses when hospitals already often have child life specialists and play therapists on staff. Although there are quite a few training programs in the US, Keaton says none are quite as established, serious, or well funded as what happens in other pro-clown countries.

There's clearly much to gain for folks of all ages by having a clown or two on a medical team; we have the data and the decades of practical experience to say that much. But until then, Keaton says, all of the exciting developments coming out of Israel and other clown conscious nations just "make our clowns very jealous that we can't get more clowns trained and into hospitals" in the US as well.

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